Impact of Diagnostic Delay on Disease Course in Pediatric- versus Adult-Onset Patients with Ulcerative Colitis: Data from the Swiss IBD Cohort

INTRODUCTION Given the lack of data, we aimed to assess the impact of the length of diagnostic delay on the natural history of ulcerative colitis (UC) in pediatric (diagnosed <18 years) and adult patients (diagnosed ≥18 years). METHODS Data from the Swiss Inflammatory Bowel Disease Cohort Study were analyzed. Diagnostic delay was defined as the interval between the first appearance of UC-related symptoms until diagnosis. Logistic regression modeling evaluated the appearance of the following complications in the long term according to the length of diagnostic delay: colonic dysplasia, colorectal cancer, UC-related hospitalization, colectomy, and extraintestinal manifestations (EIMs). RESULTS A total of 184 pediatric and 846 adult patients were included. The median diagnostic delay was 4 [IQR 2-7.5] months for the pediatric-onset group and 3 [IQR 2-10] months for the adult-onset group (p = 0.873). In both, pediatric- and adult-onset groups, the length of diagnostic delay at UC diagnosis was not associated with colectomy, UC-related hospitalization, colon dysplasia, and colorectal cancer. EIMs were significantly more prevalent at UC diagnosis in the adult-onset group with long diagnostic delay than in the adult-onset group with short diagnostic delay (p = 0.022). In the long term, the length of diagnostic delay was associated in the adult-onset group with colorectal dysplasia (p = 0.023), EIMs (p < 0.001), and more specifically arthritis/arthralgias (p < 0.001) and ankylosing spondylitis/sacroiliitis (p < 0.001). In the pediatric-onset UC group, the length of diagnostic delay in the long term was associated with arthritis/arthralgias (p = 0.017); however, it was not predictive for colectomy and UC-related hospitalization. CONCLUSIONS As colorectal cancer and EIMs are associated with considerable morbidity and costs, every effort should be made to reduce diagnostic delay in UC patients

Frequency and type of drug-related side effects necessitating treatment discontinuation in the Swiss Inflammatory Bowel Disease Cohort.

BACKGROUND AND AIM Systematic analyses of inflammatory bowel disease (IBD) drug-related side effects necessitating treatment cessation in large cohorts of patients with IBD are scarce. We aimed to assess the frequency and type of drug-related side effects requiring drug cessation in patients included in the Swiss IBD Cohort. PATIENTS AND METHODS A retrospective review was performed of data from the Swiss IBD Cohort physician questionnaires documenting a treatment cessation for the following drug categories: aminosalicylates, topical and systemic steroids, thiopurines, methotrexate, tumor necrosis factor-antagonists, and calcineurin inhibitors (tacrolimus, cyclosporine). RESULTS A total of 3192 patients were analyzed, of whom 1792 (56.1%) had Crohn's disease, 1322 (41.4%) had ulcerative colitis, and 78 (2.5%) had IBD unclassified. Of 3138 patients treated with IBD drugs, 2129 (67.8%) presented with one or several drug-related side effects necessitating drug cessation. We found a significant positive correlation between the number of concomitantly administered IBD drugs and the occurrence of side effects requiring drug cessation (P<0.001). Logistic regression modeling identified Crohn's disease diagnosis [odds ratio (OR)=1.361, P=0.017], presence of extraintestinal manifestations (OR=2.262, P<0.001), IBD-related surgery (OR=1.419, P=0.006), and the increasing number of concomitantly used IBD drugs [OR=2.007 (P<0.001) for two concomitantly used IBD drugs; OR=3.225 (P<0.001) for at least three concomitantly used IBD drugs] to be associated significantly with the occurrence of IBD drug-related adverse events that necessitated treatment cessation. CONCLUSION Physicians should keep in mind that the number of concomitantly administered IBD drugs is the main risk factor for drug-related adverse events necessitating treatment cessation

Frequency and type of drug-related side effects necessitating treatment discontinuation in the Swiss Inflammatory Bowel Disease Cohort

La maladie de Crohn et la rectocolite ulcéro-hémorragique représentent les deux principales formes des maladies inflammatoires chroniques intestinales (MICI). Les preuves actuelles confirment que les MICI résultent d'une réponse inflammatoire inappropriée au microbiote intestinal chez des hôtes génétiquement prédisposés. Les traitements reposent sur le contrôle des symptômes à court terme et à long terme, et sont associés à de potentiels effets secondaires tels que des complications dermatologique, intestinale, systémique ou cancérigène. La fréquence et le type des effets secondaires de ces médicaments sont généralement basés sur des études qui les analysent de manière individuelle. Cependant ces médicaments sont majoritairement utilisés de manière combinée tel que l'azathioprine et l'infliximab qui confirme un meilleur taux de rémission clinique et muqueuse chez des patients atteints de maladie de Crohn, en réduisant le risque de formation d'anticorps anti-TNF. Étant donné le faible nombre d'études qui fournit une vue globale des éventuels événements indésirables liés à ces traitements, nous avons réalisé une étude rétrospective à l'aide de la cohorte Suisse des MICI, dans le but de déterminer la fréquence et le type d'événements indésirables liés aux traitements utilisés en monothérapie, de déterminer la fréquence des événements indésirables liés à l'utilisation concomitante de plusieurs traitements, et de trouver d'éventuels facteurs de risque liés à l'apparition d'effets secondaires. Les traitements analysés sont les aminosalicylates, les stéroides topiques et systémiques, les thiopurines, le méthotrexate, les anti-TNF et les inhibiteurs de la calcineurine (tacrolimus, cyclosporine). 3192 patients ont été examinés dont 56.1% souffrant de maladie de Crohn, 41.4% de réctocolite ulcéro-hémorragique et 2.5% de colite d'origine indéterminée. Nos résultats confirment un taux conséquent de patients ayant du stopper ces traitements dû à un ou plusieurs effets secondaires, de l'ordre de 67.8%. Nous avons également trouvé une corrélation significative entre le nombre de médicaments utilisés de manière concomitante et le taux d'effets secondaires ayant nécessité l'arrêt du traitement. Les facteurs de risques d'apparition d'effets secondaires retrouvés sont la maladie de Crohn, la présence de manifestations extra¬intestinales, les antécédents de chirurgie relative aux MICI, et le nombre croissant de traitements concomitants. Notre analyse confirme que le nombre de médicaments administrés de manière concomitante représente le principal facteur prédictif d'effets secondaires liés aux médicaments contre les MICI nécessitant l'arrêt du traitement. Les médecins impliqués dans les soins aux patients atteints de MICI doivent maintenir un haut niveau de vigilance concernant l'apparition potentielle d'effets secondaires liés aux médicaments, en particulier lorsque ces traitements sont combinés

Outcomes of duodenal stenting: Experience in a French tertiary center with 220 cases

International audienceIntroduction: Endoscopic stenting for malignant gastroduodenal outlet obstruction (MGOO) is described as ineffective and not long-lasting despite a few favorable studies. This study aimed to evaluate the clinical outcomes of a large series of patients in a tertiary center. Methods: A single-center retrospective study was performed using data collected from all patients who received palliative duodenal self-expandable metal stents between January 2011 and December 2016. The primary endpoints were patient diet after the first duodenal procedure (Gastric Outlet Obstruction Scoring System, GOOSS) and clinical success. The secondary endpoints were the median patency duration (calculated according to the Kaplan-Meier method) and the cumulative incidence of reintervention. Results: Two-hundred twenty patients were included. The increase in the GOOSS score was significant (p < 0.001), and the clinical success rate was 86.3%. The median estimated patency duration was 9.0 months [6.5-29.1]. Patients with pancreatic adenocarcinoma had significantly longer patency durations (p = 0.02). The estimated cumulative probability of a second duodenal procedure after 4 months was 13%. Conclusions: In this large series of patients who underwent duodenal stenting for MGOO, we observed significant changes in GOOSS scores, a relatively long patency duration compared to findings in previous series, and a low probability of subsequent duodenal procedures, primarily due to a low median overall survival time (4 months)

Is Piecemeal Endoscopic Resection Acceptable for Early Colorectal Cancers in Certain Situations? A Single-Center French Study

International audienceBackground & Aims: The use of endoscopic treatment for early colorectal cancer (ECC) is increasing. The European guidelines suggest performing piecemeal endoscopic resection (pmR) for benign lesions and en bloc resection for ECC, especially for patients with favorable lymph node involvement risk evaluations. However, en bloc resections for lesions larger than two centimeters require invasive endoscopic techniques. Our retrospective single-center study aimed to determine the clinical impact of performing pmR for ECC rather than traditional en bloc resection. Methods: A single-center study was performed between January 2012 and September 2017. All ECC patients were included. The main objective was to evaluate the number of patients who potentially underwent unnecessary surgery due to piecemeal resection. The secondary endpoints were as follows: disease-free survival (DFS), defined as the time from pmR to endoscopic failure (local recurrence not treatable by endoscopy), complication rate, number of patients who did not undergo surgery by default, and factors predictive of outcomes and complications. Results: One hundred and forty-six ECC endoscopically treated patients were included. In total, 85 patients were excluded (71 who underwent en bloc resection, 14 with pending follow-up). Data from 61 patients (33 women and 28 men) were analyzed. Two patients underwent potentially unnecessary surgery [3.28% (0.9%-11.2%)]. The DFS rate was 87% (75%-93%) at 6 months and 85% [72%-92%] at 12 months. The median followup time was 16.5 months (12.4-20.9). Three patients (4.9%) had complications. One patient did not undergo surgery by default. A Paris classification of 0-2c (HR=9.3 (2.4-35.9), p<0.001) and Vienna classification of 5 [HR=16.3 (3.3-80.4), p<0.001] were factors associated with poor DFS. Conclusion: Performing pmR in place of en bloc resection for ECC had a limited impact on patients. If the pathology (especially deep margins) is analyzable, careful monitoring could be acceptable in ECC patients who undergo pmR

Primary sclerosing cholangitis in the Swiss Inflammatory Bowel Disease Cohort Study: prevalence, risk factors, and long-term follow-up.

Primary sclerosing cholangitis (PSC) represents the most common hepatobiliary extraintestinal manifestation of inflammatory bowel disease (IBD). We aimed to assess the prevalence of PSC in the Swiss Inflammatory Bowel Disease Cohort Study, to identify associated risk factors, and to describe the long-term evolution. Data of patients enrolled into the Swiss Inflammatory Bowel Disease Cohort Study were analyzed. Logistic regression modeling was performed to identify risk factors for PSC. Among 2744 patients [1188 ulcerative colitis (UC); 1556 Crohn's disease (CD)], 57 had PSC (48 UC-PSC, nine CD-PSC). The prevalence of PSC was higher in UC compared with CD (4.04 vs. 0.58%, P&lt;0.001). We identified the following significant independent risk factors for PSC in patients with UC: male sex [odds ratio (OR) 2.771, P=0.022], pancolitis (OR 2.855, P=0.011), nonsmoker at diagnosis (OR 9.253, P=0.030), and a history of appendicectomy (OR 4.114, P=0.019). During a median follow-up time of 74.8 months, four (7.0%) of PSC patients developed cholangiocarcinoma, six (10.5%) underwent liver transplantation, and five (8.8%) died. Survival of IBD-PSC patients was significantly worse compared with IBD patients without PSC (P=0.001). UC-PSC patients developed significantly more frequently colorectal cancer compared with UC patients without PSC (2/48 vs. 9/1440, P=0.017). Approximately 4% of UC patients and 0.6% of CD patients had PSC. Male sex, pancolitis, nonsmoker status, and a history of appendicectomy were significantly associated with PSC. PSC is associated with considerable morbidity and mortality in the long term

Technical feasibility, clinical effectiveness, and safety of esophageal stricture dilation using a novel endoscopic attachment cap in adults with eosinophilic esophagitis.

BACKGROUND AND AIMS BougieCap (Ovesco Endoscopy AG, Tübingen, Germany) is a new device that allows optical and tactile feedback during stricture dilation of the upper gastrointestinal tract. We evaluated the technical feasibility, clinical efficacy, and safety of a one-time esophageal stricture dilation using BougieCap in adults with eosinophilic esophagitis (EoE). METHODS EoE patients prospectively included in the Swiss EoE Cohort were dilated with BougieCap in case of the presence of esophageal strictures (esophageal diameter ≤14 mm) and stricture-related symptoms. Symptoms were assessed before and 2 weeks after a single dilation session using the validated Eosinophilic Esophagitis Activity Index Patient Reported Outcomes (EEsAI PRO)instrument (score ranges from 0-100 points). RESULTS Fifty patients (70% male, median age 41 years, median disease duration of 4 years, 50% treated with swallowed topical corticosteroids, 10% with proton pump inhibitors, 14% with combined swallowed topical corticosteroids plus proton pump inhibitors, 14% with elimination diet, 12% without anti-eosinophil therapy) were evaluated. Endoscopic bougienage was technically successful in 100%. Median esophageal diameter increased from 12 mm (IQR 12-13) to 16 mm (IQR 16-16, p<0.001)). Median symptom severity dropped from 32 points (IQR 27-41) to 0 (IQR 0-10, p<0.001) at 2 weeks post dilation. In one patient the BougieCap was temporarily lost after stricture dilation in the hypopharynx but could be retrieved. No severe adverse events were reported. CONCLUSIONS In adults with EoE, endoscopic treatment of esophageal strictures using BougieCap is technically feasible, safe and offers significant symptomatic improvement in the short term