Faculty Bibliography

BACKGROUND:Postoperative ileus (POI) is a temporary delay of coordinated intestinal peristalsis. Alvimopan, an oral peripherally acting mu-opioid receptor antagonist approved for accelerating gastrointestinal recovery, has never been studied specifically in patients with inflammatory bowel disease (IBD). AIM/OBJECTIVE:To investigate the efficacy of alvimopan in preventing POI among IBD patients. METHODS:A retrospective chart review was conducted on 246 IBD patients undergoing bowel surgery between 2012 and 2017. Data collected included demographics, IBD subtype, length of stay (LOS), postoperative gastrointestinal symptoms, and administration of alvimopan. The primary outcome was POI; secondary gastrointestinal recovery outcomes were: time to first flatus, time to first bowel movement, time to tolerating a liquid diet, time to tolerating solid food, and LOS. RESULTS:When compared with the control group, patients in the alvimopan group had shorter times to tolerating liquids and solids, first flatus, and first bowel movements (p < 0.01). LOS was shorter in the alvimopan group when compared with controls (p < 0.01). The overall incidence of POI was higher in controls than in the alvimopan group (p = 0.07). For laparoscopic surgeries, the incidence of POI was also higher in controls than in the alvimopan group (p < 0.01). On multivariable analysis, alvimopan significantly decreased time to all gastrointestinal recovery endpoints when compared to controls (p < 0.01). CONCLUSIONS:Alvimopan is effective in accelerating time to gastrointestinal recovery and reducing POI in IBD patients. While the benefits of alvimopan have been demonstrated previously, this is the first study of the efficacy of alvimopan in IBD patients.

BACKGROUND:GIB is a common complication of LVAD therapy accounting for frequent hospitalizations and high resource utilization. METHODS:We previously developed an endoscopic algorithm emphasizing upfront evaluation of the small bowel and minimizing low-yield procedures in LVAD recipients with GIB. We compared the diagnostic and therapeutic yield of endoscopy, healthcare costs, and re-bleeding rates between conventional GIB management and our algorithm using chi-square, Fisher's exact test, Wilcoxon-Mann-Whitney, and Kaplan-Meier analysis. RESULTS:We identified 33 LVAD patients with GIB. Presentation was consistent with upper GIB in 20 (61%), lower GIB in 5 (15%), and occult GIB in 8 (24%) patients. 41 endoscopies localized a source in 23 (56%), resulting in 14 (34%) interventions. Algorithm implementation in comparison to our conventional cohort was associated with a 68% increase in endoscopic diagnostic yield (p<0.01), a 113% increase in therapeutic yield (p=0.01), a 27 % reduction in the number of procedures per patient (p<0.01), a 33% decrease in length of stay (p<0.01), and an 18% reduction in estimated costs (p<0.01). The same median number of red blood cell transfusions were used in the two cohorts, with no increase in re-bleeding events in the algorithm cohort (33.3%) as compared to our conventional cohort (43.7%). CONCLUSIONS:Our endoscopic management algorithm for GIB in LVAD patients proved effective in reducing low-yield procedures, improving the diagnostic and therapeutic yield of endoscopy, decreasing healthcare resource utilization and costs, while not increasing the risk of a re-bleeding event.

Background and Aim/UNASSIGNED:Enteric tube (ET) placement is approached with caution in patients with esophageal varices (EV) due to concern of causing variceal bleeding. Data are limited on rates and predictors of gastrointestinal bleeding (GIB) in these patients. This study aims to assess the rate and predictors of bleeding from EV after ET placement. Methods/UNASSIGNED:test, and univariate logistic regression model. Results/UNASSIGNED:= 0.048). Conclusion/UNASSIGNED:ET placement in patients with EV is associated with low risk of bleeding. Elevated MELD-Na and lower EV location conferred a higher risk of bleeding after ET placement.

PURPOSE OF REVIEW/OBJECTIVE:Both the chronic inflammation in inflammatory bowel disease (IBD), and its treatment, can increase the risk of malignancy. There is also an increasing number of patients with current and prior cancer who require IBD treatment. Thus, there is a complex interplay between immunosuppressive treatment and monitoring for new and recurrent cancer. RECENT FINDINGS/RESULTS:Vedolizumab and ustekinumab have not been shown to increase the risk of malignancy. Transplant data shows a potential risk with tofacitinib although rheumatoid arthritis data does not. IBD patients have been shown to tolerate chemotherapy, specifically with cytotoxic compared with hormonal chemotherapy. Patients with prior cancer are at increased risk of new or recurrent cancers; however, immunosuppression appears to be safe. Emerging treatments for IBD have demonstrated acceptable safety profiles for malignancy risk, and immunosuppression appears to be safe for use in patients with current and prior malignancy. More data is still needed to assess long-term risk of malignancy in these patients, especially with newer treatments.

Patients with inflammatory bowel disease (IBD) are at an increased risk of developing intestinal neoplasia-particularly colorectal neoplasia, including dysplasia and colorectal cancer (CRC)-as a primary consequence of chronic inflammation. While the current incidence of CRC in IBD is lower compared with prior decades, due, in large part, to more effective therapies and improved colonoscopic technologies, CRC still accounts for a significant proportion of IBD-related deaths. The focus of this review is on the pathogenesis; epidemiology, including disease- and patient-related risk factors; diagnosis; surveillance; and management of IBD-associated neoplasia.

Background/UNASSIGNED:The Swedish Quality Register for Inflammatory Bowel Disease (SWIBREG) contains clinical data for the study of inflammatory bowel disease (IBD). The Epidemiology Strengthened by histoPathology Reports in Sweden (ESPRESSO) cohort was recently established for the study of gastrointestinal histopathology. We aimed to develop and validate a histology score from ESPRESSO using clinical information from SWIBREG, and secondarily, to evaluate the association of the score on IBD-related hospitalization. Methods/UNASSIGNED:In a nationwide, population-based cohort study of patients with IBD during 1969-2017, we linked endoscopic inflammation in SWIBREG with histologic inflammation in ESPRESSO. We established a clinically interpretable model for predicting the endoscopic score from histology using scalable Bayesian rule lists to define a SNOMED-based histology score applicable to the ESPRESSO cohort. We also assessed the impact of baseline endoscopic and histology scores on time to IBD-related hospitalization. Results/UNASSIGNED:We identified 5225 individuals with IBD comprising 11,051 endoscopic assessments in SWIBREG linked to a histopathology record in ESPRESSO. We created predictive models to calculate a SNOMED-based histology score which predicted the endoscopic score. Split-sample validated areas under the ROC curves for the score predicting a non-zero endoscopic score were 0.80 (0.78-0.81) in UC, 0.70 (0.68-0.72) in CD, and 0.76 (0.73-0.78) in IBD-U. In a subset of 2741 individuals with an initial IBD diagnosis and a corresponding record in ESPRESSO with an endoscopic assessment in SWIBREG, the baseline endoscopic and histology scores were associated with time to IBD-related hospitalization (endoscopy log-rank UC p<0.001, CD p=0.020, IBD-U p<0.001; histology log-rank UC p=0.018, CD p=0.960, IBD-U p=0.034). Conclusion/UNASSIGNED:Histopathology data in ESPRESSO accurately predict endoscopic scores in SWIBREG. Baseline endoscopic and histologic scores were associated with time to IBD-related hospitalization, particularly in UC. The SNOMED-based histology score can be used as a measure of disease activity in future register-based IBD studies.

INTRODUCTION: Diarrhea is a common complication of HIV/AIDS. Although non-infectious enteropathy may be attributed to HIV infection, enteric pathogens are frequently detected in episodes of diarrhea. The objective of this study was to investigate the relationship between CD4 count and enteric infection as detected by multiplex gastrointestinal PCR stool testing in HIV/AIDS patients.
METHOD(S): We performed a cross-sectional analysis of adult inpatients and outpatients who underwent stool testing with a FilmArray multiplex gastrointestinal pathogen PCR panel (GI PCR panel) during an acute episode of diarrhea from December 2015 to February 2019. Our primary endpoint was the detection of any enteric pathogen. Patients were stratified by the presence of HIV infection and CD4 count at time of stool testing.
RESULT(S): Of 80 HIV+patients who underwent a GI PCR panel, 45 (56%) tested positive for an enteric pathogen (Table 1). HIV+patients with CD4 counts >500 (n=26) were more likely to have a pathogen detected (19, 73%) compared to patients with a CD4 count <200 (n=30) consistent with AIDS (12, 40%; P=0.03; Figure). Patients with a CD4 count between 201 and 499 (n=24) had a positivity rate that was in between that of patients with low and high CD4 counts (14, 58%). Of 30 AIDS patients, 9 (30%) had a GI infection not detected by GI PCR including CMV, HSV, LGV, MAI, and syphilis. Among this subset of 9 AIDS patients, 4 (44%) tested negative on GI PCR. AIDS patients were less likely to be adherent to antiretroviral therapy, and more likely to be on opportunistic infection prophylaxis compared to HIV+patients with CD4 counts >200 (P=0.03 and P=0.002 respectively.) Compared to patients with CD4 counts >200, those with AIDS were more likely to receive empiric antimicrobial therapy at stool testing (P<0.001), and in the 30 days following stool testing, as likely to visit an emergency room (P=0.24), require hospitalization (P=0.31), or undergo endoscopic procedures for continued GI symptoms (P=0.67).
CONCLUSION(S): Enteric infections were common in HIV+patients who underwent a GI PCR panel for an episode of diarrhea, with the highest proportion of positive results in patients with CD4 counts >500. Based on historical data, this rate of positivity is considerably higher than in the general population of patients with an episode of diarrhea. These data suggest that AIDS patients may be more likely to have a pathogen not included on the GI PCR panel, or a chronic cause of diarrhea such as HIV-enteropathy

INTRODUCTION: Diarrhea is a common sequela of solid organ transplantation. Post-transplant diarrhea may be attributed to non-infectious causes including medications, however the contribution of infectious etiology is unclear. The objective of our study was to evaluate the relationship between post-transplant immunosuppression and enteric infection as detected by multiplex gastrointestinal PCR stool testing in solid organ transplant (SOT) recipients.
METHOD(S): We performed a multicenter cross-sectional analysis of inpatient and outpatient SOT recipients who underwent stool testing with a FilmArray multiplex gastrointestinal pathogen PCR panel (GI PCR panel) during an acute episode of diarrhea from April 2016 to May 2019. The primary endpoint was the detection of any enteric pathogen. Patients were stratified by the number of major classes of immunosuppressive agents, including calcineurin inhibitors, anti-proliferative agents, and corticosteroids, at time of stool testing.
RESULT(S): We identified 232 SOT patients who underwent a GI PCR panel comprising 52 (23%) lung, 84 (36%) kidney, 41 (18%) heart, and 55 (24%) liver transplants. 92 (40%) tested positive for an enteric pathogen. Patients whose immunosuppressive regimen included 3 medications (n = 139) were more likely to have a gastrointestinal pathogen detected (63, 45%) compared to patients on 2 immunosuppressive medications (P = 0.02; Figure 1) Renal transplant patients were more likely to have an enteric pathogen detected (60%; P < 0.0001) compared to other organ types, and more likely to be on 3 immunosuppressive medications (P < 0.01). Viruses, specifically norovirus and sapovirus, and bacteria, including C. difficile and E. coli subtypes, were common in transplant recipients on 2 immunosuppressive agents (Table 1). Of 139 patients on 3 immunosuppressive agents, 89 (59%) were more likely to be on opportunistic infection prophylaxis for CMV and P. jiroveciipneumonia compared to those patients on 2 drugs (P < 0.001). In the 30 days following stool testing, all SOT recipients, regardless of the number of immunosuppressive drugs, were as likely to visit an emergency room (P = 0.57), require hospitalization (P = 0.66), or undergo endoscopic procedures for persistent GI symptoms (P = 0.78).
CONCLUSION(S): Gastrointestinal infections, particularly enteric viruses, were common in SOT recipients who underwent a GI PCR panel for an episode of post-transplant diarrhea, with the highest proportion of positive results in patients maintained on 3 or more immunosuppressive agents