Faculty Bibliography

BACKGROUND & AIMS/OBJECTIVE:Gastrointestinal infections have been associated with later development of inflammatory bowel diseases (IBD). However, studies have produced conflicting results. We performed a nationwide case-control study in Sweden to determine whether gastroenteritis is associated with the development of Crohn's disease (CD) or ulcerative colitis (UC). METHODS:Using the Swedish National Patient Register, we identified 44,214 patients with IBD (26,450 with UC; 13,387 with CD; and 4,377 with IBD-unclassified) from 2002 to 2014 and matched them with 436,507 individuals in the general population (controls). We then identified patients and controls with reported episodes of gastroenteritis (from 1964 to 2014) and type of pathogen associated. We collected medical and demographic data and used logistic regression to estimate odds ratios (ORs) for IBD associated with enteric infection. RESULTS:Of the patients with IBD, 3105 (7.0%) (1672 with UC, 1050 with CD, and 383 with IBD-unclassified) had a record of previous gastroenteritis compared with 17,685 controls (4.1%). IBD cases had higher odds for an antecedent episode of gastrointestinal infection (aOR, 1.64; 1.57-1.71), bacterial gastrointestinal infection (aOR, 2.02; 1.82-2.24), parasitic gastrointestinal infection (aOR, 1.55; 1.03-2.33), and viral gastrointestinal infection (aOR, 1.55; 1.34-1.79). Patients with UC had higher odds of previous infection with Salmonella, Escherichia coli, Campylobacter, or Clostridium difficile compared to controls. Patients with CD had higher odds of previous infection with Salmonella, Campylobacter, Yersinia enterocolitica, Clostridium difficile, amoeba, or norovirus compared to controls. Increasing numbers of gastroenteritis episodes were associated with increased odds of IBD, and a previous episode of gastroenteritis was significant associated with odds for IBD more than 10 years later (aOR, 1.26; 1.19-1.33). CONCLUSION/CONCLUSIONS:In an analysis of the Swedish National Patient Register, we found previous episodes of gastroenteritis to increase odds of later development of IBD. Although we cannot formally exclude misclassification bias, enteric infections might induce microbial dysbiosis that contributes to the development of IBD in susceptible individuals.

Background: Gastrointestinal bleeding (GIB)is a common complication of left ventricular assist device (LVAD)therapy. Previously, we retrospectively reviewed the endoscopic evaluation and outcomes of GIB in LVAD recipients in our center and proposed an endoscopic management algorithm (Figure)to eliminate low yield procedures. Herein, we aimed to prospectively validate this algorithm.
Method(s): We prospectively tested the algorithm in LVAD recipients who presented with GIB between June 2017 and August 2018. We compared the diagnostic and therapeutic yield of endoscopy, healthcare costs, and re-bleeding rates between conventional GIB management (our retrospective cohort)and our algorithm (our prospective cohort).
Result(s): Prospectively, 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. In total, 41 endoscopies localized a source in 23 (56%)resulting in 14 (36%)interventions at a median LOS of 8 days. Of 18 lesions identified, AVMs were the most common (9, 50%)and the small bowel was the most common location (11, 48%). Despite non-adherence to the algorithm in 7 of 33 patients (21%), algorithm implementation in comparison to our retrospective cohort increased the diagnostic yield by 70% (p<0.01)and therapeutic yield by 125% (p=0.01), and reduced the number of procedures per patient by 24% (p<0.01), length of stay by 33% (p<0.01), and estimated costs by 18% (p<0.01). In assessing the safety of our algorithm, we found the same median number of packed red blood cell transfusions and observed no increase in re-bleeding events in the prospective cohort as compared to our retrospective cohort.
Conclusion(s): Our endoscopic management algorithm for GIB in LVAD patients was effective in reducing low yield endoscopic procedures, improving the diagnostic and therapeutic yield of endoscopy, and decreasing healthcare resource utilization costs while not increasing the risk of re-bleeding. [Figure presented][Figure presented]
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OBJECTIVES/OBJECTIVE:Surveillance colonoscopy is thought to prevent colorectal cancer (CRC) in patients with long-standing colonic IBD, but data regarding the frequency of surveillance and the findings thereof are lacking. Our aim was to determine whether consecutive negative surveillance colonoscopies adequately predict low neoplastic risk. DESIGN/METHODS:A multicentre, multinational database of patients with long-standing IBD colitis without high-risk features and undergoing regular CRC surveillance was constructed. A 'negative' surveillance colonoscopy was predefined as a technically adequate procedure having no postinflammatory polyps, no strictures, no endoscopic disease activity and no evidence of neoplasia; a 'positive' colonoscopy was a technically adequate procedure that included at least one of these criteria. The primary endpoint was advanced colorectal neoplasia (aCRN), defined as high-grade dysplasia or CRC. RESULTS:1 positive colonoscopy on follow-up of 6.1 (P25-P75: 4.6-8.2) years after the index procedure. CONCLUSION/CONCLUSIONS:Within this large surveillance cohort of patients with colonic IBD and no additional high-risk features, having two consecutive negative colonoscopies predicted a very low risk of aCRN occurrence on follow-up. Our findings suggest that longer surveillance intervals in this selected population may be safe.

BACKGROUND & AIMS/OBJECTIVE:Patients with inflammatory bowel diseases (IBD) who have post-inflammatory polyps (PIPs) have an increased risk of colorectal neoplasia (CRN). European guidelines propose that patients with PIPs receive more frequent surveillance colonoscopies, despite limited evidence of this increased risk. We aimed to define the risk of CRN and colectomy in patients with IBD and PIPs. METHODS:We conducted a multicenter retrospective cohort study of patients with IBD who underwent colonoscopic surveillance for CRN, from January 1997 through January 2017, at 5 academic hospitals and 2 large non-academic hospitals in New York or the Netherlands. Eligible patients had confirmed colonic disease with duration of 8 years or more (or any duration, if they also have primary sclerosing cholangitis) and no prior history of advanced CRN (high-grade dysplasia or colorectal cancer) or colectomy. The primary outcome was occurrence of advanced CRN according to PIP status; secondary outcomes were occurrence of CRN (inclusive of low-grade dysplasia) and colectomy. RESULTS:Among 1582 eligible patients, 462 patients (29.2%) had PIPs. PIPs were associated with more severe inflammation (adjusted odds ratio [aOR], 1.32; 95% CI, 1.13-1.55), greater disease extent (aOR 1.92; 95% CI, 1.34-2.74), and lower likelihood of primary sclerosing cholangitis (aOR 0.38; 95% CI, 0.26-0.55). During a median follow-up period of 4.8 years, the time until development of advanced CRN did not differ significantly between patients with vs without PIPs. PIPs did not independently increase risk of advanced CRN (adjusted hazard ratio, 1.17; 95% CI, 0.59-2.31). The colectomy rate was significantly higher in patients with PIPs (P=0.01). CONCLUSIONS:In a retrospective analysis of data from 2 large independent surveillance cohorts, PIPs were associated with greater severity and extent of colon inflammation and higher rates of colectomy, but were not associated with development of any degree of CRN. Therefore, intervals for surveillance should not be shortened solely based on the presence of PIPs.

Purpose: Gastrointestinal bleeding (GIB) is a common complication of LVAD therapy. Previously, we retrospectively reviewed endoscopic evaluation and outcomes of GIB in LVAD recipients in our center and proposed an endoscopic management algorithm (Figure) to eliminate low yield procedures. Herein, we aimed to prospectively validate this algorithm. Method(s): We prospectively tested the algorithm in LVAD recipients who presented with GIB between June 2017 and August 2018. We compared the diagnostic and therapeutic yield of endoscopy and healthcare costs between conventional GIB management to the algorithm. Result(s): 33 LVAD pts with GIB were identified. Presentation was consistent with upper GIB in 20 (61%), lower GIB in 5 (15%), and occult GIB in 8 (24%) pts. In total, 41 endoscopies localized a source in 23 (56%) resulting in 14 (36%) interventions at a median length-of-stay (LOS) of 8 d. Of 18 lesions identified, angiodysplasias were the most common (9, 50%) and the small bowel was the most common location (11, 48%). Despite non-adherence to the algorithm in 7 of 33 pts (21%), algorithm implementation increased the diagnostic yield by 70% (p=0.008) and therapeutic yield by 125% (p=0.01), reduced the number of procedures per pt by24% (p<0.01), LOS by 33% (p<0.01), and estimated costs by 18% (p<0.01) in comparison to our retrospective cohort (Table). Conclusion(s): Our endoscopic management algorithm of GIB in LVAD pts is effective in reducing low yield procedures, improving the diagnostic and therapeutic yield of endoscopy, and decreasing healthcare resource utilization.

Background/UNASSIGNED:Clostridium difficile infection (CDI) is common in patients with inflammatory bowel disease (IBD), often leading to diagnostic confusion and delays in IBD therapy escalation. This study sought to assess outcomes after CDI in IBD patients exposed to new or escalated immunosuppressive therapy. Methods/UNASSIGNED:This multicenter retrospective cohort study included IBD patients with documented CDI at 4 academic medical centers. Data were abstracted from clinical databases at each institution. Outcomes at 30 and 90 days were compared between patients undergoing new or intensified immunosuppressive therapy and those without therapy escalation. Continuous variables were compared using t tests, and proportions using chi-square tests. Multivariable logistic regression was used to determine the association of individual variables with severe outcomes (including death, sepsis, and/or colectomy) within 90 days. Secondary outcomes included CDI recurrence, rehospitalization, worsening of IBD, and severe outcomes within 30 days. Results/UNASSIGNED:A total of 207 adult patients with IBD and CDI were included, of whom 62 underwent escalation to biologic or corticosteroid therapy (median time to escalation, 13 days). Severe outcomes within 90 days occurred in 21 (15.6%) nonescalated and 1 (1.8%) therapy-escalated patients. Serum albumin <2.5 mg/dL, lactate >2.2 mg/dL, intensive care unit admission, hypotension, and comorbid disease were associated with severe outcomes. Likelihood of severe outcomes was decreased in patients undergoing escalation of IBD therapy after CDI (adjusted odds ratio [aOR], 0.12) and increased among patients aged >65 years (aOR, 4.55). Conclusions/UNASSIGNED:Therapy escalation for IBD within 90 days of CDI was not associated with worse clinical outcomes. Initiation of immunosuppression for active IBD may therefore be appropriate in carefully selected patients after treatment of CDI.

BACKGROUND:Race, ethnicity and socio-economic status impact clinical outcomes in inflammatory bowel disease (IBD) patients. However, their impact on disability has not been studied. AIM/OBJECTIVE:To determine the association between race, ethnicity and socio-economic factors with disability in IBD, using the validated IBD disability index (IBD-DI). METHODS:Ambulatory IBD patients were enrolled at five academic centres participating in the New York Crohn's and Colitis Organization. We assessed the IBD-DI, and collected clinical and socio-economic data. Factors associated with moderate-to-severe disability (IBD-DI score > 35) on univariable analysis were tested in multivariable models with adjusted odds ratios (aOR) and 95% confidence intervals (CI) reported. RESULTS:In this study, 323 patients (57.3% CD, 51.4% female) were enrolled; 17.7% were Hispanic, 17% were non-Hispanic black, 56.0% were non-Hispanic Caucasian and 9.3% belonged to non-Hispanic non-black minority races. However, 39.0% of patients were publicly insured and 38.4% of patients had low annual household income (<$50 000). 100 (31.0%) patients reported moderate-to-severe disability. On multivariable analysis, Hispanic ethnicity (aOR 2.7, 95% CI 1.3-5.6), non-Hispanic non-black minority race (aOR 3.5, 95% CI 1.3-8.9), public payer (aOR 2.1, 95% CI 1.1-4.0) and low annual household income (aOR 3.0, 95% CI 1.7-5.4) were associated with moderate-to-severe disability controlling for disease characteristics. CONCLUSIONS:IBD patients who are minorities, have public insurance, or low household income, are 2-3 times more likely to report moderate-to-severe disability independent of disease characteristics in the United States. Future studies are needed to study their complex relationship and to mitigate disability.

Introduction: Polymerase chain reaction (PCR)-based multiplex gastrointestinal (GI) pathogen panels have started to replace stool culture and ova and parasite exam as a rapid and accurate means of diagnosing acute gastroenteritis. However, there are limited data on the impact of panel testing on patient outcomes. The objective of this study was to evaluate the management and healthcare utilization of patients following GI panel compared to conventional stool testing.Methods: We performed a retrospective comparative analysis of 9,402 patients who underwent testing with the FilmArray® GI panel from March 2015 through May 2017 and 5,986 patients who underwent conventional stool testing from December 2012 through February 2015.Results: GI panel was positive in 2,746 exams (29.2%), compared to 246 exams (4.1%) with conventional testing. Within 30 days following stool testing, compared to patients who received a conventional stool test, patients who received a GI panel were less likely to undergo any endoscopic procedure (8.4% GI panel vs 9.6% stool culture, p=0.008) or any abdominal radiology (29.4% GI panel vs 31.7%, p=0.002). Within 14 days following stool testing, patients who received a GI panel were less likely to be prescribed any antibiotic (36.2% GI panel vs 40.9%, p<0.001).Conclusions: The implementation of multiplex PCR stool testing was associated with a reduction in the utilization of endoscopy, abdominal radiology, and antibiotic prescribing.

OBJECTIVES/OBJECTIVE:Few studies have examined the role of non-Clostridium difficile enteric infections in flares of inflammatory bowel disease (IBD). Our objective was to investigate enteric infection detected by multiplex PCR stool testing in patients with IBD. METHODS:We performed a cross-sectional analysis of 9403 patients who underwent 13,231 stool tests with a gastrointestinal pathogen PCR panel during a diarrheal illness from March 2015 to May 2017. Our primary outcome was the presence of an infection. Secondary outcomes included endoscopic and histologic predictors of infection, and IBD outcomes following testing. RESULTS:A total of 277 patients with Crohn's disease (CD), 300 patients with ulcerative colitis (UC), and 8826 patients without IBD underwent 454, 503, and 12,275 tests, respectively. Compared to patients without IBD, patients with IBD were less likely to test positive (CD 18.1%, UC 16.1%, no IBD 26.6%, p < 0.001). Compared to patients without IBD, CD had a higher prevalence of norovirus (p = 0.05) and Campylobacter (p = 0.043), whereas UC had a lower prevalence of norovirus (p = 0.001) and a higher prevalence of Campylobacter (p = 0.013), Plesiomonas (p = 0.049), and Escherichia coli species (p < 0.001). Of 77 patients who underwent endoscopy, there were no major endoscopic or histologic predictors of a positive test. Patients who tested negative were more likely to have IBD therapy escalated (p = 0.004). Enteric infection did not impact IBD outcomes following testing (log-rank 0.224). CONCLUSIONS:Non-Clostridium difficile enteric infections were identified in 17% of symptomatic patients with IBD. Endoscopic and histologic findings may not differentiate flare from infection. Norovirus and E.coli may play an important role in flare of IBD.