Efficacy and Safety of Endoscopic Balloon Dilatation of Ileoanal Pouch Strictures.

Background and aims: Colectomy with ileoanal pouch is the standard of care for most patients with ulcerative colitis (UC) who require surgery. However, 5%-38% of patients with ileoanal pouch develop pouch strictures that can severely impact the functional results. We retrospectively evaluated the efficacy and safety of endoscopic balloon dilation of ileoanal pouch strictures in patients with inflammatory bowel disease (IBD). Methods: All consecutive patients with IBD that underwent endoscopic balloon dilatation of a pouch stricture at our institution between January 1, 2011, and April 31, 2016, were included. Clinical, endoscopic, and surgical variables were collected retrospectively. Stricture-related pouch failure was defined by the need for surgical management of pouch stricture including pouch excision, diversion ileostomy, or stricturoplasty. Secondary outcomes included technical success, clinical success, and safety. Results: Eighty-eight endoscopic balloon dilatations were identified in 20 patients. Sixty percent of patients were female, with a median age at ileoanal pouch of 28.6 years (interquartile range [IQR], 25.5-37.2). Ileoanal pouch was performed for UC in 95% of cases; 95% of patients underwent J pouch; and 65% had a stapled anastomosis, whereas 35% had a handsewn anastomosis. Strictures were diagnosed at a median of 4.6 years (0.2-10.6) after surgery, and half of patients were symptomatic. The most frequent location of stricture was the anal-pouch anastomosis (87%). Half of patients were found to have associated pouchitis, 4 (20%) had at least 1 fistula, and 5 (25%) had ulcerations of the pouch. At the end of follow-up, 6 patients (30%) underwent a change in diagnosis from UC to Crohn's disease (CD) of the pouch, and in 1 patient (5%) a diagnosis of ischemic stricture was made. A median of 3.5 dilatations per patient (IQR, 2.0-7.0) were performed. Technical efficacy was observed in 87 procedures (98%). Twenty-two procedures were preceded by obstructive symptoms, and a clinical improvement after endoscopic balloon dilatation was observed in 95% of cases. After a median follow-up of 3.0 years (2.1-3.5), only 1 patient had stricture-related pouch failure. After the first dilatation, 4 patients were hospitalized for obstructive symptoms. Conservative management with another endoscopic balloon dilation was clinically effective in all cases. No major complications related to dilation were observed. Conclusion: Endoscopic balloon dilatation of ileoanal pouch strictures is largely effective and safe and can be recommended as the first line strategy to treat ileoanal pouch strictures in patients with IBD.

Effect of weight loss on magnetic resonance imaging estimation of liver fat and volume in patients with nonalcoholic steatohepatitis.

BACKGROUND & AIMS: Little is known about how weight loss affects magnetic resonance imaging (MRI) of liver fat and volume or liver histology in patients with nonalcoholic steatohepatitis (NASH). We measured changes in liver fat and liver volume associated with weight loss by using an advanced MRI method. METHODS: We analyzed data collected from a previous randomized controlled trial in which 43 adult patients with biopsy-proven NASH underwent clinical evaluation, biochemical tests, and MRI and liver biopsy analyses at the start of the study and after 24 weeks. We compared data between patients who did and did not have at least 5% decrease in body mass index (BMI) during the study period. RESULTS: Ten of 43 patients had at least a 5% decrease in BMI during the study period. These patients had a significant decrease in liver fat, which was based on MRI proton density fat fraction estimates (18.3% ± 7.6% to 13.6% ± 13.6%, P = .03), a relative 25.5% reduction. They also had a significant decrease in liver volume (5.3%). However, no significant changes in levels of alanine aminotransferase or aspartate aminotransferase were observed with weight loss. Thirty-three patients without at least 5% decrease in BMI had insignificant increases in estimated liver fat fraction and liver volume. CONCLUSIONS: A reduction in BMI of at least 5% is associated with significant decrease in liver fat and volume in patients with biopsy-proven NASH. These data should be considered in assessing effect size in studies of patients with nonalcoholic fatty liver disease or obesity that use MRI-estimated liver fat and volume as end points.

Outcomes of computed tomography and magnetic resonance enterography in clinical practice of inflammatory bowel disease.

BACKGROUND: Computed tomography (CT) and magnetic resonance (MR) enterography are now widely used to diagnose and monitor Crohn's disease. AIM: We sought to assess the use of enterography for management of inflammatory bowel disease (IBD) in our medical center. METHODS: We performed a retrospective review of all patients diagnosed with IBD who underwent MR or CT enterography from November 1, 2010 to October 25, 2012 at our institution. We assessed disease complications identified by enterography, agreement between disease activity determined by endoscopy and enterography, association between inflammatory markers and enterography-determined disease activity and recommended changes in medical and surgical management following enterography. RESULTS: A total of 311 enterography studies (291 MR and 20 CT enterographies) were performed on 270 patients, including 258 (83.0 %) on patients with presumed Crohn's disease and 53 (17.0 %) with presumed ulcerative colitis. Active small bowel (SB) disease was noted in 73/311 (23.5 %) studies. Complications including strictures, perianal fistulas, abscesses and SB fistulas were noted in 108/311 (34.7 %) studies. Endoscopic and enterography defined active disease had an agreement of κ = 0.36 in the ileum (n = 179). A total of 142/311 (45.7 %) enterographies were associated with recommended medication changes within 90 days while surgery or endoscopic dilation of stricture was recommended following 41/311 (13.2 %) enterographies. Enterography resulted in a change in diagnosis from ulcerative colitis to Crohn's in 5/311 (1.6 %) studies. CONCLUSION: Enterography reveals active disease and complications not evident on endoscopy and should be considered in the initial diagnosis, assessment of disease activity, and monitoring of therapy in patients with IBD.

Insulin Resistance Increases MRI-Estimated Pancreatic Fat in Nonalcoholic Fatty Liver Disease and Normal Controls.

Background. Ectopic fat deposition in the pancreas and its relationship with hepatic steatosis and insulin resistance have not been compared between patients with nonalcoholic fatty liver disease (NAFLD) and healthy controls. Aim. Using a novel magnetic resonance imaging (MRI) based biomarker, the proton-density-fat-fraction (MRI-PDFF), we compared pancreatic fat content in patients with biopsy-proven NAFLD to healthy controls and determined whether it is associated with insulin resistance and liver fat content. Methods. This nested case-control study was derived from two prospective studies including 43 patients with biopsy-proven NAFLD and 49 healthy controls who underwent biochemical testing and MRI. Results. Compared to healthy controls, patients with NAFLD had significantly higher pancreatic MRI-PDFF (3.6% versus 8.5%, P value <0.001), and these results remained consistent in multivariable-adjusted models including age, sex, body mass index, and diabetes (P value =0.03). We found a strong correlation between hepatic and pancreatic MRI-PDFF (Spearman correlation, P = 0.57, P value <0.001). Participants with increased insulin resistance determined by homeostatic-model-of-insulin-resistance (HOMA-IR) greater than 2.5 had higher pancreatic (7.3% versus 4.5%, P value =0.015) and liver (13.5% versus 4.0%, P value <0.001) MRI-PDFF. Conclusion. Patients with NAFLD have greater pancreatic fat than normal controls. Insulin resistance is associated with liver and pancreatic fat accumulation.