Comparative Evaluation of the ABC Score to Other Risk Stratification Scales in Managing High-risk Patients Presenting With Acute Upper Gastrointestinal Bleeding.

OBJECTIVE: The ABC risk score identifies patients at high risk of mortality in acute lower and upper gastrointestinal bleeding (UGIB). We aimed to externally validate the ABC score while comparing it to other prognostication scales when assessing UGIB patients at high risk of negative outcomes before endoscopy. METHODS: UGIB patients from a national Canadian registry (REASON) were studied, with mortality prediction as a primary outcome. Secondary endpoints included prognostication of rebleeding, intensive care unit (ICU) admission, ICU and hospitalization lengths of stay (LOS), and a previously proposed composite outcome measure. Univariable and areas under the receiver operating characteristic curve analyses compared discriminatory abilities of the ABC score to the AIMS65, Glasgow Blatchford Scale (GBS), and clinical Rockall score. RESULTS: The REASON registry included 2020 patients [89.4% nonvariceal; mean age (±SD): 66.3±16.4 y; 38.4% female]. Overall mortality, rebleeding, ICU admission, transfusion and composite score rates were 9.9%, 11.4%, 21.1%, 69.0%, and 67.3%, respectively. ICU and hospitalization LOS were 5.4±9.3 and 9.1±11.5 days, respectively. The ABC score displayed superior 30-day mortality prediction [0.78 (0.73; 0.83)] compared with GBS [0.69 (0.63; 0.75)] or clinical Rockall [0.64 (0.58; 0.70)] but not AIMS65 [0.73 (0.67; 0.79)]. Although most scales significantly prognosticated secondary outcomes in the univariable analysis except for ICU LOS, discriminatory abilities on areas under the receiver operating characteristic curve analyses were poor. CONCLUSIONS: ABC and AIMS65 display similar good prediction of mortality. Clinical usefulness in prognosticating secondary outcomes was modest for all scales, limiting their adoptions when informing early management of high-risk UGIB patients.

[The use of ultrasound in IBD: an essential tool?] / Échographie dans les maladies inflammatoires chroniques de l'intestin†: nouvel outil indispensable†?

Crohn's disease (CD) and ulcerative colitis (UC) are chronic inflammatory bowel diseases (IBD) characterized by an inflammation of the digestive tract wall. Current guidelines recommend a «treat to target¼ management and a "tight control" of the inflammation for an optimal follow-up. Intestinal ultrasound, due to its low cost, its feasibility at bed side, its absence of preparation and its non-invasive character, has proved its place in the diagnosis and the follow-up of IBD. It allows the evaluation of various parameters of the lumen, the intestinal wall, the mesentery, the vascularization as well as complications.

La maladie de Crohn (MC) et la rectocolite hémorragique (RCH) sont des maladies inflammatoires chroniques de l'intestin (MICI) caractérisées par une inflammation de la paroi du tube digestif. Les recommandations de prise en charge suggèrent de viser une cible thérapeutique et de procéder à une évaluation régulière de l'inflammation appelée «â€…contrôle serré ¼ (tight control en anglais). Le but est de proposer une adaptation thérapeutique si la cible n'est pas atteinte (concept du treat-to-target). L'échographie, par son faible coût, sa faisabilité au lit du malade, son absence de préparation colique et son caractère non invasif, a démontré sa place dans le diagnostic et le suivi des MICI. Elle permet d'évaluer divers paramètres de la lumière, de la paroi intestinale, du mésentère, la vascularisation et de rechercher des complications.

Update on the Management of Inflammatory Bowel Disease during Pregnancy and Breastfeeding.

Inflammatory bowel disease (IBD) affects patients during their peak reproductive years. This raises important questions, in both patients and healthcare providers, regarding conception, pregnancy, and breastfeeding. Lack of information and insufficient communication among healthcare providers can leave patients with limited information and even contradictory advice. Given the fact that pregnant and/or breastfeeding IBD patients are excluded from clinical studies the evidence on many questions related to pregnancy and postpartum period is limited. However, there exists increasing data from case series and cohort studies that allows to provide clinical guidance. The overarching concept is that optimizing the mother's health is critical for optimizing the health of the unborn child and benefit of continuing medical therapy in IBD during pregnancy outweighs possible risks in most instances. This paper provides an up-to-date systematic review of the literature on IBD in pregnancy and proposes guidance to questions frequently encountered by healthcare professionals.

[Management of gastrointestinal and hepatic diseases during the COVID-19 outbreak]. / Prise en charge des patients avec maladies digestives et hépatiques durant la pandémie COVID-19.

The current epidemic of SARS-CoV-2 infection poses new challenges in the management of patients with gastrointestinal or liver disease. Consultations with patients with chronic diseases should ideally be done via telemedicine and treatments administered at home if possible. The latter should be maintained in non-infected subjects to limit the risk of decompensation of their underlying disease. In the event of proven infection, immunomodulatory or biological treatments will tend to be reduced or discontinued unless the disease is in a severely active phase. Elective endoscopy should be postponed, and urgent procedures should be performed with appropriate personal protective equipment.

L'épidémie actuelle d'infection par le SARS-CoV-2 pose de nouveaux défis dans la prise en charge des patients avec pathologies gastroentérologique ou hépatologique. Les consultations avec les patients atteints de maladies chroniques devraient se faire idéalement par télémédecine et les traitements administrés à domicile si possible. Ces derniers doivent être maintenus chez les sujets non infectés pour limiter le risque de décompensation de leur maladie de base. En cas d'infection avérée, on aura tendance à diminuer voire interrompre les traitements immunomodulateurs ou biologiques sauf si la maladie est en phase sévèrement active. Les examens endoscopiques électifs doivent être reportés. Les interventions urgentes doivent être effectuées en appliquant des mesures de protection adéquates.

Clinical Parameters Correlate With Endoscopic Activity of Ulcerative Colitis: A Systematic Review.

BACKGROUND & AIMS: Optimal management of patients with ulcerative colitis (UC) requires assessment of disease activity-usually by endoscopy, which is invasive, costly, and not risk free. We performed a systematic review to determine whether clinical symptoms correlate with findings from endoscopy assessments of patients with UC. METHODS: We performed a systematic review of publication databases from January 1980 through July 2018 to identify clinical trials and observational studies reporting correlations among symptoms, disease activity index scores and/or patient reported outcomes (rectal bleeding and/or stool frequency), and endoscopic disease activity. Correlations were ascertained in patients with active vs inactive disease and by disease extent and treatment type. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Because of significant heterogeneity, meta-analysis was not possible. Results were synthesized qualitatively and systematically. RESULTS: Our final analysis included 23 studies (1 randomized trial, 22 observational studies) comprising 3320 patients with UC. The studies used a variety of measures to assess clinical activity, endoscopic activity, and measures of correlation (sensitivity, specificity, correlation coefficients, area under the receiver operator curve). Overall, studies were at moderate-high risk of bias. Composite clinical measures, including rectal bleeding and stool frequency, had moderate to strong correlations with endoscopic disease activity; the absence of rectal bleeding identified patients with inactive disease with higher levels of sensitivity than normalization of stool frequency. In general, symptoms correlated more strongly with endoscopic activity in patients with left-sided colitis than extensive colitis. The effect of different medications on the correlation between clinical and endoscopic activity has not been well studied. CONCLUSIONS: In a systematic review, we found a moderate to strong correlation between clinical activity, particularly the combination of rectal bleeding and stool frequency, and endoscopic activity in patients with UC. Although these clinical assessments could help prioritize patients for endoscopic evaluation in resource-limited settings, challenges associated with treating patients based on symptoms alone preclude adaptation of current management algorithms.

Low endoscopy bleeding risk in patients with congenital bleeding disorders.

INTRODUCTION: Haemophilia A and haemophilia B, von Willebrand disease (VWD), factor VII deficiency and factor XI deficiency are congenital bleeding disorders predisposing to bleeding during invasive procedures. The ageing population of people with congenital bleeding disorders will likely increasingly require gastrointestinal endoscopy. The bleeding risk postgastrointestinal endoscopy and optimal prophylactic treatment regimens are not well described. METHODS: We performed a retrospective chart review at the McGill University Health Centre. Adult patients with haemophilia A or B, VWD, FVII deficiency and FXI deficiency who underwent gastrointestinal endoscopic procedures were included. Bleeding prophylaxis included combinations of plasma-derived factor (VWD) or recombinant factor (haemophilia A and haemophilia B), desmopressin and/or tranexamic acid. Our primary outcome was the 72-hour postendoscopy bleeding rate. RESULTS: One hundred and four endoscopies were performed in 48 patients. Haemophilia A (45.3% of endoscopies) was the most common bleeding disorder, followed by VWD (38.5%), FXI deficiency (8.7%), haemophilia B (4.8%) and FVII deficiency (2.9%). All patients were reviewed by the Haemophilia Treatment Center with peri-procedure treatment protocols put in place as required. The overall 72-hour bleeding rate was 0.96%, confidence interval (CI) 95% (0.17%-5.25%). The colonoscopic postpolypectomy bleeding rate was 1/21 (4.8%, CI 95% (0.9%-22.7%)) in comparison with the general population rate of 0.3%-10% for high-risk endoscopy (including colonoscopic polypectomy). CONCLUSION: To the best of our knowledge, this is the largest study describing patients with inherited bleeding disorders undergoing gastrointestinal endoscopy. The bleeding risk is not significantly higher to the general population when haemostatically managed by a team experienced in bleeding disorders.

High-Dose Infliximab Rescue Therapy for Hospitalized Acute Severe Ulcerative Colitis Does Not Improve Colectomy-Free Survival.

BACKGROUND AND OBJECTIVE: Optimization strategies with infliximab (IFX) are increasingly used as rescue therapy for steroid refractory acute severe ulcerative colitis (ASUC). We aim to determine if intensified IFX induction improves colectomy rate and identifies outcome predictors. METHODS: Hospitalized adult patients who received IFX for ASUC between 2010 and 2016 were identified. We compared standard inductions (5 mg/kg) vs high-dose induction (10 mg/kg) with 3-month colectomy rate as primary outcome. RESULTS: Seventy-two patients (62.5% male, median age 38.5) were identified. Thirty-seven patients (51.3%) received 5 mg/kg IFX and 35 received 10 mg/kg. Baseline clinical, biochemical and endoscopic parameters were well matched between these two groups. 10 mg/kg was more likely to be used by clinicians from 2014 onwards (p < 0.001). Three-month colectomy rate was 9.7%; which was not significantly different between the standard (5.4%) and high-dose (14.3%) IFX induction (p = 0.205). CRP ≥ 60 (OR 10.9 [95% CI 1.23-96.50], p = 0.032), hemoglobin ≤ 90 g/L (OR 15.6 [95% CI 2.61-92.66], p = 0.036) and albumin < 30 g/L (OR 9.4 [95% CI 1.06-83.13], p = 0.044) were associated with increased risk of colectomy at 3 months in univariate regression analysis. CONCLUSION: Use of high-dose infliximab rescue therapy did not improve 3-month colectomy-free survival in this cohort. Tailored use in high-risk patients may be beneficial although further validation is required.

Do adjuvants add to the efficacy and tolerance of bowel preparations? A meta-analysis of randomized trials.

BACKGROUND AND STUDY AIMS : Recommendations on adjuvant use with bowel preparations remain disparate. We performed a meta-analysis determining the clinical impact of adding an adjuvant to polyethylene glycol (PEG), sodium phosphate, picosulfate (PICO), or oral sulfate solutions (OSS)-based regimens. METHODS: Systematic searches were made of MEDLINE, EMBASE, Scopus, CENTRAL and ISI Web of knowledge for randomized trials from January 1980 to April 2016 that assessed preparations with or without adjuvants, given in split and non-split dosing, and PEG high- (> 3 L) or low-dose (≤ 2 L) regimens. Bowel cleansing efficacy was the primary outcome. Secondary outcomes included patient willingness to repeat the procedure, and polyp and adenoma detection rates. RESULTS: Of 3093 citations, 77 trials fulfilled the inclusion criteria. Overall, addition of an adjuvant compared with no adjuvant, irrespective of the type of preparation and mode of administration, yielded improvements in bowel cleanliness (odds ratio [OR] 1.23 [1.01 - 1.51]) without greater willingness to repeat (OR 1.40 [0.91 - 2.15]). Adjuvants combined with high-dose PEG significantly improved colon cleansing (OR 1.96 [1.32 - 2.94]). The odds for achieving adequate preparation with low-dose PEG with an adjuvant were not different to high-dose PEG alone (OR 0.95 [0.73 - 1.22]), but yielded improved tolerance (OR 3.22 [1.85 - 5.55]). However, split high-dose PEG yielded superior cleanliness to low-dose PEG with adjuvants (OR 2.53 [1.25 - 5.13]). No differences were noted for OSS and PICO comparisons, or for any products regarding polyp or adenoma detection rates. CONCLUSIONS: Critical heterogeneity precludes firm conclusion on the impact of adjuvants with existing bowel preparations. Additional research is required to better characterize the methods of administration and resulting roles of adjuvants in an era of split-dosing.

Implementation of a checklist before colonoscopy: a quality improvement initiative.

BACKGROUND AND STUDY AIMS: Checklists can prevent errors and have a positive impact on patient morbidity and mortality in different surgical settings, and possibly also in gastrointestinal endoscopy. The aims of this study were to reinforce commitment in safety culture and better communication among team members in endoscopy, and to prove the feasibility of successful checklist adoption before colonoscopy. PATIENTS AND METHODS: The study involved a pre - post quality improvement intervention involving all consecutive patients undergoing a colonoscopy at a single academic endoscopy unit. The first part of the study was a retrospective audit, carried out over a 3-month period (July to September 2016). A checklist developed through a formal validation process was implemented during the intervention period (October to December 2016). Primary outcomes were changes in patient and team satisfaction after the quality improvement intervention, using validated 5-point scale questionnaires. Secondary outcomes included successful procedure completion rates and safety outcomes. RESULTS: During the baseline and comparative intervention period, 1317 and 1141 colonoscopies, respectively, were performed. Overall, checklists were fully completed by nurses and physicians for 791 patients (69.3 %). Mean overall patient satisfaction was high at baseline and did not differ following the quality improvement intervention (4.66 vs. 4.63; P  = 0.5). Perception of team communication and teamwork was improved after checklist implementation. Comparative analyses of per-procedure and safety outcomes did not differ between the pre- and post-checklist implementation. CONCLUSION: Adoption of an endoscopy checklist before colonoscopy is feasible, and significantly increases perception of team communication and teamwork. Additional studies are needed to assess the generalizability of these results to complex endoscopic procedures and to characterize any improvement in patient safety outcomes.

[How to deal with drug-induced diarrhoea]. / Diarrhée médicamenteuse : comment s'orienter ?

Diarrhoea is a frequent drug adverse event, implicating a number of different treatments. It occurs in an acute setting or even several months after the beginning of the treatment and different pathophysiological mechanisms are involved. It must be proactively suspected and promptly treated, however this diagnosis is often mentioned only after multiple diagnostic tests. In this review we aim to offer a practical approach to promptly identify drug-induced diarrhoea, recognise most common implicated drugs and establish the best clinical management.

La diarrhée est un effet secondaire fréquent de nombreux médicaments à travers des mécanismes physiopathologiques divers. Elle peut survenir dans un délai d'apparition variable et devrait être suspectée et prise en charge rapidement. Ce diagnostic est cependant souvent évoqué tardivement après de multiples investigations. Dans cet article, nous revoyons les différentes classes de médicaments incriminés, les examens complémentaires à réaliser en cas de suspicion de diarrhée médicamenteuse, et nous proposons une approche pratique de prise en charge.

Hepatic manifestations of inflammatory bowel diseases.

Inflammatory bowel diseases are associated with various hepatobiliary disorders, reported both in Crohn's disease and ulcerative colitis. They may occur at any moment in the natural course of the disease. The prevalence of liver dysfunction rises from 3% to 50% accordingly to definitions used in different studies. Fatty liver is considered as the most common hepatobiliary complication in inflammatory bowel diseases while primary sclerosing cholangitis is the most specific one. Less frequently, inflammatory bowel diseases-associated hepatobiliary disorders include: autoimmune hepatitis/ primary sclerosing cholangitis overlap syndrome, IgG4-associated cholangiopathy, primary biliary cholangitis, hepatic amyloidosis, granulomatous hepatitis, cholelithiasis, portal vein thrombosis and liver abscess. The spectrum of these manifestations varies according to the type of inflammatory bowel diseases. Treatments of inflammatory bowel diseases may cause liver toxicity, although incidence of serious complications remains low. However, early diagnosis of drug-induced liver injury is of major importance as it affects future clinical management. When facing abnormal liver tests, clinicians should undertake a full diagnostic work-up in order to determine whether the hepatic abnormalities are related to the inflammatory bowel diseases or not. Management of hepatic manifestations in inflammatory bowel diseases usually involves both hepatologists and gastroenterologists because of the complexity of some situations.

Split-Dose Preparations Are Superior to Day-Before Bowel Cleansing Regimens: A Meta-analysis.

BACKGROUND & AIMS: There are different regimens of preparing the colon for colonoscopy, including polyethylene glycol (PEG), sodium phosphate, picosulfate, or oral sulfate solutions. We performed a meta-analysis to determine the efficacy of split-dose vs other colon preparation regimens, the optimal products for use, and the most effective preparation volumes. METHODS: We performed systematic searches of MEDLINE, EMBASE, Scopus, CENTRAL, and ISI Web of knowledge databases, from January 1980 to March 2014, for published results from randomized trials that assessed split-dose regimens vs day-before colonoscopy preparation. We excluded studies that included pediatric or hospitalized patients, or patients with inflammatory bowel disease. The primary outcome was efficacy of bowel cleansing. Secondary outcomes included side effects or complications, outcomes of procedures, patients' willingness to repeat the procedure, and the amount of time required for patients to resume daily activities. RESULTS: We identified 47 trials that fulfilled our inclusion criteria (n = 13,487 patients). Split-dose preparations provided significantly better colon cleansing than day-before preparations (odds ratio [OR], 2.51; 95% confidence interval, 1.86-3.39), as well as day-before preparations with PEG (OR, 2.60; 95% confidence interval, 1.46-4.63), sodium phosphate (OR, 9.34; 95% confidence interval, 2.12-41.11), or picosulfate (OR, 3.54; 95% confidence interval, 1.95-6.45). PEG split-dose preparations of 3 L or more yielded greater bowel cleanliness than lower-volume split-dose regimens (OR, 1.89; 95% confidence interval, 1.01-3.46), but only in intention-to-treat analysis. A higher proportion of patients were willing to repeat split-dose vs day-before cleansing (OR, 1.90; 95% confidence interval, 1.05-3.46), and low-volume split-dose preparations vs high-volume split-dose preparation (OR, 4.95; 95% confidence interval, 2.21-11.10). There were no differences between preparations in other secondary outcome measures. However, there was variation among studies in definitions and main and secondary outcomes. CONCLUSIONS: Based on meta-analysis, split-dose regimens increase the quality of colon cleansing and are preferred by patients compared with day-before preparations. Additional research is required to evaluate oral sulfate solution-based and PEG low-volume regimens further.

Effect of hydrosoluble vitamin E on erythrocyte membrane lipid composition in patients with advanced cirrhosis: An open-label pilot trial.

AIM: Deficiency in vitamin E, a natural antioxidant, participates in abnormal erythrocyte membrane lipids, structural alterations and hemolysis in advanced cirrhosis. Poor absorption of fat-soluble vitamins limits full correction of deficiency with standard formulations in cirrhosis with cholestasis. The aim of the present study was to examine safety and effects of tocofersolan, a water-soluble derivative of vitamin E, on erythrocyte membrane lipids and anemia in patients with biopsy-proven advanced cirrhosis, vitamin E deficiency and hemolysis. METHODS: Twenty patients (age, 53 ± 10 years; Child class B/C, 8/12), with low plasma vitamin E, chronic anemia and hemolysis, received oral tocofersolan 700 mg/day for 4 weeks. Erythrocyte membrane lipid composition (cholesterol [Chol], phospholipids [Phosph]) was determined by enzymatic assays. Total and conjugated bilirubin, hemoglobin and vitamin E were measured. RESULTS: Abdominal pain occurred in one patient. Five patients received blood transfusions due to severe anemia. After 4 weeks, both Chol and Phosph decreased, but changes were not significant. Both plasma vitamin E (P < 0.05) and hemoglobin (P < 0.05) increased, together with a decrease in total (P < 0.05) and conjugated (P < 0.05) bilirubin. CONCLUSION: In patients with advanced cirrhosis, low vitamin E plasma levels and chronic anemia with hemolysis, oral tocofersolan was overall well tolerated, but did not affect erythrocyte membrane lipid composition.

[Management of refractory ascites by the automated low flow pump system (Alfapump)]. / Prise en charge de l'ascite réfractaire par la pompe péritonéovésicale (Alfapump).

Refractory ascites affects 10% of patients with advanced cirrhosis. Recurrent ascites is commonly managed by repeat large volume paracentesis with volume expansion, and in selected patients, by the implantation of a transjugular intrahepatic portosystemic shunt (TIPS). Both approaches are associated with potential complications, including vascular traumatic injuries in the setting of paracentesis. A new automatic pump has been developed to mechanically remove ascites from the peritoneal cavity to the bladder. The benefit of this pump in terms of reduced frequency of paracentesis should be balanced by the risk of adverse events that include infection, catheter dysfunction, and renal insufficiency. The place of this new device in the management of ascites due either to portal hypertension or to cancer remains to be determined.

Bone health in patients with inflammatory bowel disease.

Patients with inflammatory bowel disease (IBD) are prone to reduced bone mineral density and elevated overall fracture risk. Osteopenia affects up to 40% of patients with IBD (high regional variability). Besides disease activity, IBD specialists must consider possible side effects of medication and the presence of associated diseases and extraintestinal manifestations. Osteopenia and osteoporosis remain frequent problems in patients with IBD and are often underestimated because of widely differing screening and treatment practices. Malnutrition, chronic intestinal inflammation and corticosteroid intake are the major pathophysiological factors contributing to osteoporosis. Patients with IBD are screened for osteoporosis using dual-energy X-ray absorptiometry (DXA), which is recommended for all patients with a prolonged disease course of more than three months, with repeated corticosteroid administration, aged >40 years with a high FRAX risk score or aged <40 years with multiple risk factors. From a therapeutic perspective, besides good disease control, vitamin D supplementation and glucocorticoid sparing, several specific osteological options are available: bisphosphonates, receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitors (denosumab), parathyroid hormone (PTH) analogues and selective estrogen receptor modulators. This review provides an overview of the pathophysiology, diagnosis, prevention and treatment of IBD-associated bone loss.

[Impact of red blood cells transfusion on upper gastrointestinal bleeding]. / Impact de la transfusion sanguine dans la prise en charge de l'hémorragie digestive haute.

Upper gastrointestinal bleeding is a major digestive emergency. The compensation of hypovolemia represents the cornerstone of the initial treatment, according to international recommendations. In contrast, use of red blood cells transfusion and target hemoglobin vary considerably across different centers. The real impact of blood transfusions on the rate of rebleeding and mortality is still unknown. However, several studies suggest that transfusion may have a deleterious effect in patients with hemodynamically stable condition during upper gastrointestinal bleeding, promoting recurrent bleeding.

Comparative Efficacy of Biologic Therapies for Inducing Response and Remission in Fistulizing Crohn's Disease: Systematic Review and Network Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: The medical treatment of fistulizing Crohn's disease (CD) remains a challenge to clinicians. Over the last 20 years, biologic therapies have been the mainstay of medical treatment of fistulizing CD. The purpose of this study is to compare the efficacy of biologic therapies in inducing response and remission in fistulizing CD. METHODS: We performed a systematic review of the EMBASE, MEDLINE, and Cochrane Central databases from inception to December 2021. Inclusion criteria were any randomized controlled trials (RCTs) that evaluated the efficacy of biologic therapies against an active comparator or placebo for induction of response or remission in adults with fistulizing CD. The proportion of patients with fistula response or remission, as defined by each clinical trial, was our primary study outcome. A Bayesian random-effects network meta-analysis was used to measure treatment effects and results were reported as odds ratio (OR) and 95% confidence interval (CI). RESULTS: In our analysis, 10 studies were included, and all were RCTs. Infliximab was superior to adalimumab in inducing response (OR, 0.24; 95% CI, 0.06-0.99) but not in inducing remission (OR, 0.31; 95% CI, 0.04-2.27). Tumor necrosis factor antagonists were superior to placebo in the induction of response (OR, 0.51; 95% CI, 0.35-0.750) and remission (OR, 0.36; 95% CI, 0.22-0.58). Infliximab was superior to placebo in inducing response (OR, 0.36; 95% CI, 0.17-0.75) and remission (OR, 0.17; 95% CI, 0.03-0.87). Ustekinumab was superior to placebo in inducing response (OR, 0.48; 95% CI, 0.26-0.860) but not in inducing remission (OR, 0.50; 95% CI, 0.13-1.93). When comparing biologic therapies against each other, there was no statistical difference in inducing remission. Vedolizumab was not superior to placebo in inducing remission (OR, 0.32; 95% CI, 0.04-2.29). Certolizumab was not superior to placebo in inducing response (OR, 0.78; 95% CI, 0.40-1.55) or remission (OR, 0.78; 95% CI, 0.40-1.55). CONCLUSIONS: Tumor necrosis factor antagonists are effective in inducing response and remission in fistulizing CD. Infliximab was superior to adalimumab for inducing response but not for inducing remission. Ustekinumab is effective in the induction of response but not in the induction of remission. When compared against each other, biologic therapies showed no significant difference in the induction of remission. Based on the available data, infliximab is the preferred first-line treatment. As for other biologics, the limited published data do not allow us to make firm recommendations. This study supports current practice and emphasizes the need for dedicated RCTs to evaluate the efficacy of biologic therapies in fistulizing CD.

Despite the era of biologic therapies, the management of fistulizing Crohn's disease remains challenging. This is the first systematic review and network meta-analysis to compare the efficacy of biologic therapies in inducing response and remission in patients with fistulizing Crohn's disease. We found that anti-tumor necrosis factor agents are effective in inducing response and remission. Infliximab was superior to adalimumab for inducing response but not for inducing remission.

Nonalcoholic Fatty Liver Disease Increases Cardiovascular Risk in Inflammatory Bowel Diseases.

Background: Nonalcoholic fatty liver disease (NAFLD) is strongly associated with cardiovascular disease in the general population. Both conditions seem more frequent in patients with inflammatory bowel disease (IBD). We aimed to assess the effect of NAFLD and liver fibrosis on intermediate-high cardiovascular risk in IBD. Methods: We prospectively included IBD patients undergoing a routine screening program for NAFLD by transient elastography (TE) with associated controlled attenuation parameter (CAP). NAFLD and significant liver fibrosis were defined as CAP ≥275 dB m-1 and liver stiffness measurement by TE ≥8 kPa, respectively. Cardiovascular risk was assessed with the atherosclerotic cardiovascular disease (ASCVD) risk estimator and categorized as low if <5%, borderline if 5%-7.4%, intermediate if 7.5%-19.9%, and high if ≥20% or if previous cardiovascular event. Predictors of intermediate-high cardiovascular risk were investigated by multivariable logistic regression analysis. Results: Of 405 patients with IBD included, 278 (68.6%), 23 (5.7%), 47 (11.6%), and 57 (14.1%) were categorized as at low, borderline, intermediate, and high ASCVD risk, respectively. NAFLD and significant liver fibrosis were found in 129 (31.9%) and 35 (8.6%) patients, respectively. After adjusting for disease activity, significant liver fibrosis and body mass index, predictors of intermediate-high ASCVD risk were NAFLD (adjusted odds ratio [aOR] 2.97, 95% CI, 1.56-5.68), IBD duration (aOR 1.55 per 10 years, 95% CI, 1.22-1.97), and ulcerative colitis (aOR 2.32, 95% CI, 1.35-3.98). Conclusions: Assessment of cardiovascular risk should be targeted in IBD patients with NAFLD, particularly if they have longer IBD duration and ulcerative colitis.

Discontinuation of immunosuppression in patients with immune-mediated drug-induced liver injury or idiopathic autoimmune hepatitis: A case-control study.

Background and Aim: Drug-induced liver injury (DILI) may present with autoimmune features and require immunosuppressive therapy (IST) to reach biochemical response. Discontinuation of IST without hepatitis relapse may be more frequent in these patients as compared to patients with classical autoimmune hepatitis (AIH). We aimed to determine baseline characteristics and outcome of patients with immune-mediated drug induced liver injury (IMDILI) with particular emphasis on IST during follow-up. Methods: We performed a single-center retrospective study of consecutive patients presenting at a tertiary care center between January 2005 and December 2019 either with IMDILI or with classical AIH, for whom full baseline characteristics and a close follow-up were available over a 12-month period. Results: Overall, 31 patients (IMDILI n = 16, mean age 59 [34-74] years; AIH n = 15, mean age 47 [15-61] years) were included, showing similar biochemical, serological, and histological characteristics. Incriminating drugs in IMDILI patients were mostly represented by nonsteroidal antiinflammatory drugs and sartans. Initial corticosteroids combined with IST led to biochemical response in all patients. Compared to idiopathic AIH, more patients with IMDILI were weaned off corticosteroids at the end of follow-up (11/16 [68.7%] vs 4/15 [26.6%], P < 0.02). At 1 year of follow-up, more patients in the IMDILI group compared to the classical AIH group were off any type of IST (13/16 [81%] vs 15/15 [100%], P = 0.08). Conclusions: Although presenting with similar baseline biochemical and histological characteristics as idiopathic AIH, patients with IMDILI may not require long-term IST.