Concurrence of inflammatory bowel disease with multiple sclerosis or Hodgkin lymphoma.

BACKGROUND AND AIMS: Epidemiologic evidence suggests that Hodgkin lymphoma (HL) and multiple sclerosis (MS) share a common set of risk factors with Crohn's disease (CD) and ulcerative colitis (UC). It was hypothesized that such shared risk factors would lead to clustering of the 4 diagnoses in the same patients. METHODS: All patients with HL, MS, CD, or UC were identified in the veterans population from 2016-2020 and the Medicare population from 1986 to 1989. In a case-control study, the observed concurrences amongst these 4 diagnoses were compared with their expected frequencies in the overall veterans or Medicare population during the same time period by calculating odds ratios (OR) with their 95% confidence intervals (CI). RESULTS: The study included 6 million veterans and 35 million Medicare patients. In the veterans population, inflammatory bowel disease (IBD) was significantly associated with a concurrent diagnosis of HL (OR: 1.40, 95% CI: 1.15-1.71) and MS (1.34, 1.19-1.50). In the Medicare population, IBD was also significantly associated with HL (1.84, 1.07-3.17) and MS (2.31, 1.59-3.35). Similar trends were observed in CD or UC when analyzed separately in both datasets. In the veterans population, adjustment for the potentially confounding influence of ethnicity, sex, and age left all OR values largely unaffected and statistically significant. CONCLUSION: The concurrence of IBD with HL or MS could reflect on a common pathway in the etiology or pathogenesis of these 4 diseases.

Cost-utility advantage of interventional endoscopy.

BACKGROUND: Gastroenterologists frequently face the dilemma of how to choose among different management options. AIM: To develop a tool of medical decision analysis that helps choosing between competing management options of interventional endoscopy and surgery. METHODS: Carcinoma-in-situ of the esophagus, large colonic polyps, and ampullary adenoma serve as three examples for disorders being managed by both techniques. A threshold analysis using a decision tree was modeled to compare the costs and utility values associated with managing the three examples. If the expected healing or success rate of interventional endoscopy exceeds a threshold calculated as the ratio of endoscopy costs over surgery costs, endoscopy becomes the preferred management option. A low threshold speaks in favor of endoscopic intervention as initial management strategy. RESULTS: If the decision in favor of surgery is focused exclusively on preventing death from a given disease, surgical intervention may seem to provide the best treatment option. However, interventional endoscopy becomes a viable alternative, if the comparison is based on a broader perspective that includes adverse events and long-term disability, as well as the healthcare costs of both procedures. For carcinoma-in-situ of the esophagus, the threshold for the expected success rate is 24% (range in the sensitivity analysis: 7-29%); for large colonic polyps it is 10% (5-12%), and for duodenal papillary adenoma it is 17% (5-21%). CONCLUSIONS: Even if a management strategy surpasses its alternative with respect to one important outcome parameter, there is often still room for the lesser alternative to be considered as viable option.

Evaluating key characteristics of ideal colorectal cancer screening modalities: the microsimulation approach.

BACKGROUND AND AIMS: Screening for colorectal cancer (CRC) can effectively reduce CRC incidence and mortality. Besides colonoscopy, tests for the detection of biomarkers in stool, blood, or serum, including the fecal immunochemical test (FIT), ColoGuard, Epi proColon, and PolypDx, have recently been advanced. We aimed to identify the characteristics of theoretic, highly efficient screening tests and calculated the effectiveness and cost effectiveness of available screening tests. METHODS: Using the microsimulation-based colon modeling open-source tool (CMOST), we simulated 142,501 theoretic screening tests with variable assumptions for adenoma and carcinoma sensitivity, specificity, test frequency, and adherence, and we identified highly efficient tests outperforming colonoscopy. For available screening tests, we simulated 10 replicates of a virtual population of 2 million individuals, using epidemiologic characteristics and costs assumptions of the United States. RESULTS: Highly efficient theoretic screening tests were characterized by high sensitivity for advanced adenoma and carcinoma and high patient adherence. All simulated available screening tests were effective at 100% adherence to screening and at expected real-world adherence rates. All tests were cost effective below the threshold of 100,000 U.S. dollars per life year gained. With perfect adherence, FIT was the most effective and cost-efficient intervention, whereas Epi proColon was the most effective at expected real-world adherence rates. In our sensitivity analysis, assumptions for patient adherence had the strongest impact on effectiveness of screening. CONCLUSIONS: Our microsimulation study identified characteristics of highly efficient theoretic screening tests and confirmed the effectiveness and cost-effectiveness of colonoscopy and available urine-, blood-, and stool-based tests. Better patient adherence results in superior effectiveness for CRC prevention in the whole population.

Failure of cost-benefit analysis in gastrointestinal endoscopy.

Background and study aims We discuss the occurrence of two cases, where the endoscopic pursuit of diagnostic certainty resulted in adverse events that exceeded the clinical relevance of the endoscopic diagnosis itself. In both instances, physicians were hesitant to subject their patients to a necessary surgical intervention before gastrointestinal endoscopy had provided them with absolute assurance that no other mitigating factors could possibly jeopardize the success of a planned intervention. In trying to avoid a single and potentially bad outcome of a necessary medical intervention, the physicians exposed their patients to many more additional and unnecessary risks. As key players in clinical decision-making, physicians sometimes may find it difficult to disentangle their own risk-benefit considerations from those of their patients.

Short article: Gastrointestinal bleeding in multiorgan failure.

BACKGROUND AND AIMS: Gastrointestinal bleeding (GIB) may present as complication of multiorgan failure (MOF). The study aims to analyze the reasons for the limited success of hemostasis of GIB in MOF. METHODS: Using a Markov process, GIB is modeled as one of several complications associated with multiorgan breakdown to study how the reversal of GIB affects clinical outcome. RESULTS: Although endoscopic hemostasis can delay mortality in patients with severe systemic disease, its overall influence on survival is relatively small. In patients with a time-limited transition through an acute phase of increased mortality risk secondary to MOF, endoscopic hemostasis may substantially prolong survival in absolute terms. However, its relative contribution to overall survival still remains relatively small even in the scenario of transient risk only. The benefit of endoscopy is largest, if GIB is a major contributor to morbidity and mortality in comparison with all other disease complications. CONCLUSION: Because disease outcome in MOF is ultimately determined by other complications than GIB alone, the influence of endoscopic hemostasis on patient survival often remains disappointingly small.

Management of Suspected Choledocholithiasis: A Decision Analysis for Choosing the Optimal Imaging Modality.

BACKGROUND AND AIMS: Magnetic resonance cholangiography (MRC), endoscopic ultrasound (EUS), and endoscopic retrograde cholangio-pancreatography (ERCP) all represent viable options to establish the diagnosis of choledocholithiasis. The aim of the study was to assess how the three imaging modalities perform in head-to-head comparisons and in what order to apply them when using these procedures sequentially. METHODS: A threshold analysis using a decision tree was modeled to compare the costs associated with different imaging techniques of the biliary system in a patient with suspected cholestasis secondary to choledocholithiasis. The main outcome parameter was the pre-test probability of common bile duct (CBD) stones that would guide the physician towards starting the work-up with MRC or EUS versus going straight to ERCP as the primary procedure. RESULTS: For low pre-test probabilities of CBD stones in the common bile duct, MRC represents the procedure of choice. For pre-test probabilities ranging between 40 and 91 %, EUS should be the preferred imaging modality. If CBD stones are suspected with an even higher pre-test probability, patients could go straight to ERCP as their first procedure. Low costs associated with any of the three procedures increase its range of applicability at the expense of the other competing imaging modalities. CONCLUSIONS: MRC, EUS, and ERCP should be used in sequence and dependent on the pre-test probability of choledocholithiasis.

Impact of inflammatory bowel disease on disability.

Inflammatory bowel disease can impact individuals at a young age, thus compromising their work productivity. Besides the inability to engage in gainful work, the concept of disability also relates to the patients' diminished ability to undertake household and social activities. A literature search was performed of recent literature, and all articles containing information about the impact of inflammatory bowel disease on disability or any work-related outcomes were included. Recent studies suggest that 9 to 19% of inflammatory bowel disease patients suffer from short-term absences from work and 19 to 22% are on long-term disability. Crohn's disease patients reported being more affected by their disease than ulcerative colitis patients. A comparison of results from different studies is difficult due to the lack of consensus on how to define and measure disability. Additional research is needed to better quantify disability in inflammatory bowel disease patients.

Management of delayed postpolypectomy bleeding: a decision analysis.

OBJECTIVES: The benefit of repeat colonoscopy in managing delayed postpolypectomy bleeding is unknown. This study aimed to assess the outcome of repeat colonoscopy to achieve hemostasis. METHODS: Endoscopic management of postpolypectomy bleeding is modeled as a decision tree, measuring the expected overall fraction of patients who benefit from therapeutic hemostasis and the number of patients needed to treat (NNT) in order to achieve one beneficial hemostasis. RESULTS: A repeat colonoscopy to identify and treat postpolypectomy bleeding is beneficial in about 22% of patients, corresponding to an NNT of 4.5 patients. The outcome of the model is sensitive to assumptions underlying the fractions of patients who need treatment and would benefit from successful endoscopic hemostasis. Varying these probabilities over a broad range changes the fraction of patients benefiting from endoscopy between 3% and 33% and the NNT between 28 and 3 patients, respectively. CONCLUSIONS: The expected outcome of repeat colonoscopy justifies the endoscopic attempts at therapeutic hemostasis. The results also suggest that in many patients expectant management aimed at spontaneous resolution of the bleeding remains a valid option.

Complications following gastrointestinal bleeding and their impact on outcome and death.

BACKGROUND: Bleeding from the upper gastrointestinal tract is one of the most common life-threatening morbidities encountered by gastroenterologists. A mathematical model has been developed to gain insights into how, after an initial event of upper gastrointestinal bleeding, complications can accumulate in individual patients and expose them to an increased risk of death. METHODS: The occurrence of complications and possible death after gastrointestinal bleeding are simulated using a Markov chain model. RESULTS: The accumulation of complications in an individual patient is influenced by the length of time a patient remains vulnerable to the probability of developing new complications. The model illustrates how the initial bleeding episode sets the stage for the occurrence of subsequent complications and how each subsequent complication increases in an exponential manner the risk for additional complications. Because of such a pattern, complications tend to cluster in a group of patients who run into an ever-increasing risk of multiple complications. Although the majority of patients go through their initial bleeding episode without ever experiencing any secondary complication, in a subset of patients the initial complication sets in motion a vicious cycle with frequently more than one consecutive complication after the initial gastrointestinal bleed. CONCLUSION: The key to the successful management of a patient with gastrointestinal bleeding is to stop such a vicious cycle as early as possible, as each progression within the cycle renders the probability of additional complications more likely and its reversal more difficult.

Survival and cost-effectiveness analysis of competing strategies in the management of small hepatocellular carcinoma.

The aim of the present study is to compare the survival rates and cost-effectiveness of different treatment strategies for small (<2 cm) hepatocellular carcinoma (HCC). Markov chains are developed to model different management strategies for patients with compensated cirrhosis and small HCC. Probabilities of progression and survival and the likelihood of orthotopic liver transplantation are taken from the literature and incorporated into the models. As a starting population, 1000 patients are followed over a period of 10 years. Patients treated immediately with transarterial chemoembolization (TACE) or radiofrequency ablation (RFA) live as long as or longer than patients who are monitored expectantly with the intention of liver transplantation once the HCC has grown larger than 2 cm and a higher transplant priority score becomes available. With TACE, immediate treatment results in an average survival time of 4.269 years versus 4.324 years with the monitoring strategy. With RFA, immediate treatment results in an average survival time of 5.273 years versus 5.236 years with the monitoring strategy. In addition, the cost analysis shows that immediate treatment with either TACE or RFA is less expensive than monitoring. The better cost-effectiveness of immediate therapy versus the monitoring strategy remains robust and unaffected by variations of the assumptions built into the model. In conclusion, in patients with compensated cirrhosis and small HCC, a strategy of immediate treatment with either TACE or RFA prevails over a strategy of expectant monitoring with the intention of transplantation.