Development of a specialist ileoanal pouch surgery pathway: a multidisciplinary patient-centred approach.

Background: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the gold standard procedure for ulcerative colitis refractory to medical treatment, as an alternative to permanent end ileostomy. Gaining experience in pouch surgery is difficult as the procedure is performed infrequently. This study presents an institutional initiative to promote standardisation of multidisciplinary care in IPAA surgery. Methods: A dedicated pathway for patients who had an IPAA or are considering IPAA surgery was developed among colorectal surgeons, gastroenterologists, paediatric colorectal surgeons, inflammatory bowel disease (IBD) nurses, dietitians, stoma nurses, trainees in colorectal surgery. Pathway items were discussed and finalised via emails and videoconferences.The pathway included triaging of patients referred for IPAA surgery, preoperative IBD multidisciplinary team discussion and management plan for surgery, surgical review prior to surgery, peer to peer counselling, surgical technique, postoperative short-term and long-term follow-up, audit, research and training in IPAA surgery. Results: A multidisciplinary preoperative pathway was developed and a stepwise approach to minimally invasive ileoanal pouch surgery was formalised. A dedicated one-stop ileoanal pouch clinic was established integrating endoscopy and imaging on the same day of the consultation with the surgical and gastroenterology team. The clinic reviewed 72 patients over 24 months, and during the same time 36 patients underwent IPAA surgery at our institution. Conclusions: We have described our initial experience in establishing a specialist IPAA surgery pathway and have proposed outcome measures that we hope will support a subspecialty IPAA service.

Comparative effectiveness of a second-line biologic in patients with ulcerative colitis: vedolizumab followed by an anti-TNF versus anti-TNF followed by vedolizumab.

Background: Sequential drug treatment with biological agents in ulcerative colitis (UC) is becoming increasingly complex. There are few studies comparing head-to-head outcomes in second-line treatments. The study assesses whether using anti-tumour necrosis factor (anti-TNF)-α therapy following the α4ß7 integrin blocker vedolizumab (VDZ) or VDZ after an anti-TNF has more favourable clinical outcomes in UC in a real-world outpatient setting. Methods: Patients with UC who were exposed to first-line anti-TNF (adalimumab or infliximab) or VDZ who subsequently switched to the alternate class between May 2013 and August 2020 were identified by reviewing patient databases at 10 hospitals. Data were collected retrospectively using patient records. Baseline demographics, disease activity indices, biochemical markers, endoscopic Mayo score, colectomy rates, treatment persistence and urgent hospital utilisation composite endpoint (UHUC) rates were examined over a 52-week period. Results: Second-line week 52 treatment persistence was higher in the VDZ group (71/81, 89%) versus the anti-TNF group (15/34, 44%; p=0.0001), as were week 52 colectomy-free survival (VDZ: 77/80, 96%, vs anti-TNF: 26/32, 81%; p=0.009), week 52 UHUC survival (VDZ: 68/84, 81%, vs anti-TNF: 20/34, 59%; p=0.002) and week 52 corticosteroid-free clinical remission (CFCR) rates (VDZ: 22/34, 65%, vs anti-TNF: 4/20, 20%; p=0.001). Conclusion: Compared with second-line anti TNF usage, the VDZ second-line cohort had significantly higher 52-week treatment persistence, UHUC survival, higher colectomy-free survival rates and higher week 52 CFCR. These data suggest that VDZ is an effective biologic in UC as a second-line therapy after anti-TNF exposure. It highlights the effect of biological order on clinically important outcomes.

Novel substrates.

Enteral and parenteral feeds need at least to contain adequate amounts of water, energy, protein, electrolytes, vitamins and trace elements. Ready-manufactured parenteral feeds for example are incomplete because of shelf-life constraints and require the addition of vitamins (especially) and trace elements. Acute vitamin deficiencies, notably thiamine deficiency, can be precipitated if this is not adhered to. An increasing interest, however, exists in the use of feeds containing substrates, which are intended to improve patient outcome in particular clinical circumstances. The purpose of this article is to examine as to what is available and make recommendations on their use. It deals with artificial feeds only - disease-specific diets are outside our remit.

Oral tacrolimus as maintenance therapy for refractory ulcerative colitis--an analysis of outcomes in two London tertiary centres.

BACKGROUND: The medical management of refractory ulcerative colitis (UC) remains a significant challenge. Two randomised controlled studies have demonstrated tacrolimus therapy is effective for the induction of remission of moderate to severe UC. However, the long term outcomes of UC patients treated with tacrolimus as maintenance therapy are not certain. AIMS: This study aims to assess the efficacy of tacrolimus maintenance therapy for refractory UC. METHODS: A retrospective review of patients with UC treated with tacrolimus at two London tertiary centres was performed. Clinical outcomes were assessed at six months, at the end of tacrolimus treatment, or at the last follow-up for patients continuing tacrolimus treatment. Modified Truelove-Witts score (mTW) and Mayo endoscopy subscores were calculated. RESULTS: 25 patients with UC, treated with oral tacrolimus between 2005 and 2011, were identified. The median duration of tacrolimus treatment was 9 months (IQR 3.7-18.2 months). The median duration of follow-up was 27 months (range 3-66 months). At six months thirteen (52%) patients had achieved and maintained clinical response and eleven (44%) were in clinical remission. The mean mTW score decreased from 10+/-0.5 before therapy, to 5.8+/-0.8 (p≤0.001 95% CI 2.7-5.8) at cessation of treatment or last follow-up. Mayo endoscopy subscore decreased from 2.6+/-0.1 to 1.2+/-0.2 (p≤0.001 mean reduction 1.4, 95% CI 0.8-1.9). Eight patients (32%) subsequently underwent a colectomy within a mean time of 17 months (range 2-45 months). CONCLUSION: Tacrolimus is effective for the maintenance of refractory UC and can deliver sustained improvement in mucosal inflammation.

Prevalence and management of anemia in children, adolescents, and adults with inflammatory bowel disease.

BACKGROUND: Children and adolescents with inflammatory bowel disease (IBD) are more likely to have Crohn's disease (CD) than ulcerative colitis (UC) and their disease tends to be more extensive and severe than in adults. We hypothesized that the prevalence of anemia would therefore be greater in children and adolescents than in adults attending IBD outpatient clinics. METHODS: Using the WHO age-adjusted definitions of anemia we assessed the prevalence, severity, type, and response to treatment of anemia in patients attending pediatric, adolescent, and adult IBD clinics at our hospital. RESULTS: The prevalence of anemia was 70% (41/59) in children, 42% (24/54) in adolescents, and 40% (49/124) in adults (P < 0.01). Overall, children (88% [36/41]) and adolescents (83% [20/24]) were more often iron-deficient than adults (55% [27/49]) (P < 0.01). Multivariate logistic regression showed that both active disease (odds ratio [OR], 4.7 95% confidence interval [CI], 2.5, 8.8) and attending the pediatric clinic (OR 3.7; 95% CI, 1.6, 8.4) but not the adolescent clinic predicted iron deficiency anemia. Fewer iron-deficient children (13% [5/36]) than adolescents (30% [6/20]) or adults (48% [13/27]) had been given oral iron (P < 0.05); none had received intravenous iron compared with 30% (6/20) adolescents and 41% (11/27) adults (P < 0.0001). CONCLUSIONS: Anemia is even more common in children than in older IBD patients. Oral iron was given to half of adolescents and adults but, despite similar tolerance and efficacy, only a quarter of children with iron-deficient anemia. Reasons for the apparent underutilization of iron therapy include a perceived lack of benefit and concerns about side effects, including worsening of IBD activity.

Tobacco dependence and awareness of health risks of smoking in patients with inflammatory bowel disease.

BACKGROUND AND AIM: Smoking is a risk factor for developing Crohn's disease (CD) and worsens its outcome. Conversely, in ulcerative colitis (UC), the onset may be triggered by the smoking cessation and smoking may be beneficial. To help to ascertain whether patients with inflammatory bowel disease (IBD) would benefit from attending a smoking cessation clinic, we assessed: first, the prevalence of smoking; second, patients' awareness of the effects of smoking, and finally nicotine dependence in IBD patients compared with the healthy and disease-matched controls. METHODS: A total of 246 consecutive IBD outpatients (173 patients with CD, 73 patients with UC) completed a questionnaire on smoking habits and its effect on IBD. Smokers were assessed for dependence using the Fagerstrom test for nicotine dependence (FTND) score and their results were compared with those of age, sex, and ethnicity-matched healthy (five controls for each IBD patient) and asthma controls (one control for each IBD patient) attending a smoking cessation clinic. RESULTS: Thirty five out of 173 patients (20%) with CD and nine out of 73 patients (12%) with UC were current smokers, with 52 out of 173 patients (30%) with CD and 28 out of 73 patients (38%) with UC being ex-smokers. Ninety out of 173 patients (52%) with CD knew that smoking worsens CD, whereas only 15 out of 73 patients (21%) with UC knew of the beneficial effects of smoking on their disease (P=0.032). Knowledge was unrelated to smoking status. In patients with CD, the median (range) FTND score was 3 (0-8) compared with 7 (2-10) in healthy (P<0.001) and 6 (2-9) in asthma controls (P<0.0001). Only seven of the 35 (20%) smoking patients with CD were highly dependent (FTND score ≥6). Similarly, in the patients with UC, the FTND score was 1 (0-4), lower than in healthy, [6 (2-10)], and asthma controls, [7 (4-10); (P<0.004 for both groups)]. CONCLUSION: Patients with CD were better informed about the effects of smoking on their own disease than the patients with UC. Nicotine dependence in IBD patients is lower than in smokers' clinic clients and comparable with that of the general population. Their low nicotine dependence suggests that most IBD patients could be weaned off the smoking habit successfully in the IBD clinic and referral to a smoking cessation clinic was offered to the highly dependent minority and others expressing interest in attending.

Efficacy and tolerability of intravenous iron dextran and oral iron in inflammatory bowel disease: a case-matched study in clinical practice.

OBJECTIVES: Iron deficiency anaemia is common in inflammatory bowel disease (IBD); however, the optimum route of administration of iron replacement therapy is unclear. As inflammation may limit the absorption and efficacy of oral iron, we hypothesized that in routine clinical practice IV iron would be more effective than oral iron in patients with IBD matched for disease type, extent and activity. METHODS: Thirty-three IBD patients who had received IV iron dextran (Cosmofer) in 2008-2010 were identified and matched for age, sex, diagnosis and baseline disease activity, extent and behaviour to IBD patients given oral iron. RESULTS: Patients given IV iron dextran were more anaemic at baseline than those receiving oral iron. Although haemoglobin (Hb) concentrations were normalized in about a third of patients, and increased significantly in both groups, the mean increase in Hb after 8 weeks was greater in the iron dextran group [2.0 g/dl (0.3) vs. 0.6 g/dl (0.1), P<0.0001]. Response to oral or IV iron was unrelated to age, sex, ethnicity, disease duration, extent or activity. Fifteen percent (five out of 33) patients discontinued oral iron because of gastrointestinal side-effects and a further two out of 35 had anaphylactoid reactions to the IV iron dextran test doses. Neither of the iron formulations worsened disease activity. CONCLUSION: In routine clinical practice, in anaemic patients with IBD of similar type, extent and activity, IV Cosmofer is more efficacious in increasing Hb concentration than oral iron. Active disease does not impair the response to either IV or oral iron in patients with IBD, and neither product itself worsens disease activity.

Does psychological counseling alter the natural history of inflammatory bowel disease?

BACKGROUND: There is increasing evidence that psychological stress can increase mucosal inflammation and worsen the course of inflammatory bowel disease (IBD). We have now assessed whether psychotherapy by a counselor specially trained in the management of IBD can influence the course of disease. METHODS: Using retrospective case note review, we compared the course of IBD in 24 patients (13 ulcerative colitis; 11 Crohn's disease), during the year before (year 1) and the year after referral (year 2) for supportive outpatient psychotherapy to an IBD counselor, to that of 24 IBD controls who were matched to individual cases for age, sex, disease, duration of disease, medication at baseline, and for relapse rate in year 1. Counselor assessments were made using a visual analog scale 0-6 (0 denotes poor, 6 excellent response to counseling). The results are shown as median (range). RESULTS: Patients were referred for counseling because of disease-related stress (14 patients), work problems (3), concerns about surgery (5), and bereavement (2); they received 6 (1-13) 1-hour sessions in year 2. In the year after starting counseling (year 2), patients had fewer relapses (0 [0-2]) and outpatient attendances (3.5 [1-10]) than in the year before referral (year 1) (2 [0-5], P = 0.0008; and 6.5 [1-17], P = 0.0006, respectively; furthermore, steroid usage (1 course [0-4] before, 0 [0-2] after, P = 0.005) and relapse-related use of other IBD medications declined during psychotherapy (1 drug [0-5] before, 0 [0-2] after, P = 0.002). There were no differences in any of these measures between years 1 and 2 in the control group. Numbers of hospital admissions did not change between year 1 and 2 in either group. In the 20 patients who attended >1 session counseling helped solve stress-related difficulties (counselor's score 4 [3-5]), the counselor scored them 4 (3-6) overall in psychological well-being after the counseling sessions. CONCLUSIONS: IBD-focused counseling may improve not only psychological well-being, but also the course of IBD in individuals with psychosocial stress.

Management of stress in inflammatory bowel disease: a therapeutic option?

There is increasing evidence that psychological stress and associated mood disorders are linked with, and can adversely affect the course of, inflammatory bowel disease (IBD). Unfortunately, owing to methodological difficulties inherent in undertaking appropriately targeted and blinded trials, there are limited high-quality data regarding the effects on IBD of interventions aimed to ameliorate stress and mood disorders. Nevertheless, patients want psychological intervention as well as conventional medical strategies. Emerging trial evidence supports the suggestion that psychologically orientated therapy may ameliorate IBD-associated mood disorders, but there are no strong data as of yet to indicate that stress management has a beneficial effect on the activity or course of IBD. As yet, which, when and how interventions targeted at psychological stress and mood disturbances should be offered to individual patients with IBD is not clear.