P053 Interstitial Nephritis from IBD: Complicated Conclusions.

CASE: BACKGROUND: Kidney injury in IBD is challenging. Tubulointerstitial nephritis (TIN) is linked to aminosalicylates, but also described in drug-naïve patients, suggesting that TIN may be a direct manifestation of IBD. We describe three cases of TIN in IBD to illustrate the challenges in determining the etiology of the injury. CASES: Case #1: 58-year-old male with a horseshoe kidney deformity, uncontrolled hypertension, GERD and small bowel stricturing Crohn's disease (CD), previously on mercaptopurine and allopurinol, subsequently transitioned to adalimumab, maintaining clinical and radiologic remission. Two years later, he developed acute kidney injury in setting of high fevers and sweats, with negative infectious evaluation. Medications included adalimumab, PPI, valacyclovir and torsemide. Renal biopsy revealed TIN with dense, zonal and focal granulomatous features suggestive of drug-induced hypersensitivity, chronic infection, sarcoidosis or an extra-intestinal manifestation of CD. Case #2: 45-year-old female with SLE, nephrolithiasis, GERD, hypertension and ulcerative colitis (UC), initially on mesalamine, then vedolizumab, with clinical and endoscopic remission. Her SCr increased at the time of her UC diagnosis, and worsened over 6 months while on mesalamine, vedolizumab, PPI and losartan. Renal biopsy demonstrated acute and chronic TIN with eosinophils raising concern for an allergic/drug-induced injury. Nephrology concluded that her TIN was secondary to either UC or one of her medications. Case #3: 33-year-old male with UC transitioned to vedolizumab, having failed budesonide and mesalamine. He had latent TB and received 9 months of isoniazid. While on mesalamine, vedolizumab and PPI, he developed fever, chills and night sweats, with an acute rise in SCr, prompting discontinuation of meds. Three months later, still in remission and with improved SCr, he restarted vedolizumab. A year later he developed low-grade fever with elevated SCr, prompting discontinuation. Renal biopsy revealed acute and chronic TIN with severe interstitial fibrosis, tubular atrophy and focal global glomerulosclerosis. He started prednisone and remained off other IBD therapy for 6 months, but repeat colonoscopy revealed mild colitis. He restarted mesalamine, but again developed elevated SCr 2 months later. Repeat renal biopsy revealed TIN with less interstitial fibrosis and focal global glomerulosclerosis, and nephrology suggested his interstitial nephritis was likely secondary to UC over his medications. He started azathioprine with significant improvement in SCr and clinical remission of UC. DISCUSSION: In all three cases, neither nephrology consultation nor renal biopsy helped distinguish the etiology of renal injury, defaulting to either the IBD meds or an extra-intestinal manifestation of IBD, and not accounting for the acute inflammatory symptoms in two of the cases. While literature review reveals several cases that allege kidney injury as an extra-intestinal target of IBD serious doubts remain. TIN secondary to aminosalicylates is well-documented, but there are few reports of adalimumab-induced granulomatous TIN and only one report of vedolizumab-induced TIN. Each of our patients had well-controlled IBD and multiple confounding variables that could impact kidney function or cause TIN, including hypertension and multiple potential culprit medications, illustrating the dilemma of determining the etiology of renal injury in IBD patients.

P041 Successful Reduction in Opioid Prescription for IBD Flare in the Emergency Department: A Retrospective Study and Quality Improvement Initiative.

BACKGROUND: Opioid use is associated with increased mortality, emergency department (ED) utilization, 30-day readmission rates and decreased quality-of-life in patients with inflammatory bowel disease (IBD). Opioid use in the ED for acute IBD presentations has not been well characterized in the literature. Safe, evidence-based, and effective pain management guidance for IBD flares is needed to promote opioid stewardship in the ED. METHODS: We performed a retrospective cohort study of adult patients who presented to an academic tertiary center ED with IBD flares from June 2019 through December 2019. Demographic and disease specific information and ED course, including analgesic use and numeric rating pain scores at ED presentation and discharge, were collected from the medical record. We designed and implemented a multimodal quality improvement intervention consisting of an evidenced-based IBD pain guideline, customized electronic health record order-set, Gastroenterology (GI) consult note smart-phrase and clinician education to promote opioid stewardship. The impact of our intervention was measured with a repeat retrospective analysis from December 2020 through April 2021. Run charts were generated to correlate the timing of interventions to changes in opioid exposure and prescription. RESULTS: Seventy-one patients were included in the pre-intervention cohort. A total of 78% of patients who presented to the ED with IBD flare were prescribed opioid(s) with an average of 29.3 morphine milligram equivalence (MME) per ED stay. Approximately half (49%) of patients did not receive any non-opioid analgesic and 13% patients received an opioid prescription at ED or hospital discharge. In the post-intervention cohort consisting of 49 patients, there was a significant reduction in the proportion of patients receiving opioids (45% vs. 78%; p < 0.001) and a significant reduction in the average total opioid administration (10.8 vs. 22.6 MME; p < 0.001). For each month during the post-intervention period, the proportion of patients who received an opioid in the ED and the average total opioid administered remained less than the median of the entire study period, which represents a nonrandom pattern. The use of a non-opioid analgesic, IV acetaminophen, was significantly increased (27% vs 3%; p < 0.001) and the risk of new or recurrent gastrointestinal bleeding was negligible in both cohorts (0% vs. 1%; p = 1.0). There was no significant difference between the average pain score (4.9 vs. 5.4 [10-point-scale]; p=0.440) and the difference between reported triage and final ED pain scores (-1.8 vs. -2.0; p=0.729). Furthermore, there was a significant reduction in GI consultation (35% vs. 58%; p <0.016) and a non-significant reduction in hospital admission (63% vs. 80%; p=0.058). CONCLUSION: Almost 80% of patients who present to ED with IBD flare are prescribed opioids, while only half of patients receive non-opioid analgesics. Also concerning was the high rate of opioid prescription at ED or hospital discharge. A multimodal intervention successfully reduced the proportion and amount of opioid prescribing in the ED without compromising pain control or increasing the risk of GI bleeding. This was also associated with a significant increase in a non-opioid analgesic administration and a significant decrease in GI service consultation. These findings support the role of implementing an evidence-based IBD pain management guideline with electronic prescribing support and education in the ED setting for acute IBD flares. Additional research is needed to determine long-term benefits of reduced opioid exposure in this population.

Split-Dose Bowel Preparation Reduces the Need for Early Repeat Colonoscopy Without Improving Adenoma Detection Rate.

BACKGROUND AND AIMS: Split-dose bowel preparation is associated with improved mucosal visualization and patient tolerance, becoming a standard of care. However, quality measures data associated with this preparation are limited. At our academic tertiary-care facility, we aim to study the effect of changing from single- to split-dose preparation on colonoscopy quality measures. METHODS: A retrospective cohort study with quality indicators was conducted using electronic medical record data. Cases were identified via ICD9 code V76.51, "Special screening for malignant neoplasms of colon." Single-dose preparation data was collected from 9/1/13 to 8/31/14. Split-dose preparation was implemented 11/2014, and data were collected from 1/1/15 to 8/31/15. RESULTS: A total of 1602 colonoscopies in the single-dose group and 1061 colonoscopies in the split-dose group were analyzed. The Boston Bowel Preparation Scale was significantly improved in the split-dose group 8.64 ± SD 1.25 versus 8.25 ± SD 1.61, p < 0.001. There was no significant difference in adenoma detection rate 40.7% (95% CI 37.8-43.7%) versus 40.5% (95% CI 38.1-42.9%), p = 0.92; however, the rate for recommending an early repeat examination due to an inadequate bowel preparation was significantly decreased to 3.9% (95% CI 2.7-5.0%) versus 8.9% (95% CI 1.52-2.97%), p < 0.001. CONCLUSION: While split-dose preparation significantly improves overall bowel cleanliness, there is no significant adenoma detection rate improvement with high baseline rate, suggesting a threshold which may not improve with enhanced preparations. Split-dose preparation significantly reduces the frequency with which inadequate preparation prompts an early repeat examination, which has important clinical implications on performance, costs, and patient experience, providing further evidence supporting split-dose preparation use.

Zenker's diverticulitis secondary to alendronate ingestion: a rare cause of recurrent dysphagia.

OBJECTIVE: Acute dysphagia/odynophagia developed in a 79-year-old female patient secondary to what we believe was a caustic injury to a large Zenker's diverticulum (ZD) in the setting of long-term alendronate use. She reported severe dysphagia and odynophagia of 1-week duration. She had experienced a similar episode 10 months earlier that had resolved after stopping alendronate temporarily. Although she was able to handle secretions, she was unable to swallow solids or liquids. She was noted to be dehydrated. On endoscopy, a large and markedly inflamed ZD was identified. There was no visual esophageal mucosal injury within the esophagus. Alendronate therapy was discontinued, and parenteral nutrition and proton pump inhibitors were initiated. Her symptoms resolved within 1 week, and she was able to resume oral intake. DESIGN: Case report. SETTING: University Hospital. LIMITATIONS: Case report. DISCUSSION: Bisphosphonate therapy is commonly used to treat osteoporosis and is therefore an increasingly prevalent component of the medication list of elderly patients. These medications may cause significant caustic injury and are therefore administered with strong caution in the setting of dysphagia or known structural abnormalities of the esophagus. The fear is that tablets may become entrapped within a diverticulum and lead to intense acute inflammatory changes. CONCLUSIONS: Health care providers should be aware of potential complications with ulcerogenic medications in patients with ZD. These medications should be administered with caution in the setting of dysphagia or known structural abnormalities of the esophagus. When patients with history of dysphagia are evaluated for their suitability to receive oral bisphosphonate therapy, care should be taken to investigate the etiology of dysphagia. Evaluation should focus not only on the tubular esophagus, but also on excluding a Zenker's pharyngeal diverticulum with appropriate contrast imaging.

Hemolytic Anemia in Inflammatory Bowel Disease: Our "Gut" Tells Us to Blame the Drug.

Background: Several studies determined that autoimmune hemolytic anemia (AIHA) is a rare extraintestinal IBD manifestation, related to the underlying disease activity. However, evidence linking biologic therapy to AIHA is sparse. Methods: This article reviews the evidence on the association of these clinical phenomena. Results: There are two retrospective studies and a few case reports linking biologic therapies to AIHA. Conclusions: While some autoimmune phenomenon triggered by our biologic therapies have been well recognized, we do not find the evidence associating these therapies to AIHA sufficiently compelling.

Late-Onset Posttransplant Lymphoproliferative Disorder Results in Jejunal Stricture Managed with Endoscopic Dilation.

BACKGROUND: Late-onset posttransplant lymphoproliferative disorder (PTLD) after orthotopic heart transplantation is rare. Case Presentation. We present a rare diagnosis of small bowel stricture caused by healed lymphomatous ulcers in a patient with orthotopic heart transplantation and PTLD diagnosed 25 years after initial transplantation. We also demonstrate successful endoscopic balloon dilations that improved the patient's obstructive symptoms. CONCLUSION: It is important to consider stricture from healed lymphomatous ulcers in posttransplant patients presenting with obstructive symptoms.

Sustained improvement in health-related quality of life measures in patients with inflammatory bowel disease receiving prolonged anti-tumor necrosis factor therapy.

OBJECTIVE: The aim of this study was to determine whether the effects of prolonged therapy (≥1 year) with anti-tumor necrosis factor (TNF) agents were sustained on the health-related quality of life (HRQoL) in patients with inflammatory bowel disease (IBD). METHODS: A cross-sectional survey of patients with IBD who were treated with anti-TNF agents was performed. Results of the validated HRQoL measures (inflammatory bowel disease questionnaire [IBDQ], EuroQoL-5 dimensions [EQ-5D], health status visual analogue scale [VAS] and the Zung self-rating depression scale) were recorded and compared between patients treated with anti-TNF agents for <1 year and ≥1 year. RESULTS: A total of 41 patients were finally enrolled in the study. Among them, 11 (26.8%) had received anti-TNF therapy for less than one year with a median duration of 7 months (range 3-11 months), while the other 30 (73.2%) had been treated for ≥1 year with a median duration of 42 months (range 12-104 months). Crohn's disease was the most common type in both groups. None of the mean IBDQ, EQ-5D and EQ-5D plus VAS, or Zung self-rating depression scale scores differed significantly between the two groups of patients. CONCLUSIONS: Improvements in HRQoL for IBD patients on anti-TNF therapy were sustained for longer than one year. HRQoL measures for IBD patients treated with anti-TNF therapy for <1 year do not differ significantly from those treated for ≥1 year, but a trend towards improved HRQoL measures with prolonged therapy can be obtained.