The impact of inpatient capsule endoscopy on the need for therapeutic interventions in patients with obscure gastrointestinal bleeding.

BACKGROUND/AIM: There are limited data evaluating the impact of inpatient video capsule endoscopy (VCE) on the need for therapeutic interventions in hospitalized patients with obscure gastrointestinal bleeding (OGIB). The objective of this study was to determine the impact of inpatient VCE on the need for therapeutic interventions and rehospitalization for recurrent bleeding. PATIENTS AND METHODS: Hospitalized patients who underwent VCE for OGIB indication were retrospectively included. Clinical data were collected including therapeutic interventions performed after VCE. Specific therapeutic interventions were defined as the medical, endoscopic, or surgical treatment directly targeting the cause of OGIB. Patients were followed up to determine the rate of rehospitalization. RESULTS: A total of 48 inpatient VCE were identified, of which 43 VCE were performed for OGIB indication and were included for analysis. The completion rate and the diagnostic yield were 78.5% and 55.8%, respectively. Subsequent specific therapeutic interventions were performed in 65.2% and 5.8% of patients with positive and negative VCE, respectively (P < 0.001). After a median follow up of 30 months (minimum 12, maximum 58), rehospitalization for recurrent bleeding occurred in 30.4% and 17% of patients with positive and negative VCE, respectively. Patients with angiodysplasia on VCE were significantly more likely to be readmitted (P = 0.02). Throughout the course of the follow-up, only 2 (11.7%) patients with negative VCE underwent specific therapeutic interventions. CONCLUSION: Inpatient VCE is an effective tool to identify patients who need specific therapeutic interventions. Patients with negative VCE are unlikely to be readmitted or require specific therapeutic interventions in the index admission.

Colorectal Polyps in Childhood Cancer Survivors Treated with Radiation Therapy.

BACKGROUND: Cancer survivors treated with abdominal or pelvic radiation therapy (RT) for childhood cancer have an increased risk of colorectal cancer. However, clinical guidelines are inconsistent on recommendations regarding the early initiation of screening in these patients due to the lack of supporting evidence that these patients pass through a pre-invasive phase, in which adenomatous polyps can be detected and removed. AIMS: To determine the prevalence of adenomatous polyps in cancer survivors treated with RT for childhood cancer; the prevalence in average-risk patients aged 17-49; and the prevalence in average-risk patients aged 50-75. METHODS: We conducted a retrospective study comparing the prevalence of adenomatous polyps among three patient groups: childhood cancer survivors aged 17-49 with prior RT who underwent colonoscopy screening from 2006 to 2017; age- and gender-matched patients in the average-risk population; and average-risk patients aged 50-75. RESULTS: One hundred and forty-five patients were included in the study. The proportion of patients with adenomatous polyps in the cancer survivor group was significantly higher than that in the age- and gender-matched average-risk group (58.6 vs 17.2%, p = 0.00) and higher than the average-risk group aged 50-75 (58.6 vs 27.6%, p = 0.009). The prevalence of adenomas with high-risk features was higher in the survivor group compared to patients aged 50-75 (20.7 vs 3.5%, p = 0.015). CONCLUSIONS: Cancer survivors treated with RT for childhood cancer have a higher prevalence of adenomatous polyps compared to the average-risk population. These findings support the early initiation of colonoscopy screening 10 years after radiation therapy, even in patients who have received RT doses below 30 Gy.

The Effect of Prucalopride on Small Bowel Transit Time in Hospitalized Patients Undergoing Capsule Endoscopy.

Background: The inpatient status is a well-known risk factor for incomplete video capsule endoscopy (VCE) examinations due to prolonged transit time. We aimed to evaluate the effect of prucalopride on small bowel transit time for hospitalized patients undergoing VCE. Methods: We included all hospitalized patients who underwent VCE at a tertiary academic center from October 2011 through September 2016. A single 2 mg dose of prucalopride was given exclusively for all patients who underwent VCE between March 2014 and December 2015. VCE studies were excluded if the capsule was retained or endoscopically placed, if other prokinetic agents were given, in cases with technical failure, or if patients had prior gastric or small bowel resection. Results: 442 VCE were identified, of which 68 were performed in hospitalized patients. 54 inpatients were included, of which 29 consecutive patients received prucalopride. The prucalopride group had a significantly shorter small bowel transit time compared to the control group (92 versus 275.5, p < 0.001). There was a trend for a higher completion rate in the prucalopride group (93.1% versus 76%, p = 0.12). Conclusions: Our results suggest that the administration of prucalopride prior to VCE is a simple and effective intervention to decrease small bowel transit time.

Low volume polyethylene glycol with ascorbic acid, sodium picosulfate-magnesium citrate, and clear liquid diet alone prior to small bowel capsule endoscopy.

AIM: To compare low volume polyethylene glycol with ascorbic acid, sodium picosulfate-magnesium citrate and clear liquid diet alone as bowel preparation prior to small bowel capsule endoscopy (CE). METHODS: We retrospectively collected all CE studies done from December 2011 to July 2013 at a single institution. CE studies were reviewed only if low volume polyethylene glycol with ascorbic acid, sodium picosulfate-magnesium citrate or clear liquid diet alone used as the bowel preparation. The studies were then reviewed by the CE readers who were blinded to the preparation type. Cleanliness and bubble burden were graded independently within the proximal, middle and distal small bowel using a four-point scale according to the percentage of small bowel mucosa free of debris/bubbles: grade 1 = over 90%, grade 2 = between 90%-75%, grade 3 = between 50%-75%, grade 4 = less than 50%. Data are expressed as mean ± SEM. ANOVA and Fishers exact test were used where appropriate. P values < 0.05 were considered statistically significant. RESULTS: A of total of 123 CE studies were reviewed. Twenty-six studies were excluded from analysis because of incomplete small bowel examination. In the remaining studies, 39 patients took low volume polyethylene glycol with ascorbic acid, 31 took sodium picosulfate-magnesium citrate and 27 took a clear liquid diet alone after lunch on the day before CE, followed by overnight fasting in all groups. There was no significant difference in small bowel cleanliness (1.98 ± 0.09 vs 1.84 ± 0.08 vs 1.76 ± 0.08) or small bowel transit time (213 ± 13 vs 248 ± 14 ± 225 ± 19 min) for clear liquid diet alone, MoviPrep and Pico-Salax respectively. The bubble burden in the mid small bowel was significantly higher in the MoviPrep group (1.6 ± 0.1 vs 1.9 ± 0.1 vs 1.6 ± 0.1, P < 0.05). However this did not result in a significant difference in diagnosis of pathology. CONCLUSION: There was no significant difference in small bowel cleanliness or diagnostic yield of small bowel CE between the three preparations regimens used in this study.

Hypovitaminosis D in adults with inflammatory bowel disease: potential role of ethnicity.

BACKGROUND: Although vitamin D deficiency occurs in inflammatory bowel disease (IBD), it is currently unclear to what extent ethnicity affects vitamin D levels. Our aim was therefore to determine the ethnic variation in serum 25-hydroxyvitamin D status and its association with disease severity in adults with IBD. METHODS: We conducted a prospective cohort study in ambulatory care IBD patients. Clinical disease severity was assessed through validated questionnaires. Serum 25-hydroxyvitamin D levels were used for vitamin D status. C-reactive protein (CRP), ferritin and hemoglobin (Hgb) levels were correlated with serum 25-hydroxyvitamin D levels. RESULTS: Sixty ulcerative colitis (UC) and forty Crohn's disease (CD) patients were enrolled comprising 65 % Caucasians and 29 % South Asians. However, South Asians had consistently lower average serum 25-hydroxyvitamin D levels (All 44.8 ± 18.1 nmol/L, UC 48.2 ± 18.3 nmol/L, CD 24.3 ± 13.3 nmol/L). Hypovitaminosis D was found in 39 % of All, 36.7 % of UC and 42.5 % of CD patients. A significantly higher proportion of South Asians were vitamin D deficient when compared to Caucasians in All and CD groups (58.6 % vs. 30.8 %, p = 0.01 and 85.7 % vs. 32.3 %, p < 0.01, respectively). CONCLUSIONS: A significantly higher percentage of South Asians had hypovitaminosis D when compared to Caucasians. Disease severity trended towards an inverse relationship with vitamin D status in all South Asian and Caucasian CD patients, although most patients in this study had only mild to moderate disease. We suggest that vitamin D supplementation should be considered in all adult IBD patients.

Gastric polyps in patients with portal hypertension.

OBJECTIVES: Gastric hyperplastic polyps are usually associated with chronic gastritis including Helicobacter pylori gastritis and postantrectomy stomachs. Here, we report on a series of 12 patients with portal hypertension secondary to liver cirrhosis, who were found to have a unique histological type of gastric polyp on endoscopy. METHODS: Retrospective chart review of 12 patients with portal hypertension, who presented with histologically diagnosed gastric hyperplastic polyps. These polyps were reviewed and compared with hyperplastic polyps from 21 patients who did not have portal hypertension. RESULTS: The endoscopic appearances of portal hypertension-associated polyps varied considerably, with sizes ranging up to 18 mm. They were sessile or pedunculated, singular or multiple, found in the antrum or body of the stomach, and endoscopically appeared to be typical hyperplastic polyps. Histopathological examination, however, showed mucosal hyperplasia and extensive vascular proliferation and granulation tissue formation. CONCLUSION: The unique histological appearance of gastric hyperplastic polyps in patients with portal hypertension polyps is described. The exact pathogenetic mechanism of polyp formation is unclear although it seems possible that the underlying cause is mucosal injury that is vascular in nature rather than being secondary to surface inflammation. Although there is an emerging evidence of the neoplastic potential of usual hyperplastic polyps, the natural history of portal hypertension-associated polyps is unknown. Identification and management of portal hypertension-associated gastric polyps present a particular dilemma, as these patients often have coagulopathies and vascular ectasias. Therefore, the natural history and endoscopic features of gastric polyps arising in portal hypertensive patients warrants further exploration.

Development of testicular germ cell cancer following successful infliximab induction therapy for ulcerative colitis.

Antitumor necrosis factor alpha (anti-TNFα) agents have substantially altered the management of inflammatory bowel diseases (IBD). Their benefits must however be weighed against increased risks for infections, lymphoma, and possibly other malignancies. We report on a 27-year-old man, with a six-year history of ulcerative colitis maintained on mesalamine suppositories, presenting with clinical, radiographic and biopsy evidence of an acute colitis flare. Due to the refractory nature of his disease, infliximab was started, resulting in induction of remission within six weeks. Three months after the first dose of infliximab, the patient was diagnosed with a testicular mixed germ cell tumor requiring orchiectomy. Four cases of testicular cancer development among patients using anti-TNFα agents have been identified. Given the prevalence of IBD in young men and recent suggestions for "top-down therapy," testicular cancer as a potential complication of anti-TNFα agents should be further explored on a population basis.

Acetylcholine receptor antibody positive generalized myasthenia gravis in association with primary biliary cirrhosis.

Primary Biliary Cirrhosis and Myasthenia Gravis are both autoimmune conditions, however, there are only rare case reports of their association. This is a case report of acetylcholine receptor antibody positive generalized myasthenia gravis in a female patient with antimitochondrial antibody positive, liver biopsy-confirmed primary biliary cirrhosis.

Clozapine-induced fatal fulminant hepatic failure: a case report.

Fulminant hepatic failure (FHF) refers to the rapid development of severe acute liver injury with impaired synthetic function and encephalopathy in a person who previously had a normal liver or had wellcompensated liver disease. The potential causes of FHF are numerous, but viral or toxin-induced hepatitis are the most common. Clozapineinduced hepatotoxicity has rarely been reported in the literature, occurs via an unknown mechanism and results in liver biochemical abnormalities that are usually of no clinical significance. In approximately 30% to 50% of patients treated with clozapine, there is an asymptomatic rise in serum aminotransaminase levels; however, there are no current guidelines for routine monitoring of liver function tests and liver enzymes during its use. Fatal fulminant hepatitis has only been reported in three patients receiving clozapine. A case of fatal FHF that occurred in a schizophrenic woman who began clozapine therapy shortly before her illness developed is described.

Line sepsis in home parenteral nutrition patients: are there socioeconomic risk factors? A Canadian study.

BACKGROUND: Line sepsis complicates home parenteral nutrition (HPN). This study examined nonmedical risk factors that may contribute to line sepsis and compared 2 HPN programs with different administrative structures (Ontario and British Columbia [BC]) in terms of line sepsis and patient satisfaction. METHODS: A survey was developed to evaluate possible correlation between line sepsis and (1) patients' perceptions of HPN care, (2) family support, (3) community support, and (4) socioeconomic status. Data were analyzed by categorizing into high- and low-risk groups using a cutoff point. A second method analyzed the incidences of line sepsis as a continuous variable. RESULTS: Sixty-eight patients responded to the survey: 33 from Ontario (62%), 35 from BC (44%). Community agency, socioeconomic and educational status were not significant in determining line sepsis. Patients who had (1) medication or blood work done through the catheter, (2) a higher number of dependents, or (3) had a trained family member involved in HPN were in the high-risk category for line sepsis, in addition to patients who were part-time students or receiving social assistance. When comparing the provinces, there was no difference in line sepsis. However, significant differences between the provinces include (1) BC patients rate their level of care lower; (2) Ontario patients rely more on family members for HPN; and (3) Ontario patients have more community support. CONCLUSIONS: Line sepsis may be increased by some nonmedical risk factors. However, when comparing the 2 programs, rates of line sepsis were not influenced by different administrative structures.

Transplant immunosuppressive agents in non-transplant chronic autoimmune hepatitis: the Canadian association for the study of liver (CASL) experience with mycophenolate mofetil and tacrolimus.

BACKGROUND: Conventional treatment of autoimmune hepatitis consists of either prednisone alone or in combination with azathioprine. Ten to 20% of patients do not respond to or are intolerant of this treatment. Novel drug treatments include immunosuppressive drugs such as tacrolimus (TAC), mycophenolate mofetil (MMF), methotrexate and cyclosporine. We describe a multi-centre Canadian experience with MMF and TAC. OBJECTIVE: To study a multi-centre patient population who had failed conventional therapy and were treated with non-conventional medical therapy for autoimmune hepatitis and document response. METHODS: Members of the Canadian Association for the Study of Liver (CASL) obtained MMF from Hoffmann-La Roche Ltd, as part of a compassionate release program, were contacted for standardized data on patients with AIH who received MMF or TAC. Response definitions based on aminotransferase changes were: Complete response (CR)-sustained normalization, partial response (PR)-improvement by greater than 50%, non-response (NR)-less than 50% improvement and relapse (RP)-initial CR or PR followed by an increase in aminotransferases. RESULTS: A total of 16 patients were identified: six in Ontario, one in Quebec, five in Alberta and four in British Columbia. Three were treated with TAC, eleven with MMF and two with combination MMF and TAC. CR was observed in 50%, PR in 12.5%, RP in 25% and NR occurred in 12.5%. The CR for MMF without TAC was approximately 64%. CONCLUSIONS: MMF is effective and well tolerated by patients with autoimmune hepatitis who do not respond to, or are intolerant of, conventional immunosuppressive agents.

Regression of cirrhosis associated with hepatitis B e (HBe) antigen-negative chronic hepatitis B infection with prolonged lamivudine therapy.

In theory, hepatic fibrosis should be a dynamic process with the potential for remodelling after the injury-provoking stimulus has been removed. Clinically, there has been an accumulation of a small number of cases, including hepatitis B e (HBe) antigen-positive chronic hepatitis B infection, in which cirrhosis regressed after successful treatment. We report a 42-year-old HBe antigen-negative Chinese man with detectable serum hepatitis B virus DNA and histologically established cirrhosis (Ludwig score 4) who, after 4 years of successful lamivudine therapy, was found to have regression of cirrhosis on repeat liver biopsy. The repeat biopsy revealed normal liver architecture with fibrosis confined to the portal tracts and short fibrosis septae extending into the lobule without bridging (Ludwig score 1-2). Although cirrhosis may take many years to develop, our experience suggests that successful treatment may reverse the process within a relatively short time.