Symptoms and Extraintestinal Manifestations in Active Cannabis Users with Inflammatory Bowel Disease.

Introduction: Cannabis use is common in the setting of inflammatory bowel disease (IBD). Patients frequently use cannabis to treat IBD-associated symptoms, and there is evidence that cannabis and its derivatives are helpful for this purpose. However, it is unclear how the symptom profiles of active IBD cannabis users and nonusers compare and how these symptoms may relate to their underlying disease state and/or complications. Materials and Methods: We performed a retrospective cohort study using a consented IBD natural history registry from a single tertiary care referral center between January 1, 2015 and August 31, 2020. We asked patients about current cannabis use and frequency. We also abstracted demographic and clinical characteristic information, including endoscopic severity, and totals and subscores of surveys assessing IBD characteristics, presence of anxiety/depression, and IBD-associated symptoms. We compared clinical and demographic factors of cannabis users and nonusers and developed a logistic regression model to evaluate for independent associations with cannabis use. Results: Three hundred eighty-three IBD patients met the inclusion criteria (206 females, 177 males; 258 Crohn's disease [CD], 118 ulcerative colitis, and 7 indeterminate colitis). Thirty patients (7.8%) were active cannabis users, consuming it for an average of 2.7 times per week. Cannabis users were more likely to report abdominal pain (83.3% vs. 61.7%), gas (66.7% vs. 45.6%), tenesmus (70.0% vs. 47.6%), and arthralgias (53.3% vs. 20.3%) compared to those that did not use cannabis (p<0.05 for each). Incidence of moderate-severe endoscopic inflammation was similar between cannabis users and nonusers, while CD-associated complications were more common in nonusers (39.1% vs. 69.7%, p<0.05). The only factor that demonstrated a significant association with cannabis use on multivariable analysis was arthralgia (p<0.01). Discussion: Active IBD cannabis users were more likely to report a variety of symptoms, including abdominal pain, gas, tenesmus, and arthralgias. However, they did not demonstrate more frequent active disease or IBD-associated complications, suggesting that other nonluminal factors influence their symptoms and/or decision to use cannabis. These findings demonstrate the importance of evaluating for extraintestinal contributors to symptom burden in IBD cannabis users, as well as the ongoing need to develop safer and more effective methods for recognizing and managing abdominal pain and other symptoms in this setting.

Hepatitis D diagnostics:Utilization and testing in the United States.

Hepatitis D virus (HDV) infection may accompany acute or chronic hepatitis B virus infection. While HDV infection in the United States is thought to be uncommon, there are limited data regarding frequency of testing, and prevalence of HDV antibody and HDV RNA. We evaluated the use of HDV antibody testing using electronic medical record (EMR) data. Among 1007 HBsAg positive patients, only 121 had been tested for HDV antibody. Testing was performed primarily by gastroenterologists/hepatologists and limited testing was performed in identifiable high risk groups including those with HBV/HIV coinfection. Overall, HDV antibody was detected in 3.3% (95% C.I. = 0.9%-8.2%) An HDV RNA assay was developed and validated and 138 HBV or HBV/HIV coinfected patients were tested. The prevalence of HDV among the HBV/HIV coinfected subjects was 2.2% (95% C.I. = 0-5.3%). In a U.S. Midwestern population of HBV infected patients, HDV testing is under-employed. Overall prevalence exceeds 2% whether testing by antibody or HDV RNA and more comprehensive HDV surveillance may be indicated.

Gastric Pneumatosis from Isolated Gastric Calciphylaxis.

A 58-year-old man with end-stage renal disease presented with hypotension and emesis, pale conjunctivae, and a distended abdomen. Labs revealed hypercalcemia and leukocytosis. Abdominal imaging showed gastric pneumatosis. Endoscopy demonstrated significant hemorrhage and necrosis in the gastric cardia and fundus. Biopsies revealed acute ulcerative gastritis and focal intravascular calcium phosphate crystals. The patient remained nil per os and was placed on omeprazole and sucralfate. Repeat endoscopy demonstrated mucosal healing. Gastric calciphylaxis in the setting of gastric pneumatosis is an uncommon finding, especially in patients without cutaneous findings.

Occult Hepatitis B Virus Infection in a Previously Vaccinated Injection Drug User.

INTRODUCTION: Occult hepatitis B virus (HBV) is defined by the presence of HBV DNA in patient sera in the absence of HBsAg. Occult HBV has been associated with hepatocellular carcinoma, reactivation during immune suppression, and transmission to others. While the hepatitis B vaccine is very effective at preventing chronic HBV infection, recent studies indicate it is less effective at preventing occult HBV following infant vaccination. No studies, however, have examined the efficacy of adult HBV vaccination at preventing occult HBV. Here, we present the first report of occult HBV following adult vaccination. CASE PRESENTATION: A 21-year old Caucasian female presented with tricuspid valve endocarditis secondary to methicillin-susceptible Staphylococcus aureus with non-ischemic cardiomyopathy. She reported active use of intravenous drugs. Her liver enzymes were elevated (ALT = 1873 IU/mL; AST = 4518 IU/mL), and she was found to have HCV and occult HBV. HBV viral loads ranged from 4608 - 8364 copies IU/mL during hospitalization. The patient's HBV was sequenced and found to be genotype D3 without any known diagnostic escape mutations. Immune complexes that may have prevented HBsAg detection were not observed. CONCLUSIONS: HBV vaccination in infancy is effective at preventing chronic HBV infection but is less effective at preventing occult HBV infection. Similar studies examining the efficacy of adult HBV vaccination in preventing occult HBV have not been performed. This case highlights the importance of carefully determining the HBV status of high-risk individuals, as vaccination history and the presence of anti-HBs may not be adequate to rule out HBV infection, even in the absence of HBsAg.

Step up versus early biologic therapy for Crohn's disease in clinical practice.

BACKGROUND: Recent studies have demonstrated superior outcomes of early biologic therapy. Our purpose was to evaluate differences in disease course among patients in clinical practice treated with early biologic therapy compared with those receiving conventional Step Up therapy. METHODS: Patients with Crohn's disease evaluated from July 2004 to November 2010 at a tertiary referral center were included. Demographic data were obtained from a prospectively maintained database. Patients were categorized into 1 of 2 groups: Early Bio group (with or without concomitant immune suppressants) or Step Up group (initial immune suppressants with or without escalation to biologic). Disease activity, quality of life, use of steroids, and number of hospitalizations, and surgeries were assessed. RESULTS: Ninety-three patients with Crohn's disease met inclusion criteria: 39 (45%) in the Step Up group and 54 (58%) in the Early Bio group. There was no significant difference in demographic and clinical variables between groups. Mean Harvey-Bradshaw index and Short Inflammatory Bowel Disease Questionnaire scores at 3, 6, and 12 months were not different between groups. Response rates were higher in the Step Up group compared with the Early Bio group only at 3 months. Early Bio patients had a greater number of hospitalizations at 1 year (P = 0.04). CONCLUSIONS: In clinical practice, early biologic therapy did not improve disease activity or quality of life and did not decrease the need for steroids or surgeries 1 year after therapy. Our results suggest that clinical outcomes are not worsened using the conventional approach. Therefore, an accelerated Step Up approach for most patients seems reasonable.