Diagnosis and treatment of autoimmune hepatitis. / Diagnostikk og behandling av autoimmun hepatitt.

Autoimmune hepatitis is a chronic liver disease which, if untreated, can lead to cirrhosis of the liver and liver failure. The majority of patients respond well to standard immunosuppressive therapy, but some experience adverse effects, or lack of treatment efficacy. Diagnosis, assessment of therapeutic response and choice of second-line therapy may be challenging. This article provides a summary of updated knowledge concerning diagnosis and treatment of patients with complex autoimmune hepatitis.

Effect of Therapeutic Drug Monitoring vs Standard Therapy During Infliximab Induction on Disease Remission in Patients With Chronic Immune-Mediated Inflammatory Diseases: A Randomized Clinical Trial.

Importance: Proactive therapeutic drug monitoring (TDM), defined as individualized drug dosing based on scheduled monitoring of serum drug levels, has been proposed as an alternative to standard therapy to maximize efficacy and safety of infliximab and other biological drugs. However, whether proactive TDM improves clinical outcomes when implemented at the time of drug initiation, compared with standard therapy, remains unclear. Objective: To assess whether TDM during initiation of infliximab therapy improves treatment efficacy compared with standard infliximab therapy without TDM. Design, Setting, and Participants: Randomized, parallel-group, open-label clinical trial of 411 adults with rheumatoid arthritis, spondyloarthritis, psoriatic arthritis, ulcerative colitis, Crohn disease, or psoriasis initiating infliximab therapy in 21 hospitals in Norway. Patients were recruited from March 1, 2017, to January 10, 2019. Final follow-up occurred on November 5, 2019. Interventions: Patients were randomized 1:1 to receive proactive TDM with dose and interval adjustments based on scheduled monitoring of serum drug levels and antidrug antibodies (TDM group; n = 207) or standard infliximab therapy without drug and antibody level monitoring (standard therapy group; n = 204). Main Outcomes and Measures: The primary end point was clinical remission at week 30. Results: Among 411 randomized patients (mean age, 44.7 [SD, 14.9] years; 209 women [51%]), 398 (198 in the TDM group and 200 in the standard therapy group) received their randomized intervention and were included in the full analysis set. Clinical remission at week 30 was achieved in 100 (50.5%) of 198 and 106 (53.0%) of 200 patients in the TDM and standard therapy groups, respectively (adjusted difference, 1.5%; 95% CI, -8.2% to 11.1%; P = .78). Adverse events were reported in 135 patients (68%) and 139 patients (70%) in the TDM and standard therapy groups, respectively. Conclusions and Relevance: Among patients with immune-mediated inflammatory diseases initiating treatment with infliximab, proactive therapeutic drug monitoring, compared with standard therapy, did not significantly improve clinical remission rates over 30 weeks. These findings do not support routine use of therapeutic drug monitoring during infliximab induction for improving disease remission rates. Trial Registration: ClinicalTrials.gov Identifier: NCT03074656.

Palliative surgical outcome score (PSOS) in patients treated palliatively with self-expanding metal stent (SEMS) for malignant incurable colorectal obstruction.

AIM: The palliative surgical outcome score (PSOS) was proposed for evaluation of the effect of palliative surgical interventions. As a surrogate measure for successful symptom control, it is defined as the proportion of days outside the hospital of the remaining life time up to six months after a palliative intervention. In this study we evaluate the PSOS in patients treated palliatively with self-expanding metal stents (SEMSs) for incurable malignant colorectal obstruction. METHODS: All eligible patients endoscopically treated with palliative intent with SEMSs were identified. Demographics and clinical characteristics, including complete follow-up, were recorded, and the PSOS was calculated. Non-parametric tests were used for comparisons, and survival was evaluated by univariable and multivariable analyses. RESULTS: Between 2005 and 2013, 116 patients (median age 71.5 years; 53.4% women) were identified. Most obstructions were caused by primary colorectal cancers. Technical- and clinical success rates were 94.0% and 87.1%, respectively. Procedure-related complications occurred in 17 (14.7%) of the patients, and most were minor. A PSOS>70 (regarded as excellent palliation) was achieved in 79 (68.1%) patients. This goal was significantly more often achieved in patients who survived at least 6 months than in those with shorter survival (p < 0.001). No clinical variables at the time of the endoscopic palliative procedure could predict a PSOS>70. However, in patients who survived at least 6 months (n = 69), a PSOS>70 was independently associated with better survival in the multivariable Cox analysis. CONCLUSIONS: PSOS could be used as a practical proxy or a pragmatic tool for the effectiveness of palliative interventions, when such interventions are compared. Clinical factors that could significantly add to the clinical decision-making and predict a PSOS>70 in an individual patient were not identified for this specific group of patients.

A case of Ménétriere´s disease treated with the monoclonal antibody cetuximab.

Ménétriere´s disease is a rare disorder of the body and fundus of the stomach, characterized by a massive proliferation of the foveolar cells and subsequent excess mucous secretion. This results in hypoproteinemia due to loss of serum proteins across the gastric mucosa. The cause of Ménétriere´s disease is unknown, and due to the irreversible and premalignant character of the disorder, the patients affected have been subdued to gastrectomy as the only curable treatment. Epidermial growth factor (EGF) has been implicated in the pathogenesis, a finding that makes the disorder receptive to monoclonal antibody treatment against the EGF receptor. In this case report, we present a 41-year-old woman referred to our emergency department due to dizziness, nausea, and vomiting. A thorough medical investigation, combining clinical history, laboratory investigations, an upper endoscopy with full-thickness snare biopsies, and a CT scan confirmed Ménétriere´s disease, and she was successfully treated with the monoclonal antibody cetuximab.

Endoscopic retrograde cholangiopancreatography (ERCP): lessons learned from population-based national registries: a systematic review.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) was introduced more than four decades ago as a diagnostic tool for biliary and pancreatic diseases. Currently, ERCP is mainly used as a therapeutic approach to relieve biliary or pancreatic duct obstruction. Clinical practice has been based on a few large reports and some randomized controlled trials. These data are valuable and important, but the external validity of these reports is limited. Implementation into routine practice should be balanced with the knowledge that these studies were conducted under very specific circumstances. This review was undertaken to describe ERCP results from population-based national registries recorded during routine clinical practice. METHODS: A systematic literature search of the electronic databases Medline Ovid and Embase was conducted. Eligible papers were selected and data were recorded according to the PRISMA criteria. RESULTS: Thirty-one studies were included: 15 true national population-based and 16 population-level studies. Most studies originated from countries with a governmental public health care system. At least three-quarters of the ERCP procedures are currently therapeutic, and the technical success rate is high (> 90%). The postprocedure 30-day mortality rate ranged between 1 and 5% and was strongly correlated with older age, male sex, emergency admission, and noncancer comorbidities, but exhibited a lower correlation with the annual ERCP volume. Patients with primary sclerosing cholangitis or liver cirrhosis should receive particular attention. The risk of developing a bile duct, liver, or pancreas malignancy after ERCP tended to increase, but endoscopic sphincterotomy did not affect this risk. CONCLUSION: ERCP is currently mainly used as a therapeutic approach, and the results are generally likely to improve patients' conditions. A nationwide registry enables better monitoring of routine clinical practice. The collection of valuable information from routine clinical practice in population-based databases may help to improve patient care from best evidence to best practice.

Subtherapeutic concentrations of infliximab and adalimumab are associated with increased disease activity in Crohn's disease.

BACKGROUND: Low anti-tumor necrosis factor α (TNFα) serum concentrations may result in lack of treatment response in patients with inflammatory bowel disease. We determined the anti-TNFα drug concentrations in patients with inflammatory bowel disease and investigated whether or not subtherapeutic drug concentrations were associated with increased levels of disease activity. METHODS: In a single-center cross-sectional study, we included patients with ulcerative colitis or Crohn's disease who were receiving infliximab or adalimumab maintenance therapy. Demographic data, disease activity symptom scores (Partial Mayo Score, Harvey Bradshaw Index), inflammatory markers [C-reactive protein (CRP), fecal calprotectin], antidrug antibodies and serum drug concentrations were recorded. Therapeutic drug concentrations were defined as 3-8 mg/liter for infliximab and 5-12 mg/liter for adalimumab. RESULTS: Of 210 patients included, 137 (65.2%) had Crohn's disease. In the adalimumab group, subtherapeutic drug concentrations were measured in 16.7% of patients with ulcerative colitis and in 27.7% of patients with Crohn's disease. In the infliximab group, subtherapeutic drug concentrations were found in 23% (ulcerative colitis) and 30.3% (Crohn's disease) of patients. In Crohn's disease, subtherapeutic adalimumab concentrations were associated with higher fecal calprotectin and CRP concentrations compared with therapeutic concentrations. Subtherapeutic infliximab concentrations in patients with Crohn's disease were also associated with higher CRP concentrations compared with therapeutic concentrations. CONCLUSIONS: The prevalence of subtherapeutic drug levels ranged from 17% to 30%. In patients with Crohn's disease, subtherapeutic serum drug concentrations were associated with significantly higher disease activity with both anti-TNFα agents. These findings were not observed in patients with ulcerative colitis. Clinicaltrials.gov identifier [NCT02134054].

Intramural gastric pseudocyst: A case report and a comprehensive literature review.

RATIONALE: Intramural pseudocyst, although first reported several decades ago, is a rare entity. Scientific knowledge regarding its clinical management is sparse. PATIENT CONCERNS: We present three cases to show the diverse clinical patterns of patients diagnosed with an intramural gastric pseudocyst. DIAGNOSIS: A final diagnosis should rest on proper evaluation by cross sectional imaging, including computer tomography and magnetic resonance imaging. Endoscopic ultrasound adds to the work-up. INTERVENTIONS: Previously, identified "lesions of the gastric wall" were not well recognized as an intramural pseudocyst, and treatments including resectional surgery were employed. Contemporary proper diagnostics should provide support to a less aggressive treatment approach. OUTCOMES: While an indolent natural history without any clinical symptoms or discomfort could be expected in most cases, individual clinical evaluation should be applied. LESSONS: A heterogeneous information pattern from the limited number of cases in the literature makes it difficult to draw any firm conclusions. Attention to this rare condition should be increased to help clinicians arrive at a correct diagnosis and possibly prevent some patients from being over treated or from the use of unnecessary surgery.

Consecutive fecal calprotectin measurements to predict relapse in patients with ulcerative colitis receiving infliximab maintenance therapy.

BACKGROUND: This study examined whether fecal calprotectin can be used in daily practice as a marker to monitor patients with ulcerative colitis (UC) receiving infliximab maintenance therapy. METHODS: This prospective multicenter study enrolled adult patients with UC in clinical remission under infliximab maintenance therapy. Fecal calprotectin levels were measured every 4 weeks. Sigmoidoscopies were performed at inclusion and at study end. Relapse was defined as a clinical need for change in treatment or an endoscopic Mayo subscore of ≥2 at week 52. Sustained deep remission was defined as a partial Mayo score <3 at all points and an endoscopic Mayo score 0 at week 52. RESULTS: Full analysis was possible for 87 of 113 included patients with UC (77%). Of these patients, 30 (34.4%) were considered to be in sustained deep remission and 13 (14.9%) to have relapsed. Calprotectin levels in patients with sustained deep remission remained very low (median < 40 mg/kg at all time points). Patients who flared had significantly higher calprotectin levels (median > 300 mg/kg) already 3 months before the flare. Further receiver operator curve analysis suggested that a calprotectin level >300 mg/kg had a reasonable sensitivity (58.3%) and specificity (93.3%) to model flare. Two consecutive calprotectin measurements of >300 mg/kg with 1-month interval were identified as the best predictor of flare (61.5% sensitivity and 100% specificity). CONCLUSIONS: Fecal calprotectin can be used in daily practice to monitor patients with UC receiving infliximab maintenance therapy. Two consecutive measurements >300 mg/kg is more specific than a single measurement for predicting relapse.