Interferon-Induced Crohn's Disease: An Unusual Side Effect of Interferon Therapy in a Patient With Chronic Hepatitis C Virus Infection.

Gastrointestinal side effects of interferon (IFN) therapy for chronic hepatitis C virus (HCV) infection are non-specific. Rarely, this therapy has been reported to induce ischemic colitis and even ulcerative colitis. However, IFN-induced Crohn's disease (CD) has previously been reported in only two individuals. We share our own experience of a patient treated for chronic HCV infection who developed CD after IFN therapy for chronic HCV infection. A 28-year-old asymptomatic man with a history only of chronic HCV infection was treated with IFN and ribavirin, which he tolerated for 18 months and achieved sustained viral response (SVR). Halfway through the IFN regimen, he noticed infrequent painful bowel movements and bloody diarrhea. Following treatment, his symptoms resolved. Six months after therapy, colonoscopy showed a normal terminal ileum and colitis with skipped lesions and rectal sparing. Pathology demonstrated spotty chronic active colitis, with diffuse cryptitis, crypt distortion, and abundant abscesses, compatible with CD. The patient declined treatment and remained asymptomatic for two years. Labs including C-​reactive protein (CRP), erythrocyte sedimentation rate (ESR), fecal calprotectin, and celiac panel were normal. Upper GI endoscopy and capsule endoscopy were normal. Repeat colonoscopy showed normal terminal ileum and normal colonic mucosa, and biopsies of the terminal ileum and all segments of the colon were unremarkable. The patient was observed off treatment and has continued to remain asymptomatic, with a resolution of symptoms and disease continuing away from IFN exposure. This is a rare case of CD induced by IFN, exhibiting significant importance regarding the evaluation of new cases of inflammatory bowel disease (IBD). Gastroenterologists need to keep in mind that INF therapy can be an uncommon cause of IBD.

Correction: An Unusual Finding of a Ladybug on Screening Colonoscopy.

[This corrects the article DOI: 10.14309/crj.0000000000000174.].

Virtual reality for management of pain in hospitalized patients: A randomized comparative effectiveness trial.

OBJECTIVES: Therapeutic virtual reality (VR) has emerged as an effective, drug-free tool for pain management, but there is a lack of randomized, controlled data evaluating its effectiveness in hospitalized patients. We sought to measure the impact of on-demand VR versus "health and wellness" television programming for pain in hospitalized patients. METHODS: We performed a prospective, randomized, comparative effectiveness trial in hospitalized patients with an average pain score of ≥3 out of 10 points. Patients in the experimental group received a library of 21 VR experiences administered using the Samsung Gear Oculus headset; control patients viewed specialized television programming to promote health and wellness. Clinical staff followed usual care; study interventions were not protocolized. The primary outcome was patient-reported pain using a numeric rating scale, as recorded by nursing staff during usual care. Pre- and post-intervention pain scores were compared immediately after initial treatment and after 48- and 72-hours. RESULTS: There were 120 subjects (61 VR; 59 control). The mean within-subject difference in immediate pre- and post-intervention pain scores was larger in the VR group (-1.72 points; SD 3.56) than in the control group (-0.46 points; SD 3.01); this difference was significant in favor of VR (P < .04). When limited to the subgroup of patients with severe baseline pain (≥7 points), the effect of VR was more pronounced vs. control (-3.04, SD 3.75 vs. -0.93, SD 2.16 points; P = .02). In regression analyses adjusting for pre-intervention pain, time, age, gender, and type of pain, VR yielded a .59 (P = .03) and .56 (P = .04) point incremental reduction in pain versus control during the 48- and 72-hour post-intervention periods, respectively. CONCLUSIONS: VR significantly reduces pain versus an active control condition in hospitalized patients. VR is most effective for severe pain. Future trials should evaluate standardized order sets that interpose VR as an early non-drug option for analgesia.

Impact of moderate versus deep sedation on adenoma detection rate in index average-risk screening colonoscopies.

BACKGROUND AND AIMS: The debate between moderate sedation versus deep sedation for index average-risk screening colonoscopies is well known to gastroenterologists. Ensuring the best of all metrics to perform quality colonoscopies for colon cancer prevention is paramount for both patients and physicians alike, because colon cancer remains the leading cause of cancer death and is the most-used screening tool in the United States. The aim of this study was to determine if moderate sedation versus deep sedation affects outcomes of adenoma detection rate (ADR) or polyp detection rate (PDR) in index, average-risk colonoscopies for colon cancer screening. METHODS: A retrospective, single, tertiary care outpatient center study of 585 healthy average-risk patients who underwent index screening colonoscopy between June 1, 2015 to December 31, 2015 (moderate sedation only) and June 1, 2016,to December 31, 2016 (deep sedation only) was performed after Institutional Review Board approval. Demographic data and polyp details were collected to determine ADR and PDR. Patients who were not average risk were excluded from the study. RESULTS: A total of 585 index average-risk screening colonoscopies were included in this study with 57.7% moderate sedation and 42.2% deep sedation. Neither ADR nor PDR was significantly different between the 2 groups (44.1% vs 38.5% [P = .18] and 71.9% vs 67.6% [P = .27], respectively). CONCLUSIONS: In index average-risk screening colonoscopies, deep sedation appears to have no benefit compared with moderate sedation for ADR and PDR.

The dirty aspects of fecal microbiota transplantation: a review of its adverse effects and complications.

Fecal microbiota transplantation is becoming a growing therapy for a variety of indications, including recurrent or refractory Clostridium difficile infection (CDI), as well as many other gastrointestinal and extra-intestinal diseases. In fact, fecal microbiota transplantation is now strongly recommended as the treatment of choice for multiple recurrences of CDI, given its strong efficacy and a favorable short-term side effect profile. As the application of this therapy expands, awareness of its adverse events has also developed. The purpose of this review is to bring to light the side effects and complications associated with fecal microbiota transplantation, with an emphasis on findings from recently published studies.

Fecal microbiota transplantation donation: the gift that keeps on giving.

Fecal microbiota transplantation (FMT) is being studied and utilized for various medical conditions including Clostridium difficile colitis, inflammatory bowel diseases (IBD), obesity, myasthenia gravis, and so on. Yet, FMT donation, whether from an individual or a stool bank, can be challenging given the numerous requirements and donor costs. Furthermore, data outcomes on recipients of FMT regarding donor's health co-morbidities, age, and weight are limited but emerging. The purpose of this review is to evaluate cost, safety, and accessibility in FMT donation.

Interventions to improve sarcopenia in cirrhosis: A systematic review.

BACKGROUND: Sarcopenia, i.e., muscle loss is now a well-recognized complication of cirrhosis and in cases of non-alcoholic fatty liver disease can contribute to accelerate liver fibrosis leading to cirrhosis. Hence, it is imperative to study interventions which targets to improve sarcopenia in cirrhosis. AIM: To examine the relationship between interventions such nutritional supplementation, exercise, combined life style intervention, testosterone replacement and trans jugular intrahepatic portosystemic shunt (TIPS) to improve muscle mass in cirrhosis. METHODS: We search PubMed, EMBASE and Cochrane between June-August 2018, without a limiting period and the types of articles (RCTs, clinical trial, comparative study) in adult patients with sarcopenia and cirrhosis. The primary outcome of interest was improvement in muscle mass, strength and physical function interventions mentioned above. In the screening process, 154 full text articles were included in the review and 129 studies were excluded. RESULTS: We identified 24 studies that met review inclusion criteria. The studies were diverse in terms of the design, setting, interventions, and outcome measurements. We performed only qualitative synthesis of evidence due to heterogeneity amongst studies. Risk of bias was medium in most of the included studies and low quality of evidence showed improvement in the muscle mass, strength and physical function following aerobic exercise. 60% of the included studies on the nutritional intervention, 100% of the studies on testosterone replacement in hypogonadal men and trans-jugular portosystemic shunt were proved to be effective in improving sarcopenia in cirrhosis. CONCLUSION: Although the quality of evidence is low, the findings of our systematic review suggest improvement in the sarcopenia in cirrhosis with exercise, nutritional interventions, hormonal and TIPS interventions. High quality randomized controlled trials needed to further strengthen these findings.

Extra-thoracic Extrinsic Compression: An Unusual Cause of Dysphagia.

BACKGROUND: Dysphagia affects one in twenty-five adults yearly in the United States. OBJECTIVE: While dysphagia may be common, the prevalence of dysphagia may be underestimated primarily due to under-reporting. Dysphagia may be caused by intraluminal, intrinsic, extrinsic, or motility disorders. METHOD/RESULTS: We present a case of dysphagia caused by extra-thoracic extrinsic compression due to bra use. CONCLUSION: Despite many published reports on dysphagia caused by other diagnoses, we occasionally overlook extrinsic abdominal compression as the cause for dysphagia.

Probiotics for Gastrointestinal and Liver Diseases: An Updated Review of the Published Literature.

BACKGROUND: Probiotics can be viewed as biological agents that modify the intestinal microbiota and certain cytokine profiles, which can lead to an improvement in certain gastrointestinal diseases, including diarrhea, inflammatory bowel disease, and liver disease. DISCUSSION: Consumption of probiotics in their various forms, including yogurt, functional foods, and dietary supplements, is frequently encountered worldwide. Often, however, the correct prescription of these agents is dampened due to a lack of knowledge of the scientific evidence and the different presentations and microbial compositions of the currently available probiotic options. Here, we provide an up-to-date review of the evidence of probiotics in the prevention and treatment of various gastrointestinal diseases. OBJECTIVE: Consumption of probiotics in their various forms, including yogurt, functional foods, and dietary supplements, is frequently encountered worldwide. Often, however, the correct prescription of these agents is dampened due to a lack of knowledge of the scientific evidence and the different presentations and microbial compositions of the currently available probiotic options. METHODS/RESULTS: Here, we provide an up-to-date review of the evidence of probiotics in the prevention and treatment of various gastrointestinal diseases. CONCLUSION: While not efficacious in every disease process studied, probiotics have demonstrated some benefit in several specific gastrointestinal and liver diseases.

Stem cells for luminal, fistulizing, and perianal inflammatory bowel disease: a comprehensive updated review of the literature.

Much research has been performed over the last decade on stem cell therapy as treatment for patients with inflammatory bowel disease. Hematopoietic and mesenchymal stem cells, both allogeneic (from someone else) and autologous (from own patient), have been studied with safe and efficacious results in the majority of patients treated for luminal, perianal, and/or fistulizing disease. Here in this review, we highlight all human trials that have been conducted utilizing stem cell therapy treatment in patients with inflammatory bowel disease.

One more chance of fistula healing in inflammatory bowel disease: Stem cell therapy.

Patients with fistulizing inflammatory bowel disease are traditionally difficult to treat. This patient population often experiences delayed or insufficient healing of fistulas using current standard regimens including antibiotics, immunomodulators, anti-tumor necrosis factor-α drug, placement of setons, and surgical repair. Several studies over the last ten to fifteen years have been conducted using stem cell therapies with promising results in this patient population. These studies show stem cell therapy in fistulizing disease to be successful in healing between 60%-88% compared to currently 50% with infliximab. Moreover, remission was seen 24 wk to 52 wk in these studies. Further research with a multi-approach treatment using medications, stem cell therapy, and surgical interventions will likely be the future of this innovative treatment approach.

Review of stem cells as promising therapy for perianal disease in inflammatory bowel disease.

Those patients with perianal Crohn's disease or ulcerative colitis experience a difficult to treat disease process with a delayed state and often inability to heal despite current therapies. The approaches currently used to treat these patients with corticosteroids, antibiotics, immunomodulators, anti-tumor necrosis factor-α drug, and surgical repair are limited in their healing ability. This review presents all current literature since emergence in the early 2000s of stem cell therapy for patients with perianal inflammatory bowel disease and analyzes the efficacy, outcomes and safety within these studies.

Non-Alcoholic Fatty Pancreas Disease (NAFPD): A Silent Spectator or the Fifth Component of Metabolic Syndrome? A Literature Review.

BACKGROUND AND OBJECTIVE: Fat accumulation in the pancreas has remained a relatively unknown disease since it was initially described in 1926. However, it has gained increasing attention in the past two decades with the emergence of the obesity epidemic. Pancreatic steatosis is a general term used for fat accumulation in the pancreas. It is further classified into fatty replacement, fatty infiltration, lipomatous pseudo-hypertrophy, non-alcoholic fatty pancreas disease (NAFPD) and non-alcoholic fatty steatopancreatitis (NASP). NAFPD is defined as obesity-associated accumulation of fat in the pancreas without significant alcohol consumption. Data on the prevalence of NAFPD are limited due to a lack of standardized screening tests. METHODS: MEDLINE/PubMed was searched to find relevant studies and abstracts on pancreatic steatosis. RESULTS: Pancreatic fat can be quantified by various imaging techniques including ultrasonography, computed tomography, magnetic resonance imaging and magnetic resonance spectroscopy. The pathophysiology of NAFPD has not been completely understood. Chronic exposure of ß-cells to hyperglycemia and higher levels of free fatty acids results in increased intracellular triglyceride accumulation, which ultimately causes reduced insulin secretion, insulin resistance, cell apoptosis and subsequent fatty replacement. This vicious cycle likely is a determining factor in the development of diabetes mellitus and metabolic syndrome. There is no approved pharmacologic therapy for NAFPD. Caloric restriction might have a role in normalization of ß-cell function by reducing pancreatic fat content. Troglitazone (blend of telmisartan and sitagliptin) has demonstrated effectiveness in animal models but is still in experimental stages. CONCLUSION: The cause and effect relationship between the metabolic syndrome and NAFPD has not yet been established. Further studies are required to study the effect of NAFPD on glucose hemostasis.

Epidemiology, determinants, and management of AIDS cholangiopathy: A review.

Diseases of the liver and biliary tree have been described with significant frequency among patients with human immunodeficiency virus (HIV), and its advanced state, acquired immunodeficiency syndrome (AIDS). Through a variety of mechanisms, HIV/AIDS has been shown to affect the hepatic parenchyma and biliary tree, leading to liver inflammation and biliary strictures. One of the potential hepatobiliary complications of this viral infection is AIDS cholangiopathy, a syndrome of biliary obstruction and liver damage due to infection-related strictures of the biliary tract. AIDS cholangiopathy is highly associated with opportunistic infections and advanced immunosuppression in AIDS patients, and due to the increased availability of highly active antiretroviral therapy, is now primarily seen in instances of poor access to anti-retroviral therapy and medication non-compliance. While current published literature describes well the clinical, biochemical, and endoscopic management of AIDS-related cholangiopathy, information on its epidemiology, natural history, and pathology are not as well defined. The objective of this review is to summarize the available literature on AIDS cholangiopathy, emphasizing its epidemiology, course of disease, and determinants, while also revealing an updated approach for its evaluation and management.

Patient Understanding of the Risks and Benefits of Biologic Therapies in Inflammatory Bowel Disease: Insights from a Large-scale Analysis of Social Media Platforms.

BACKGROUND: Few studies have examined inflammatory bowel disease (IBD) patients' knowledge and understanding of biologic therapies outside traditional surveys. Here, we used social media data to examine IBD patients' understanding of the risks and benefits associated with biologic therapies and how this affects decision-making. METHODS: We collected posts from Twitter and e-forum discussions from >3000 social media sites posted between June 27, 2012 and June 27, 2015. Guided by natural language processing, we identified posts with specific IBD keywords that discussed the risks and/or benefits of biologics. We then manually coded the resulting posts and performed qualitative analysis using ATLAS.ti software. A hierarchical coding structure was developed based on the keyword list and relevant themes were identified through manual coding. RESULTS: We examined 1598 IBD-related posts, of which 452 (28.3%) centered on the risks and/or benefits of biologics. There were 5 main themes: negative experiences and concerns with biologics (n = 247; 54.6%), decision-making surrounding biologic use (n = 169; 37.4%), positive experiences with biologics (n = 168; 37.2%), information seeking from peers (n = 125; 27.7%), and cost (n = 38; 8.4%). Posts describing negative experiences primarily commented on side effects from biologics, concerns about potential side effects and increased cancer risk, and pregnancy safety concerns. Posts on decision-making focused on nonbiologic treatment options, hesitation to initiate biologics, and concerns about changing or discontinuing regimens. CONCLUSIONS: Social media reveals a wide range of themes governing patients' experience and choice with IBD biologics. The complexity of navigating their risk-benefit profiles suggests merit in creating online tailored decision tools to support IBD patients' decision-making with biologic therapies.

Virtual Reality for Management of Pain in Hospitalized Patients: Results of a Controlled Trial.

BACKGROUND: Improvements in software and design and reduction in cost have made virtual reality (VR) a practical tool for immersive, three-dimensional (3D), multisensory experiences that distract patients from painful stimuli. OBJECTIVE: The objective of the study was to measure the impact of a onetime 3D VR intervention versus a two-dimensional (2D) distraction video for pain in hospitalized patients. METHODS: We conducted a comparative cohort study in a large, urban teaching hospital in medical inpatients with an average pain score of ≥3/10 from any cause. Patients with nausea, vomiting, dementia, motion sickness, stroke, seizure, and epilepsy and those placed in isolation were excluded. Patients in the intervention cohort viewed a 3D VR experience designed to reduce pain using the Samsung Gear Oculus VR headset; control patients viewed a high-definition, 2D nature video on a 14-inch bedside screen. Pre- and postintervention pain scores were recorded. Difference-in-difference scores and the proportion achieving a half standard deviation pain response were compared between groups. RESULTS: There were 50 subjects per cohort (N=100). The mean pain reduction in the VR cohort was greater than in controls (-1.3 vs -0.6 points, respectively; P=.008). A total of 35 (65%) patients in the VR cohort achieved a pain response versus 40% of controls (P=.01; number needed to treat=4). No adverse events were reported from VR. CONCLUSIONS: Use of VR in hospitalized patients significantly reduces pain versus a control distraction condition. These results indicate that VR is an effective and safe adjunctive therapy for pain management in the acute inpatient setting; future randomized trials should confirm benefit with different visualizations and exposure periods. TRIAL REGISTRATION: Clinicaltrials.gov NCT02456987; https://clinicaltrials.gov/ct2/show/NCT02456987 (Archived by WebCite at http://www.webcitation.org/6pJ1P644S).

Hepatitis C Virus Therapy for Decompensated and Posttransplant Patients.

Treatment of hepatitis C (HCV) has been revolutionized with the introduction of the direct-acting antivirals (DAA). The DAAs allowed patients to better tolerate HCV therapy with much lower side effects and better efficacy. The DAA also offered hope for a cure in HCV patients who cannot tolerate interferon-based therapy. Such populations include patients with decompensated cirrhosis and postliver transplantation. Despite DAA therapy showing cure rate of over 95% in the absence of cirrhosis, cure rate in the decompensated liver disease setting remains lower. In this paper, we aim to review the current recommendations for the treatment of HCV in patients with decompensated cirrhosis and postliver transplantation.