Picco, Michael F.

Abstract Background Prior studies have examined small intestinal dysplasia and cancer in Crohn’s disease; however, there is limited information on ulcerative colitis (UC). We describe characteristics of small intestinal dysplasia and cancer in patients with UC. In this study, we aimed to identify common characteristics between patients with UC that were diagnosed with small intestinal malignancy. Methods Electronic medical records were reviewed for 3 tertiary referral centers to identify patients with a diagnosis of UC and small intestinal dysplasia or cancer between 2010 and 2023. Data collection included demographics, family history of gastrointestinal malignancy, UC diagnosis date, duration and location of disease, prior UC medical treatment or surgery, diagnosis of primary sclerosing cholangitis (PSC), PSC-related complications, and details of cancer or dysplasia. Descriptive statistics were performed. Results Thirty-five patients (60% male, mean age of diagnosis 39.3 ± 21.5 years old) were identified with UC and subsequent small intestinal dysplasia or cancer. Most had pancolitis (74.3%) or pancolitis with backwash ileitis (8.57%). Half underwent surgery for their UC, and half of these had the cancer or dysplasia found at the time of surgery. Ileal dysplasia was found in 2 patients (5.71%), duodenal adenocarcinoma in 2 (5.71%), ileal adenocarcinoma 2 (5.71%), duodenal carcinoid in 4 (11.4%), ileal carcinoid in 24 (68.6%), other duodenal neuroendocrine tumor in 1 (2.86%). Primary sclerosing cholangitis was diagnosed in 5 patients (14%), and 3 required liver transplants. Conclusions Small intestinal dysplasia and cancer are rare in this population. Most patients with small intestinal cancer or dysplasia were male, Caucasian, and had a history of extensive colitis. Ileal carcinoid had the highest incidence. Gastroenterologists should be aware of this finding in patients with UC.

Background and Goals: Ulcerative colitis (UC) readmissions to the hospital pose a burden to patients and health care systems. Preventing readmissions is important for the quality of care and quality of life of patients with UC. We aimed to identify the incidence of 30 and 90-day readmissions and its predictors in patients with UC. Study: Retrospective review of the 2018 National Readmission Database (NRD) of adult patients readmitted after an index admission (IA) of UC. ICD-10CM/PCS codes were used to identify patients with UC, other comorbidities, and procedures. We identified the most common causes for readmission and independent risk factors for readmission were identified using Cox regression analysis. Results: The 30 and 90-day readmission rates for UC in 2018 were 16.6% and 28.3%. In-hospital mortality and mean length of stay were higher in patients readmitted within both 30 and 90 days. Independent predictors of 30-day readmission were higher Charlson Comorbidity Index (CCI), undergoing ileostomy, increasing length of stay, malnutrition and opioid use disorder at IA. In the 90-day readmission cohort, independent predictors were CCI score of 2 or ≥3, developing shock, admission to large bed size hospitals, undergoing colectomy, increasing length of stay and opioid use disorder at IA. The number one readmission cause at 30 and 90 days was sepsis of unspecified organism. Conclusion: Readmission is associated with higher mortality and is associated with risk factors such as malnutrition, undergoing ileostomy during IA and opioid use disorder. Readmissions in UC continue to pose a high burden to patients and our health care system.

Abstract Background Patients with inflammatory bowel disease (IBD) often experience symptoms refractory to available treatments, prompting the use of alternative therapies like cannabis. Previous studies have shown cannabis users require higher levels of sedation for procedures. The anti-inflammatory effects of cannabis have been studied with mixed conclusions. We aimed to investigate if patients with IBD who reported cannabis use required more resources for endoscopic procedures and were more likely to have endoscopic inflammation. Methods This is a retrospective case–control study of adult patients with IBD between November 2018 and November 2022 at a tertiary academic medical center undergoing endoscopic evaluation of acute complaints related to IBD. Cases were matched for age, sex, and body mass index. Results There were 124 patients with IBD with 62 patients reporting cannabis use and 62 patients without reported cannabis use. There was a significant difference in endoscopy duration (P < .001) and endoscopic inflammation (P = .044) between groups. There was no significant difference in recovery room length of stay (P = .15), IBD treatment during time of endoscopy (P = .84), stricture (P = .53), propofol dose administered when adjusted for procedure duration (P = .082), or endoscopic duration between cannabis users with and without endoscopic inflammation (P = .194). Conclusions IBD cannabis users had longer endoscopic durations and were more likely to exhibit inflammation on endoscopic evaluation compared to cannabis non-users. Our study underscores the importance of medication reconciliation for more accurate resource allocation. Additionally, federal expansion of cannabis research is needed for randomized control trials to fulfill the presently unmet need for data on patient outcomes.

Abstract Introduction The objective of the study was to investigate the characteristics of patients who underwent surgery for dysplasia detected during chromoendoscopy (CE) surveillance for inflammatory bowel disease (IBD) and the incidence of cancer in the surgical specimen. Methods A retrospective review of medical records of all patients with dysplasia on a background of underlying IBD diagnosed through CE was carried out at a tri-site enterprise tertiary referral center between 2006 and 2019. We aimed to assess the clinical characteristics of patients requiring surgery for dysplasia and the incidence of cancer in the surgical specimen. Results Out of 219 patients with dysplasia on CE, 35 underwent surgery for dysplasia (16%). Indications for surgery were multifocal disease (n = 6), endoscopically unresectable lesions (n = 13), visible HGD (n = 7) and unifocal invisible LGD (n = 9). Out of 35 patients requiring surgery, 5 were found to have adenocarcinoma, one of whom with stage IIIB disease received postoperative chemotherapy. No patient with a pathologic diagnosis of adenocarcinoma had any evidence of recurrent disease after a mean postoperative follow-up of 32 months. Conclusions While the incidence of cancer at the time of surgery for IBD-related dysplasia is not negligible, the rate of node-positive disease is low.

Background: Video capsule retention is a complication that can have serious consequences in patients with Crohn’s disease (CD). The patency capsule was developed to detect small bowel strictures. The usefulness of patency capsules in patients who do not have evidence of small bowel disease on imaging is uncertain. Study: This is a multicenter retrospective study of patients with suspected or confirmed CD who underwent a patency capsule study between January 2017 and February 2023. We excluded patients who were lost to follow-up or did not have computerized tomography or magnetic resonance imaging of the abdomen within 180 days before or after the patency capsule study. Results: A total of 105 patients met the inclusion criteria with 69% having a confirmed CD diagnosis. The majority of patients (95/105; 90.5%) passed their patency capsule. A total of 91 patients had their subsequent video capsule endoscopy (VCE), with 96.7% (88/91) successfully passing the capsule. Out of those who passed the VCE, 2 patients had patency capsule retention. Both had normal small bowel imaging. Meanwhile, the 3 patients who had VCE retention had evidence of small bowel disease in their imaging scans. The presence of abnormal small bowel wall thickening or stricture on imaging had a statistically significant association with VCE retention (P=0.02). Conclusion: Our study demonstrated a statistically significant association between small bowel disease on imaging and retention of both patency capsules and VCE. Small bowel imaging in patients with suspected or documented CD had a negative predictive value of 100% for VCE retention.

Abstract Background Metformin exerts anti-inflammatory properties through a positive effect on oxidative stress, gut barrier integrity, and the gut microbiota. Our aim was to evaluate the influence of metformin on inflammatory bowel disease (IBD) outcomes in patients with type 2 diabetes mellitus (T2DM). Methods We conducted a retrospective cohort study using the TriNetX database in patients with IBD and T2DM who initiated metformin vs oral hypoglycemics or insulin (control cohort) between August 31, 2002, and August 31, 2022. One-to-one propensity score matching was performed. Primary outcomes were need for intravenous (IV) steroid use or IBD-related surgery within 1, 2, and 3 years after metformin initiation. Results Our cohorts included 1323 patients with ulcerative colitis (UC) (mean age 58.7 ± 12.2 years, 50.1% female, 77.3% White) and 1278 patients with Crohn’s disease (CD) (mean age 56.3 ± 12.6 years, 58.2% female, 76.5% White). At 1 year, patients with UC and CD were less likely to require IV steroids (UC: adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.34-0.59; P < .01; CD: aOR, 0.67; 95% CI, 0.53-0.85; P < .01). The decreased need for IV steroids persisted in all metformin groups at 2 and 3 years. Patients with CD were at a lower risk for IBD-related surgery at year 1 (aOR, 0.5; 95% CI, 0.31-0.81; P < .01), and this finding persisted at 3 years (aOR, 0.62; 95% CI, 0.43-0.89; P < .01). Metformin did not affect risk for surgery in patients with UC. Conclusions Patients with IBD and T2DM on metformin had a decreased likelihood of worse IBD outcomes.

ABSTRACT Treatment options for patients with inflammatory bowel disease are constantly evolving; however, medication-refractory disease remains an issue. Pediatric case series show the potential benefit of sirolimus therapy in refractory Crohn's disease (CD); however, limited data exist in adult patients. As such, we retrospectively identified and report clinical outcomes for 4 patients prescribed sirolimus for treatment of refractory CD. Despite a median sirolimus therapy duration of 524 days and some therapeutic benefits, all patients discontinued therapy due to adverse effects. Our findings suggest that while sirolimus may have clinical utility, its role may be limited by treatment-derived adverse effects.

INTRODUCTION: Hepatitis B virus (HBV) vaccination is recommended in patients with inflammatory bowel disease (IBD). Although the 2-dose Heplisav-B vaccine has proven effective, more than 20% of patients with IBD do not seroconvert. We prospectively evaluated the effectiveness of a third Heplisav-B dose in patients with IBD lacking HBV immunity despite 2-dose vaccination. METHODS: Adults with IBD who had received 2-dose Heplisav-B vaccination between 2018 and 2023 were identified. Seroconversion was defined as hepatitis B surface antibody (HBsAb) ≥ 10 IU/L measured at ≥4 weeks after vaccination. Patients who did not seroconvert were prospectively offered a third Heplisav-B dose, followed by repeat HBsAb measurement. Demographic, clinical, medication, and vaccination data were compared between those who did and did not seroconvert. RESULTS: Of 192 patients identified, 71.9% (138/192) seroconverted after 2-dose Heplisav-B vaccination. The 54 patients (28.1%) who did not seroconvert were more likely to be male, have diabetes, chronic kidney disease, or elevated Charlson Comorbidity Index. Of the 54 patients, 30 (55.6%) elected to receive a third Heplisav-B dose, with 56.7% (17/30) achieving seroconversion (median HBsAb titer 376 IU/L, IQR 47–1,000 IU/L) despite a median intervaccination time of 416 days (IQR 90.8–667.8). No differences were noted between patients who did vs did not seroconvert after third-dose vaccination. DISCUSSION: In patients with IBD lacking HBV immunity despite 2-dose Heplisav-B vaccination, administration of a third dose resulted in a 56.7% seroconversion rate. Our results suggest that administration of an additional Heplisav-B dose may be an effective strategy in patients lacking immunity despite primary 2-dose vaccination.