Introduction

The risk of colorectal advanced adenomas (CAAs) and colorectal cancer (CRC) in siblings aged ≤ 50 years of patients diagnosed with early-onset CAAs (E-CAAs), defined as having CAA at or below the age of 50 years​, is poorly understood.

Aims & Methods

This study aimed to compare the risks of adenomas, CAA, and CRC in siblings aged ≤ 50 years of patients diagnosed with E-CAA to those in individuals aged ≤ 50 without such a family history.
This case-control study was conducted at a tertiary hospital in Vietnam. The participants included 96 cases who were siblings aged ≤ 50 years of patients diagnosed with E-CAA. Controls were randomly selected from consecutive patients aged ≤ 50 years who did not have siblings diagnosed with E-CAA. The absence of a family history of CAA in the control group was confirmed through comprehensive history taking. ​The controls were matched to cases in a 2:1 ratio for age (±3 years), sex, and smoking status. Individuals with alarming features of CRC or a family history of CRC were excluded. All the participants underwent standard bowel preparation and colonoscopy.

Results

The mean age was similar between cases (40.9 ± 6.0 years) and controls (41.1 ± 6.0 years). Except for the indications for colonoscopy, there were no significant differences in the baseline demographics between the two groups. A higher risk of CAA was documented in cases compared with controls (odds ratio [OR] = 6.33; 95% confidence interval [CI], 1.43–43.8; P = 0.018). This increased risk of CAA was more pronounced among male participants (OR = 13.7; 95% CI, 1.23–262; P = 0.006). Higher risks of colorectal adenomas (OR = 2.43; 95% CI, 1.27–4.67; P = 0.009) and colorectal neoplasia (OR = 2.23; 95% CI, 1.24–4.40; P = 0.011) were also found in cases compared with controls. CRC was found in one case and two controls.

Conclusion

Siblings aged ≤ 50 years of patients diagnosed with E-CAA have an increased risk of adenomas, CAA, and colorectal neoplasia. CRC screening should be initiated early in high-risk individuals.

Table 1. Risk of Colorectal Neoplasia among Siblings of Patients Diagnosed with Advanced Adenomas (n = 288)

References

Ng SC, Lau JY, Chan FK, et al. Risk of Advanced Adenomas in Siblings of Individuals With Advanced Adenomas: A Cross-Sectional Study. Gastroenterology. 2016;150(3):608-e17.
Cottet V, Pariente A, Nalet B, et al. Colonoscopic screening of first-degree relatives of patients with large adenomas: increased risk of colorectal tumors. Gastroenterology. 2007;133(4):1086-1092.

Introduction

Alternate day oral iron therapy is better than daily oral iron therapy in Iron deficiency anemia (IDA) as it increases the fractional absorption of iron. In Ulcerative colitis (UC) with IDA increased fractional absorption of iron with alternate day iron may not only be better in improvement of anemia but also results in reduced unabsorbed iron delivery to distal bowel and may hence reduce adverse effects.

Aims & Methods

In a randomized, open label trial, from February 2023 to December 2024 patients of UC in remission (Mayo ≤2 OR partial Mayo ≤1 with fecal calprotectin <150mcg/gm for last 3 months) with IDA (ferritin <30mcg/l, transferrin saturation <20%, Hb 8-12 gm/dl) were randomized to every other day 132mg (EOD group) or daily 66mg (OD group) elemental oral iron given as ferrous fumarate for 8 weeks. Primary outcome was the difference in mean change in Hemoglobin (Hb) at 8 weeks. Secondary outcomes were the difference in mean change in RBC indices, iron indices and adverse events at 8 weeks.

Results

54 patients were randomized between both groups. One patient in EOD and 2 in OD group withdrew before treatment initiation. Eleven patients had disease flare on oral iron therapy (5 in EOD and 6 in OD group) p= 0.62 and two patients in EOD group had intolerance requiring oral iron stoppage. Thirty-eight patients completed treatment. The mean change in Hb at 8 weeks in EOD and OD groups was 2.08±1.0gm/dl and 2.09±1.11gm/dl respectively in per protocol analysis (p=0.797). The mean change in serum ferritin, serum iron, transferrin saturation and total iron binding capacity in both the groups is not significant. Disease flare within 6 months prior to oral iron therapy correlated with increased incidence of flare on oral iron therapy. (P=0.04)

Conclusion

Alternate day oral iron is not better than daily oral iron in improving Hb levels, iron indices and with similar incidence of adverse events in patients of UC in remission. A recent flare has increased chances of disease flare with oral iron therapy

Introduction

During the COVID-19 pandemic the British Society of Gastroenterology (BSG) introduced interim guidelines supporting a non-biopsy pathway for the diagnosis of coeliac disease. These guidelines reflect the current recommendations of the American Gastroenterological Association (AGA). According to these guidelines, symptomatic or high risk adults with anti-Tissue transglutaminase (TTG) IgA titres ≥10× the upper limit of normal (ULN) and a positive endomysial antibody (EMA) on a repeat sample can be diagnosed without endoscopy and referred directly to a specialist coeliac clinic. Patients who do not meet these criteria should be referred for a gastroscopy (OGD) with biopsy for the confirmation of coeliac, prior to starting a gluten free diet.

Aims & Methods

To assess whether general practitioners (GPs) in the community appropriately referred patients with suspected coeliac disease in line with the AGA and BSG interim non-biopsy diagnostic criteria.
A retrospective review was conducted of all new patients referred to the Coeliac clinic in Galway university hospital between January 2023 and December 2024. Data regarding TTG level at diagnosis, EMA result, and compliance with the diagnostic pathway outlined above was collected for each new referral. This data was collected via Evolve - the hospital's electronic based patient record system.

Results

• There were 119 “new” referrals to our Coeliac Service between January 2023 and December 2024. Of these, 44 cases were known coeliac who were referred by primary care for re-engagement with the clinic, 18 were referred from secondary or tertiary care including GI surgery, Dermatology, Paediatrics, etc. 4 coincidental diagnoses (i.e. OGD performed for indications other than coeliac disease), and 5 outliers (i.e. with incomplete data or incorrectly referred to coeliac clinic) leaving 48 new coeliac cases referred from primary care.
• 18 of these referrals met the non-biopsy criteria for diagnosis (TTG ≥100 + positive EMA)
  • Within this cohort 66% (n=12) were incorrectly referred directly for an OGD which may have delayed the diagnosis of coeliac disease while the remaining 33% (n=6) were correctly referred for direct review at the coeliac clinic.
• The remaining 29 patients all had TTG values less that 10x ULN. 48% (n=14) of these patients were incorrectly referred to clinic prior to endoscopy and of greater concern, 45% (n=13) were recommended by their primary care physician to start a gluten free diet prior to any review or endoscopic procedure.
• Overall, only 44% (n=21) of referrals were compliant with the AGA/BSG guidance.

Conclusion

There is a notable gap in adherence to AGA and BSG non-biopsy coeliac diagnostic guidance in community settings. Half of patients eligible for a non-biopsy diagnosis underwent unnecessary endoscopy, and the majority of ineligible patients were commenced on a gluten free diet prior to, or without, referral for endoscopy. Further GP education is warranted to align referral practices with evidence-based pathways. Dedicated streamlined referral pathways for coeliac disease should ensure a timely diagnosis without mandatory endoscopy in those fulfilling the criteria for a non-biopsy diagnosis and facilitate a timely endoscopy prior to gluten elimination in those who require histological diagnosis.

References

Husby, S., Murray, J.A. and Katzka, D.A. (2019) ‘AGA clinical practice update on diagnosis and monitoring of celiac disease—changing utility of serology and histologic measures: Expert review’, Gastroenterology, 156(4), pp. 885–889. doi:10.1053/j.gastro.2018.12.010.
Tashtoush, L.B. et al. (2021) ‘Letter: The BSG covid‐19 interim coeliac disease guidance no‐biopsy approach is safe in adults’, Alimentary Pharmacology &amp; Therapeutics, 54(8), pp. 1090–1092. doi:10.1111/apt.16553.

Disclosure

No conflict of interest