Introduction

Terminal ileitis is the endoscopic manifestation of a wide range of diseases: inflammatory, infectious, vasculitic, ischemic, drug-induced and malignancy. When it comes to asymptomatic terminal ileitis, it is incidentally found on screening ileo-colonoscopy. The prevalence of this entity was not well established and is found in few studies with heterogenous results.

Aims & Methods

We conducted this study to define the prevalence and histopathologic characteristics of asymptomatic terminal ileitis. This is a cross-sectional study. The study population is composed of all the patients that underwent a colonoscopy between September 2020 and March 2023. Selection bias were avoided by excluding patients with inflammatory bowel disease (IBD), sacroiliitis, chronic diarrhea, elevated calprotectin, medical history of ileitis diagnosed either on previous colonoscopy or on imaging showing wall thickening, and those with altered anatomy (colectomy with ileo-colic anastomosis).

Results

A total of 3901 colonoscopies were realized in a single center between September 2020 and March 2023; 3035 met our inclusion criteria based on medical history and the indication of the colonoscopy that excluded the above-mentioned reasons. Ileal intubation was performed in 91.4% (n=2773) of these cases, representing the final study population. Terminal ileitis was found in 5% (n=139) of patients, of whom 58.3% (n=81) were men and 41.7% (n=58) were women. The median age at diagnosis was 50 and and the mean age was 49.43 +/-15.5. The three main indications for colonoscopy were: colorectal cancer screening in 57.5% (n=80) of cases, gastrointestinal red flag symptoms including bleeding, anemia, and weight loss in 28.8% (n=40) of cases, and abdominal pain in 13.7% (n=19) of cases. Biopsies were performed in 90.6% (n=126) of ileo-colonoscopies and showed, regardless of the indication, normal histology, erosive and ulcerated ileitis, and non specific and other findings in 12.7% (n=16), 36.5% (n=46) and 44.4% (n=56) of samples respectively. Definitive Crohn’s disease diagnosis was found in 5.75% (n=8) of asymptomatic ileitis patients.

Conclusion

The prevalence of asymptomatic terminal ileitis was 5% in our population. This finding was not associated with the indication of the colonoscopy, namely colorectal cancer screening, gastrointestinal red flag symptoms including bleeding, anemia, and weight loss and abdominal pain. The clinical significance of this finding requires longitudinal follow-up studies to assess the incidence of IBD or other conditions.

Introduction

Persistent High-Risk Human Papillomavirus (HR-HPV) infection can lead to an anal high-grade squamous intraepithelial lesion (HSIL), the precursor lesion to anal squamous cell carcinoma (SCC). Anal cytology and HR-HPV testing are strategies used for anal SCC screening. Anal HR-HPV prevalence in HIV-negative MSM and in MSM living with HIV (MSM-HIV) is 41% and 74%, respectively. The use of Pre-Exposure Prophylaxis (PrEP) in HIV-negative MSM to prevent HIV contraction created a new Sexual Minority Group among MSM, i.e. MSM using PrEP (MSM-PrEP). The aim of this study was to determine the prevalence of anal HR-HPV infection and abnormal anal cytology in MSM-PrEP and MSM-HIV.

Aims & Methods

MSM-PrEP and MSM-HIV were enrolled in this mono-centric study during consultations at the S-clinic and the HIV-reference centre respectively. Patient characteristics, sexual behavior and demographics were collected using a questionnaire, completed on the day of the anal swab testing.

Results

We enrolled 150 MSM-PrEP and 152 MSM-HIV. Quality of anal swabs was sufficient in respectively 96.7% (n=145) and 96.1% (n=146). HR-HPV prevalence in MSM-PrEP was comparable with HR-HPV prevalence in MSM-HIV; respectively 74.5% (n=108) and 76.6% (n=111) tested positive for at least one HR-HPV (p=0.78). No significant difference in abnormal cytology was seen; 53.1% (n=77) of the MSM-PrEP and 57.2%(n=83) of MSM-HIV had either ASCUS, ASC-H, LSIL or HSIL (p=0.56).

Conclusion

The risk of HR-HPV infection and abnormal anal cytology in MSM-PrEP is comparable to that in MSM-HIV, both of which are higher than observed in HIV-negative MSM not using PrEP. This heightened prevalence of HPV in MSM-PrEP poses an increased risk for HSIL. Recent guidelines on anal screening from International Anal Neoplasia Society recommend screening for anal cancer in both MSM-HIV and HIV-negative MSM, reflecting respective anal cancer incidence rates of 70-100 per 100,000 person-years and 18-34 per 100,000 person-years. Our findings suggest that MSM-PrEP constitutes a distinct risk group for anal SCC positioned between MSM-HIV and HIV-negative MSM not using PrEP.

References

Gaisa M, Gypsyamber D et al. Epidemiology of anal human papillomavirus infection and high-grade squamous intraepithelial lesions in 29 900 men according to HIV status, sexuality, and age: a collaborative pooled analysis of 64 studies. Lancet HIV. 2021;8(9):531-43.
Machalek D, Poynten M, Jin F et al. Anal human papillomavirus infection and associated neoplastic lesions in men who have sex with men: a systematic review and meta-analysis. Lancet Oncol. 2012;13(5):487-500.
Stier E, Clarke M, Deshmukh A et al. International Anal Neoplasia Society's consensus guidelines for anal cancer screening.Int.J.Cancer.2024;154:1694-1702.

Introduction

In Australian patients receiving intravenous (IV) infliximab (IFX) treatment, 44% of patients do not respond to standard regimen and require dose escalation within a year. The REMSWITCH (6-month evaluation) and REMSWITCH-LT (18-months evaluation) investigated the effectiveness of switching from IV to subcutaneous (SC) IFX in patients with inflammatory bowel disease (IBD) who received standard and dose-escalated IV regimen. The two studies concluded that a fixed dose of 120 mg Q2W is feasible, safe and well-accepted leading to a low risk of long-term relapse in patients with escalated IV doses except for those on 10mg/kg/4weeks regimen. In this study, we developed a model to estimate the financial implications of switching.

Aims & Methods

Clinical efficacy parameters were derived from the REMSWITCH and REMSWITCH-LT studies and applied to the Australian context. Number of Australian patients who are on IFX, the proportion of patients on dose escalated regimen, and cost parameters were identified from the published literature or publicly available resources. A financial model was developed based on the assumption that a cohort of patients will receive either IV or SC IFX, and the analysis concluded with the cost difference.

Results

The model assumes that a total of 5.6K patients are receiving IV IFX, with 44.2% of them receiving dose escalation and/or shortened interval of IV IFX. The model produced 6 months and 12 months results, suggesting savings between 582 and 882 AUD per patient, respectively, and equates to a yearly societal savings of 5 million AUD.

Conclusion

IFX SC deserves premium over IFX IV, given that the novel formulation offers tangible and intangible benefits that originator Remicade and biosimilars cannot provide. There is a concern regarding the affordability of SC IFX because it is generally priced higher than IV IFX, which has many biosimilars on the market. However, this study asserts that fixed dosing of 120mg of IFX is cost-saving for society, considering highly prevalent practice of dose escalation and/or shortened intervals of IFX regimen.

Introduction

Optimal timing of endoscopy in patients with acute variceal bleeding (AVB) remains unclear. Studies in patients with peptic ulcer bleeding (PUB) have indicated that urgent endoscopy <6 hours from presentation may be associated with worsened patient outcome. We aimed to analyse the association between timing of endoscopy and mortality in AVB.

Aims & Methods

Prospective multicenter cohort study based on data from the 2022UK Audit on Acute upper gastrointestinal bleeding. The association between timing of endoscopy and in-hospital mortality was evaluated using logistic regression analyses with adjustment for differences in patients’ characteristics and severity of bleeding.

Results

We included 401 AVB patients. Mean age was 58 years, 65% were males, 75% had known cirrhosis at time of presentation, mean Child-Pugh score was 8.2, 31% had other comorbidities, 13% had ongoing bleeding at time of endoscopy, 78% were treated with terlipressin, 75% were treated with antibiotics, and 12.6% died during hospital admission. Mortality rates were 22%, 17%, 11%, and 11% for patients undergoing endoscopy in the periods <6, <12, 6-24 and >24 hours from presentation. Patients undergoing endoscopy < 6 hours had lower blood pressure, higher heart rate, lower haemoglobin, and higher peak-lactate levels than patients undergoing later endoscopy (see table). However, even haemodynamically stable patients with systolic blood pressure above 100mmHg had high mortality rates (16%) when performing urgent endoscopy < 6 hours. When adjusting for differences in patients’ characteristics, and severity of bleeding, we did not find any association between timing of endoscopy and mortality (Odds ratio (95% confidence interval): 1.01 (0.99-1.03); p=0.17).

Table: Patient characteristics in relation to time of endoscopy (n=401)

Conclusion

AVB is associated with significant mortality, in particular in patients undergoing urgent endoscopy <6 hours from presentation, which may be explained by more severe bleeding. When taking differences in patients characteristics and severity of bleeding into consideration, endoscopy within 6-12 hours appears to be associated with similar outcomes to endoscopy undertaken 6-24 hours from presentation, despite less time to patient optimization before endoscopy. Thus, the association between timing of endoscopy and outcome may differ between patients with AVB and patients with PUB.

Disclosure

No conflicts of interest.

Introduction

Persistent high-risk Human Papillomavirus (HR-HPV) infection can lead to an anal high-grade squamous intraepithelial lesion (HSIL), the precursor lesion to anal squamous cell carcinoma (SCC).
HR-HPV prevalence is higher in men who have sex with men living with HIV (MSMLWH) than in HIV-negative MSM, respectively 74% and 37-41% (1,2). The use of Pre-Exposure Prophylaxis (PrEP) in HIV-negative MSM to prevent HIV contraction created a new Sexual Minority Group among MSM, i.e. MSM using PrEP. The aim of this study was to determine the prevalence of anal HR-HPV infection and abnormal anal cytohistology in MSM using PrEP and MSMLWH. Preliminary data are reported here and final results are expected in coming months.

Aims & Methods

MSM using PrEP and MSMLWH were enrolled in this mono-centric study during consultations at the S-clinic and the HIV-reference centre respectively. Patient characteristics, sexual behavior and demographics were collected using a questionnaire, completed on the day of the anal swab testing. Patients with HR-HPV infection, abnormal cytology or both were subsequently sent for High Resolution Anoscopy (HRA).

Results

At present, we enrolled 150 MSM using PrEP and 107 MSMLWH. Quality of anal swabs was sufficient in respectively 95% (n=143) and 81% (n=87). HR-HPV prevalence in MSM using PrEP was comparable with HR-HPV prevalence in MSMLWH; respectively 74% (n=106) and 75% (n=65) tested positive for at least one HR-HPV (p=1.000). No significant difference in abnormal cytology was seen; 53% (n=76) of MSM using PrEP and 58% (n=51) of MSMLWH had either ASC-US, ASC-H, LSIL or HSIL (p=0.6). Until today, 58 MSM using PrEP and 31 MSMLWH underwent HRA. Biopsies were performed in 43 MSM using PrEP and 25 MSMLWH. Preliminary results on histology of lesions show presence of anal HSIL in 19% (n=11) and 32% (n=10) respectively (p= 0.706).

Conclusion

MSM using PrEP have a similar risk of HR-HPV infection and abnormal anal cytohistology as MSMLWH, which is higher than what has been reported in HIV-negative MSM not using PrEP (1). ANCHOR showed that treating anal HSIL reduces the incidence of anal SCC in people living with HIV (3), but the risk of progression to anal cancer and thus the need for screening and treatment is to be investigated in this immunocompetent population of MSM using PrEP.

References

1. Wei F, Gaisa M, Gypsyamber D et al. Epidemiology of anal human papillomavirus infection and high-grade squamous intraepithelial lesions in 29 900 men according to HIV status, sexuality, and age: a collaborative pooled analysis of 64 studies. Lancet HIV. 2021;8(9):531-43.
2. Machalek D, Poynten M, Jin F et al. Anal human papillomavirus infection and associated neoplastic lesions in men who have sex with men: a systematic review and meta-analysis. Lancet Oncol. 2012;13(5):487-500.
3. Palefsky J, Lee J, Jay N et al. Treatment of Anal High-Grade Squamous Intraepithelial Lesions to Prevent Anal Cancer. N Engl J Med. 202;386(24):2273-82.

Introduction

Cirrhosis is a chronic condition with a high mortality. Cirrhotic patients with portal hypertension frequently present with large esophageal varices with bleeding or need for endoscopic intervention. The choice of treatment for variceal hemorrhage is endoscopic ligation and beta-blockers, which can be used as secondary prophylaxis. The pleiotropic effects of statins have been reported for the treatment of cardiovascular diseases, but at the liver level they favor the reduction of the hepatic venous pressure gradient (HVPG), with a decrease in the number of variceal hemorrhage events; however, their use had been restricted in cirrhotic patients due to their association with elevations in liver biochemistries.

Aims & Methods

To evaluate the safety statins in cirrhotic patients with an indication for high cardiovascular risk. And as a secondary aim, determine the presence of variceal hemorrhage during follow-up. This retrospective cohort study was carried out by the "Centro Médico Nacional 20 de Noviembre" between 2018 to 2022. Child Pugh A and B cirrhotic patients with a history of variceal hemorrhage or large varices with endoscopic ligation intervention without active hemorrhage were included and observed over a period of 4 years. To determine adverse events, compatible clinical data and biochemical examinations were searched in the electronic record, and pharmacovigilance committee records were reviewed.

Results

A total of 106 patients were included, of which 53 with statin use and 53 without statins. The characteristics were 41.5% men (n=44), 58.5% women (n=62). The average age was 62 ± 10 years. In order of frequency, the causes were: cryptogenic 25.5% (n=27), hepatitis C virus (HCV) 21.7% (n=23), primary biliary cholangitis (PBC) 14.2% (n=15), metabolic dysfunction-associated fatty liver disease (MAFLD) 13.2% (n=14), alcohol 12.3% (n=13), autoimmune hepatitis (AIH) 11.3% (n=12), hepatitis B virus (HBV) 1.9% (n= 2). With Child Pugh A 67% (n=71) Child Pugh B 35% (n=33). In the statin and non-statin group, the average values of the following variables were PT 12.7 ±1.9 vs 14 ±2.2, AST 39.6 ±24 vs 61 ±40, ALT 37.6 ±28 vs 51 ±38, albumin 3.8 ±0.6 vs 3.6 ±0.5, total cholesterol 157.6 ±35 vs 179.4 ±68, INR 1.06 ±0.17 vs 1.1 ±0.18 (p=< 0.05) (Table 1). In the group of patients with statin use in 18.4% (n=10) Variceal ligation was performed, and in the group without statins, 24.5% (n=13), with a RR of 1.075, 95% CI (0.8-1.3). In the group of patients with statin use, 9.5% (n=5) had a bleeding event, and in the group without statins, 7.5% (n=4) had a bleeding event, with an RR of 1.25, CI 95% (0.3-4.4). None of the participants had clinical adverse effects.

Table 1. Demographics, selected clinical characteristics, and outcomes of patients

Conclusion

The use of statins in cirrhosis compensated with portal hypertension was safe. In this study we could not demonstrate the pleiotropic effect of statins, probably due to the sample size. Therefore, it is necessary to generate subsequent studies including a larger number of patients.

Disclosure

The authors declare that they have no conflict of interest.