Introduction

The role of ustekinumab and vedolizumab in articular extra-intestinal manifestations of IBD remains unclear and most existing studies are retrospective.

Aims & Methods

The aim of this study is to analyze the incidence of new onset or worsening of a preexisting IBD-associated arthropathy in patients treated with ustekinumab or vedolizumab.
An observational prospective study in a tertiary care University hospital was conducted. IBD patients undergoing treatment with vedolizumab or ustekinumab with previous or new onset arthropathy were included. Articular manifestations were evaluated by a rheumathologist. IBD and rheumatological related variables were assessed at baseline and after 6 months, including demographics, clinical, biochemical, endoscopic and ultrasound data.

Results

201 patients are treated with ustekinumab/vedolizumab for IBD in our center.
36 patients (17.1%) with previous arthropaties and 5 (3.3%) patients who developed new onset arthropathy after the starting of the treatment were included.
Most patients were anti-TNF experienced (26, 72.2%) or other biological therapy (9, 24.9%) with a median of 2 previous biological treatments per patient (IQR: 1-3).
Of the patients with new onset arthropaty 1 was treated with ustekinumab (20%) and 4 with vedolizumab (80%). Type of arthritis was: peripheral arthritis 3 (60%), axial 1 (20%) and mixed 1 (20%).
Among patients with previous arthropaties, 14 were under treatment with vedolizumab (38.9%) and 22 (61.1%) with ustekinumab for a mean time of 27.8 ± 19.7 months. 12 (38.7%) had worsening joint activity or flare-ups during ustekinumab/vedolizumab treatment. Of these, 5 (41.7%) had parallel intestinal activity (4 with ustekinumab and 1 with vedolizumab). There were no significant differences between the two biological therapy groups and worsening joint activity.
In our study, in most of the patients, joint symptoms were independent of clinical intestinal activity, although the differences were not significant. However, we did find that fecal calprotectin levels was significantly higher in patients with joint worsening (588.4 µg/g) vs. no joint activity (188.8 µg/g); p=0.05.

Conclusion

A significant proportion of patients treated with ustekinumab/vedolizumab have poor control of both axial and peripheral joint activity. In our experience, joint activity is not related to the clinical but biochemical activity of IBD.

Introduction

Endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDS) is primarily used for biliary drainage in patients with malignant distal biliary obstruction. A recent meta-analysis reported a reintervention rate of 15.8% with EUS-CDS. However, studies analyzing the factors associated with reintervention on follow-up after EUS-CDS are limited.

Aims & Methods

The study aimed to analyze the incidence and predictors of reintervention in patients with malignant biliary obstruction undergoing EUS-CDS. The present study is a retrospective analysis of data from eight tertiary care centers in India from January 2022 to January 2024. Patients aged 18-70 years with malignant distal biliary obstruction undergoing EUS-CDS, with a follow-up duration of more than eight weeks, were included. The study's primary outcome was reintervention, which was required in patients with failure of jaundice to improve due to stent migration or stent blockage during the follow‑up, presenting as the worsening of jaundice, with or without cholangitis. The secondary outcomes included clinical success and adverse events. Multivariate analysis using the logistic regression model was used to identify the independent predictors of reintervention.

Results

A total of 140 patients underwent EUS-CDS, out of which 134 patients completed the 8-week follow-up. The median age of the patients was 54.5 (range: 22-90) years, with 53% (71/134) being male. The most common indication for EUS-CDS was inaccessible papilla (59/134, 44.0%), followed by failed cannulation (57/134, 42.5%). The technical success rate was 97.8% (131/134), with placement of self-expanding metal stent (SEMS) in 86.6% (116/134) and lumen-apposing metal stent in 11.2% (15/134). Coaxial double pigtail plastic stent was placed in 19.4% (26/134) cases. Periprocedural adverse events (AE) were seen in 6% (8/134) cases, with severe AE in 0.7% (1/134) cases. Clinical success was achieved in 93.9% (123/131) of the cases with successful stent placement. Over a median follow-up of 20 weeks, reintervention was required in 8.4% of the cases after a median interval of 11 weeks. All patients requiring reintervention could be managed successfully with endoscopic or percutaneous techniques. On multivariate analysis (Table 1), cholangitis at presentation [Odd ratio (OR) 6.26, 95% confidence interval (CI) 1.03-38.09; p =.046] and the absence of coaxial stent with concomitant duodenal stent (OR 7.41, 95% CI: 1.44-38.05; p=.016) were independent predictors of reintervention in the overall cohort. On subgroup analysis of patients undergoing EUS-CDS with SEMS, the absence of coaxial stent with concomitant duodenal stent (OR 10.15, 95% CI: 1.80-57.29; p=.009) was an independent predictor of reintervention.

Conclusion

Reintervention on follow-up after EUS-CDS is required in around 8.4% of cases, with all cases being managed successfully. The absence of coaxial stent with concomitant duodenal stent was an independent predictor of reintervention in the overall cohort as well as in those undergoing EUS-CDS with SEMS.

Clinical Case Summary

Intestinal failure is a rare condition associated with significant reduction of gut function. Depending on the severity of the loss of gut function and the adaptability of the small intestine, patients may require long-term home parenteral nutrition (HPN) with higher risk to develop complications as intestinal failure-associated liver disease (IFALD). Therapy for IFALD is based on optimization of HPN composition and calories and restoring gut functions by enabling the enteral route; surgical strategies should be considered either by restoration of bowel continuity but their efficacy is not quite clear. Here we present the case of a 60 years old woman with intestinal failure due to short bowel syndrome, who developed IFALD, non-responding to medical therapy but completely resolved after resuming enteral nutrition and surgical approach. Patient was admitted with traumatic mesentery root laceration with rupture of superior mesenteric artery and intestinal infarction with signs of perforation. Small bowel resection and jejunostomy was performed, configuring a short bowel syndrome-type I jejunostomy with tenus “in transitum” to ostomy of 70 cm while 10 cm of ileum with ileocecal valve and entire colon were excluded. Total parenteral nutrition was set up and the patient was discharged without significant biochemical alterations. Two months later blood tests found out elevation of cholestasis and hepatocytonecrosis, suspected for IFALD. Thus HPN composition and medical therapy were optimized, without any laboratory improvement.Thus intestinal recanalization surgery was performed by packing a double ileo-ileal anastomosis preserving the IC valve, restoring intestine continuation with colon for about 80 cm, resulting in SBS type 2, with subsequent complete normalization of blood tests. Although more risky, surgical therapy should be considered a viable strategy for patients with IFALD refractory to conservative therapy.

Introduction

Patients with an ileostomy are at increased risk of dehydration and sodium depletion.

Aims & Methods

We aimed to investigate if protein type or protein hydrolysation affects absorption from oral rehydration solutions (ORS) in patients with an ileostomy.
This was a randomised, double-blinded, active comparator-controlled 3x3 crossover intervention study. We developed three ORS with whey protein isolate, caseinate or whey protein hydrolysate. The ORS contained 40-48 g protein/L, 34-45 mmol sodium/L and had an osmolality of 248-270 mOsm/kg. The patients ingested 500 mL/d during three 4-week periods with a >2-week washout. The primary outcome was wet-weight ileostomy output.

Results

Thirteen patients were included in the analyses. Wet-weight ileostomy output did not change and there was no difference between interventions (p=0.38). A series of statistically significant improvements were observed following intake of whey protein isolate ORS, including decreased faecal losses of energy (-365 kJ/d, 95% confidence interval (CI), -643 to -87, p=0.012), magnesium (-4.0 mmol/d, 95%CI, -7.4 to -0.7, p=0.020), plasma aldosterone (-4,674 pmol/L 95%CI, -8,536 to -812, p=0.019), and increased eGFR (2.8 mL/min/1.73m2, 95%CI, 0.3 to 5.4, p=0.03).

Conclusion

Ingestion of 500 mL/d of three protein-based iso-osmolar solutions resulted in unchanged and comparable ileostomy outputs in patients with an ileostomy. Following whey protein isolate ORS, we observed discrete improvements in a series of absorption proxies in both faeces and blood. The protein-based ORS were safe and well-tolerated. Future studies are warranted to explore if different compositions or doses of protein-based ORS can improve absorption in patients with an ileostomy.

Disclosure

Aarhus University and Arla Foods Ingredients Group P/S financed the wages for CLR’s doctoral studies, but in no way influenced the data collection, analyses, interpretation or publishing of the data. SMBD is an active member of the EurFMT alliance, a non-profit academic association, and has received a speaker honorarium from Takada on a subject unrelated to this manuscript. CLH has received lecture honoraria from Baxter and BMS on subjects unrelated to this manuscript, and is the Head of the board of the Danish Society for Clinical Nutrition. The other authors have no potential conflicts of interest to report.