Clinical Case Summary

Background and aim: Post-colectomy pan-enteritis (PCE) is a rare complication of colectomy for ulcerative colitis (UC), represented by an early-onset diffuse, ulcerative mucosal inflammation, possibly involving the entire small bowel. Corticosteroids, anti-Tumor Necrosis Factor (TNF) alpha drugs or azathioprine have been used for remission induction and maintenance, respectively.
Material and methods: We present the first case of a severe steroid-refractory PCE treated with ustekinumab, an anti-IL-12/IL-23 monoclonal antibody, which modulates T lymphocyte-mediated immunity. We performed a systematic research in PubMed, Medline and Embase databases for case reports or series of definite PCE, and reviewed the adopted therapeutic strategies.
Results: A 77-year-old man underwent subtotal colectomy with definitive ileostomy for severe steroid-refractory anti-TNF-alfa non-responsive UC. After surgery, he developed a severe PCE with high ileostomy fecal output, severe dehydration, and hydro-electrolyte imbalance. No clinical response was obtained with corticosteroids. Given patient’s frailty, his recent history of numerous severe infections, and his previous anti-TNF alpha failure, we opted for a rescue therapy with ustekinumab. No adverse events occurred. At four-months follow-up, a clinical, radiological and endoscopic response was reported. With regards to the systematic review, a total of 25 cases of definite PCE have been previously reported. Out of all, 20 cases were treated with corticosteroids, of which 4 needed a rescue 2^nd line therapy with infliximab or cyclosporine. Among the remaining 5 reported cases of PCE, infliximab or golimumab were used. Four patients underwent revisional surgery.
Conclusions: To our knowledge, this is the first PCE steroid-refractory case for which stekinumab proved to be safe and effective. Further research with larger number of cases is required to confirm the effectiveness of this therapeutic option.

Disclosure

Nothing to declare

Introduction

Pancreatobiliary disease during pregnancy, though uncommon, poses significant risks. Gallstone-related disorders affect 3–12% of pregnancies and may progress to life-threatening complications such as cholangitis or biliary pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) is a highly effective therapeutic approach; however, concerns about foetal radiation exposure and procedure-related maternal complications limit its broader acceptance. There remains a need for rigorous real-world data on the safety and neonatal outcomes of ERCP during pregnancy.

Aims & Methods

This retrospective observational study aimed to evaluate the safety of ERCP in pregnant patients, focusing on two key outcomes:
(1) Maternal and foetal safety during and after the procedure, and
(2) Effectiveness of radiation-minimisation strategies, including fluoroscopy reduction and abdominal shielding.
We reviewed 25 pregnant patients undergoing ERCP at a tertiary referral centre. Indications included choledocholithiasis (84%), cholangitis (4%), biliary pancreatitis (4%), and stent management (8%). Mean maternal age was 19.2 years; mean gestational age at ERCP was 28.3 weeks. Fluoroscopy usage, post-ERCP complications, Apgar scores, and neonatal follow-up at day 30 were recorded. Fluoroscopy-minimising techniques included suction-verification of bile and stent release without imaging.

Results

No maternal or foetal adverse events occurred peri- or post-procedure. ERCP was performed successfully in all 25 patients, with 23 (92%) undergoing sphincterotomy. Fluoroscopy was utilised in 20 cases (80%), with lead shielding employed in all. In five cases (20%), ERCP was conducted without fluoroscopy by using alternative bile verification techniques. Apgar scores ranged from 7 to 10, and all neonates exhibited normal development at 30-day follow-up.

Conclusion

This study confirms that ERCP can be safely performed during pregnancy when executed by skilled endoscopists adhering to radiation-limiting protocols. Fluoroscopy-free ERCP appears feasible in selected cases, significantly reducing foetal radiation exposure without compromising efficacy. Our findings support ERCP as a viable and safe therapeutic option in pregnant patients with biliary obstruction, providing novel evidence for the growing implementation of protective strategies and alternative imaging techniques in high-risk obstetric settings.

References

• Cappell MS, Friedel D. The role of endoscopy in pregnant and lactating women. Gastrointest Endosc Clin N Am. 2020;30(1):69–95.

• Lee SH, et al. Safety of ERCP during pregnancy: systematic review. World J Gastroenterol. 2009;15(4):357–64.

• Ko CW, et al. Complications of ERCP: a prospective study. Gastrointest Endosc. 2007;66(5):1114–9

Introduction

Functional defecation disorders are causes of obstructive defecation due to alteration in the coordination of abdominal contraction and anal relaxation. Four manometric patterns of dyssynergic defecation (DD) have been described, such that in type I and III there is an alteration of anal relaxation with adequate rectal propulsion, and in types II and IV rectal propulsion fails. According to the Rome IV criteria, the diagnosis of DD requires confirmation with two tests of anorectal function, with the most commonly used being high-resolution anorectal manometry (HRAM) and the balloon expulsion test (BET). Within the manometric parameters, the rectoanal gradient (RAG) appears to be the most useful.

Aims & Methods

To evaluate the clinical characteristics of patients according to patterns of DD defecation and to establish the cutoff point of the RAG and relaxation percentage (RP) that allows predicting balloon expulsion or not.
A total of 960 high-resolution anorectal manometries (HRAMs) performed from January 2021 to April 2024 were reviewed, including 337 patients with DD (35%). Prior to performing the HRAM, epidemiological and clinical data of the patients were collected. Although retrospectively reviewed, all data were prospectively collected. HRAM was performed with solid-state catheters (Medtronic). For BET a balloon (Matla Systems S.L) was filled with 50 mL of water was used under conditions of privacy while sitting on a toilet. Values of 60 seconds or less were considered normal.

Results

Included were 337 patients with a mean age of 61.7 ± 13.9 years. Among them, 226 (67.1%) were female. The diagnosis of DD was confirmed with an altered BET in 96 (28.5%) of the patients. In the remaining cases, the diagnosis of DD was inconclusive.
The epidemiological and clinical characteristics are described in table 1. The presence of associated structural causes was observed in all groups: 102 cases (42.7%) in types I-III; and 52 patients (53.6%) in types II-IV. The frequency for rectal hyposensitivity was 47.5%, and it was similar in both groups: 112 cases (46,6%) in types I-III, and in 48 cases (49,5%) in types II-IV.
The Area Under the Curve (AUC) for RAG was 0.738 (95% CI 0.682 - 0.794), identifying a cut-off value for RAG of -34.1 with an estimated sensitivity of 81.3% and specificity of 57.3% (figure 1). The AUC for RP was 0.544 with a cutoff point of 5.5% (95% CI 0.476 - 0.611), demonstrating low sensitivity (62,5%) and specificity (52,7%) (figure 2).

Conclusion

The frequency of DD diagnosed by HRAM is high (35% in our series), being more common in women. The high coexistence of structural causes, which can give a false manometric pattern of DD, is noteworthy. In types II and IV (rectal propulsion disorders), the diagnosis was confirmed by the failure to expel the balloon more frequently than in types I and III. Rectal hyposensitivity is very frequent in these patients. So far, the Rectoanal Gradient (RAG) is the best parameter of HRAM to evaluate DD. A value below -34 mmHg allows reasonably discriminating whether patients will expel the balloon or not.

Disclosure

No conflict of interests