Introduction

Motorized Spiral Enteroscopy (MSE) reduces procedure time and increases insertion depth into the small bowel. MSE has shown to be safe and effective for deep enteroscopy in studies performed at expert centers in patients with and without prior abdominal surgery.
Here we present data on our first 250 MSE procedures, focusing on the safety profile using the MSE for various diagnostic and therapeutic small bowel examinations.

Aims & Methods

Data on safety were collected retrospectively on patients who underwent MSE with an indication for deep small bowel enteroscopy.
Adverse events (AEs) were recorded during and after the procedure within a 30-day follow-up period. AEs were classified as minor or serious AEs (SAEs). Minor events included: mucosal abrasions or superficial lacerations in the small bowel, stomach, esophagus, or colon; a sore throat of less than 72 hours duration; abdominal discomfort lasting less than 48 hours, and mild nausea or vomiting not requiring hospital admission. SAEs included perforation, significant bleeding requiring blood products, pancreatitis, or unplanned hospital admission related to the procedure.

Results

A total of 240 patients (150 M/90 F; median age 66 years, range 23–91) were included. Between March 2020 and March 2023, these patients underwent a total of 250 procedures in a single center. 20% of patients had previous abdominal operations or surgically-altered GI anatomy. The American Society of Anesthesiologists score (ASA score) was: ASA 1 [33 (14%)], ASA 2 [159 (66%)], ASA 3 [48 (20%)]. All procedures were performed under propofol sedation without endotracheal intubation.
Enteroscopy procedures were either antegrade only (80), retrograde only (20), or bidirectional in one session (150). In other words, a total of 230 and 170 procedures via antegrade and retrograde routes were performed, respectively.
Total (pan)-enteroscopy in one session was achieved in 70% of intended procedures, either exclusively antegrade or bi-directional.
The following interventions were performed: hemostasis using APC and/or hemoclips (90; 36%), balloon dilatation of strictures (13; 5%), EMR polypectomies (4; 1.6%), and VCE retrieval (3; 1.2%).
A total of 44 (17.6%) adverse events were documented; 40 (16%) were minor, while SAEs occurred in 3 (1.2%) patients. No significant hemodynamic changes were observed. Except for those 3 SAE, no other patient required hospital admission, a blood transfusion, or other interventions. No special care was needed for the mucosal damages observed during MSE. Previous operations or altered GI anatomy did not increase the risk of complications. An overview of the adverse events is given in the table.

Conclusion

This retrospective data show that MSE is a safe procedure in a large cohort of patients. Previous abdominal operations and an altered GI anatomy did not increase the risk of complications. Although progress of the enteroscope may be slower in postoperative situations, this did not translate into an increased risk of adverse events.
Meticulous adherence to procedural safety instructions and careful patient selection are necessary to achieve optimal results and decrease the incidence of serious adverse events.

Clinical Case Summary

A 39-year-old woman was admitted on June 20, 2024, with a right middle cerebral artery stroke, nine weeks after starting Upadacitinib for ulcerative colitis. She presented with dysarthria, dysphagia, and severe left-sided weakness. CT imaging revealed a wedge-shaped infarction without intracranial hemorrhage (CT head/ Brain MRI).
She was diagnosed with ulcerative colitis in November 2023, she initially responded to Mezavent and steroids but was hospitalized on March 31, 2024 for moderate UC flare, requiring infliximab rescue therapy. The patient presented with four bloody bowel movements and elevated inflammatory markers (CRP>100), confirmed by a Mayo score of 2 on flexible sigmoidoscopy and cytomegalovirus (CMV) infection was excluded. Clostridium difficile tests were negative twice and a CT scan revealed pancolitis. Despite minimal response to rescue therapy, she opted for medical treatment over colectomy.
On April 23, 2024, she began an eight-week induction of Upadacitinib 45 mg, which she tolerated well. However, on June 20, she developed sudden stroke symptoms while eating dinner, including difficulty swallowing, choking, left-sided weakness, and numbness. She had no vascular risk factors or family history of premature cardiovascular conditions. Lupus, and vasculitis work up were unremarkable and extensive thrombophilia screenings were all negative.
Discussion: Thrombosis in IBD patients can result from various potential causes. First of all, Inflammation and hypercoagulability, driven by elevated cytokines like TNF, interleukins, and CRP, activate the coagulation cascade, increasing thrombosis risk.
Conclusion: IBD is a known risk of thromboembolic disease, this risk increased during flare up will raise future research questions regarding extended anticoagulation prophylaxis during flare and uses of Jak stats inhibitor.

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Introduction

Patients with ulcerative colitis (UC) are at an increased risk of cytomegalovirus (CMV) infection. CMV infection in acute severe ulcerative colitis (ASUC) may worsen disease severity and clinical outcomes. Current guidelines recommend colonic biopsies for the exclusion of CMV in all patients with ASUC. One study found that CMV positivity in ASUC was associated with greater need for rescue therapy, longer hospital length of stay (LOS) and higher readmission rates but found no difference in rate of colectomy.¹ We aimed to investigate the impact of positive CMV result on clinical outcomes in patients presenting with ASUC.

Aims & Methods

A retrospective review included all ASUC presentations to a quaternary hospital over a 10-year period based on modified Truelove and Witts’ criteria. ASUC presentations were grouped based on CMV positivity as determined by colonic biopsy. Data on pre-admission medications was collected. Data was collected on rates of rescue therapy, referral to colorectal surgery, colectomy, total parenteral nutrition (TPN). Outcomes assessed included intensive care unit (ICU) admission, 30- and 90-day readmission rates, 30- and 90-day mortality rates and mean LOS.

Results

A total of 172 ASUC presentations were identified. Of these, 133 had available colonic biopsy CMV results. 11 patients (8%) had positive CMV. Positive CMV result was significantly associated with increased need for TPN (36% vs 11%, p=0.02), ICU admission (27% vs 5%, p=0.004) and referral to colorectal surgery (82% vs 43%, p=0.01). Patients with CMV had longer LOS (27.1±14.0 vs 11.0±7.4, p=0.003). There were no significant differences in rates of rescue therapy, inpatient colectomy, readmission or mortality rates. 9 of the patients (82%) were treated with ganciclovir or valganciclovir. Patients on maintenance advanced UC therapies, including biologics and small molecule inhibitors, had significantly higher rate of CMV (22% vs 5%, p=0.01). Biologic therapy alone was associated with higher rate of CMV (24% vs 7%, p=0.02), whereas small molecule inhibitor alone was not (p=0.6). Pre-admission use of 5-aminosalicylates, high dose steroids, thiopurines or combination therapies were not associated with CMV positivity.

Table 1: Comparison data of clinical outcomes in ASUC between patients with and without CMV positivity on colonic biopsy

Conclusion

Patients with CMV positive colonic biopsies tend to require more inpatient interventions, including increased need for TPN, ICU admission, referral to colorectal surgery and longer hospital length of stay. Despite more complex admission course of ASUC patients with concurrent CMV infection, these patients were not observed to have worse outcomes than those without CMV diagnosis. Maintenance biologic and small molecule inhibitor use was associated with higher rates of CMV, reflecting the immunosuppressant effects of advanced UC therapies. CMV detection needs to be considered as a potential exacerbating factor in disease severity.

References

1. Huang D, Rennie M, Krasovec A, Nagubandi S, Liu S, Ge E, Khehra B, Au M, Sivagnanam S, Kwan V, Rogge C, Mitrev N, Kariyawasam V. Impact of cytomegalovirus on outcomes in acute severe ulcerative colitis: a retrospective observational study. Ther Adv Chronic Dis. 2024 Mar 28;15:20406223241233203. doi: 10.1177/20406223241233203. PMID: 38560721; PMCID: PMC10981253.