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.

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

Coeliac disease (CeD) is an autoimmune condition affecting the small intestine. Research has shown a likely bidirectional association between CeD and Inflammatory Bowel Disease (IBD)¹.

Aims & Methods

Our aim is to retrospectively assess whether patients with IBD are screened for CeD in Malta.
284 patients with a histological diagnosis of IBD were randomly selected from the hospital IBD pool. They were grouped into those receiving biological therapy and those solely on immunomodulators. Data collected included age, sex and whether coeliac serology (TTG – IgA or EMA) and/or duodenal biopsies were taken and whether the results were compatible with a diagnosis of CeD.

Results

From 284 patients (58.1% male, mean age 44.5 years SD=16.4). 58.5% had Crohn’s disease, 41.5% had Ulcerative Colitis. 65.1%(n=185) were on biological treatment (Infliximab=21.5%, Adalimumab=22.2%, Vedolizumab=17.6%, Ustekinumab=3.9%).
Out of all patients, 79.9%(n=227) underwent CeD immunology tests either at the time of diagnosis or during follow-up, with no difference in gender (p=0.79) or IBD subtype (p=0.32) whether serology was taken or not. Among them, five patients (2.2%) tested positive for coeliac antibodies. However, only three of these individuals proceeded to have duodenal biopsies performed. One of these patient’s biopsies yielded results consistent with Coeliac disease. All these five patients had repeat TTGs, while four of them had DEXA scan performed. 3 patients with positive CeD serology had small bowel imaging. 33.5% of IBD patients had duodenal biopsies taken during upper GI endoscopy.

Conclusion

It's reassuring to observe that a significant majority (79.9%) of patients with IBD underwent testing for CeD. However, despite consistent follow-up in gastroenterology clinics, one-fifth of IBD patients in our cohort were never tested. Our findings reveal a local incidence of CeD in IBD of 0.4%, which is slightly lower than the reported 0.75% [1]. This underscores the significance of considering CeD as a potential pathology that may contribute to ongoing symptoms and abnormal blood test results in IBD patients.

References

[1] Pinto-Sanchez MI, Seiler CL, Santesso N, Alaedini A, Semrad C, Lee AR, Bercik P, Lebwohl B, Leffler DA, Kelly CP, Moayyedi P, Green PH, Verdu EF. Association Between Inflammatory Bowel Diseases and Celiac Disease: A Systematic Review and Meta-Analysis. Gastroenterology. 2020 Sep;159(3):884-903.e31. doi: 10.1053/j.gastro.2020.05.016. Epub 2020 May 13. PMID: 32416141.

Disclosure

No disclosures or Conflict of Interest.

Introduction

MASLD patients is increasing worldwide and the clinical outcomes of different phenotypes had shown varied especially the occurrence of of liver related events (LRE) or major cardiovascular events (MACE)(Eslam M, et al. Hepato Inter 2020, 14:889–919) In addition, the prognostic factors for LRE. or MACE. are not well studied.

Aims & Methods

Aims: We aimed to study the rate of LRE. or MACE and the predictors for LRE. Or MACE. in MASLD patients with liver biopsy proven.
Methods: In a single-tertiary-center prospective cohort, we collected data of MASLD patients with biopsy-proven who were followed up of at least 1 years at King Chulalongkorn Memorial Hospital during 2005-2022. The primary outcome was the presence of LRE. or MACE. which included cirrhotic complications: acute decompensations; EV/GV bleeding, ascites, hepatic encephalopathy or HCC or acute complications requiring liver transplantation or death. MACE was defined by the occurrence of stroke or acute coronary disease or myocardial infarction. Related baseline characteristics, LSM, FIB-4, and liver biopsy were collected.

Results

Among 286 MASLD patients, the MASLD patients with mean age of 50.1 +/- 14.5 years old (range 19-80 yr.) Male and female were 44% and 56 % respectively. MASLD patients were categorized into 3 groups which were type 2 diabetes mellitus (T2DM) in 119 (41.6%), overweight or obese group in 149 (52.1%), and lean MASLD (BMI<23) in 18 (6.3%). Their baseline characteristics were shown in Table 1.
The average BMI was 41.3 kg/m² (range 19.1-88.7). Other metabolic abnormalities were hypertension in 165 (57.7%), and dyslipidemia in 157 (54.9%). There were 6 cirrhotic cases (2.1%) at diagnosis. Presence of advanced liver fibrosis (TE>12KPA) was found in 15 cases (5.2%). After a mean follow-up of 9.5 years (range 1-19); there were 11 cases (3.8%) developed coronary artery disease and 3 cases (1%) developed stroke. LRE. were present in 7 cases (2.4%) which included acute decompensation (3 cases; 1%), HCC (3 cases; 1%), and death (1 cases; 0.3%). The overall complications of LRE. or MACE. were present in 16 cases (5.6%). By using multivariate analysis, the predictors of LRE. or MACE. were in presence of hypertriglyceridemia (aOR 1.01 (1.00-1.01); p =0.002) and older age (aOR 1.06 (1.01-1.11); p =0.023).

Conclusion

The overall complication of LRE. or MACE. was not uncommon (5.6% of this cohort with a mean follow-up of 9.5 years). Older age and hypertriglyceridemia were predictors of LRE. or MACE. occurrence.

References

Eslam M, et al. Hepato Inter 2020, 14:889–919.

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.