Introduction

Up to 30% of patients inflicted with acute severe ulcerative colitis (ASUC) requires an urgent colectomy during their inpatient stay¹, despite use of corticosteroid therapy. In younger population cohort, of which Ulcerative Colitis (UC) is fairly prevalent, the idea of having a colectomy with stoma formation does not constitute an ideal physical image, hence many prefer to be managed conservatively through medical therapy. The two options licensed for this purpose are infliximab and ciclosporin².

Aims & Methods

Our audit aims to look at the use of infliximab and ciclosporin to manage an ASUC and whether they result in long term remission and significant colon retention rate at 30 days and 1 year mark.
We carried out a retrospective audit on 74 patients who received said therapies between 2021 to 2022 for ASUC. Subsequently we calculated the number of patients who required re-admission with flare-ups, the colon retention rate at 30 days and 1 year post therapy initiation, as well as the 30 days and 1 year mortality rate as a direct or indirect result of said therapies (we defined this as evidence of clinically immunosuppressive state leading to severe sepsis).

Results

There are only 6 patients in total (8.69%) who were given ciclosporin to treat an ASUC episode as compared to infliximab, which forms the majority of the population (68 patients). All of them were commenced in an inpatient setting . On top of that, they failed to improve despite this and subsequently required a form of rescue colectomy. Of these, 5 required ciclosporin as the second line treatment following failed primary therapy with infliximab, going by the recommendation by the BSG Guideline.
Among those who were prescribed infliximab, 32 (47.1%) requires initiation as inpatient (IP) as compared to 36 (52.9%) who commenced in an outpatient (OP) setting. Among those who requires IP initiation, we saw there is 84.4% complete colon retention rate at 1 year mark and 6.25% colon retention rate lasting less than 30 days and more than 30 days but less than 1 year respectively. 1 patient died within 1 year of receiving the scheduled infliximab therapy as a result of overwhelming chest sepsis, which may or may not be related to this. Most patients successfully avoided further flare up at 1 year mark post infliximab initiation (78.1%).
Further focusing onto infliximab therapy initiation as IP, 14 patients were co-prescribed purine analogues as compared to 18 who were not. All these 14 patients successfully avoided colectomy at 1 year mark as compared to 14 out 18 patients from the other group.
Accelerated infliximab therapy was trialled in 2 IP cases and they both demonstrated complete colon retention at 1 year mark, though we acknowledge that our data is too small to make any conclusive statement for or against this regime.

Conclusion

In summary, our data on colon retention rate, the survival rate and the need for re-admission demonstrated a strong case to advocate for biological therapy as a mean to avoid colectomy and re-admission in those with ASUC. The rate of colectomy in the calcineurin inhibitor group is high but we must note that their ASUC severity is higher as they failed to respond to the 1st line treatment to begin with. No difference in outcome was seen in the accelerated regime group, but co-prescription of purine analogues appears to be protective.

References

1. Berinstein JA, Sheehan JL, Dias M, Berinstein EM, Steiner CA, Johnson LA, Regal RE, Allen JI, Cushing KC, Stidham RW, Bishu S, Kinnucan JAR, Cohen-Mekelburg SA, Waljee AK, Higgins PDR. Tofacitinib for Biologic-Experienced Hospitalized Patients With Acute Severe Ulcerative Colitis: A Retrospective Case-Control Study. Clin Gastroenterol Hepatol. 2021 Oct;19(10):2112-2120.e1. doi: 10.1016/j.cgh.2021.05.038. Epub 2021 May 25. PMID: 34048936; PMCID: PMC8760630.
2. Mowat C, Cole A, Windsor A, Ahmad T, Arnott I, Driscoll R, Mitton S, Orchard T, Rutter M, Younge L, Lees C, Ho GT, Satsangi J, Bloom S; IBD Section of the British Society of Gastroenterology. Guidelines for the management of inflammatory bowel disease in adults. Gut. 2011 May;60(5):571-607. doi: 10.1136/gut.2010.224154. PMID: 21464096.

Clinical Case Summary

Our case study presents a 51-year-old female with a history of Short Bowel Syndrome (SBS) secondary to previous extensive bowel resection as a result of bowel ischemia. She presented as an emergency following a fall, sustaining a right-sided femoral fracture. She also exhibited altered mental status and slurred speech, which was initially thought to be a stroke. Physical examination, however, was unremarkable. Computed tomography (CT) of the head was normal. Laboratory testing revealed a high anion gap metabolic acidosis with normal lactate level and kidney function (lab results table will be inserted).

Initial treatment was commenced with intravenous 0.9% saline solution and her fractured femur was promptly operated on. Subsequently, she admitted to having consumed a high carbohydrate diet and regular alcohol intake for the past few weeks. On this basis, D-lactic acid assay was checked and was found to be markedly elevated. Diagnosis of D-lactic acidosis (D-LA) was made and she was treated with parenteral nutrition and hydration, correction of electrolyte imbalances, and oral Rifaximin. Specialist dietitian input was sought and she was subsequently commenced on low carbs diet and was warned against alcohol consumption. Remarkable improvement in her mental and physical status was achieved within 1 week.D-LA is a rare metabolic complication and should be considered in the differential diagnosis of patients with a history of SBS and altered mental status¹. It often mimics a neurological disorder hence diagnosing it in an acute setting can be challenging. This relates largely to colonic flora-driven anaerobic carbohydrates fermentation, releasing D-lactic acid (which is an enantiomer of L-lactic acid, a common compound of human metabolism) into the bloodstream². D-lactic acid is shown to accumulate in and damages the cerebellum³ in many case studies. Prompt recognition and early specialist dietitian input are key to avoid complications and improve outcomes.

References

1. Kowlgi NG, Chhabra L. D-lactic acidosis: an underrecognized complication of short bowel syndrome. Gastroenterol Res Pract. 2015;2015:476215. doi: 10.1155/2015/476215. Epub 2015 Apr 22. PMID: 25977687; PMCID: PMC4421027.
2. Sheedy, J. R., Wettenhall, R. E., Scanlon, D., Gooley, P. R., Lewis, D. P., Mcgregor, N., Stapleton, D. I., Butt, H. L., & Meirleir, K. L. D. (2009, July 1). Increased D-lactic acid intestinal bacteria in patients with chronic fatigue syndrome. In Vivo. Retrieved April 16, 2023, from https://iv.iiarjournals.org/content/23/4/621#ref-6.
3. N. Gurukripa Kowlgi, Lovely Chhabra, "D-Lactic Acidosis: An Underrecognized Complication of Short Bowel Syndrome", Gastroenterology Research and Practice, vol. 2015, Article ID 476215, 8 pages, 2015. https://doi.org/10.1155/2015/476215.

Introduction

Delayed bleeding after gastric endoscopic submucosal dissection (ESD) is one of the most frequent complications (up to 7%). The BEST-J score is a risk predictive model for delayed bleeding following gastric ESD. We aim to assess potential risk factors associated with bleeding and validate the BEST-J score in a population of patients undergoing ESD.

Aims & Methods

Prospective cohort study, single centre, of patients who underwent gastric ESD between 2017 and 2023. The characteristics of the lesion were evaluated, and logistic regression of risk factors associated with bleeding after ESD was performed. The BEST-J score was calculated for each patient and the discriminative ability was evaluated through the area under the receiver operating characteristic curve (AUC-ROC).

Results

Included 101 gastric ESDs (63.4% female), with a mean age of 69.7 ± 8 years. 17.8% of patients were on antiplatelet therapy and 13.9% were on anticoagulant therapy. Among the analyzed lesions: 43.6% measured between 0-20mm, 56.4% were ≥ 20mm; 13.9% were sessile, 60.4% flat, 14.9% depressed and 10.9% subepithelial; 22.8% were located in the cardia, fundus, or body, 17.8% in the incisura angularis and 59.4% in the antrum. The most frequent histological results were: 38.6% low-grade dysplasia, 26.7% high-grade dysplasia and 19.8% intramucosal adenocarcinoma. The mean procedure duration was 87±43 minutes. Delayed bleeding after ESD occurred in 5.9% (n=6) of cases. In the univariate analysis of risk factors, the lesion size ≥ 20mm showed statistical significance (10.5% vs. 0%; p=0.034), but not the location in the antrum (6.7% vs. 4.9%; p=0.5), lesion nature (7.1% vs. 8.2% vs. 0% vs. 0%; p=0.5) or procedure duration ≥60 minutes (5% vs. 9.5%; p=0.3). The BEST-J score predicted the risk of delayed bleeding after gastric ESD with an AUC of 0.70 (95% CI: 0.53-0.87; p=0.1).

Conclusion

The use of bleeding predictive scores may be useful in identifying high-risk patients; in our series, the BEST-J score was not very effective, with only lesion size ≥ 20mm being a relevant factor for bleeding after ESD.

Introduction

Endoscopic resection of lesions involving the appendiceal orifice is an alternative to surgery. Long term outcomes have not been determined.

Aims & Methods

To determine the long-term efficacy and safety of endoscopic resection of appendiceal lesions.
Retrospective analysis of the endoscopic resection of lesions with appendiceal involvement was performed in seven centers in Spain between January 2016 and July 2022. The technical success rate (complete macroscopic resection at index procedure), recurrence rate and short- and long-term complications were evaluated, including delayed appendicitis with a clinical follow-up of at least 12 months. The intra-appendicular extension of the lesion was described as superficial (visible appendiceal margin) or deep (if it was not possible to determine the appendiceal margin of the lesion before resection) and the circumferential extension was described according to the affected percentage.

Results

98 lesions with appendiceal involvement were treated, 73 had a clinical follow-up >12 months with a median follow-up of 26 months ([IQR]16-37 months). There were 35 lesions with deep intra-appendicular involvement and 63 with superficial appendiceal involvement, 64 with a circumferential involvement ≥50%. The median size of the lesions was 20mm([IQR]10-30mm) and 19(19%) had previous manipulation. Underwater endoscopic mucosal resection (UEMR) was performed in 53% of the lesions (24% by underwater cap-suction pseudopolyp formation, CAP-UEMR) with a technical success of 93% (49% en bloc and 51% piecemeal).
Among these cases, there were 7 incomplete resection, with 3 patients undergoing surgery and the remaining 4 undergoing endoscopic treatment during a subsequent session. Within the entire cohort, there were 3 cases of malignant histology: one low-risk pT1 which underwent surgery resulting in no residual cancer and negative lymph nodes, another low-risk pT1a (which chose follow-up and experienced no recurrence), and a third with suspected incomplete resection and pT2 cancer, necessitating surgery.
There were 6 intraprocedural bleeding and 2 delayed bleeding, all managed endoscopically. 45 patients completed at least 12 months of endoscopic follow-up (median 18, [IQR] 8-29months), showing recurrence in 12 cases (6 lesions with deep intra-appendicular extension), 8 (67%) treated endoscopically. There was 1 case of intraprocedural perforation, managed endoscopically.
Surgery was needed during follow-up in 7 additional cases [recurrence=3; pT2 cancer =1; pT1a =1; appendicitis=2 (at 11 months and 56 months post-endoscopic resection)], in total 10 surgeries were needed in the entire cohort.

Table 1- Baseline characteristics of patients and resected lesions

Conclusion

The endoscopic management of lesions involving the appendix may indeed prove effective and safe after following a minimum follow-up of 12 months, offering a viable alternative to surgery. It is important to note that delayed-onset acute appendicitis, though rare can be observed beyond 11 months post-procedure, although a casual mechanism cannot be proven.

References

1. Ferlitsch M, Moss A, Hassan C, et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2017 Mar;49(3):270-297. doi: 10.1055/s-0043-102569. Epub 2017 Feb 17. PMID: 28212588.
2. Albéniz E, Pellisé M, Gimeno García AZ, et al; en nombre del Grupo Español de Resección Endoscópica de la Sociedad Española de Endoscopia Digestiva. Clinical guidelines for endoscopic mucosal resection of non-pedunculated colorectal lesions. Gastroenterol Hepatol. 2018 Mar;41(3):175-190. English, Spanish. doi: 10.1016/j.gastrohep.2017.08.013. Epub 2018 Feb 12. PMID: 29449039.
3. Mi Song E, Yang H, Jung Lee H, et al. Endoscopic Resection of Cecal Polyps Involving the Appendiceal Orifice: A KASID multicenter Study. Dig Dis Sci. 2017, 62, 3138–3148, DOI: 10.1007/s10620-017-4760-2.
4. Jacob H, Toyonaga T, Ohara Y, et al. Endoscopic submucosa dissection of cecal lesions in proximity to the appendiceal orifice. Endoscopy, 2016. 48(09): v23-v23. DOI:10.1055/S-0042-110396.
5. Schmidt A. Lesions at the appendiceal orifice- the Achilles’heel of endoscopic resection? Endoscopy, 2022. 54(01): 25-26
   DOI: 10.1055/a-1686-8800
6. Patel AP, Khalaf MA, Riojas-barrett M, et al. Expanding endoscopic boundaries: Endoscopic resection of large appendiceal orifice polyps with endoscopic mucosal resection and endoscopic submucosal dissection. World J Gastrointest Endoscp 2023, 15(5):386-396. DOI: 10.4253/wjge.v15.i5.386.

Disclosure

Dr Hugo Uchima collaborates as proctor with Erbe Spain and Olympus Iberia. Has received congress registration from Casen Recordati.

Introduction

Endoscopic submucosal dissection (ESD) is the first-line treatment for superficial gastric lesions with a negligible or very low risk of lymph node metastasis. However, a permanent risk of developing metachronous lesions persists. We intend to analyze the risk factors associated with the development of metachronous lesions in a population of patients undergoing ESD.

Aims & Methods

Prospective cohort study conducted at a single centre, involving patients who underwent gastric ESD for lesions between 2017 and 2023, with a follow-up period of ≥ 6 months. Lesion characteristics were analyzed, including the rate of metachronous lesions, and logistic regression was performed to identify risk factors associated with the development of metachronous lesions.

Results

Included 78 ESDs performed on gastric epithelial lesions (59% female), with a mean age of 70.3±7.9 years. Regarding family history of gastric adenocarcinoma, 17.9% of patients had a first-degree relative. Among the analyzed lesions: 42.3% measured between 0-20mm, 57.7% ≥ 20mm; 12.8% were sessile, 71.8% flat and 15.4% depressed; 19.2% were located in the cardia, fundus or body, 21.8% in the incisura angularis and 59% in the antrum. Regarding histological findings: 42.3% low-grade dysplasia, 30.8% high-grade dysplasia, 23.1% intramucosal adenocarcinoma and 3.8% adenocarcinoma with submucosal invasion. Nine metachronous lesions (11.5%) were detected, with a median time of occurrence of 24 [13-32] months. In the analysis of risk factors, statistical significance was found for location outside the antrum (21.6% vs. 1.9%; p=0.002) and the presence of adenocarcinoma (23.8% vs. 7%; p=0.039), but not for size ≥20mm (13.7% vs. 5.1%; p=0.178) or ulceration of the lesion (9.1% vs. 10.1%; p=0.915). Logistic regression analysis revealed that only location outside the antrum had a significant risk for the development of metachronous lesions (OR 13.4; 95% CI: 1.4-127.1).

Conclusion

Given the permanent risk of developing metachronous lesions, the identification of associated risk factors is important as it may eventually allow for the adaptation of surveillance programs.

Introduction

Endoscopic submucosal dissection (ESD) is a widely used and effective treatment modality for colonic neoplasm, such as lateral spreading tumors or early colorectal cancer. However, ESD can cause several procedure-related complications. Coagulation syndrome (CS) is one of the common complications described as localized abdominal pain, fever, and leukocytosis after ESD temporarily.

Aims & Methods

This study aims to evaluate the effect of reducing the incidence of CS by administering UI-EWD after ESD and the practicability and safety of applying UI-EWD to post-ESD ulcer sites. CS occurs more frequently when a tumor size ≥20 mm and a lesion located in the left side colon. This study was conducted retrospectively on 79 consecutive patients were treated with ESD between November 2022 and January 2024. We evaluated the rate of CS and the rate of bleeding within 30 days. CS was defined as localized abdominal pain and fever at the ESD site that occurred within 3 days of ESD without perforation.

Results

The total incidence of CS in enrolled patients with CS high risk is large colorectal tumor is 21.5% (14/65). The incidence of CS after ESD was statistically significantly lower in patients who applied UI-EWD. (0% (0/14) vs 27.5% (14/51), p=0.029) The rebleeding rate within 30 days was not observed in the UI-EWD application group, but there was no statistically significant difference. (0% (0/14) vs 9.8% (5/51), p=0.347) No UI-EWD-related adverse events were observed.

Conclusion

Less CS was observed in the UI-EWD group. It was suggested that the application of UI-EWD after colon ESD in CS high-risk group has a good association with a decrease in CS occurrence. To obtain significant information on the performance of UI-EWD in a decrease of CS, a well-designed, large-scale, randomized control study is needed.

References

1) Arimoto, Jun, et al. "Risk factors for post-colorectal endoscopic submucosal dissection (ESD) coagulation syndrome: a multicenter, prospective, observational study." Endoscopy international open 6.03 (2018): E342-E349.\
2) Hong, Mi Jin, et al. "Prevalence and clinical features of coagulation syndrome after endoscopic submucosal dissection for colorectal neoplasms." Digestive diseases and sciences 60 (2015): 211-216.