Introduction

The first-line treatment for patients hospitalized with Acute severe ulcerative colitis (ASUC) is intravenous corticosteroid therapy, but 30% require second-line 'rescue' infliximab (IFX) therapy or colon resection due to incomplete response. Identifying patients with acute severe ulcerative colitis who are refractory to corticosteroid therapy remains challenging, as physicians have no markers to predict non-response to steroids on admission. This study aims to investigate whether the CRP/albumin ratio on days 1 and 3 of hospitalization could predict early response to intravenous steroids.

Aims & Methods

Data from all admissions for acute severe ulcerative colitis over 4 years from January 2019 to December 2022 were retrospectively collected.
All patients initially received intravenous corticosteroids. Demographic, clinical, biological, and endoscopic data were collected; C-reactive protein (CRP) and albumin levels were recorded at baseline and during hospitalization. Receiver operating characteristic statistics were used to determine the optimal stool frequency, Lichtiger index, CRP, albumin, and CRP/albumin ratio (CAR) to predict steroid response.

Results

A total of 81 ASUC patients were admitted. Sixty-six patients (81.5%) were steroid responsive, 8 patients (10%) received rescue IFX and 7 patients (8.6%) required colectomy. By comparing two groups of patients (steroid-responsive and steroid-refractory), baseline stool frequency, Lichtiger index, CRP and CRP/Albumin ratio data didn’t show any significant difference between the two groups. While baseline albumin was lower in the steroid-refractory group (Median 26, IQR 18-36, p=0.041).
Day 3 stool frequency and Lichtiger index were significantly higher in the steroid refractory group (p<0.001).
By receiver operating characteristic statistics, day 3 CAR was a more accurate marker of steroid responsiveness than day 3 CRP or day 3 albumin alone [area under curve=0.911 (P<0.001)]. The optimal CAR to predict response to steroids on day 3 was 2.67 (sensitivity 80%, specificity 91%).

Conclusion

An elevated CRP and low albumin level on day 3 is an early predictor of steroid-refractory ASUC. When combined in a ratio, their predictive ability improves. In patients with predicted steroid nonresponse, early introduction of rescue IFX at this stage may be more effective, before serum albumin falls profoundly.

Introduction

Enteropathy Associated T Cell Lymphoma (EATL) is a rare and highly aggressive T-cell non-Hodgkin’s lymphoma (NHL)¹ that is strongly associated with refractory coeliac disease (RCD), particularly type 2 RCD ², and possibly inflammatory bowel disease (IBD). The incidence and prevalence of both coeliac disease³ and IBD⁴ have been rising around the world for several decades, including in both Englandand Denmark^​. Some of the potential drivers of EATL are the antigen-driven proliferation of intra-villous T-cells from coeliac disease and chronic inflammation in IBD, so it is important to understand if changes in these diseases are altering clinical presentations of EATL and its survival.

Aims & Methods

Our aim was to describe the contemporary incidence and survival of EATL from two European countries on a national scale, given the rising incidence and prevalence of coeliac disease and use of immunosuppression in inflammatory bowel disease, to give further insights into epidemiology of this rare and often fatal malignancy.
People with EATL were identified from national cancer registries from 2013-2019 in England and 2004-2020 in Denmark. Within each country we used direct standardisation to estimate incidence, Poisson regression to compare incidence between groups and Cox regression to assess overall survival.

Results

172 and 39 patients were identified in England (E) and Denmark (DK) respectively with a mean age at diagnosis of 66 and 68 years. Approximately half of all cases had coeliac disease (E 52%, DK 41%), and ~7% (E 6%, DK 8%) had inflammatory bowel disease (Table). The overall age-standardised incidence rate was (E) 0.48 (95% CI 0.41-0.56) and (DK) 0.44 (95% CI 0.30-0.58) per million population per year. In both countries incidence was higher in older age groups. The 5-year overall survival was 10% (95% CI: 6%-18%) in England and 20% (95% CI: 9%-33%) in Denmark. Those with coeliac disease fared better than those without: (adjusted Hazard Ratio E 0.65 (95% CI 0.45-0.93), DK 0.57 (95% CI 0.26-1.27)).

Table: Characteristics of people with EATL in England (2013-2019) and Denmark (2004-2020)

Conclusion

This analysis of two nationwide cancer registries is the largest population-based study to date to provide contemporary and comprehensive epidemiologic estimates of all ICD-O-3 coded EATL. It shows that a higher incidence is associated with older age, male sex (in England) and that half of cases also have coeliac disease. Our finding of the high proportion of people with inflammatory bowel disease compared to the background prevalence in both countries requires further investigation, as reasons for this are unclear, but it could be related to chronic inflammation or immunosuppression. Overall survival is poor and gets worse in older age groups but is better in those with coeliac disease, following surgical resection and those able to tolerate intensive therapies.

References

1. Ferreri AJ, Zinzani PL, Govi S, et al. Enteropathy-associated T-cell lymphoma. Crit Rev Oncol Hematol 2011;79:84-90.
2. Pelizzaro F, Marsilio I, Fassan M, et al. The Risk of Malignancies in Celiac Disease-A Literature Review. Cancers (Basel) 2021;13.
3. King JA, Jeong J, Underwood FE, et al. Incidence of Celiac Disease Is Increasing Over Time: A Systematic Review and Meta-analysis. Am J Gastroenterol 2020;115:507-525.
4. Ng SC, Shi HY, Hamidi N, et al. Worldwide incidence and prevalence of inflammatory bowel disease in the 21st century: a systematic review of population-based studies. Lancet 2017;390:2769-2778.

Introduction

Endoscopic suturing offers a novel minimally invasive technique for deploying full thickness sutures in the gastrointestinal (GI) tract. Indications range from defect closure, post operative leaks, fistula repair, stent fixation and tissue plication for endoscopic sleeve gastroplasty.
Here we report our updated experience of endoscopic suturing for non-bariatric applications in the upper GI tract using the Apollo OverStitch^TM device (Apollo Endosurgery, Austin, Texas). This represents the largest and most diverse case series in a UK cohort of patients.

Aims & Methods

We retrospectively evaluated cases where the Apollo OverStitch^TM device was used at our tertiary upper GI centre. The primary outcomes were immediate technical and clinical success. Technical success was defined as the successful application of sutures. Immediate clinical success was defined according to indication. For defect closure this was evaluated using on the table fluoroscopy/endoscopic visualisation. For stent fixation it was determined by the absence of stent migration at follow up endoscopy.
Secondary outcomes included defect recurrence at follow up investigation. We also evaluated long term clinical success by assessing for resolution of the index clinical issue at the time of latest follow up.

Results

The Apollo OverStitch ^TM device was used 56 times across 35 patients (57% female) between August 2018 and March 2023. The mean age of patients at the time of the index procedure was 58 (+/-17.3 years). Outcomes according to indication are highlighted below (Table 1).
There were five cases (5/56, 8.9%) of technical failure. Three (3/5, 60%) involved iatrogenic perforations at the junction between D1/D2. Three cases (3/37, 8.1%) of immediate clinical failure were reported for the defect closure cohort. In the defect closure cohort there was a recurrence rate of 61.8% (21/34), with a long term clinical success rate of 68.2% (15/22). 14 cases of stent fixation were conducted with a stent migration rate of 35.7% (5/14).
There were two (2/56, 3.6%) cases of bleeding following endoscopic suturing. In both cases bleeding was stemmed endoscopically on the table and prior to the end of the procedure.

Conclusion

Our case series suggests that the Apollo OverStitch^TM device can be used for a diverse range of indications with high rates of immediate technical and clinical success.
We note a high recurrence rate reflecting that many defects require repeat suturing attempts to achieve durable long term closure. We postulate that this may be related tissue epithelisation and/or friability impacting opposition. Furthermore, technical failure occurred most with perforations at the D1/D2 junction. This is likely related to acute angulation which impedes the ability to deploy sutures.
The heterogenous follow up data from this case series impacts the ability to draw firm conclusions regarding long term outcomes. There is an ongoing prospective multicentre registry which will assist in evaluating long term outcomes.

Clinical Case Summary

Introduction: Primary epiploic appendagitis (PEA) is a rare cause of acute abdominal pain. The clinical is non-specific, making the diagnosis difficult; hence the interest of CT scan. The preferred treatment is essentially medical.
Objectives: Focus on the particularities of this entity, which can mimic the picture of an acute surgical abdomen, in order to minimize the risk of an unnecessary surgery.
Materials and methods: We present a retrospective and descriptive study of 4 cases diagnosed with PEA, managed in the hepatogastroenterology department in collaboration with the visceral surgery department 2, during the year 2021.
Results:
- The average age of the patients was 50.75 years, with a male predominance.
- Obesity was a predisposing factor for PEA; three patients were overweight.
- The clinical picture was dominated by abdominal pain, found in all patients.
- Associated signs (nausea, vomiting, transit disorders) were rare or absent, found respectively in 2 patients and one patient.
- The clinical examination revealed abdominal tenderness in 3 patients, defensiveness in only one patient, and a temperature higher than 37.3 °Cin 3 patients.
- Laboratory examinations showed hyperleukocytosis in 2 patients and a moderate increase in C-reactive protein in 3 patients.
- CT scan was the key examination for the diagnosis of PEA, performed in all patients.
- Three patients benefited from conservative management, only one patient was operated on.
- The evolution was favorable; no case of recurrence or complication was noted.
Conclusion: PEA is a condition that should be kept in mind as it is managed medically and to spare patients unnecessary surgery or hospitalization.

Introduction

Double-headed capsules enable the non-invasive one-step endoscopic evaluation of both the small bowel and colon (pan-intestinal capsule endoscopy, PCE).

Aims & Methods

We aim to evaluate the diagnostic accuracy and safety of PCE vs. the current standard of care (conventional colonoscopy) as the first-line examination in patients with iron deficiency anaemia (IDA) and/or overt bleeding after a non-diagnostic upper endoscopy (suspected mid or lower gastrointestinal bleeding, MLGIB).
We conducted a prospective, single-centre, single-blinded cohort study including consecutive patients with suspected MLGIB. All patients were submitted to PCE, followed by same-day colonoscopy under deep sedation. The physicians performing PCE and conventional colonoscopies were independent and blinded to each other’s observations. The diagnostic yield for potentially haemorrhagic lesions (PHL) was compared for efficacy analysis, and adverse events were assessed for both examinations. The gold standard diagnosis was defined by consensus panel. This trial has been registered in ClinicalTrials.gov (ID NCT04782986).

Results

We included 100 consecutive patients with suspected MLGIB, mean age 66.5 (18-92) years, 65% female gender, presenting with IDA (81%) or overt bleeding (19%). Mean haemoglobin level was 8.4 (4.1-12.8) g/dL and 40% were inpatients. For PCE, the PillCam Crohn’s® capsule was used in 88 patients, and PillCam COLON® 2 in the remaining. Patients with overt bleeding performed PCE within 2 weeks in 70% of cases, 15% in the first 72h after the bleeding episode. PCE was complete in 76% of cases, vs. colonoscopy 95% (p<0.01). The quality of bowel preparation was adequate in 72% of PCE vs. 85% of colonoscopies (p=0.012). Overall, PHL were diagnosed, based on the combination of PCE + colonoscopy, in 46% of patients, corresponding to small bowel and/or colon angioectasias in more than two-thirds (69.6%) of cases. PHL were detected by both examinations in 13/46 (28.3%), only by colonoscopy in 3/46 (6.5%), and only by PCE in 30/46 (65.2%) of cases (p<0.01). Overall, colonoscopy detected PHL in 23% of the entire cohort, which means 50% (23/46) of all patients with PHL according to the consensus panel, while for PCE the overall diagnostic yield was 44%, meaning 95.7% (44/46) of all PHL (p<0.01). Considering the gold standard diagnosis for PHL, colonoscopy had a sensitivity of 23/46=50%, specificity 54/54=100%, positive predictive value (PPV) 23/23=100% and negative predictive value (NPV) 54/77=70,1%, while for PCE the sensitivity was 44/46=95.7%, specificity 54/54=100%, PPV 44/44=100% and NPV 54/56=96.4%. Thirty-one percent of patients had PHL accessible to ileocolonoscopy; in those cases, the PCE was able to make the diagnosis in 29/31 (93.5%) vs. conventional colonoscopy in 23/31 (74.2%) of cases, p<0.01. Regarding safety, no significant adverse events occurred with PCE, vs. 2% (cardiopulmonary) with conventional colonoscopy.

Conclusion

PCE is safe and more effective than conventional colonoscopy in identifying PHL both in the small bowel and the colon, and could be considered as a first-line examination in patients with IDA or overt bleeding after a non-diagnostic upper endoscopy. In more than half of patients with suspected MLGIB, PCE does not detect any PHL either in the small bowel or the colon, dismissing any further invasive endoscopic investigations.

Disclosure

Medtronic provided financial support to the acquisition of some of the capsules which were used in the trial