Introduction

Esophageal food bolus obstruction (FBO) is a common presentation to Emergency Departments worldwide¹. There remains a paucity of data relating to efficacy of pre-endoscopic and endoscopic management resulting in a wide variety of clinical practice. Consensus guidelines do not advocate strongly for pre-endoscopic medications however they remain commonly used^2,3. This study evaluated the safety and efficacy of pre-endoscopic and endoscopic treatment in successful clearance of FBO and assessed the prevalence of underlying esophageal pathology.

Aims & Methods

ICD-10 codes retrospectively identified adult patients ≥18 years admitted to the Monash Health network (Melbourne, Australia) with esophageal FBO from 2010 to 2021. Medical records were reviewed to determine baseline characteristics, medical and endoscopic treatments and outcomes. Pre-endoscopic therapies included glucagon, glyceryl trinitrate (GTN), buscopan and Coca Cola. Multivariable analysis was performed to determine factors associated with pre-endoscopic clearance of FBO.

Results

608 patients were included. The median age was 56 years (IQR 39 – 71) and 405 (66.6%) were male. A prior history of FBO was noted in 228 (37.5%) patients, 110 (18.1%) had gastro-oesophageal reflux disease, 71 (11.7%) had dysphagia and 51 (8.4%) had a history of esophageal strictures. Inability to swallow saliva was noted in 296 (49.7%) patients at presentation.
Pre-endoscopic therapy was administered to 389 (64.0%) patients with a mean of 2 medications prescribed. Glucagon (47.4%), GTN (37.2%) and Coca Cola (36.3%) were most commonly administered. Successful FBO clearance was documented in 36.8% patients receiving medical therapy (glucagon 35.1%, GTN 36.2%, Coca Cola 38.0%); no individual medication significantly reduced the need for endoscopic intervention. Multi-variable analysis demonstrated that tolerating saliva (OR 1.95, p=0.025) and liquids (OR 2.28, p=0.001) significantly predicted spontaneous resolution of the EFBO without endoscopy.
474 (78.0%) patients proceeded to endoscopy. Median time to endoscopy was 14 hours (IQR 6 – 16) with 36.1% patients intubated for the procedure. The FBO was most commonly located in the lower esophagus (32.7%). The most common endoscopic findings were esophagitis (30.2%) and peptic ulcer disease (18.8%), with 3 (0.6%) malignancies identified. Endoscopic complications occurred in 35 (7.4%) patients (partial esophageal tear (n=24), aspiration pneumonia (n=5)). At endoscopy, a cause for the FBO was found in 130 (27.4%) patients, most commonly due to esophageal strictures (13.9%), eosinophilic esophagitis (11.2%) and Schatzki rings (9.1%). Esophageal biopsies were taken in 155 (32.7%) patients, of which 34.2% reached the diagnostic criteria for eosinophilic esophagitis.

Conclusion

Despite limited evidence, pre-endoscopic medical treatment of FBO is safe, commonly utilised, and results in spontaneous clearance in 36.8% patients. Patients’ clinical symptoms, in particular the ability to tolerate saliva or liquids, is the best predictor for spontaneous FBO clearance. Endoscopy remains highly effective and has a low complication rate.

References

1. Longstreth GF, Longstreth KJ, Yao JF. Esophageal food impaction: Epidemiology and therapy. A retrospective, observational study. Gastrointest Endosc. 2001;53(2):193-198. doi:10.1067/mge.2001.112709
2. Ikenberry SO, Jue TL, Anderson MA, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6):1085-1091. doi:10.1016/j.gie.2010.11.010
3. Birk M, Bauerfeind P, Deprez P, et al. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016;48(05):489-496. doi:10.1055/s-0042-100456

Introduction

The impact of achieving endoscopic remission in ulcerative proctitis (UP) is unclear. The preferred long-term treatment goal in ulcerative colitis (UC) is achieving both the symptomatic resolution and endoscopic remission (ER),¹ which has been associated with reduced risk of complications, including colectomy.^2,3 UP is an anatomically limited form of UC, involving only the rectum. Unlike in extensive or left-sided UC, UP has not been associated with elevated colorectal cancer risk. Therefore, the achievement of endoscopic healing as compared to clinical remission in UP represents an uncertain therapeutic target.⁴

Aims & Methods

This study assessed the impact of achieving EH on subsequent outcomes in UP patients. This was a single-center retrospective cohort study including patients aged ≥ 18 with a confirmed diagnosis of UP based on clinical and endoscopic criteria. Included patients had at least two endoscopies and active endoscopic disease (Mayo endoscopy score [(MES) of 1, 2, or 3]) at the first (baseline) endoscopy. EH was defined as an MES of 0 or 1 at the second (follow-up) procedure. A minimum time of 1 month between scopes was required for inclusion. Descriptive statistics were used for baseline characteristics. The relationship of EH to IBD-related outcomes was assessed using univariate analysis (Pearson's Chi-squared test; Fisher's exact test; Welch Two Sample t-test) and we identified those independently associated with EH using multivariable logistic regression analysis (odds ratio with 95% confidence interval).

Results

Among 200 UP patients with baseline endoscopic activity, 109 patients (54.5%) achieved EH at follow-up. The median time from baseline to follow-up was 15 months (IQR: 6, 31). EH at follow-up was significantly associated with fewer IBD-related ED visits (healing: 8.3%, no healing: 21%) or hospitalizations (5.5% vs 18%) and fewer GI visits (mean: 8 [SD: 9], vs 17 [22]) after the second scope. Patients with EH were less likely to have iron deficiency anemia (IDA; 23% vs 41%), iron infusion (10% vs 25%), C. difficile infection (0.9% vs 6.6%), or to initiate a new biologic after relapse (15% vs 33%). Patients with EH also had a greater time to clinical relapse (650 days [730] vs 270 days [416]). In multivariable analysis, patients with mucosal healing had 68% lower odds of an IBD-related ED visit (OR: 0.32, 95% CI: 0.13, 0.73), 74% lower odds of IBD-related hospitalization (0.26 [0.09, 0.67]), and 64% lower odds of biologic initiation after relapse (0.36 [0.13, 0.95]) compared to patients with no mucosal healing, adjusting for the index MES score.

Conclusion

UP patients with endoscopic healing had less IBD-related healthcare utilization (ED visits, hospitalizations, GI visits), fewer IBD-related complications (IDA, iron infusion, C. difficile infection), and were less likely to escalate to biologics after relapse. Our findings suggest that using a treatment target of endoscopic healing is desirable in UP and shed light on its potential utility in preventing disease-related complications and improving long-term outcomes.

References

1. Peyrin-Biroulet L, Sandborn W, Sands BE, et al. Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE): Determining Therapeutic Goals for Treat-to-Target. Off J Am Coll Gastroenterol ACG. 2015;110(9):1324-1338. doi:10.1038/ajg.2015.233
2. Colombel JF, Rutgeerts P, Reinisch W, et al. Early Mucosal Healing With Infliximab Is Associated With Improved Long-term Clinical Outcomes in Ulcerative Colitis. Gastroenterology. 2011;141(4):1194-1201. doi:10.1053/j.gastro.2011.06.054
3. Impact of mucosal healing on long‐term outcomes in ulcerative colitis treated with infliximab: a multicenter experience - Laharie - 2013 - Alimentary Pharmacology & Therapeutics - Wiley Online Library. Accessed September 24, 2022. https://onlinelibrary.wiley.com/doi/full/10.1111/apt.12289
4. Zhou Q, Shen ZF, Wu B sheng, et al. Risk of Colorectal Cancer in Ulcerative Colitis Patients: A Systematic Review and Meta-Analysis. Gastroenterol Res Pract. 2019;2019:1-11. doi:10.1155/2019/5363261

Disclosure

E.L., A.A.: no conflicts of interest to disclose
R.B.: Consulting/Speaker: Janssen, Abbvie, Bristol Myers Squibb, Prometheus Laboratories, Pfizer, Takeda
R.L.: Consulting/Speaking Fees: Pfizer, Enzymetrics, Ancilia Biosciences. Grant Support: National Institute of Health (NIH)
E.S.: Consulting/Speaking Fees: AbbVie, Crohn’s and Colitis Foundation of America (CCFA), Entera Health, Evidera, GI Health Foundation, Janssen, Protagonist Therapeutics, Seres Health, Takeda Pharmaceuticals, Bristol Myers Squibb. Grant Support: Abbott (AbbVie), AstraZeneca, CCFA, Janssen Research & Development, Johns Hopkins University, National Institute of Diabetes and Digestive and Kidney (NIDDK), National Institute of Health (NIH), New York Crohn’s Foundation, Pfizer, UCB, UCSF–CCFA Clinical Research Alliance, Genentech, Seres Therapeutics, Celgen. R.B.: Consulting: Prometheus
D.L.: Consulting/Speaking Fees: Abbvie, Boehringer Ingelheim, Eli Lilly, Fresenius Kabi, Janssen, Palatin, Pfizer, Prometheus Biosciences, Takeda; Grants: Abbvie, Janssen, Takeda

Introduction

Multiple treatment choices are available for patients with either Ulcerative Colitis (UC) or Crohn’s Disease (CD) requiring a first biologic therapy, but there is very limited data on comparative efficacy of different agents. Outcomes from robust, large-scale cohort studies can help to inform therapeutic decisions.

Aims & Methods

To compare the efficacy of first line biologic therapies [infliximab (IFX), adalimumab (ADA), golimumab (GLM), vedolizumab (VDZ)] in biologic-naïve patients with UC and CD and enrolled in the UK Inflammatory Bowel Disease (IBD) BioResource. Patients receiving first-line tofacitinib and ustekinumab were excluded from the analysis due to low numbers. Demographic, disease, treatment and outcome data were retrieved. Inverse probability of treatment weighting (IPTW) was used to balance groups using a propensity score-weighting approach accounting for baseline patient or disease related clinical characteristics. Balancing success was assessed with standardized mean differences (SMDs). Effectiveness of treatment was based on persistence free of treatment discontinuation or treatment failure. Failure was defined as occurring if any of the following occurred: (a) clinician-recorded treatment failure (b)start of treatment with a different biologic drug (c)occurrence of resectional or defunctioning bowel surgery. We compared Kaplan Meier curves for treatment failure-free survival after IPTW and used a log rank test for differences between the groups.Cox proportionate hazard ratios (HR)were used for comparisons between treatments.

Results

In total, 12747 patients were included in the analysis (UC=3967, CD=8780). Over a four-year follow up period, treatment survival free of treatment failure or treatment escalation was significantly different between different treatment groups both in UC and CD (log rank p=0.007 and p=0.011 respectively). For UC, we found that VDZ was superior to all anti-TNF agents [vs GLM HR 3.4 (95% CIs 2.2-5.2), vs ADA HR 3.1 (95% CIs 2.1-4.5), vs IFX HR 1.9 (95% CIs 1.3-2.8), all p values <0.001]. When compared between anti-TNF agents IFX was superior to both ADA and GLM [vs ADA HR 1.6 (95% CIs 1.4-1.8), vs GLM HR 1.7 (95% CIs 1.3-2.2)] while no significant difference was detected when ADA and GLM were compared. For CD, IPTW did not achieve optimal balancing for baseline differences in the presence of perianal disease. Restricting analysis to the subgroup with the absence of perianal disease, we did not observe a significant difference in treatment outcomes.

Conclusion

Our study showed superiority of VDZ over anti-TNF agents in biologic naïve patients with UC. This is in accordance with, and extends the findings of, a prior head-to-head trial in UC comparing VDZ and ADA¹. In patients with luminal CD, no difference was detected between VDZ and anti-TNF agents. Our data offer guidance to physicians and patients as to relative drug efficacy for first line therapies in IBD.

References

1. Sands BE, Peyrin-Biroulet L, Loftus EV Jr, et al. Vedolizumab versus Adalimumab for Moderate-to-Severe Ulcerative Colitis. N Engl J Med. 2019;381(13):1215-1226. doi:10.1056/NEJMoa1905725