Gastrointestinal (GI) dysmotility disorders can be debilitating and their management challenging. Patients often require feeding tubes to support nutrition, which can be complicated by discomfort and/or displacement. Laparoscopically Assisted-Enteroscopically Positioned Jejunostomy Tube (LA-EPJT) insertion is a novel technique not previously described in GI literature. It involves enteroscopic insertion of a jejunostomy tube under direct laparoscopic vision and general anaesthesia. This study reviews the experience of LA-EPJT insertion for GI dysmotility disorders at a district hospital.
Methods
Endoscopy records were used to identify all patients who had undergone LA-EPJT insertion. Patient notes were reviewed to identify indications, previous tube requirements and outcomes.
Results
7 LA-EPJTs were placed between 2014 and 2017 (6 females; age 19–77; median 35; mean 43). Table 1 shows patient symptoms and indications for LA-EPJT insertion. No tubes migrated or were dislodged after insertion. 1/7 patients (14.3%) had early bleeding and tube-site infection. Perforation rates were 0%. 5/7 (71.4%) had initial pain with feeding after LA-EPJT insertion although this universally subsided, 1/7 (14.3%) had ongoing vomiting. 5/7 (71.4%) tubes remain in situ. 1 was replaced with a PEG-J to allow venting of intestinal contents, and 1 was removed and TPN commenced (psychological factors precluded continued tube-feeding).
Conclusions
This study suggests that LA-EPJTs are useful nutritional adjuncts for patients with GI dysmotility disorders. They are a more permanent solution, with little risk of migration. They appear to better control symptoms such as pain and vomiting than traditional tubes, and are simple to change. The procedure benefits from direct laparoscopic vision of the jejunum and therefore carries low perforation rates. Further studies are needed to assess long-term complications and efficacy of LA-EPJTs for symptom control and nutrition. However, this data is promising and GI centres could consider adoption of this novel technique for patients with GI dysmotility disorders. Previous non-pharmacological treatments and nutritional support utilised by patients are shown in table 2.
The association between primary sclerosing cholangitis (PSC) and ulcerative colitis (UC) is well recognised. The prevalence of PSC in patients with UC has been reported widely and ranges from 2.4% to 7.5%. The mean annual incidence rates were between 0.9 and 1.3 cases per 100 000 person years. Patients with UC may frequently be found to have abnormal liver biochemistry (LFTs) for numerous reasons although PSC is uncommon. Given the known increased risk of colorectal cancer in patients with both UC and PSC as well as cholangiocarcinoma, early recognition of PSC is crucial.
Methods
Aims: To identify known patients with UC from our clinic population who also had persistently elevated LFTs and to determine the extent to which the cause of the abnormal LFTs had been investigated.
Methods
A representative sample of patients with UC was identified from those who had contacted the nurse led IBD telephone help line at Gloucestershire Hospitals NHS Foundation Trust during September and October 2010. UC diagnosis was based on histology proven on biopsies including colectomy. Abnormal LFTs were defined as a persistent elevation above the local laboratory upper limit of normal (ALT >40 IU/l, ALP >200 IU/l, GGT >30 IU/l and bilirubin >17 mmol/l). The investigations performed to identify the cause of the abnormalities were noted.
Results
A total of 450 phone calls were made to the IBD help line during the study period. Of those, 82 patients with ulcerative colitis were identified. Of these, 15 patients (18.3%) had so far been found to have abnormal LFTs at some time during the course of their illness. Persistently abnormal LFTs were identified in 10 patients (12.2%). Of these 10, 6 (60%) had auto immune screen, four patients (40%) had viral hepatitis screen, four patients (40%) had a liver ultrasound, three patients (30%) had CT abdomen. Furthermore no patients had targeted investigations to exclude PSC such as a liver biopsy or magnetic resonance cholangiography.
Conclusion
Our results suggest that 12% of ulcerative colitis patients in our cohort had persistently abnormal liver function tests although none had had further investigations for PSC. Given expected prevalence data we could perhaps expect to see one patient with PSC in this cohort. The monitoring and following of LFTs in patients with UC should be part of standard follow-up procedures.
Competing interests
None declared.
References
1. Chapman R, Fevery J, Kalloo A, et al. Diagnosis and management of primary sclerosing cholangitis. Hepatology 2010;51:600–78. 2. Tishendorf JJW, Geier A, Trautwein C. Current diagnosis and management of primary sclerosing cholangitis. Liver Transplantation 2008;14:735–46.
Current medical options for patients with refractory steroid-dependent, chronic-active ulcerative colitis (UC) are limited. Immunosuppressants (IS) and biologics carry risks of severe side effects and patients may not respond. The efficacy of of Granulocyte, Monocyte/Macrophage adsorptive (GMA) apheresis with Adacolumn® is supported by an increasing number of randomised controlled trials. The present study intended to generate further data to document efficacy and identify subpopulations of refractory UC that may benefit from GMA apheresis.
Methods
This was an uncontrolled, open-label, multicenter trial conducted in the UK, France and Germany. Consecutive eligible patients (age >18 <75 years) with steroid-dependent active UC, a Rachmilewitz (CAI) index ≥6, an Endoscopic Activity Index (EAI) ≥4, and insufficient response or intolerance to IS and/or biologicals were included. Patients received at least 5 weekly GMA aphereses. Evaluation visits were planned at Week 12, 24 and 48. The primary endpoint was the remission rate (CAI ≤4) at Week 12 in the Intention-to-treat (ITT) population.
Results
We report interim results from the 12 Week visit. The ITT population comprised 84 enrolled and treated patients at cutoff date. At Week 12, 33 (39.3%) subjects had achieved remission. For 30 patients with prior failure of IS and/or biologicals, the remission rate was 30%. Secondary efficacy parameters were clinical response with reduction in CAI of ≥3 (47 or 55.9%), steroid-free remission (23%) and steroid-free response (36%). In remitters, EAI dropped from 8.2 to 4.4; in responders from 8.6 to 5.3. Quality of Life improved in parallel. Most subjects had Adverse Events (AEs) of mild or moderate intensity. Six (7.1%) of 85 subjects in the Safety Population experienced serious (SAEs), all in the treatment-emergent period; however none was considered related to study treatment. No new safety signals were seen.
Conclusion
This study describes a larger cohort of steroid-dependent moderate-severe active UC patients intolerant or refractory to IS and/or biologicals treated with GMA apheresis. Apheresis was safe and showed benefit in over half of these patients and remission in 39.3% at week 12. Leukocyte aphaeresis (Adacolumn) for IBD has been reviewed by NICE as suitable for carefully selected patients with IBD, and these results help define this sub-group. Further controlled studies are needed.
Summary Background : Oral aloe vera gel is widely used by patients with inflammatory bowel disease and is under therapeutic evaluation for this condition. Aim : To assess the effects of aloe vera in vitro on the production of reactive oxygen metabolites, eicosanoids and interleukin‐8, all of which may be pathogenic in inflammatory bowel disease. Methods : The anti‐oxidant activity of aloe vera was assessed in two cell‐free, radical‐generating systems and by the chemiluminescence of incubated colorectal mucosal biopsies. Eicosanoid production by biopsies and interleukin‐8 release by CaCo2 epithelial cells in the presence of aloe vera were measured by enzyme‐linked immunosorbent assay. Results : Aloe vera gel had a dose‐dependent inhibitory effect on reactive oxygen metabolite production; 50% inhibition occurred at 1 in 1000 dilution in the phycoerythrin assay and at 1 in 10–50 dilution with biopsies. Aloe vera inhibited the production of prostaglandin E 2 by 30% at 1 in 50 dilution ( P = 0.03), but had no effect on thromboxane B 2 production. The release of interleukin‐8 by CaCo2 cells fell by 20% ( P < 0.05) with aloe vera diluted at 1 in 100, but not at 1 in 10 or 1 in 1000 dilutions. Conclusion : The anti‐inflammatory actions of aloe vera gel in vitro provide support for the proposal that it may have a therapeutic effect in inflammatory bowel disease.
Alongside a thorough clinical assessment NICE clinical guideline 61 recommends that patients meeting diagnostic criteria for irritable bowel syndrome (IBS), as defined by the Rome III criteria, should undergo laboratory testing for inflammation (C-reactive peptide (CRP) and plasma viscosity (PV) or erythrocyte sedimentation rate (ESR)), full blood count (FBC) and antibody testing for coeliac disease to exclude non-organic pathology.1 Faecal calprotectin is a reliable and cost effective adjuvant test to help differentiate between functional and inflammatory bowel disease (IBD).2,3 Our aim was to assess local adherence to NICE guidelines on investigating patients who meet diagnostic criteria for IBS.
Methods
As part of a wider study into the use of faecal calprotectin as a diagnostic tool within Gloucestershire Hospitals NHS Foundation Trust, we interrogated clinic letters, endoscopy reports and pathology results for patients in whom a negative (<50 mg/g faeces) or intermediate (50–150 mg/g faeces) faecal calprotectin level had been measured between September 2014 and September 2015. In patients diagnosed with IBS, we identified which of CRP, PV/ESR, FBC and antibody testing for coeliac disease had been done prior to or concurrent with faecal calprotectin measurement.
Results
Of the 148 patients (age range: 16–81, median age: 35; 72% female) who satisfied inclusion criteria, 63.5% (n = 94) had not undergone at least one of the recommended laboratory tests around the time of faecal calprotectin measurement. PV/ESR had not been checked in a majority (54.1%). Notably, 7.4% of patients had never had coeliac serology checked, 72.7% of whom presented with a change in bowel habit.
Conclusion
Although clear guidance exists for the investigation of patients meeting diagnostic criteria for IBS and use of faecal calprotectin as a diagnostic tool, insufficient essential accessory investigations are being completed. This risks conditions such as IBD, gastrointestinal cancer and coeliac disease being misdiagnosed as IBS with significant implications for delays in management and ongoing avoidable morbidity. We are reviewing measures to improve local adherence to NICE guidance, and call on other Trusts nationally to reflect on their own practice.
References
1 Irritable bowel syndrome in adults: diagnosis and management. NICE guidelines [CG61]. Published: February 2008. 2 Konikoff MR, Denson LA. Role of faecal calprotectin as a biomarker of intestinal inflammation in inflammatory bowel disease. Inflammatory Bowel Diseases 2006;12(6):524–34. 3 Faecal calprotectin diagnostic tests for inflammatory diseases of the bowel. NICE diagnostics guidance [DG11]. Published: October 2013.
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