Management of pregnant women with inflammatory bowel disease (IBD) can be complex. Women often report getting conflicted information from different health care professionals and needing to attend too many hospital appointments. Following the success of other combined medical-obstetric clinics that were already running at Homerton hospital we set up a monthly IBD – obstetric clinic in January 2016. The aim of this study was to review the effect of this clinic on pregnancy outcomes.
Method
A retrospective review of patient records was performed to obtain patient demographics, medical, surgical and drug history, mode of delivery and birth weight from January 2016 to January 2018.
Results
A total of 45 pregnancies in 44 women were identified. 18 women have Crohn's disease (CD) and 26 ulcerative colitis (UC). Most women were on some treatment with only 4 being on none. 21 women were on 5-ASA (oral, topical or both). 7 women were on thiopurines. 8 women were on biologics (Infliximab 3, adalimumab 4, vedolizumab 1). 5 women were on biologics and thiopurines (3 adalimumab, 2 infliximab). Biologics were stopped at 28 weeks in 6/8 women, 1 woman stopped at 20 weeks and in one case it was necessary to continue Adalimumab throughout the pregnancy. 2 patients needed treatment with prednisolone due to flare up during pregnancy. One woman was diagnosed with UC during pregnancy and required prednisolone. One woman with severe perianal CD needed surgical drainage during pregnancy. All pregnancies resulted in live births. Mean birth weight was 3203 g. 7 women had emergency caesarean section (CS), 9 women elective CS and 5 had instrumental deliveries. The commonest indications for elective CS were obstetric or maternal choice and emergency CS foetal distress or failure to progress. There were 5 preterm deliveries (<37 weeks), 4 spontaneous, 1 emergency. There was one birth with severe intrauterine growth retardation (IUGR) secondary to a large placental haemorrhage at the beginning of the pregnancy and 1 duodenal atresia. One woman on infliximab and azathioprine developed listeria sepsis 10 days after the last infliximab infusion at 28 weeks. This was identified and treated appropriately, the pregnancy continued to term with no foetal complications. Average number of clinic visits was 3. There were a total of 115 appointments with a rising trend as the clinic became established and better known to GPs and midwives.
Conclusion
This study showed that a combined IBD-obstetric clinic improves adherence to treatment and guidelines with good pregnancy outcomes. Patient feedback is that they value this combined approach both in terms of the medical/obstetric expertise and in terms of convenience.
Acute physical stress causes alteration in gut autonomic function and visceral hypersensitivity in patients with irritable bowel syndrome (IBS). We have developed a model to measure this stress response.To assess whether treatment with a drug effective in treating IBS (amitriptyline) alters the response to acute stress in IBS patients.Nineteen patients with IBS were given amitriptyline 25-50 mg. Patients underwent physical stress (cold pressor) test at baseline and after 3 months of treatment. Physiological parameters measured were: stress perception; systemic autonomic tone [heart rate (HR) and blood pressure (BP)]; gut specific autonomic innervation [rectal mucosal blood flow (RMBF)] and visceral sensitivity (rectal electrosensitivity).Fourteen of 19 (74%) patients improved symptomatically after 3 months of amitriptyline. Acute stress induced increased perception of stress and systemic autonomic tone and reduced RMBF in symptomatic responders and nonresponders (P > 0.05 for all). All nonresponders but only 3 of 14 responders continued to exhibit stress-induced reduced pain threshold at 3 months (change from baseline -31% vs. +2%, P < 0.03 respectively).In this open study, amitriptyline appears to decrease stress-induced electrical hypersensitivity; this effect is independent of autonomic tone. The gut response to acute stress deserves further study as a model to study drug efficacy in IBS.
Systemic sclerosis is an autoimmune connective tissue disorder, which can be progressive with multisystem involvement. Guidance on the management of complications is based on a limited data set and practice amongst clinicians can vary. The UK Scleroderma study group set up several working groups to agree some consensus pathways for the management of specific complications. Approximately nine out of ten patients with systemic sclerosis will have involvement of the gastrointestinal system and in this review article we explore the management of these complications in a symptom-based approach. The algorithms are a useful tool for clinicians, which we hope, will be a point of reference and highlight the need for further research in these areas.
Introduction: Following British Society Gastroenterology (BSG) recommendations in March 2020 [1], UK endoscopy other than essential or emergency cases was paused during the first wave of the Covid-19 pandemic. This led to a significant backlog of patients waiting for endoscopy. At the end of April 2020 the BSG issued new guidance for safe resumption of endoscopy services [2]. Aims & Methods: The aim of this study was to describe how we managed the endoscopy backlog generated by the first wave of the Covid-19 pandemic in a Covid-minimised unit utilising BSG guidance [2]. We evaluated the impact of service suspension on backlog;recovery strategy, infection control policy, results of pre-procedure Covid-19 testing, and 7/14-day post-procedure Covid-19 symptom screening. Results: 937 elective procedures were cancelled between 23 March and June 2020. A vetting tool linked to the booking system was used to categorise these as High-risk 2-week wait (n=57), Defer 3 months (n=439), Defer 6 months (n=300), Defer 12 months (n=9), Surveillance (n=45), Discharge back to referrer (n=87). Elective procedures restarted on 8 June 2020. A single endoscopy room operated for the first 3 days, 2 rooms until 22 June, and subsequently all 3 rooms. Lists were initially booked with 50% reduction in volume compared to pre-Covid-19, to accommodate requirements for PPE, downtime and social distancing. We increased endoscopy administration from 2 to 5 staff, to implement 7-day pre-procedure 'SCOTS criteria' telephone screening, 3-day preprocedure Covid-19 PCR testing, and 7/14-day post-procedure telephone follow-up. We introduced outpatient information leaflets and consent forms regarding risk of Covid-19. Inpatient endoscopy was carried out in the operating theatre rather than endoscopy unit until the end of August. On 17 July we removed the requirement for downtime after lower GI endoscopy (following clarification that this was not considered 'aerosol generating') and increased lower GI endoscopy volume accordingly. Twice weekly evening lists resumed in August. From 1 August until 10 October we utilised weekend insourcing delivered by an agency endoscopy team. We trialed outsourcing of 2 lists per week to an independent provider for 4 weeks in August, but did not find this strategy effective. In September we increased to 5 evening lists per week. Additional Saturday lists were performed by 6 endoscopists made available through removal from the general internal medicine (GIM) rota. Through these measures we were able to clear our waiting list by mid-October. In mid-November we offered mutual aid to a neighbouring hospital with 2 lists per week. Between June and November we performed endoscopy in 3,481 outpatients. Each patient had pre-endoscopy Covid-19 testing and 20 (0.57%) were positive. 3,261 patients were called at day 7 and 14 post-endoscopy: 23 (0.71%) patients developed symptoms compatible with Covid-19 after 7 days and 29 (0.89%) after 14 days. Conclusion: We demonstrate effective clearance of the endoscopy backlog in a Covid-19 safe environment over 4 months, which exceeded the expected pace of recovery [3]. The key interventions were advance vetting of procedures, increased administrative support, an endoscopy unit located in a separate building, quick implementation of infection control policies, insourcing and freeing of endoscopists from the GIM rota. Learning points were underestimating burnout of endoscopy nursing staff returning from redeployment and the decreased endoscopy demand due to reduced referrals and patients' fear of attending hospital.
Background Ustekinumab is a recognised treatment for moderate-to-severe Crohn’s disease. We aimed to examine its effectiveness in an adult population in three London centres, and to identify patient, disease or drug-related factors associated with effectiveness. Methods A retrospective observational study on adults with Crohn’s disease prescribed Ustekinumab between 2017 and 2019. The primary outcome was clinical response at Week 12. Other outcomes included clinical response at Week 52, clinical remission at Weeks 12 and 52, disease activity on biochemical markers (CRP and faecal calprotectin), endoscopic remission (resolution of ulceration at ileocolonoscopy) and fistula improvement or closure in a subset of patients with perianal fistulising disease. Results A total of 134 patients with a median follow-up of 12 months. Clinical response and remission rates were 58% and 46% at 12 weeks and 64% and 57.5% at 52 weeks respectively. Median HBI score reduced from 9 to 5 at 12 weeks and to 4 at 52 weeks. Concomitant reduction in C-reactive protein and calprotectin and endoscopic healing or improvement (52%). Twelve per cent experienced at least one adverse event, 22% discontinued Ustekinumab and 31% required rescue therapy. Rescue therapy with corticosteroids was independently associated with short time to treatment discontinuation. Conclusion Clinical response and remission rates were comparable to other studies. Previous exposure to biologics and longer disease duration were associated with less favourable outcomes. Rescue therapy with corticosteroids was the only factor independently associated with treatment discontinuation. Future studies should examine outcomes of Ustekinumab prescribed early in the disease course.
Anti-TNF drugs, such as infliximab, are associated with attenuated antibody responses after SARS-CoV-2 vaccination. We aimed to determine how the anti-TNF drug infliximab and the anti-integrin drug vedolizumab affect vaccine-induced neutralising antibodies against highly transmissible omicron (B.1.1.529) BA.1, and BA.4 and BA.5 (hereafter BA.4/5) SARS-CoV-2 variants, which possess the ability to evade host immunity and, together with emerging sublineages, are now the dominating variants causing current waves of infection.
SSc is a connective tissue, multisystem disorder of unknown aetiology. The gastrointestinal tract (GIT) is affected in up to 90% of patients. The exact pathophysiology of GIT involvement is not known, but it is related to both neurogenic and myogenic abnormalities as well as possible vascular and ischaemic changes. Thinning of the internal anal sphincter (IAS) has been demonstrated in SSc with faecal incontinence. We aimed to investigate anal sphincter structure in patients with SSc.Forty-four SSc patients [24 symptomatic (Sx) and 20 asymptomatic (ASx)] and 20 incontinent controls (ICs) were studied. Patients underwent anorectal manometry and endoanal US.In the ICs, external anal sphincter defects were more common, but the IAS was less atrophic, evident by both atrophy scores and IAS thickness. There was no significant difference in atrophy scores [Sx: 2 (1.5-3) vs ASx: 2 (1-2)] or IAS thickness [Sx: 1.85 (1.5-2.3) vs ASx: 1.8 (1.7-2.25)] between the Sx and ASx SSc patients.Patients with SSc (both Sx and ASx) have thin and atrophic IAS, suggesting that IAS atrophy develops even in ASx patients and this may be amenable to treatment with sacral neuromodulation.
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