Background & Aims Crohn's disease often involves the terminal ileum (TI), but skipping of the distal TI can occur. This can lead to negative results from ileocolonoscopy. We analyzed advanced ...cross-sectional images to determine how frequently this occurs. Methods We analyzed data from 189 consecutive patients (55% women) with Crohn's disease, evaluated in 2009 by computed tomography enterography (CTE) and ileocolonoscopy. The discharge impression of the gastroenterologist who treated the patients was used as the reference standard for Crohn's disease activity. Results Of the patients evaluated, 153 underwent TI intubation during endoscopy; 67 of these (43.8%) had normal results from ileoscopy, based on endoscopic appearance. Despite their normal results from ileoscopy, 36 of these patients (53.7%) had active, small-bowel Crohn's disease. The ileum appeared normal at ileoscopy because the disease had skipped the distal ileum of 11 patients (30.6%), developed only in the intramural and mesenteric distal ileum of 23 patients (63.9%), and appeared only in the upper gastrointestinal region of 2 patients (5.6%). These patients had a shorter duration of disease (61.1% for less than 5 years) compared with those found to have Crohn's disease based on ileoscopy (41.1% for less than 5 years; P < .05). CTE detected extracolonic Crohn's disease in 26% of patients; 14% of patients were found to have disorders unrelated to inflammatory bowel disease that warranted further investigation or consultation (including 4 cancers). Conclusions Ileoscopy examination can miss Crohn's disease of the TI because the disease can skip the distal ileum or is confined to the intramural portion of the bowel wall and the mesentery. CTE complements ileocolonoscopy in assessing disease activity in patients with Crohn's disease.
Fecal calprotectin (FC) is a highly sensitive disease activity biomarker in inflammatory bowel disease. However, there are conflicting reports on whether the diagnostic accuracy in Crohn's disease is ...influenced by disease location. The aim of this study was to undertake a systematic review of the published literature. Relevant databases were searched from inception to November 8, 2016 for cohort and case control studies which had data on FC in patients with isolated small bowel (SB) and large bowel (LB) Crohn's disease. Reference standards for disease activity were endoscopy, magnetic resonance imaging, computed tomography or a combination of these. The QUADAS-2 research tool was used to assess the risk of bias. There were 5,619 records identified at initial search. The 2,098 duplicates were removed and 3,521 records screened. Sixty-one full text articles were assessed for eligibility and 16 studies were included in the final review with sensitivities and specificities per disease location available from 8 studies. Sensitivities of FC at SB and LB locations ranged from 42.9% to 100% and 66.7% to 100% respectively while corresponding specificities were 50% to 100% and 28.6% to 100% respectively. The sensitivities and specificities of FC to accurately measure disease activity in Crohn's disease at different disease locations are diverse and no firm conclusion can be made. Better studies need to be undertaken to categorically answer the effect of disease location on the diagnostic accuracy of FC.
Crohn's disease is a form of chronic inflammatory bowel disease that can lead to structural bowel damage due to transmural inflammation. Ileo-colonosocopy is currently essential for initial ...diagnosis. Reassessment of disease burden is frequently needed during episodes of active disease and when evaluating treatment efficacy. This review compares the role of Magnetic Resonance Enterography (MRE) and ileocolonoscopy in Crohn's disease management and whether cross-sectional imaging can replace invasive endoscopic tests. MRE can give information on the small bowel not visible at ileo-colonoscopy, and on extra-luminal complications. Evaluation of the bowel by MRE allows assessment of the submucosa and serosa, and thus transmural healing. MRE offers a well tolerated investigation and additional information on disease activity to better manage patients with Crohn's disease.
Increasingly, there are a range of newer techniques such as diffusion weighted imaging, magnetisation transfer and motility MRI which provide greater information on fibrosis and predictors to treatment response which has been lacking despite the use of ileo-colonoscopy for several decades.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
BACKGROUNDMesalazine-refractory ulcerative proctitis is common, with a significant proportion of the patients requiring escalation to immunomodulators or biological therapy. Three small preliminary ...cohort studies suggested good clinical efficacy for the organic arsenic derivative acetarsol in the management of proctitis. Our aim was to describe our experience on the use of acetarsol in proctitis and to review all existing evidence on its safety and efficacy.
PATIENTS AND METHODSWe retrospectively reviewed clinical records of all ulcerative colitis patients exposed to acetarsol at Nottingham University Hospitals since 2012. Clinical response was determined basing on physicians’ global assessments and patients’ improvement over the baseline (reduction in stool frequency and rectal bleeding). Clinical remission was defined as total resolution of symptoms including bleeding cessation. Serum arsenic, C-reactive protein and faecal calprotectin levels reviewed when available. Nonparametric analysis performed.
RESULTSTwenty-eight (16 males) patients with median (range) age 39 (35) and 9 (19) years disease duration received acetarsol suppositories for proctitis. All had failed mesalazine or corticosteroid topical therapy, with 50% having additionally failed immunomodulators. Median treatment duration was 70 (64) days. 16/28 were prescribed acetarsol more than once. 67.9% achieved clinical response and 46.4% clinical remission. 32.1% required treatment escalation to steroids, thiopurines or antitumour necrosis factor agents. 6/28 patients stopped acetarsol due to side effects.
CONCLUSIONAcetarsol could be an effective and safe option in the management of refractory proctitis. A definitive trial with long-term safety follow-up is required to investigate the efficacy and safety of this promising drug.
We sought to identify clinical and demographic features influencing hospitalization and colectomy in a population-based inception cohort of ulcerative colitis.
Between 1970 and 2004, a total of 369 ...patients (58.5% males) from Olmsted County, MN, were followed from diagnosis for 5401 person-years. The cumulative probability of hospitalization and colectomy were estimated using the Kaplan-Meier method. Cox proportional hazards regression was used to identify factors associated with hospitalization and colectomy.
The cumulative probability of first hospitalization was 29.4% at 5 years (95% confidence interval CI, 24.5%-34.1%), 38.7% at 10 years (33.1%-43.8%), 49.2% at 20 years (42.7%-55.2%), and 52.3% at 30 years (45.1%-59.7%). The incidence rate of hospitalizations decreased over the last 4 decades, although cumulative probability of first hospitalization increased with successive decades of diagnosis. Early need for corticosteroids (hazard ratio HR, 1.8; 95% CI, 1.1%-2.7%) and early need for hospitalization (HR, 1.5; 95% CI, 1.02-2.4) were independent predictors of hospitalization after 90 days of illness. The cumulative probability of colectomy from the time of diagnosis was 13.1% at 5 years (95% CI, 9.4%-16.6%), 18.9% at 10 years (95% CI, 14.4%-23.2%), and 25.4% at 20 years (95% CI, 19.8%-30.8%). Male gender (HR, 2.1; 95% CI, 1.3-3.5), diagnosis in the 1990s (HR, 2.0; 95% CI, 1.01-4.0), and diagnosis in 2000 to 2004 (HR, 3.7; 95% CI, 1.7-8.2) were significantly associated with colectomy risk.
Colectomy rates were comparable to reports from northern Europe. The numbers of hospitalizations show a decreasing trend. Male gender and being diagnosed in the 2000 to 2004 period predicted colectomy while extensive colitis predicted future hospitalizations.
Summary
Background
Accelerated induction regimens of infliximab have been proposed to improve response rates in patients with steroid‐refractory acute severe colitis.
Aim
To determine the differences ...in outcome for acute severe ulcerative colitis between accelerated and standard‐dose infliximab
Methods
We collected data on hospitalised patients receiving differing regimens of rescue therapy for steroid‐refractory acute severe ulcerative colitis. Our primary outcome was 30‐day colectomy rate. Secondary outcomes were colectomy within index admission, and at 90 days and 12 months. We used propensity score analysis with optimal calliper matching using high risk covariates defined a priori to reduce potential provider selection bias.
Results
We included 131 patients receiving infliximab rescue therapy; 102 received standard induction and 29 received accelerated induction. In the unmatched cohort, there was no difference by type of induction in the 30‐day colectomy rates (18% vs 20%, P = .45), colectomy during index admission (13% vs 20%, P = .26) or overall colectomy (20% vs 24%, P = .38). In the propensity score‐matched cohort of 52 patients, 30‐day colectomy (57% vs 27%, P = .048) and index admission colectomy (53% vs 23%, P = .045) rates were higher in those receiving standard induction compared to accelerated induction but there was no difference in overall colectomy rates (57% vs 31%, P = .09). There was no significant difference in length of stay or in complication and infection rates.
Conclusion
In a propensity score‐matched cohort, steroid‐refractory acute severe ulcerative colitis patients, short‐term, but not long‐term, colectomy rates appear to be lower in those receiving an accelerated induction regimen.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Diagnostic errors are a major source of patient harm, most of which are caused by cognitive errors and biases. Despite research showing the relationship between software systems and cognitive ...processes, the impact of the electronic health record (EHR) on diagnostic error remains unknown.
We conducted a scoping review of the scientific literature to (1) survey the association between aspects of the EHR and diagnostic error, and (2) through a human-systems integration lens, identify the types of EHR issues and their impact on the stages of the diagnostic process.
We analyzed 11 research articles for the relationship between EHR use and diagnostic error. These articles highlight specific technical, usability, and workflow issues with the EHR that pose risks for diagnostic error at every stage of the diagnostic process.
Although technical problems such as EHR interoperability and data integrity pose critical issues for the diagnostic process, usability and workflow issues such as poor display design, and inability to track test results also hamper clinicians' ability to track, process, and act in the diagnostic process. Current research methods have limited coverage over clinical settings, are not standardized, and rarely include measures of patient harm.
The available evidence shows that EHRs pose risks for diagnostic error throughout the diagnostic process, with most issues involving their incompatibility with providers' cognitive processing. A structured and systematic model of collecting and reporting on these errors is needed to understand how the EHR shapes the diagnostic process and improve diagnostic accuracy.
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