Part 2

The Lowdown on the Lower GI Tract --More From WCOG at ACG 2017

World Congress of Gastroenterology (WCOG) at the American College of Gastroenterology (ACG) 2017 Annual Scientific Meeting

David A. Johnson, MD

Disclosures

November 09, 2017

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

Welcome to part 2 of highlights from the American College of Gastroenterology (ACG) and the World Congress of Gastroenterology (WCOG) meeting in Orlando, Florida. In part 1, I profiled my take-home messages about gastroenterology and physician burnout, a serious issue in bariatric surgery, and then focused on the esophagus, stomach, and liver. Now I will focus on the biliary tract, pancreas, small bowel, and colon.

Biliary Tract and Pancreas

Gallbladder Disease

Let's put things in motion.

From the biliary standpoint, one study really put the nail in the coffin for using the HIDA scan to predict outcomes of cholecystectomy. I see this test overused. How many of you have seen surgeons use this test to at least suggest that patients may need their gallbladder out?

This study[1] looked at the sensitivity and specificity of HIDA scan with gallbladder ejection fraction used to evaluate gallbladder disease. Sensitivity was reasonably high at 86%, but specificity was 28%, which corresponded to a false-positive rate of 72%. Overall, the positive likelihood ratio was 1.2 and the negative likelihood ratio was 0.5. This suggests that the majority of patients who do not improve following cholecystectomy had abnormal preoperative HIDA scans. Beware of this; surgeons like this test. I never use it, and it is something that continues to be a problem. Patients go to surgery and then we see them back with—guess what—postcholecystectomy syndrome.

Acute Pancreatitis

Some have questioned whether enhanced approaches to recovery might lead to ways that we can restore gut function in patients hospitalized for acute pancreatitis.

A single-blind, randomized controlled study from the Kaiser group[2] looked at enhanced recovery in acute pancreatitis. Patients admitted directly from the emergency department over the course of a year were randomized to receive either enhanced recovery (ie, patient-directed oral intake, early ambulation, and nonopioid analgesia) or standard treatment (ie, opioids, physician-directed diet, and nursing parameters). The study did not include patients with severe pancreatitis; patients with organ failure or systemic inflammatory response syndrome were excluded. The primary endpoint was time to oral refeeding. The enhanced-recovery group had improved oral refeeding times and lower pancreatic activity scores compared with standard treatment. Length of stay and frequency of 30-day readmission were not significantly different between groups.

For quite some time, we initially would use postpyloric feeding, then stomach feeding, and then oral feeding, provided that there was no nausea and vomiting. These study results look very consistent with what we have seen evolving in the literature. Do not be hesitant to entertain oral feeding and do not wait for the endpoint of no pain before you start refeeding these patients.

The Small Intestine

Irritable Bowel Syndrome

A study recently published in Gut[3] found that microcellular integrity barrier changes can occur in the small bowel. They found that miRNAs are associated with barrier function dysregulation through modulation of claudin-2 and cingulin expression of the jejunum in patients with irritable bowel syndrome (IBS)..

Microcellular changes in the colon were confirmed here; a study from Ecuador[4] looked at in vivo detection of colonic mucosa microinflammatory changes with confocal laser endomicroscopy probe in patients with IBS. [They found that patients with IBS are six times more likely than healthy patients to have mucosa microinflammatory changes.]

Functional disease is not really so functional when we are seeing microinflammatory changes and barrier disruptions in the small intestine and in the colon.

Celiac Disease

Should patients with celiac disease be monitored for the risk for autoimmune endocrinopathies?

In a retrospective review, the Mayo group in Rochester[5] found that both pediatric and adult populations with celiac disease had a higher incidence of type 1 diabetes and thyroid disease. Independent of how their celiac disease is controlled, these people need to have continued surveillance.

The Colon

Clostridium difficile Infection and Inflammatory Bowel Disease

Let's turn to the colon.

What do you do with a patient who has Clostridium difficile and inflammatory bowel disease (IBD)? A concern is that C difficile precipitates the flare, and once you treat the C difficile and start immune suppression or biologic therapy, do you put them at greater risk?

A multicenter retrospective analysis[6] in four academic centers in New York looked at the impact of immunosuppressive therapy on outcomes of patients with IBD after C difficile infection. They found that initiation of immunosuppressive therapy after C difficile infection did not affect adverse clinical outcomes compared with patients who were not escalated on immunosuppressive therapy. There were no differences between groups for C difficile recurrence or rehospitalization, but sepsis and severe outcomes were significantly more common in patients not undergoing the escalation.

It would be nice to have prospective studies before we can really act on this, but I think we have a pretty strong implication that we can use these data and go ahead and start therapy directed at the IBD.

Sedation in Colonoscopy

Next, a randomized controlled study from Oklahoma City[7] evaluated diphenhydramine as an adjunctive sedative for patients on chronic opioids undergoing colonoscopy. They found no difference in fentanyl or midazolam use. Patient satisfaction and sedation scores judged by the physician and nurses were statistically in favor of the diphenhydramine group. Patients' assessments for their scoring of pain and amnesia favored the group receiving diphenhydramine. Diphenhydramine is an easy thing to add if you have a patient on chronic opioids.

Chronic Constipation

Dr Eamonn Quigley presented data[8] on use of a vibrating capsule for chronic constipation, with the idea that the vibrations in the colon would stimulate colonic motility. Results from two studies were aggregated to compare dosing as it related to spontaneous bowel movement. Study 1 was an 8-week, double-blind, sham-controlled study, and study 2 was a 6-week, open-label, single-arm study. Participants in the first study ingested two capsules per week at the site, and participants in the second study ingested five capsules per week at home. Study 1 patients increased their endpoint by an increment of 20%. In study 2, the endpoint was met in nearly two thirds of the patients. New ways for stimulating colon motility are interesting. Let's wait and see how this pans out. Cost has yet to be determined.

Colon Cancer Incidence in Younger Adults

The next topic is a growing concern: colon cancer in the younger patient population.

A single-center cohort study from Memorial Sloan Kettering[9] looked at the rising incidence in adults younger than 50 years. Guidelines are primarily directed for those 50 years or older with average risk.[10] But the most recent iteration of the guidelines,[11] suggests that those younger than 50 with any earlier bleeding workup should be screened. That was borne out by this study where about 50% of adults (median age, 44 years) with early colon cancer had symptoms of rectal bleeding. Other symptoms included abdominal bloating and change in bowel habits. In the guideline it was suggested that those symptoms did not have incremental concern for early colon cancer and should not be used as a justification for colonoscopy, but bleeding should always be used as an indication.

Thiopurine and Risk for Nonmelanoma Skin Cancer

The concern for nonmelanoma skin cancer (NMSC) in patients taking thiopurine for IBD is well recognized. After developing a NMSC, what happens? This retrospective study[12] followed about 260 patients with NMSC for a median of 3.2 years. The vast majority of these patients were male and white. Nearly 98% continued thiopurine after the initial NMSC diagnosis. In 56% of patients, at least one recurrence of NMSC occurred; 47% had two or more recurrences, with a median number of three recurrences. Three percent of these patients died from complications of NMSC.

Here is a caveat: Get a dermatologist involved if your patients are taking thiopurine. We recommend this routinely in our patients because you should not dismiss the skin monitoring. It certainly needs to be delegated to somebody who is much more attuned to this. We monitor our patients on thiopurine each time they come in, and we ask, "When was your last dermatologic exam?"

'A Lot of Great Science'

There was a lot of great science. There are tremendous take-home messages from these points, but there is lots more if you delve into them. Look as these abstracts move toward publication. Hopefully these tidbits will give you some insight as to what I'm doing differently in my practice because of the exciting news from this year's meeting.

I'm Dr David Johnson. Thanks again for listening.

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