- Email: [email protected]
Sa1155 Risk Factors and Outcome of Acute Severe Lower Gastrointestinal Bleeding in Crohn's Disease
Sa1153
of bleeding after diagnosis of CD was 1.7% after 1 year, 3.6% after 5 years, 6.5% after 10 years, and 10.3% after 20 years. Median age at the time of acute severe LGIB was 27.5 years (range, 14-59 years). At presentation, the median hemoglobin concentration was 8.4 g/dL (range, 4.7-11.6 g/dL). C-reactive protein level was within the normal range in 32 (47.8%) of 67 patients. Use of azathioprine/6-mercaptopurine decreased the risk of LGIB (OR: 0.525, 95% CI: 0.304-0.906, P = 0.021). Bleeding recurred in 29 patients (41.4 %) after a median time of 3.2 months (range, 15 days-94.7 months). Only one out of eleven patients treated with infliximab rebled. The cumulative probability of rebleeding tended to be lower in patients treated with infliximab than in those receiving other treatments (p = 0.076). Conclusions: Azathioprine/6-mercaptopurine may reduce the risk of acute severe LGIB. The recurrence after severe LGIB is common, but infliximab may prevent bleeding recurrence.
AGA Abstracts
A Novel Device (Clearpath®Easy-Glide, Israel) for Rapid Cleaning of Poorly Prepared Colons: Initial Experience in Clinical Practice Menachem Moshkowitz, Jonathan Cohen, Erwin M. Santo, Fred M. Konikoff, Yoav Hirsch, Thomas Rösch, Jerome D. Waye, Nadir Arber Background: Adequate bowel preparation is a key necessity for an ideal colonoscopy. Excellent bowel preparation is seen in only ~35% of cases. Poor preparation reduces the quality of colonoscopy, as it increases the procedure time, raises the rate of missed polyps/cancers (in particular in the right colon), increases complications risk and increases the costs. We recently described the safety and efficacy of a novel attachable colon-cleaning device in a porcine model Aim: To perform a proof of concept study, in humans, to clear residual debris during colonoscopy in random patients using a new device with an increased volume of water for irrigation and a large suction channel The device: ClearPath® has been approved by the EU and cleared for marketing by the and FDA to be used in all types of endoscopy. It has two main components, the control cabinet and the single-use disposable unit. The control cabinet includes a peristaltic pump, a control unit, and a pinch valve that enables control of the suction flow. The disposable element comprises of two channels, one for supplying water for irrigation and one for suction. Both channels are connected to an irrigation and suction head which attaches firmly to the tip of the colonoscope (Fig. 1). The ClearPath® tube is attached to the entire length of the colonoscope with a polyurethane sleeve (Fig. 2). Irrigation (upto 2 bars and limited to pulses of 2.5 seconds) flows through four 0.6-mm nozzles in the distal head, and debris is evacuated through a single 18-mm2 cross-sectional aperture. Two slits on opposite sides of the suction orifice maintain the flow of air when the head is positioned against the colonic wall. Suction is not time-limited, but rather halted for 0.08 seconds every 1 second. Patients and Methods: Patients previously scheduled for colonoscopy in accordance with the recommendations of the ASGE guidelines were randomly selected to participate in this protocol. Subjects underwent a complete bowel preparation according to each center's protocol. Recorded were: the level of preparation, ease of handling the device, and quality of cleaning and debris evacuation, on a 5 point Likert scale (1=poor, 5= excellent). Results: A total of 219 subjects (103 females) underwent full colonoscopy (age range 25-80 years), in 31 gastroenterologic centers, worldwide. 21 gastroenterologists had used the device three times or more. All endoscopists felt that handling the device was easy with a short learning curve. The device enabled rapid and effective cleaning of all partially prepared colons with no immediate or delayed (30 days) adverse consequence. The water pump is useful in applying the water immersion technique. Conclusions: The ClearPath® device was safe and effective in performing intra-procedural irrigation and suction in inadequately prepared human colons.
Sa1156 Complementary and Alternative Medicine (CAM) in Inflammatory Bowel Diseases (IBD) - Why, Who and What Francisco Portela, Paula Ministro, Claudia Dias, Paulo Caldeira, Marilia L. Cravo, João Deus, Raquel Gonçalves, Paula M. Lago, Fernando Magro, Henrique Morna, Paula Peixe, Jaime C. Ramos, Helena T. Sousa, Lurdes Tavares, Helena M. Vasconcelos Introduction : CAM comprises a large number of practices and therapies which are widely used by patients in various pathologies that IBD is no exception. Although there are no scientific data to support its efficacy or safety, CAM is frequently used by patients, most of the time concurrently with conventional medicine and the impact of its use can`t be ignored. Objectives: To evaluate the extent of CAM use and understand the motivation for its use among Portuguese IBD patients. Methods: A 30-item questionnaire was mailed to the members of the Portuguese Crohn's and Colitis Association and also distributed among patients attending several IBD clinics. Predictors of CAM use were evaluated by logistic regression models. Results: The study included 442 IBD patient, female 57 %, with a mean age ± sd 43 ± 13 years. Most of the patients had a degree (39%) or graduation (33%) and work in a tertiary sector (79%). Sixty five percent had the diagnosis of Crohn`s disease, 33% ulcerative colitis and 2% with unclassified colitis. Median disease duration was 11 years. In the past five years 21% did biological therapy, 47% immunosuppressive, 41% corticosteroids, 94% 5 ASA. Thirty one percent of patients (145) did use MAC in the past and 12% (57 ) still uses it. Most of patients didn`t feel well when started CAM (66%) and only a third (34%) started it during a symptom free period. The main reason to start was because they didn't get better with conventional medicine (33%). The type of CAM was : Homeopathy ( 42%), Herbalism (39%), Chinese traditional medicine (29,6%), Vitamins (24,8%), Naturopathy ( 15,8%), Meditation (9,6%), Osteopathy (7,5%)Dietary manipulation (6,8%), Creative therapeutics (4,1%), Reflexology (3,4%). Most of patients considered that they did well (43%) or very well (24%) with CAM. Forty one percent of patients spent more than 100 Euros per month with CAM. Most of patients maintained conventional therapy simultaneously with CAM, did do the exams and analysis but they didn't inform their doctor about CAM use . Eighty five percent of patients would like to discuss this subject with their doctors. In univariate analysis we found that gender, academic level of education, the present use of immunosuppressives or corticosteroids, and the past use of biological therapy or corticosteroids had significant association with the use of CAM but only academic grade OR 3,6 95%CI ( 1,5-8,6) and past use of corticosteroids OR 2,8 95% CI ( 1,6-5,1) are independently associated with CAM use. Conclusions: Roughly a third of Portuguese IBD patients had used CAM. Steroid treatment and an academic education are associated with CAM use. Given the potential side effects and interactions, IBD doctors should focus on improving patients information about the benefits and limitations of conventional and complementary treatments.
Sa1154 Are We Measuring Vitamin D in Inflammatory Bowel Disease (IBD) Patients? Shamaila Butt, Kalpesh Besherdas Background There is increasing interest in the role of vitamin D in IBD, outside of its traditional role in metabolic bone disease. Novel insights into additional roles for vitamin D are being established and these include anti-inflammatory and immune-modulating effects. Active vitamin D is known to exert its biological functions via the vitamin D receptor (VDR). Immune cells have been found to express VDR and possess the enzymes necessary to produce active vitamin D. This suggests vitamin D may have actions beyond endocrine activity. Furthermore, Vitamin D deficiency has been linked to higher rates of cancers including colorectal cancer. Previous studies have found that almost 50% of the IBD patients were vitamin D deficient at some point and 11% were severely deficient. Vitamin D deficiency has been demonstrated to be independently associated with higher disease activity scores in patients compared to those that had normal levels of vitamin D. Furthermore, vitamin D deficient Crohn's patients have a poorer quality of life when compared to patients who are not vitamin D deficient. Currently, ECCO guidelines do not mention measurement of vitamin D in patients with IBD but given its effects, we set out to identify whether we were checking for and correcting for vitamin D deficiency in our IBD patients. Aims and Methods The aim of the study was to investigate whether we were measuring vitamin D levels at any encounter in out IBD patients. This study was conducted in a busy District General Hospital in North London. Information was gathered using the hospital powerchart system and the IBD database of patients. Results A total of 225 patients were correctly identified as having IBD. Of these, 157 (70%) had Ulcerative colitis and 68 (30%) had Crohn's disease. 24 (15%) Ulcerative colitis patients and 8 (12%) Crohn's patients had their vitamin D checked on hospital records. The range of vitamin D levels were 14 to 84 with lower limit of normal being 50. 13/32 (41%) patients has low vitamin D levels Of these only 2 patients were also under the Rheumatology team for co-existing arthropathy/arthritis. Conclusion This study demonstrates that despite evidence of Vitamin D and its role in anti-inflammatory and immune-modulating effects (in addition to bone protection) we are not actively measuring and treating its deficiency. Perhaps guidance from ECCO may encourage our testing of vitamin D in IBD patients.
Sa1157 The Vast Majority of Patients With Colorectal Cancer Found on Colonoscopy Have Bleeding Related Symptoms at Presentation Johann P. Hreinsson, Einar Bjornsson Background: Colorectal cancer (CRC) is among the most common cancers in the world. Despite this, data on the presenting symptoms of colon cancer patients are remarkably scarce, especially in recent decades. Furthermore, there is very limited literature available on the correlation of patients symptoms and the finding of CRC on colonoscopy. We aimed to assess the proportion of unselected patients diagnosed with colorectal cancer with colonoscopy who had bleeding related symptoms vs. those with non-bleeding-related symptoms. Methods: In a population based sample of 220,000 inhabitants, a prospective study was undertaken on all patients who underwent colonoscopy during the year of 2010 in a European teaching hospital. Indication for the colonoscopy was recorded by the gastroenterologists and complete blood count obtained. Bleeding-related symptoms were defined as rectal bleeding, iron deficiency anemia (IDA), positive hemoccult and melena. All other symptoms without any of these were regarded non-bleeding-related symptoms. Results: A total of 1275 colonoscopies were performed on 1134 patients during the study period. Overall 558/1134 (49%) patients (296 males and 262 females; median age 66 (IQR 51-78) had any of the bleeding related symptoms at the first colonoscopy whereas 51% had non-bleeding-related symptoms. A total of 51 patients, 32 males (63%), median age 69 years (66-87) and 19 females, median age 74 years (37%) were diagnosed with CRC during the study period. Among the patients found to have CRC, any or several bleeding related symptoms were present in 47/51 (92.2%) whereas non-bleeding related symptoms were present in only 4 (7.8%). Bleeding related symptoms in the CRC cohort were: IDA in 36 (71%), rectal bleeding in 18 (35%), 5 with positive hemoccult (9.8%) and melena in 2 (3.9%). Other symptoms in the CRC patients with bleeding related symptoms were abdominal pain in 5 (9.8%), diarrhea and/or constipation in 6 (11.8%), changes in bowel habits in 2 (3.9%) and others in 13 (27.5%). Among the 4 patients without bleeding related symptoms, two patients with rectal cancer had anorectal discomfort as the presenting symptom and the other non-bleeding related symptoms in two patients were diarrhea (n=1) and abdominal pain and changes in bowel habits (n=1), respectively. Conclusions: The vast majority of patients referred for colonoscopy and found to have colorectal cancer have bleeding related symptoms. The chance of finding CRC in patients without bleeding related symptoms is
Sa1155 Risk Factors and Outcome of Acute Severe Lower Gastrointestinal Bleeding in Crohn's Disease Kyung Jo Kim, Bong-Jun Han, Suk-Kyun Yang, Soo-Young Na, Soo-kyung Park, Sun-Jin Boo, Sang Hyoung Park, Dong-Hoon Yang, Jae-Ho Park, Kee Wook Jung, Byong Duk Ye, Jeong-Sik Byeon, Seung-Jae Myung, Jin-Ho Kim Background: Acute severe lower gastrointestinal bleeding (LGIB) in Crohn's disease (CD) is an uncommon complication, but is a diagnostic and therapeutic challenge. We aimed to identify the clinical characteristics and risk factors for acute LGIB in patients with CD and assess the cumulative probability of rebleeding in relation to therapeutic modality. Methods: Among 1,731 CD patients registered at the Asan Medical Center, we retrospectively reviewed the medical records of 70 CD patients (4.0%) who had acute severe LGIB and compared these with matched CD patients who did not have LGIB. Results: The cumulative probability
AGA Abstracts
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of bleeding after diagnosis of CD was 1.7% after 1 year, 3.6% after 5 years, 6.5% after 10 years, and 10.3% after 20 years. Median age at the time of acute severe LGIB was 27.5 years (range, 14-59 years). At presentation, the median hemoglobin concentration was 8.4 g/dL (range, 4.7-11.6 g/dL). C-reactive protein level was within the normal range in 32 (47.8%) of 67 patients. Use of azathioprine/6-mercaptopurine decreased the risk of LGIB (OR: 0.525, 95% CI: 0.304-0.906, P = 0.021). Bleeding recurred in 29 patients (41.4 %) after a median time of 3.2 months (range, 15 days-94.7 months). Only one out of eleven patients treated with infliximab rebled. The cumulative probability of rebleeding tended to be lower in patients treated with infliximab than in those receiving other treatments (p = 0.076). Conclusions: Azathioprine/6-mercaptopurine may reduce the risk of acute severe LGIB. The recurrence after severe LGIB is common, but infliximab may prevent bleeding recurrence.
AGA Abstracts
A Novel Device (Clearpath®Easy-Glide, Israel) for Rapid Cleaning of Poorly Prepared Colons: Initial Experience in Clinical Practice Menachem Moshkowitz, Jonathan Cohen, Erwin M. Santo, Fred M. Konikoff, Yoav Hirsch, Thomas Rösch, Jerome D. Waye, Nadir Arber Background: Adequate bowel preparation is a key necessity for an ideal colonoscopy. Excellent bowel preparation is seen in only ~35% of cases. Poor preparation reduces the quality of colonoscopy, as it increases the procedure time, raises the rate of missed polyps/cancers (in particular in the right colon), increases complications risk and increases the costs. We recently described the safety and efficacy of a novel attachable colon-cleaning device in a porcine model Aim: To perform a proof of concept study, in humans, to clear residual debris during colonoscopy in random patients using a new device with an increased volume of water for irrigation and a large suction channel The device: ClearPath® has been approved by the EU and cleared for marketing by the and FDA to be used in all types of endoscopy. It has two main components, the control cabinet and the single-use disposable unit. The control cabinet includes a peristaltic pump, a control unit, and a pinch valve that enables control of the suction flow. The disposable element comprises of two channels, one for supplying water for irrigation and one for suction. Both channels are connected to an irrigation and suction head which attaches firmly to the tip of the colonoscope (Fig. 1). The ClearPath® tube is attached to the entire length of the colonoscope with a polyurethane sleeve (Fig. 2). Irrigation (upto 2 bars and limited to pulses of 2.5 seconds) flows through four 0.6-mm nozzles in the distal head, and debris is evacuated through a single 18-mm2 cross-sectional aperture. Two slits on opposite sides of the suction orifice maintain the flow of air when the head is positioned against the colonic wall. Suction is not time-limited, but rather halted for 0.08 seconds every 1 second. Patients and Methods: Patients previously scheduled for colonoscopy in accordance with the recommendations of the ASGE guidelines were randomly selected to participate in this protocol. Subjects underwent a complete bowel preparation according to each center's protocol. Recorded were: the level of preparation, ease of handling the device, and quality of cleaning and debris evacuation, on a 5 point Likert scale (1=poor, 5= excellent). Results: A total of 219 subjects (103 females) underwent full colonoscopy (age range 25-80 years), in 31 gastroenterologic centers, worldwide. 21 gastroenterologists had used the device three times or more. All endoscopists felt that handling the device was easy with a short learning curve. The device enabled rapid and effective cleaning of all partially prepared colons with no immediate or delayed (30 days) adverse consequence. The water pump is useful in applying the water immersion technique. Conclusions: The ClearPath® device was safe and effective in performing intra-procedural irrigation and suction in inadequately prepared human colons.
Sa1156 Complementary and Alternative Medicine (CAM) in Inflammatory Bowel Diseases (IBD) - Why, Who and What Francisco Portela, Paula Ministro, Claudia Dias, Paulo Caldeira, Marilia L. Cravo, João Deus, Raquel Gonçalves, Paula M. Lago, Fernando Magro, Henrique Morna, Paula Peixe, Jaime C. Ramos, Helena T. Sousa, Lurdes Tavares, Helena M. Vasconcelos Introduction : CAM comprises a large number of practices and therapies which are widely used by patients in various pathologies that IBD is no exception. Although there are no scientific data to support its efficacy or safety, CAM is frequently used by patients, most of the time concurrently with conventional medicine and the impact of its use can`t be ignored. Objectives: To evaluate the extent of CAM use and understand the motivation for its use among Portuguese IBD patients. Methods: A 30-item questionnaire was mailed to the members of the Portuguese Crohn's and Colitis Association and also distributed among patients attending several IBD clinics. Predictors of CAM use were evaluated by logistic regression models. Results: The study included 442 IBD patient, female 57 %, with a mean age ± sd 43 ± 13 years. Most of the patients had a degree (39%) or graduation (33%) and work in a tertiary sector (79%). Sixty five percent had the diagnosis of Crohn`s disease, 33% ulcerative colitis and 2% with unclassified colitis. Median disease duration was 11 years. In the past five years 21% did biological therapy, 47% immunosuppressive, 41% corticosteroids, 94% 5 ASA. Thirty one percent of patients (145) did use MAC in the past and 12% (57 ) still uses it. Most of patients didn`t feel well when started CAM (66%) and only a third (34%) started it during a symptom free period. The main reason to start was because they didn't get better with conventional medicine (33%). The type of CAM was : Homeopathy ( 42%), Herbalism (39%), Chinese traditional medicine (29,6%), Vitamins (24,8%), Naturopathy ( 15,8%), Meditation (9,6%), Osteopathy (7,5%)Dietary manipulation (6,8%), Creative therapeutics (4,1%), Reflexology (3,4%). Most of patients considered that they did well (43%) or very well (24%) with CAM. Forty one percent of patients spent more than 100 Euros per month with CAM. Most of patients maintained conventional therapy simultaneously with CAM, did do the exams and analysis but they didn't inform their doctor about CAM use . Eighty five percent of patients would like to discuss this subject with their doctors. In univariate analysis we found that gender, academic level of education, the present use of immunosuppressives or corticosteroids, and the past use of biological therapy or corticosteroids had significant association with the use of CAM but only academic grade OR 3,6 95%CI ( 1,5-8,6) and past use of corticosteroids OR 2,8 95% CI ( 1,6-5,1) are independently associated with CAM use. Conclusions: Roughly a third of Portuguese IBD patients had used CAM. Steroid treatment and an academic education are associated with CAM use. Given the potential side effects and interactions, IBD doctors should focus on improving patients information about the benefits and limitations of conventional and complementary treatments.
Sa1154 Are We Measuring Vitamin D in Inflammatory Bowel Disease (IBD) Patients? Shamaila Butt, Kalpesh Besherdas Background There is increasing interest in the role of vitamin D in IBD, outside of its traditional role in metabolic bone disease. Novel insights into additional roles for vitamin D are being established and these include anti-inflammatory and immune-modulating effects. Active vitamin D is known to exert its biological functions via the vitamin D receptor (VDR). Immune cells have been found to express VDR and possess the enzymes necessary to produce active vitamin D. This suggests vitamin D may have actions beyond endocrine activity. Furthermore, Vitamin D deficiency has been linked to higher rates of cancers including colorectal cancer. Previous studies have found that almost 50% of the IBD patients were vitamin D deficient at some point and 11% were severely deficient. Vitamin D deficiency has been demonstrated to be independently associated with higher disease activity scores in patients compared to those that had normal levels of vitamin D. Furthermore, vitamin D deficient Crohn's patients have a poorer quality of life when compared to patients who are not vitamin D deficient. Currently, ECCO guidelines do not mention measurement of vitamin D in patients with IBD but given its effects, we set out to identify whether we were checking for and correcting for vitamin D deficiency in our IBD patients. Aims and Methods The aim of the study was to investigate whether we were measuring vitamin D levels at any encounter in out IBD patients. This study was conducted in a busy District General Hospital in North London. Information was gathered using the hospital powerchart system and the IBD database of patients. Results A total of 225 patients were correctly identified as having IBD. Of these, 157 (70%) had Ulcerative colitis and 68 (30%) had Crohn's disease. 24 (15%) Ulcerative colitis patients and 8 (12%) Crohn's patients had their vitamin D checked on hospital records. The range of vitamin D levels were 14 to 84 with lower limit of normal being 50. 13/32 (41%) patients has low vitamin D levels Of these only 2 patients were also under the Rheumatology team for co-existing arthropathy/arthritis. Conclusion This study demonstrates that despite evidence of Vitamin D and its role in anti-inflammatory and immune-modulating effects (in addition to bone protection) we are not actively measuring and treating its deficiency. Perhaps guidance from ECCO may encourage our testing of vitamin D in IBD patients.
Sa1157 The Vast Majority of Patients With Colorectal Cancer Found on Colonoscopy Have Bleeding Related Symptoms at Presentation Johann P. Hreinsson, Einar Bjornsson Background: Colorectal cancer (CRC) is among the most common cancers in the world. Despite this, data on the presenting symptoms of colon cancer patients are remarkably scarce, especially in recent decades. Furthermore, there is very limited literature available on the correlation of patients symptoms and the finding of CRC on colonoscopy. We aimed to assess the proportion of unselected patients diagnosed with colorectal cancer with colonoscopy who had bleeding related symptoms vs. those with non-bleeding-related symptoms. Methods: In a population based sample of 220,000 inhabitants, a prospective study was undertaken on all patients who underwent colonoscopy during the year of 2010 in a European teaching hospital. Indication for the colonoscopy was recorded by the gastroenterologists and complete blood count obtained. Bleeding-related symptoms were defined as rectal bleeding, iron deficiency anemia (IDA), positive hemoccult and melena. All other symptoms without any of these were regarded non-bleeding-related symptoms. Results: A total of 1275 colonoscopies were performed on 1134 patients during the study period. Overall 558/1134 (49%) patients (296 males and 262 females; median age 66 (IQR 51-78) had any of the bleeding related symptoms at the first colonoscopy whereas 51% had non-bleeding-related symptoms. A total of 51 patients, 32 males (63%), median age 69 years (66-87) and 19 females, median age 74 years (37%) were diagnosed with CRC during the study period. Among the patients found to have CRC, any or several bleeding related symptoms were present in 47/51 (92.2%) whereas non-bleeding related symptoms were present in only 4 (7.8%). Bleeding related symptoms in the CRC cohort were: IDA in 36 (71%), rectal bleeding in 18 (35%), 5 with positive hemoccult (9.8%) and melena in 2 (3.9%). Other symptoms in the CRC patients with bleeding related symptoms were abdominal pain in 5 (9.8%), diarrhea and/or constipation in 6 (11.8%), changes in bowel habits in 2 (3.9%) and others in 13 (27.5%). Among the 4 patients without bleeding related symptoms, two patients with rectal cancer had anorectal discomfort as the presenting symptom and the other non-bleeding related symptoms in two patients were diarrhea (n=1) and abdominal pain and changes in bowel habits (n=1), respectively. Conclusions: The vast majority of patients referred for colonoscopy and found to have colorectal cancer have bleeding related symptoms. The chance of finding CRC in patients without bleeding related symptoms is
Sa1155 Risk Factors and Outcome of Acute Severe Lower Gastrointestinal Bleeding in Crohn's Disease Kyung Jo Kim, Bong-Jun Han, Suk-Kyun Yang, Soo-Young Na, Soo-kyung Park, Sun-Jin Boo, Sang Hyoung Park, Dong-Hoon Yang, Jae-Ho Park, Kee Wook Jung, Byong Duk Ye, Jeong-Sik Byeon, Seung-Jae Myung, Jin-Ho Kim Background: Acute severe lower gastrointestinal bleeding (LGIB) in Crohn's disease (CD) is an uncommon complication, but is a diagnostic and therapeutic challenge. We aimed to identify the clinical characteristics and risk factors for acute LGIB in patients with CD and assess the cumulative probability of rebleeding in relation to therapeutic modality. Methods: Among 1,731 CD patients registered at the Asan Medical Center, we retrospectively reviewed the medical records of 70 CD patients (4.0%) who had acute severe LGIB and compared these with matched CD patients who did not have LGIB. Results: The cumulative probability
AGA Abstracts
S-230