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Goals: We aimed to assess the impact of very cold days on inflammatory bowel disease (IBD) flares and infectious gastroenteritis (IG). We defined a cold day using the World Meteorological definition of an ice day, which is a day with a maximum temperature below 0°C. Background: Recently, we have shown that heat waves increase the risk for IG and IBD flares. Study: We retrospectively collected data from 738 IBD and 786 IG patients admitted to the University Hospital of Zurich between 2001 and 2005 and from 506 patients with other noninfectious chronic intestinal inflammations as controls. Climate data were received by the Swiss Federal Office for Meteorology and Climatology. Results: There was no evidence for an increased risk of IBD flares (relative risk, RR = 0.99, 95% confidence interval, CI: 0.72-1.33, = 0.94) or IG flares (RR = 1.16, 95% CI: 087-1.52, = 0.30) on very cold days. This negative finding was confirmed in alternative formulations with lagged or cumulative (possibly lagged) effects. Conclusion: In this retrospective controlled observational study, no evidence for an increase in hospital admissions due to flares of IBD and IG during cold days was observed. This may be attributed to not relevantly altered bacterial growth conditions during cold days compared to heat waves.

BACKGROUND amp; AIMS: Primary sclerosing cholangitis (PSC) is an orphan hepatobiliary disorder associated with inflammatory bowel disease (IBD). We aimed to estimate the risk of disease progression based on distinct clinical phenotypes in a large international cohort of patients with PSC. METHODS: We performed a retrospective outcome analysis of patients diagnosed with PSC from 1980 through 2010 at 37 centers in Europe, North America, and Australia. For each patient, we collected data on sex, clinician-reported age at and date of PSC and IBD diagnoses, phenotypes of IBD and PSC, and date and indication of IBD-related surgeries. The primary and secondary endpoints were liver transplantation or death (LTD) and hepatopancreatobiliary malignancy, respectively. Cox proportional hazards models were applied to determine the effects of individual covariates on rates of clinical events, with time-to-event analysis ascertained through Kaplan-Meier estimates. RESULTS: Of the 7121 patients in the cohort, 2616 met the primary endpoint (median time to event of 14.5 years) and 721 developed hepatopancreatobiliary malignancy. The most common malignancy was cholangiocarcinoma (n = 594); patients of advanced age at diagnosis had an increased incidence compared with younger patients (incidence rate: 1.2 per 100 patient-years for patients younger than 20 years old, 6.0 per 100 patient-years for patients 21-30 years old, 9.0 per 100 patient-years for patients 31-40 years old, 14.0 per 100 patient-years for patients 4150 years old, 15.2 per 100 patient-years for patients 51-60 years old, and 21.0 per 100 patient-years for patients older than 60 years). Of all patients with PSC studied, 65.5% were men, 89.8% had classical or large-duct disease, and 70.0% developed IBD at some point. Assessing the development of IBD as a time-dependent covariate, Crohns disease and no IBD (both vs ulcerative colitis) were associated with a lower risk of LTD (unadjusted hazard ratio [HR], 0.62; P amp;lt;.00, Funding Agencies|German Federal Ministry of Education and Research through the Integrated Research and Treatment Center Transplantation at Hannover Medical School [01EO0802]; Wellcome Trust; NIHR Birmingham Biomedical Research Centre (BRC); NIHR University College London Hospitals Biomedical Research Centre; NIH [R01 DK84960]; German Research Community [MU 2864/1-1, MU 2864/1-3]; German Research Community (DFG) [SFB 841]; YAEL-Foundation; Helmut and Hannelore Greve Foundation

BACKGROUND AND AIMS Low-quality bowel preparation reduces efficacy of colonoscopy. We aimed to summarize effects of bowel preparation on detection of adenomas, advanced adenomas and colorectal cancer. METHODS A systematic literature search was performed regarding detection of colonic lesions after normal and low-quality bowel preparation. Reported bowel preparation quality was transformed to the Aronchick scale with its qualities "excellent", "good", "fair", "poor", and "insufficient" or "optimal" (good/excellent), "suboptimal" (fair/poor/insufficient), "adequate" (good/excellent/fair) and "inadequate" (poor/insufficient). We identified two types of studies: i) Comparative studies, directly comparing lesion detection according to bowel preparation quality, and ii) repeat colonoscopy studies, reporting results of a second colonoscopy after previous low-quality preparation. RESULTS The detection of early adenomas was reduced with inadequate vs. adequate bowel preparation (Odds Ratio (OR) 0.53, CI: 0.46-0.62, p<0.001). The advanced adenomas were affected less in comparison (0.74, CI: 0.62-0.87, p<0.001). The large number of subjects considered in the present meta-analysis resulted in smaller confidence intervals compared to earlier studies. Classifying the bowel-preparation quality as suboptimal vs. optimal led to the same qualitative conclusion (OR: 0.81, CI: 0.74-0.89, p<0.001 for early adenomas, OR: 0.94, CI: 0.87-1.01, n.s. for advanced adenomas). Bowel preparation was equally important for right-sided/ flat/ serrated vs. other lesions in most observational studies but more relevant in some repeat colonoscopy studies; data regarding carcinoma detection were insufficient. CONCLUSION Inadequate bowel preparation affects detection of early colonic lesions stronger than advanced lesions.

BACKGROUND/AIMS To identify the number and potential causes of unnecessary diagnostic procedures in a cohort of patients with autoimmune pancreatitis (AIP). METHODS All AIP cases at our centre between April 2006 and April 2013 were collected and followed up. Diagnosis was established by the International Consensus Diagnostic Criteria (ICDC). Demographic, clinical, radiological, serological data, the number of diagnostic procedures and the reason for referral were recorded. Possible risk factors for a delayed diagnosis of AIP were analysed. RESULTS A total of 29 patients (median age 60 years; 22 males and 7 females) were diagnosed with AIP using ICDC. Twenty-five patients were diagnosed with definite, 2 with possible type 1 AIP and 2 with type 2 AIP. In 29 patients, 50 ERCPs and 18 EUS were carried out; based on ICDC recommendations, a total of 20 ERCPs and 4 EUS were unnecessary diagnostic procedures. Eight patients (23.0%) were referred for unnecessary surgery. Jaundice was shown to be a significant risk factor for unnecessary endoscopic investigations (OR 11.00, 95% CI 1.14-106.43, p = 0.04). CONCLUSION Diagnosis of AIP still remains a challenge. Patients with jaundice are at particular risk of being subjected to unnecessary endoscopic procedures. Use of ICDC would help avoid unnecessary examinations or even major surgeries at times.

BACKGROUND: In recent years several trials have addressed treatment challenges in Crohn's disease. Clinical trials however, represent a very special situation. AIMS: To perform a cross-sectional survey among gastroenterologists on the current clinical real life therapeutic approach focussing on the use of biologics. METHODS: A survey including six main questions on clinical management of loss of response, diagnostic evaluation prior to major treatment changes, preference for anti-tumour necrosis factor (TNF) agent, (de-)escalation strategies as well as a basic section regarding personal information was sent by mail to all gastroenterologists in Switzerland (n=318). RESULTS: In total, 120 questionnaires were analysed (response rate 37.7%). 90% of gastroenterologists in Switzerland use a thiopurine as the first step-up strategy (anti-TNF alone 7.5%, combination 2.5%). To address loss of response, most physicians prefer shortening the interval of anti-TNF administration followed by dose increase, switching the biologic and adding a thiopurine. In case of prolonged remission on combination therapy, the thiopurine is stopped first (52.6%) after a mean treatment duration of 15.7 months (biologic first in 41.4%). CONCLUSIONS: Everyday clinical practice in Crohn's disease patients appears to be incongruent with clinical data derived from major trials. Studies investigating reasons underlying these discrepancies are of need to optimize and harmonize treatment.

BACKGROUND AND AIMS: Hypoxia can induce inflammation in the gastrointestinal tract. However, the impact of hypoxia on the course of inflammatory bowel disease (IBD) is poorly understood. We aimed to evaluate whether flights and/or journeys to regions lying at an altitude of >2000m above the sea level are associated with flare-ups within 4weeks of the trip. METHODS: IBD patients with at least one flare-up during a 12-month observation period were compared to a group of patients in remission. Both groups completed a questionnaire. RESULTS: A total of 103 IBD patients were included (43 with Crohn's disease (CD): mean age 39.3±14.6years; 60 with ulcerative colitis (UC): mean age 40.4±15.1years). Fifty-two patients with flare-ups were matched to 51 patients in remission. IBD patients experiencing flare-ups had more frequently undertaken flights and/or journeys to regions >2000m above sea level within four weeks of the flare-up when compared to patients in remission (21/52 [40.4%] vs. 8/51 [15.7%], p=0.005). CONCLUSIONS: Journeys to high altitude regions and/or flights are a risk factor for IBD flare-ups occurring within 4weeks of travel.

Due to misunderstandings about their effectiveness and feasibility, topical (or rectal) therapies with aminosalicylates (5-aminosalicylic acid, 5-ASA) and steroids are often underused in patients with ulcerative colitis (UC). However, many of these patients could be treated solely with rectal/topical therapies, or could benefit from them in combination with oral therapies. We review the evidence for topical therapies containing 5-ASA and budesonide in UC and discuss how these therapies can be optimized in daily practice, thereby improving compliance. Finally, we provide a brief summary of studies on the use of other topical treatments in UC, the results of which were both promising and negative.

Despite the increasing use of carbon dioxide for endoscopies during the last years, ambient air is still used. The amount of air depends on several factors such as examination time, presumable diameter of the endoscope channel and of course active use of air by the operator. Although endoscopic complications due to ambient air in the gastrointestinal (GI) tract are a rare observation and mostly described in the colon, we report five cases in the upper GI tract due to insufflating large amounts of air through the endoscopes. All 5 patients needed an emergency upper endoscopy for acute presumed upper GI bleeding. In two cases both esophageal variceal bleeding and ulcer bleeding were detected; the fifth case presented with a bleeding due to gastric cancer. Due to insufflation of inadequate amounts of air through the endoscope channel, all patients deteriorated in circulation and ventilation. Two rumenocenteses and consecutively three laparotomies had to be performed in three patients. In the other two, gastroscopies had to be stopped for an emergency computed tomography. All critical incidents were believed to be a consequence of a long-lasting examination with use of too much air. Therefore in emergency situations, endoscopies should be performed with either submersion, low air flow pumps or even better by the use of carbon dioxide.