Search

Summary Background There is a paucity of evidence to support safe and effective management of patients with acute severe ulcerative colitis during the COVID-19 pandemic. We sought to identify alterations to established conventional evidence-based management of acute severe ulcerative colitis during the early COVID-19 pandemic, the effect on outcomes, and any associations with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and severe COVID-19 outcomes. Methods The PROTECT-ASUC study was a multicentre, observational, case-control study in 60 acute secondary care hospitals throughout the UK. We included adults (≥18 years) with either ulcerative colitis or inflammatory bowel disease unclassified, who presented with acute severe ulcerative colitis and fulfilled the Truelove and Witts criteria. Cases and controls were identified as either admitted or managed in emergency ambulatory care settings between March 1, 2020, and June 30, 2020 (COVID-19 pandemic period cohort), or between Jan 1, 2019, and June 30, 2019 (historical control cohort), respectively. The primary outcome was the proportion of patients with acute severe ulcerative colitis receiving rescue therapy (including primary induction) or colectomy. The study is registered with ClinicalTrials.gov , NCT04411784 . Findings We included 782 patients (398 in the pandemic period cohort and 384 in the historical control cohort) who met the Truelove and Witts criteria for acute severe ulcerative colitis. The proportion of patients receiving rescue therapy (including primary induction) or surgery was higher during the pandemic period than in the historical period (217 [55%] of 393 patients vs 159 [42%] of 380 patients; p=0·00024) and the time to rescue therapy was shorter in the pandemic cohort than in the historical cohort (p=0·0026). This difference was driven by a greater use of rescue and primary induction therapies with biologicals, ciclosporin, or tofacitinib in the COVID-19 pandemic period cohort than in the historical control period cohort (177 [46%] of 387 patients in the COVID-19 cohort vs 134 [36%] of 373 patients in the historical cohort; p=0·0064). During the pandemic, more patients received ambulatory (outpatient) intravenous steroids (51 [13%] of 385 patients vs 19 [5%] of 360 patients; p=0·00023). Fewer patients received thiopurines (29 [7%] of 398 patients vs 46 [12%] of 384; p=0·029) and 5-aminosalicylic acids (67 [17%] of 398 patients vs 98 [26%] of 384; p=0·0037) during the pandemic than in the historical control period. Colectomy rates were similar between the pandemic and historical control groups (64 [16%] of 389 vs 50 [13%] of 375; p=0·26); however, laparoscopic surgery was less frequently performed during the pandemic period (34 [53%] of 64] vs 38 [76%] of 50; p=0·018). Five (2%) of 253 patients tested positive for SARS-CoV-2 during hospital treatment. Two (2%) of 103 patients re-tested for SARS-CoV-2 during the 3-month follow-up were positive 5 days and 12 days, respectively, after discharge from index admission. Both recovered without serious outcomes. Interpretation The COVID-19 pandemic altered practice patterns of gastroenterologists and colorectal surgeons in the management of acute severe ulcerative colitis but was associated with similar outcomes to a historical cohort. Despite continued use of high-dose corticosteroids and biologicals, the incidence of COVID-19 within 3 months was low and not associated with adverse COVID-19 outcomes. Funding None.

Purpose of review The current review discusses current practices regarding appropriate indications for parenteral nutrition in acutely ill hospitalized patients. We address-specific indications for parenteral nutrition in the perioperative period, and in inflammatory bowel disease, oncology, hepatobiliary, critical care and end-stage renal disease patients. Recent findings Acutely ill hospitalized patients can develop intestinal failure requiring parenteral nutrition. Recent studies have provided insight into the main indications. The most common indications for inpatient parenteral nutrition include postsurgical complications, including prolonged ileus, sepsis, fistula and leaks, and bowel obstruction, predominantly malignant. Severe or complicated inflammatory bowel disease and cancer treatment-related mucosal enteropathies (mucositis, enterocolitis, gut graft-versus-host disease) are the next commonest indications. Less frequent indications are primary motility disorders and inability to secure enteral access for enteral nutrition. Gastrointestinal failure of the intensive care patient is a separate entity resulting from multiple mechanisms, including an enteropathy and dysmotility. Summary Despite the wider availability of nutrition support teams, use of parenteral nutrition is not without risk. The risks and benefits of parenteral nutrition in the acute setting need to be carefully considered even when it is indicated.

Patients with inflammatory bowel disease are currently managed with the assumption that trial data are applicable to all ethnic groups. Previous studies demonstrate differences in disease severity and phenotype of Asian patients with Crohn’s disease (CD), including Bangladeshi Asians within the UK. No study has evaluated the impact of ethnicity on response to anti-TNFs. Our primary endpoint was a comparison of failure-free survival on first prescribed anti-TNF (anti-tumor necrosis factor) therapy in UK Bangladeshi and Caucasian patients with CD. Our secondary aims were to evaluate disease phenotype, indication for anti-TNF prescription, and duration from diagnosis until first anti-TNF prescribed between groups. The records of consecutive outpatient appointments over a 12-month period were used to identify Caucasian and Bangladeshi patients prescribed an anti-TNF for CD. Information on patient demographics, ethnicity, disease phenotype, immunomodulator use, outcome from first biologic, duration of therapy, and reason for cessation was recorded. In total, 224 Caucasian and Bangladeshi patients were prescribed an anti-TNF for CD. Bangladeshi patients started an anti-TNF 4.3 years earlier after diagnosis than Caucasian patients (3.9 years vs. 8.2 years: p

The microbiome plays an important role in maintaining human health. Despite multiple factors being attributed to the shaping of the human microbiome, extrinsic factors such diet and use of medications including antibiotics appear to dominate. Mucosal surfaces, particularly in the gut, are highly adapted to be able to tolerate a large population of microorganisms whilst still being able to produce a rapid and effective immune response against infection. The intestinal microbiome is not functionally independent from the host mucosa and can, through presentation of microbe-associated molecular patterns (MAMPs) and generation of microbe-derived metabolites, fundamentally influence mucosal barrier integrity and modulate host immunity. In a healthy gut there is an abundance of beneficial bacteria that help to preserve intestinal homoeostasis, promote protective immune responses, and limit excessive inflammation. The importance of the microbiome is further highlighted during dysbiosis where a loss of this finely balanced microbial population can lead to mucosal barrier dysfunction, aberrant immune responses, and chronic inflammation that increases the risk of disease development. Improvements in our understanding of the microbiome are providing opportunities to harness members of a healthy microbiota to help reverse dysbiosis, reduce inflammation, and ultimately prevent disease progression.

Introduction Macroscopic mucosal healing is an established therapeutic target in ulcerative colitis (UC) and can be objectively measured using endoscopic indices. The Mayo Endoscopic Sub-score (MES) and UC Endoscopic Index Score (UCEIS) are validated scores that can guide clinical decision making and prognostication. This multi-centre study aimed to assess the use of these indices in the endoscopic assessment of UC and whether an intervention bundle impacts reporting quality. Methods We retrospectively reviewed 1160 endoscopy reports for UC patients across 7 London centres (April-October 2019), evaluating the use of 10 reporting elements recommended by the Building Research in Inflammatory Bowel Disease Globally (BRIDGe) group. In addition to the MES (recommended by BRIDGe), we included the UCEIS as an alternative index. We segregated endoscopists according to specialty, level of training and interest in inflammatory bowel disease (IBD) and compared the number of BRIDGe elements in reports between groups. We then implemented an intervention bundle at a single centre and compared index use pre- and post-intervention. The bundle included integrating a proforma into reporting software, training on endoscopic indices (online and face-to-face) and posters in endoscopy suites. Statistics: Chi squared for categorical variables and Mann-Whitney U for continuous variables. Results The use of endoscopic indices was higher in centres with a pre-existing reporting proforma compared to centres without (77.7% (202/260) vs 44.4% (400/900), p Endoscopic indices were used more frequently by gastroenterologists compared to other specialists (544/1002 (54.3%) vs 58/158 (36.7%), p Conclusion Implementing a UC reporting proforma as part of an intervention bundle results in quality improvement in endoscopic reporting. Our results also support running dedicated lists for UC assessment, carried out by gastroenterologists with an interest in IBD. High quality reporting achieved by implementing this strategy may translate to improved clinical decision making and patient outcomes.

Introduction 50% of patents with Crohn’s disease (CD) develop fistulae, resulting in significant morbidity. Isolated internal penetrating CD (IPCD), without enterocutaneous manifestations, is the second most prevalent fistulating phenotype after perianal CD(Schwartz et al., 2019) yet the management of isolated IPCD remains poorly characterised in therapeutic trials. This study aims to assess outcomes of IPCD at a large, tertiary IBD centre. Methods All adult patients with penetrating CD were screened from imaging reports and corroborated with radiology meeting, surgical and biologic databases between January 2016 and April 2019. Concurrent perianal or enterocutaneous fistulation was excluded from analysis. Complete, partial or no resolution of fistula was an assessed composite of imaging, symptoms and nutritional independence(Samimi et al., 2010). Statistics: categorical variables, Fisher’s exact. Results 29 patients had IPCD diagnosed between 2008 and 2018. 28% had undergone prior gastrointestinal surgery. At fistula diagnosis, 41% had prior biologic exposure including 6 on their third line biologic, and 66% on a previous or current immunomodulator. Only 4 (14%) were on a current biologic. IPCD was diagnosed at median 62 months [IQR 24–117] after IBD diagnosis with the majority enterocolonic (47%) and enteroenteric (27%) in configuration. 69% had documented distal obstruction or stenosis, 7% had a confirmed abscess. 52%, 24% and 24% underwent medical, surgical or no additional intervention, respectively, as primary management of their IPCD. Compared with no intervention, only the presence of symptoms was predictive of medical (14% vs 93%, p=0.0006) or surgical (14% vs 100%, p=0.0047) intervention, whereas prior surgery, current or prior biologic therapy, IPCD configuration were not. Of medically treated IPCD, 73% (11/15) had a biologic at median duration 29 months with Adalimumab 1st line in 64% (7/11) and Ustekinumab 2nd line in 67% (4/6). There was a trend to greater complete or partial fistula resolution by surgery versus medical management (86% (6/7) vs 47% (7/15), p=0.1649) and surgery versus biologics (86% (6/7) vs 64% (7/11), p=0.596) at reassessment interval (17 [12–43] vs 8 [7–17] months, respectively) (figure 1). Of medical and no intervention cohorts, 53% and 29% eventually had surgery at median intervals 6 and 72 months. Of the whole cohort, 59% had surgery, in whom 35% had a pre-operative biologic, 12% pre-operative parenteral nutrition (PN), 18% post-operative PN (duration 14, 41, 8 months respectively), and 18% post-operative intra-abdominal septic complications within 30 days. Conclusion Most patients in this cohort require surgery to achieve complete of resolution of IPCD with medical therapy including biologics offering limited temporising effect. For those predominantly asymptomatic patients, no intervention can be a suitable management option.

We describe a retrospective cohort study of patients with malignant bowel obstruction to examine their nutritional care pathways between 1.1.16 and 31.12.16 with readmissions until 31.12.17. Data were analyzed by comparing patients who were referred (R) and not referred (NR) for PN. We identified 72 patients with 117 MBO admissions (mean ± SD age:63.1 ± 13.1yrs, 79% female). 24/72 patients were in R group. Predominant primary malignancies were gynaecological and lower-gastrointestinal cancers (76%). 83% patients had metastases (61% sub-diaphragmatically). All patients were at high-risk of malnutrition and baseline mean weight loss was 7%. Discussion of PN at multidisciplinary team meeting (MDT) (22% vs.5%, P = 0.02) and dietetic contact (94% vs. 41%, P < 0.0001) were more likely to occur in the R group. In 13/69 MBO admissions in NR group, reasons for non-referral were unclear. Median baseline and follow-up weight was similar (55-55.8 kg). Overall survival was 4.7 (1.4-15.2)months, with no differences by referral groups. We compared a sub-sample of patients who 'may have' required PN (n = 10) vs. those discharged on home PN (n = 10) and found greater survival in the HPN group (323vs.91 day, P < 0.01). Our findings highlight disparity in care pathways suggesting that nutritional care should be integrated into clinical management discussion(s) at MDT to ensure equal access to nutritional services.

Although herbal preparations are widely used by patients with inflammatory bowel disease (IBD), evidence for their efficacy is limited and they may not always be safe. Mainly small studies of varying quality have suggested that several herbal preparations could be of benefit in IBD, but larger better-designed trials are needed to establish their place in inducing and maintaining remission. Patients and health care workers need to be made more aware of the limitations and risks of using herbal products for IBD.

ObjectiveGenomics and personalised medicine are increasingly relevant for patients with gastroenterological conditions. We aim to capture the current state of genomics training in gastroenterology to review current understanding, clinical experience and long-term educational needs of UK trainees.Design and settingA web-based nationwide survey of all UK gastroenterology specialty trainees was conducted in 2017.Results100 trainees (14% of UK gastroenterology trainees) completed this survey. Only 9% and 16% of respondents believe that their local training programme adequately prepares them for the future clinical practice using genomic medicine and personalised medicine, respectively. Barriers identified include the need for greater trainee education (95%), inadequate clinical guidance to base interventions on the results of genomic testing (53%), concerns over misinterpretation by patients (43%) and overuse/misuse of testing by clinicians (34%).Survey respondents felt prepared to perform HFE genotyping (98%), assess TPMT status (97%) and interpret HLA subtyping for suspected coeliac disease (85%). However, only a minority felt prepared to perform the following investigations: polyposis screening (34%), hereditary pancreatitis screening (30%), testing for Lynch yndrome (33%) and KRAS testing for colorectal cancer (20%).Most respondents would support holding dedicated training days on genomic medicine (83%), formal training provisions for the mainstreaming of genomic testing (64%), an update to the UK gastroenterology specialty training curriculum and examinations (57%) and better-defined referral pathways for local genomic services (91%).ConclusionMost gastroenterology trainees in this survey feel ill equipped to practise genomic and personalised medicine as consultants. We propose specific revisions to the UK gastroenterology specialty curriculum that addresses trainees needs.

Medical and surgical treatments for Crohn’s disease are associated with toxic effects. Medical therapy aims for mucosal healing and is achievable with biologics, immunosuppressive therapy, and specialised enteral nutrition, but not with corticosteroids. Sustained remission remains a therapeutic challenge. Enteral nutrition, containing macro- and micro-nutrients, is nutritionally complete, and is provided in powder or liquid form. Enteral nutrition is a low-risk and minimally invasive therapy. It is well-established and recommended as first line induction therapy in paediatric Crohn’s disease with remission rates of up to 80%. Other than in Japan, enteral nutrition is not routinely used in the adult population among Western countries, mainly due to unpalatable formulations which lead to poor compliance. This study aims to offer a comprehensive review of available enteral nutrition formulations and the literature supporting the use and mechanisms of action of enteral nutrition in adult Crohn’s disease patients, in order to support clinicians in real world decision-making when offering/accepting treatment. The mechanisms of actions of enteral feed, including their impact on the gut microbiome, were explored. Barriers to the use of enteral nutrition, such as compliance and the route of administration, were considered. All available enteral preparations have been comprehensively described as a practical guide for clinical use. Likewise, guidelines are reported and discussed.

Background Repeated endoscopic assessments are an essential part of ulcerative colitis (UC) disease management and current guidelines recommend the use of an endoscopic activity score, either the endoscopic Mayo score or Ulcerative Colitis Endoscopic Index of Severity (UCEIS) as treatment targets. These indices have prognostic value, with endoscopic healing associated with favourable short- and long-term outcomes. This multi-centre study aimed to assess the frequency of using endoscopic disease activity scores in UC patients undergoing lower GI endoscopy. Methods Lower GI endoscopy reports from patients with UC were retrospectively reviewed from 7 sites in London between April and October 2018. Endoscopy reports were assessed based on the BRIDGe endoscopic reporting criteria including the use of Mayo or UCEIS score. The comparison was made between site factors (specialist IBD centres/non-specialist centres, use of reporting proforma), endoscopist speciality (gastroenterology, surgery or nurse endoscopist), level of training (consultant, registrar or nurse endoscopist) and interest in IBD. Chi-squared was used to compare groups. Results 899 lower GI endoscopy reports were reviewed. Mayo or UCEIS was used in 51% of cases (453/899). The use of endoscopic scores were significantly higher in gastroenterologists than in surgeons and nurse endoscopists respectively (401/762 (53%) vs. 22/54 (41%) vs. 30/83 (36%)), and higher in registrar trainees than consultants and nurse endoscopists (175/251 (70%) vs. 248/565 (44%) vs. 30/83 (36%)) and in those with a specialist interest in IBD compared with those without (237/409 (58%) vs. 216/490 (44%), p < 0.0001). The use of endoscopic scores was more frequent in specialist IBD centres than in non-specialist centres (417/728 (58%) vs. 36/172 (21%), p < 0.001). One centre used a reporting proforma which was associated with a significantly higher frequency of score use compared with centres without a proforma (202/260 (78%) vs. 251/639 (39%), p < 0.0001). Conclusion Reporting of endoscopic disease activity using a standardised scoring system occurs in only half of cases from this large multi-centre cohort. Frequency of use is higher in specialist IBD centres and when performed by gastroenterology specialists. Endoscopy reports from a site that used a standardised reporting proforma were significantly more likely to include an endoscopic index as well as a range of other reporting items. This suggests, at least in part, that endoscopy reporting may be optimised by the introduction of a proforma. Integration of a standardised proforma into reporting software would target all endoscopists performing UC endoscopies regardless of speciality, site or IBD interest.

Introduction Genomics and personalised medicine are increasingly important for patients with gastroenterological conditions. The higher training curricula of other specialities (e.g. cardiology and oncology) have been revised with the addition of modular training in genomics. Our aim was to capture the present state of genomics training in gastroenterology to review current trainee understanding, clinical experience and long-term training needs, and to assess their preparedness for future consultant practice. Methods A web-based nationwide survey of all UK Gastroenterology specialty trainees was carried out in November and December 2017, supported by the British Society of Gastroenterology national training committee. Results 100/658 UK Gastroenterology trainees (15.2%) across 17/18 deaneries and all specialty training levels responded to this survey. Only 9% and 16% of trainees believe that their local training adequately prepares them for future clinical practice utilising genomic medicine and personalised medicine respectively. Barriers identified (% agreeing or strongly agreeing) include the need for greater trainee education (95%), inadequate clinical guidance to base interventions on results of genomic testing (53%), concerns over misinterpretation by patients (43%) and overuse/misuse of testing by clinicians (34%). When assessing current mainstream genetic and personalised tests, trainees felt prepared to interpret HFE genotyping (98%), TPMT status (97%), and coeliac disease HLA subtyping (85%). However, only a minority of trainees felt prepared to interpret gene tests in patients with polyposis (34%), hereditary pancreatitis (30%), Lynch syndrome (33%), and KRAS in colorectal cancer (20%). For their future clinical practice, 76% of trainees did not know what mainstreaming of genomics would entail, with only 6% of trainees having recruited patients for the 100 k Genomes Project. Most trainees would support having dedicated training days on genomic medicine (83%), formal training provisions for mainstreaming of genomic testing (64%), an update to the gastroenterology JRCPTB curriculum and SCE examination (57%), and better-defined pathways for referral to local genomic services (91%). Conclusions Most UK gastroenterology trainees feel ill-equipped to practice genomic or personalised medicine as consultants, at a time of progressive mainstreaming of genomic practice in our specialty. We propose that the gastroenterology specialty curriculum requires specific revision to prepare trainees for genomics in their future clinical practice.

This article presents a case of a patient with undiagnosed ulcerative colitis who presented with autoimmune haemolytic anaemia.