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Dedicated studies evaluating the impact of COVID-19 on outcomes of pancreatobiliary IgG4 related disease (IgG4-RD) patients are scarce. Whether COVID-19 infection or vaccination would trigger IgG4-RD exacerbation remains unknown.Pancreatobiliary IgG4-RD patients ≥ 18 years old with active follow-up since January 2020 from nine referral centers in Asia, Europe, and North America were included in this multicenter retrospective study. Outcome measures include incidence and severity of COVID-19 infection, IgG4-RD disease activity and treatment status, interruption of indicated IgG4-RD treatment. Prospective data on COVID-19 vaccination status and new COVID-19 infection during the Omicron outbreak were also retrieved in the Hong Kong cohort.Of the 124 pancreatobiliary IgG4-RD patients, 25.0% had active IgG4-RD, 71.0% were on immunosuppressive therapies and 80.6% had ≥ 1 risk factor for severe COVID. In 2020 (pre-vaccination period), two patients (1.6%) had COVID-19 infection (one requiring ICU admission), and 7.2% of patients had interruptions in indicated immunosuppressive treatment for IgG4-RD. Despite a high vaccination rate (85.0%), COVID-19 infection rate has increased to 20.0% during Omicron outbreak in the Hong Kong cohort. A trend towards higher COVID-19 infection rate was noted in the non-fully vaccinated/unvaccinated group (17.6% vs 33.3%, P = 0.376). No IgG4-RD exacerbation following COVID-19 vaccination or infection was observed.While a low COVID-19 infection rate with no mortality was observed in pancreatobiliary IgG4-RD patients in the pre-vaccination period of COVID-19, infection rate has increased during the Omicron outbreak despite a high vaccination rate. No IgG4-RD exacerbation after COVID-19 infection or vaccination was observed.

Background Gastrointestinal endoscopy is frequently recommended for chronic diarrhea assessment in Western countries, but its benefit in the Southeast Asia region is not well established. Methods Medical records of consecutive patients undergoing esophagogastroduodenoscopy (EGD), colonoscopy, and small bowel endoscopy for chronic diarrhea from 2008 to 2018 were reviewed. Small bowel endoscopy included push enteroscopy, balloon-assisted enteroscopy (BAE), and video capsule endoscopy (VCE). The diagnostic yield of each endoscopic modality and predictors for positive small bowel endoscopy were analyzed. Results A total of 550 patients were included. The mean age was 54 years, and 266 (46.3%) patients were male. The mean hemoglobin and albumin levels were 11.6 g/dL and 3.6 g/dL, respectively. EGD and colonoscopy were performed in 302 and 547 patients, respectively, and the diagnostic yield was 24/302 (7.9%) for EGD and 219/547 (40.0%) for colonoscopy. EGD did not reveal positive findings in any patients with normal colonoscopy. Fifty-one patients with normal EGD and colonoscopy underwent small bowel endoscopy. Push enteroscopy, BAE, and VCE were performed in 28, 21, and 19 patients with a diagnostic yield of 5/28 (17.9%), 14/21 (66.7%), and 8/19 (42.1%), respectively. Significant weight loss, edema, and hypoalbuminemia were independent predictors for the positive yield of small bowel endoscopy. Conclusion Colonoscopy was an essential diagnostic tool in identifying the cause of chronic diarrhea in Thai patients, whereas EGD provided some benefits. Small bowel endoscopy should be performed when colonoscopy and EGD were negative, particularly in patients with significant weight loss, edema, and hypoalbuminemia.

BACKGROUND Biologics have been used for the treatment of inflammatory bowel disease (IBD) worldwide; however, their use is still limited in Southeast Asia. This study aimed to describe the pattern of biologic use and outcomes in a tertiary referral center in Thailand. METHOD All patients with IBD who used biologics from the first case in 2012 to present in our center were enrolled. The data were prospectively collected since 2017; the data of patients before 2017 were retrospectively reviewed. The treatment outcomes comprised cumulative clinical, endoscopic, radiologic response or remission, and quality of life assessed by SIBDQ. Furthermore, the biologic persistence was reported. RESULTS Of 296 cases currently in the IBD clinic, 85 used biologics, including infliximab (IFX), vedolizumab (VDZ), and ustekinumab (UST). The mean age was 44.4 years, and 62% were male. Fifty-eight (68.2%) had Crohn’s disease (CD) and 27 (31.8%) had ulcerative colitis (UC). In CD, 58% had ileocolonic disease, 48% had bowel stricture, 29% had fistula, and 19% had perianal diseases. In UC, 19% had left-sided colitis, and 81% had extensive colitis. Most patients (97%) failed conventional treatment. In CD, 60%, 31%, and 8.6% use IFX, VDZ, and UST as the first biologic, respectively. While 81.5% of UC used VDZ and 18.5% used IFX. Concomitant immunomodulator was used in 77.6%. The median duration of the first biologic use was 12.6 months. The outcomes of the treatment were shown in Table 1. The overall cumulative clinical response and remission at 1 year were 94% and 63%, respectively, without significant differences among each biologic. The cumulative rate of endoscopic remission was 29%, 64%, and 82% at 1, 3, and 5 years, respectively, also without significant differences among each biologic (p=0.21). However, subgroup analysis in Crohn’s disease showed a trend of a better endoscopic remission rate for IFX and UST when compared to VDZ (p=0.15). The radiologic remission rate was only 12% of 25 patients who underwent CT enterography. The SIBDQ increased from 52.0 to 57.4 after 1 year of treatment. Thirty-six (42%) stopped the medicine. As shown in Figure 1, the overall cumulative rate of biologic discontinuation was 19% and 39% in the first and second year, respectively, without significant differences among biologics. However, the reason for drug discontinuation was different as all adverse events occurred in only patients using IFX. CONCLUSION Biologics were mostly used in refractory patients in this cohort. The outcomes were comparable to those previously reported in western. Current biologics could significantly improve patients’ symptoms, quality of life, and mucosal healing, but not transmural healing. The adverse events were less in newer biologics.

Background Proton pump inhibitors are often inappropriately prescribed during hospital admission and after discharge. The inappropriate prescription may be associated with increased and unnecessary healthcare costs. Objective To determine the prevalence of inappropriate prescription of proton pump inhibitors during hospital admission and after discharge at Thailand’s largest national tertiary referral center. Setting Medicine wards at Siriraj Hospital (Bangkok, Thailand) during September 2016 to September 2017. Method This prospective observational cross-sectional study in hospitalized patients who were prescribed, or who were already taking proton pump inhibitors. Medical records were reviewed to determine whether proton pump inhibitors were prescribed at discharge and at the 1-month follow-up. Main outcome measure Prevalence of inappropriate prescription of proton pump inhibitors during hospital admission and after discharge, indication of inappropriate prescription. Results Two hundred and sixty-five patients (mean age: 65.8 ± 18.3 years, 50.9% men) were included. Approximately half of patients had proton pump inhibitor treatment initiated in the hospital, and the other 50.6% started treatment earlier. Among all patients, 50.6% were inappropriately prescribed proton pump inhibitors, in which 79.1% resulted from invalid indications. Fifty-two percent and 47.3% of patients who were prescribed proton pump inhibitors at discharge and at the 1-month follow-up had no indications for them. Gastrointestinal ulcer prophylaxis in low-risk patients was the most commonly observed incorrect indication. Aspirin (p = 0.030) and corticosteroids (p = 0.038) were both found to be significantly associated with the inappropriate prescription of proton pump inhibitors. The estimated cost of inappropriate use among inpatients and outpatients was $118,659 and $214,663 per year, respectively. Conclusion Proton pump inhibitors are excessively and inappropriately prescribed during hospital admission and after discharge in Thailand. The cost of this overprescribing is excessive and needs to be controlled.