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Oral Nano Vitamin D Supplementation Reduces Disease Activity in Ulcerative Colitis: A Double-Blind Randomized Parallel Group Placebo-controlled Trial Introduction: Vitamin D possesses anti-inflammatory properties and could be beneficial in ulcerative colitis (UC). Methods: We studied the effect of oral nano vitamin D3 supplementation on disease activity in active UC [ulcerative colitis disease activity index (UCDAI)≥3]. Patients with active UC and vitamin D <40 ng/mL were randomized to receive either oral nano vitamin D (60,000 IU/d×8 d) or placebo. They were evaluated for disease activity (UCDAI scores, C-reactive protein, erythrocyte sedimentation rate, and fecal calprotectin) at baseline and reassessed at 4 weeks. The response was defined as a 3-point reduction in UCDAI score at 4 weeks and reduction in inflammatory markers. Results: The median vitamin D levels increased from 15.4 to 40.83 mg/dL in vitamin D group (P≤0.001) and marginally from 13.45 to 18.85 mg/dL (P=0.027) in controls. The 3-point reduction in UCDAI was seen more often in vitamin D group as compared with the control (53% vs. 13%; P=0.001). Increase in vitamin D levels correlated with reduction in UCDAI score (P≤0.001; ρ=−0.713), C-reactive protein (P≤0.001; ρ=−0.603), and calprotectin (P=0.004; ρ=−0.368). Patients who achieved target vitamin D of >40 ng/mL (n=17) more often had a 3-point reduction in UCDAI (80% vs. 20%; P≤0.001) and reduction in grade of severity from 60% to 35% (P=0.038). Vitamin D administration (odds ratio, 9.17; 95% confidence interval, 2.02-41.67) and baseline histologic activity (odds ratio, 1.92; 95% confidence intervals, 1.2-3.08) independently predicted response. Conclusions: Oral nano vitamin D supplementation in active UC is associated with a reduction in disease activity and severity grade and is seen more often in those who achieved a target vitamin D level of 40 ng/mL.

Autoimmune and Allergic Disorders are More Common in People With Celiac Disease or on a Gluten-free Diet in the United States Goals: We analyzed demographics, lifestyle patterns, and clinical characteristics of people with celiac disease (CD) and people without CD avoiding gluten (PWAG) to better understand associations with medical conditions and consumer behavior. Background: Clinical significance of CD and gluten avoidance in the general population is incompletely understood. Recently, a high incidence of CD in adolescents with susceptibility genotypes, similar to other autoimmune or allergic disorders, and regional differences in consumer practices of gluten avoidance were reported. Methods: Among 22,277 participants in the National Health and Nutrition Examination Survey 2009-2014, we identified persons with CD by testing CD serology or by both a health care provider diagnosis and adherence to a gluten-free diet. Similarly, PWAG were defined as adherent to a gluten-free diet without a CD diagnosis. Consumer behavior and characteristics of both groups, CD and PWAG were compared with those without these conditions, using survey-weighted generalized logistic regression. Results: Participants with CD considered nutrition very important when grocery shopping and tended to have more constipation and thyroid disease. PWAG tended to spend more money on groceries, purchase organic foods, and check food labels more frequently during grocery shopping. They also reported having more food allergies, asthma, and thyroid disease. Conclusions: Our study confirms that CD and PWAG share comorbidities of autoimmune nature. PWAG had more autoimmune/allergy-related disorders that may be associated with non-celiac gluten sensitivity a self-justifiable reason to be on the diet.

Peripartum Maternal Hepatitis B Care in a US Nationwide Data Set Background: Hepatitis B virus (HBV) screening during pregnancy is standard of care to prevent vertical transmission to infants, yet the mothers themselves may not receive appropriate follow-up. Goals: Using a national database, we sought to determine rates of maternal peripartum follow-up with a HBV specialist and identify factors associated with a lack of follow-up. Materials and Methods: We identified women who delivered in 2000 to 2012 and were diagnosed with HBV according to International Classification of Diseases-9 codes using a national database (Optum) derived from commercial insurance claims with ∼46 million members ages 0 to 64 in all 50 states. Our primary outcome was follow-up during or after pregnancy with a HBV specialist (gastroenterology/infectious diseases). Results: The prevalence of HBV was 0.27% (2558/959,747 pregnancies), and median follow-up was 45 months. Only 21% of women had peripartum HBV specialist follow-up. On multivariable regression, predictors of peripartum follow-up at 1-year included younger age [odds ratio (OR), 0.97/y; 95% confidence interval (CI), 0.94, 0.99], Asian race/ethnicity (OR, 1.56 vs. white; 95% CI, 1.13, 2.17), and residing in the Northeast (OR, 1.70; 95% CI, 1.09, 2.66) and Midwest (OR, 1.73; 95% CI, 1.07, 2.81) versus West. Predictors of testing for HBV DNA and alanine aminotransferase at 1 year included Asian race (OR, 1.72; 95% CI, 1.23, 2.41), a primary care physician visit within 2 years of delivery (OR, 1.63; 95% CI, 1.19, 2.22), and peripartum HBV specialist follow-up within 1 year (OR, 15.68; 95% CI, 11.38, 21.60). Conclusions: Maternal HBV specialist follow-up rates were extremely low in this large, diverse cohort representing all United States regions. Referral to a HBV specialist was the strongest predictor of appropriate postpartum HBV laboratory testing. Follow-up rates may be even lower in uninsured populations.

Comparison Between an Oral Sulfate Solution and a 2 L of Polyethylene Glycol/Ascorbic Acid as a Split Dose Bowel Preparation for Colonoscopy Background/Aims: This study aimed to compare the efficacy and tolerability of an oral sulfate solution (OSS) versus 2 L of polyethylene glycol/ascorbic acid (2L-PEG/Asc) for bowel cleansing before colonoscopy. Methods: A prospective, single-center, single-blinded, noninferiority, randomized, controlled trial was performed. The primary outcome was the rate of successful bowel cleansing, evaluated using the Boston Bowel Preparation Scale (BBPS). Secondary outcomes were examination time, polyp, and adenoma detection rate (PDR and ADR), tolerability, and safety. Ease of use, palatability, intention to reuse, and satisfaction were evaluated using a questionnaire. Results: A total of 187 participants were randomized to receive either OSS (n=93) or 2L-PEG/Asc (n=94). Successful bowel cleansing was achieved in 86.0% (80/93) of the OSS group, which was noninferior to the 2L-PEG/Asc group (88.3%, 83/94), with a difference of −2.3% by ITT analysis [95% confidence interval (CI) −12.0 to +7.4]. The withdrawal time of the OSS group was significantly shorter than that of the 2L-PEG/Asc group (11.8±5.2 vs. 14.3±8.5; P=0.016). Ease of use, palatability, intention to reuse, and satisfaction were similar between the 2 groups. Adverse events were also similar between the 2 groups. Mucosal erythema (4.3%) and aphthous lesions (2.1%) were found only in the 2L-PEG/Asc group. Conclusions: OSS was as effective as 2L-PEG/Asc for successful bowel cleansing and had acceptable tolerability. OSS is a promising and safe low-volume preparation alternative for colonoscopy. (Clinical trial registration number: NCT02761213.)

Financial Toxicity in Crohn’s Disease Background: A patient-reported outcome measure called Comprehensive Score for Financial Toxicity (COST) was previously developed and validated in patients with cancer. Goals: We sought to assess the financial toxicity associated with Crohn’s disease (CD) by administering the COST questionnaire to patients treated at a tertiary care center. Study: Forty-eight patients diagnosed with CD completed questionnaires, which included the COST quality of life instrument as well as questions with regard to sociodemographics and clinical characteristics. Analysis of results was performed with Minitab. Results: Forty-eight completed questionnaires were scored. The mean age of the cohort was 37.6±13.4 years and 58% of patients were women. COST scores had a normal distribution (Anderson-Darling, P=0.31). The median COST score was 22, a result associated with mild negative impact on health-related quality of life. Patients’ COST score stratum differed based on their education level (P<0.001), employment status (P=0.037), disability status (P=0.016), household income (P=0.004), and housing arrangement (P=0.006). Disease activity in the past 6 months and more frequent feelings of anxiety and depression also correlated with higher COST score. Conclusions: In this survey study, we found that the majority of our patients with CD experienced at least mild financial distress. Lower income and education level increased disease activity, and the presence of anxiety and depression increased the financial distress experienced by patients. Further research is needed to develop effective interventions to minimize financial toxicity in this patient population.

Risk of Renal Injury After the Use of Polyethylene Glycol for Outpatient Colonoscopy: A Prospective Observational Study Goal: The goal of this study was to estimate the risk of renal injury after the use of 3-L polyethylene glycol (PEG) before outpatient colonoscopy. Background: Population-based studies showed that the use of PEG was associated with renal injury, but this association has not been confirmed by prospective study. Study: Patients ≥40 years of age with an estimated glomerular filtration rate ≥30 mL/min were screened for enrollment. Laboratory data were collected before, during, and after the colonoscopies. Patients with a ≥30% increase in baseline serum creatinine levels were followed until a peak level was detected. Renal injury included acute renal dysfunction (ARD) and acute kidney injury (AKI), defined as a 30% to 49% increase and ≥50% increase in creatinine levels compared with the baseline, respectively. Results: A total of 1163 patients (mean age, 55.7 y) completed the study. Baseline and first postcolonoscopy laboratory data were obtained an average of 17.0 days before and 17.3 days after the colonoscopies were performed, respectively. Renal injury was identified in 32 patients; 26 patients (2.2%) had ARD, and 6 patients (0.5%) had AKI. All patients with renal injury recovered fully during follow-up. In the subgroup analysis, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) before colonoscopy was statistically associated with the development of AKI (odds ratio, 6.5; 95% confidence interval, 1.2-35.5; P=0.03). Conclusions: This prospective study showed that the use of PEG was associated with a small risk of renal injury. NSAIDs use was statistically associated with AKI in the context of colonoscopy for which PEG was used for bowel preparation.

Chronic Obstructive Pulmonary Disease and the Risk of Esophagitis, Barrett’s Esophagus, and Esophageal Adenocarcinoma: A Primary Care Case-Control Study Background: Chronic gastroesophageal reflux predisposes to the development of esophageal adenocarcinoma (EAC). Asthma and medication to treat it are associated with gastroesophageal reflux and EAC. We studied subjects with chronic obstructive pulmonary disease (COPD) to examine the relationship between COPD and medication used to treat it, and the risk of reflux esophagitis, Barrett’s esophagus, and EAC. Methods: A case-control study from the UK General Practice Research Database was conducted. Cases were aged 50 or above with a diagnosis of COPD and were matched with controls without a diagnosis of COPD by age, general practitioners practice, and time on the database. EAC was confirmed by cross-referencing cancer registry data. Cox-regression analysis was performed to assess the relationship between COPD, reflux esophagitis, Barrett’s esophagus, and EAC. Results: A total of 45,141 cases were studied [24,464 male, age 75 (50 to 100) years]. Among COPD cases there were 55 esophageal cancers (30 EAC) and 506 Barrett’s esophagus, compared with 62 (34 EAC) and 329 Barrett’s esophagus among controls. COPD was not associated with EAC on univariable [0.92 (0.56 to 1.50), P=0.73] and multivariable analysis [0.85 (0.52 to 1.40), P=0.53]. COPD was however, associated with Barrett’s esophagus on univariable [0.92 (0.56 to 1.50), P=0.73] and multivariable [1.53 (1.31 to 1.78), P<0.001] analysis and reflux esophagitis on univariable [1.41 (1.36 to 1.48), P<0.001] and multivariable [1.33 (1.27 to 1.40), P<0.001] analysis. Conclusion: COPD is associated with an increased risk of reflux esophagitis and Barrett’s esophagus but not EAC.

Impact of Automated Time-released Reminders on Patient Preparedness for Colonoscopy Goals: To evaluate the effect of an automated time-released colonoscopy reminder program on preparation quality and the rates of canceled procedures. Background: Patients missing colonoscopy appointments or arriving with inadequate bowel preparations result in delays in care and increase in health care costs. Study: We initiated a quality improvement program which included switching to a split-dose preparation and delivering preparation instructions and appointment reminders via text messages and emails sent with an automated time-released HIPAA-compliant software platform. All patients scheduled for a colonoscopy from March through June 2017 were enrolled unless mobile phone, email, or preparation type data was missing (nonintervention cohort). Primary outcome metrics were the rate of adequate bowel preparation and the rate of canceled procedures. Outcomes of the intervention group were compared with outcomes from colonoscopies performed from March through June 2016 (baseline cohort). Results: There were 1497 patients (40.7% male, mean age 56.4 y) enrolled in the automated reminder program. Compared with the baseline cohort, the rate of adequate bowel preparation increased from 88.5% to 96.2% (P<0.0001). The rate of canceled procedures decreased from 6.1% to 4.3% (P=0.02). On multivariable analysis, the automated reminder program improved adequate preparation quality 2.85-fold (95% confidence interval, 2.03-3.99; P<0.0001). Sensitivity analysis comparing the intervention to nonintervention cohorts showed that improvement in preparation quality was attributable to the automated reminder program. Conclusions: Implementation of automated time-released colonoscopy preparation reminders via text messages and emails improved patient preparedness for colonoscopy, with significantly improved bowel preparation quality and fewer canceled procedures.

Changes in Lower Gastrointestinal Bleeding Presentation, Management, and Outcomes Over a 10-Year Span Background: There are only limited data available on changes in the etiology, management, and clinical outcomes in patients with lower gastrointestinal bleeding over the past decade. Study: We compared 2 groups of consecutive patients hospitalized with lower gastrointestinal bleeding during 2 time periods: 2005 to 2007 (301 patients) and 2015 to 2017 (249 patients). Results: Compared with the 2005 to 2007 group, the mean Charlson comorbidity index in the 2015 to 2017 group was higher (5.0±2.6 vs. 6.0±3.0, P=0.028), whereas the use of computerized tomographic angiography and small bowel capsule endoscopy was more common (12.9% vs. 58.1%, P<0.001, and 28.8% vs. 69.0%, P=0.031, respectively). In 2005 to 2007, ischemic colitis (12.0%) was the most common confirmed etiology of bleeding and diverticular bleeding the second most common (8.6%), whereas in 2015 to 2017, diverticular bleeding was the most common etiology (10.4%), followed by angiodysplasia (8.4%). Small bowel bleeding sources were confirmed more often in the 2015 to 2017 group (P=0.017). Endoscopic treatment was attempted in 16.6% of patients in 2005 to 2007 versus 25.3% in 2015 to 2017 (P=0.015). Higher rebleeding rates, longer hospitalization durations (4.6±4.3 vs. 5.5±3.4 d, P=0.019), and a higher proportion of patients needing a transfusion (62.0% vs. 78.4%, P=0.016) were noted in 2015 to 2017. Conclusions: Over a 10-year span, there were several notable changes: (1) more comorbidities in patients hospitalized for lower gastrointestinal bleeding; (2) marked increase in the use of computerized tomographic angiography and capsule endoscopy for diagnostic evaluation; and (3) longer hospitalization durations and greater need for blood transfusion, possibly reflecting the selection of sicker patients for in-patient management in 2015 to 2017.