Introduction Split bowel preparation for colonoscopy leads superior cleansing than a day before regime. Most endoscopy units in the UK do not use split timing for morning procedures. In this study we assessed the acceptability and effect of an introduction of a split preparation at a large endoscopy unit. Methods Acceptability of split bowel preparation was measured by survey. The effect of the introduction of split preparation on cleansing quality was measured for all diagnostic morning colonoscopies in a 3 month period before (group A) and after (group B) the change in practice. Grading of bowel preparation was measured using Boston Bowel Preparation Scale (BBPS) and categorical grading. The primary end point was the adequacy of preparation defined by a BBPS of ≥ 2 in each colonic segment. Sleep disturbance and effect on continence was surveyed in both groups. Results 410 patients completed a survey on acceptability of early morning bowel preparation. 86% of whom would be willing to wake early. Subsequently, group A was made up of 690 patients with 884 in group B. The median age was 61 with 48.2% male sex in group A and 45.3% in group B. 83.2% had adequate bowel preparation in group B compared with 76.3% in group A (p <0.001). Within group A 149 patients completed a survey on sleep disturbance with 5.4% describing moderate/severe sleep disturbance compared with 25.8% of 124 patients in group B. Conclusion Most patients were willing to undertake split bowel preparation for morning colonoscopy. Split bowel preparation had a greater degree of adequate cleansing, but was associated with a greater degree of sleep disturbance.

Abstract Background Tofacitinib is an oral small molecule directed against the JAK/STAT pathway. It is the first JAK inhibitor approved for the treatment of ulcerative colitis (UC) and is licenced for use in moderate to severely active disease. This study aims to evaluate tofacitinib effectiveness and safety in real-world clinical practice for moderate-to-severely active UC. Methods Consecutive patients receiving Tofacitinib for UC in four Irish tertiary referral centres were identified. Baseline clinical data and information on therapy outcomes were collected by retrospective review of electronic patient records. Patients included in the study cohort were older than 18 years of age, had a confirmed diagnosis of UC, had received at least one induction dose of tofacitinib, and had available clinical follow-up. The primary study endpoint was 6-month corticosteroid-free remission rate. Secondary endpoints included 3-month clinical response, inflammatory biomarkers responses to tofacitinib therapy, rates of tofacitinib discontinuation, and side effects. Continuous variables are presented as median [range]. P values < 0.05 were considered significant in all analyses. Results Fifty-three UC patients were included; age 40.4 [33.3 – 53.9] years, 66% male, disease duration 5.7 [2.6–10.9] years; follow-up 8.7 [6.4–14.1] months. 43%, 40% and 17% of patients had extensive, left-sided disease and proctitis respectively. At baseline, clinical Mayo subscore was 7 [5–8], CRP 4.0 [1.0–16.7] mg/L and faecal calprotectin 914 [444.0–1000] mcg/g. The 3-month clinical response and 6-month corticosteroid-free remission rates were 69% and 43%, respectively. Following tofacitinib therapy, compared with baseline values, a significant reduction in 3-month clinical Mayo score, 3-month CRP, and post-induction faecal calprotectin was observed, p <0.03 for all comparisons. 36% of patients (n=19) discontinued tofacitinib during study follow-up (time to Tofacitinib discontinuation 1.9 [0.5–18.9] months). Side effects occurred in 26% percent of patients with the majority minor and self-limiting. No cardiovascular or venous thromboembolic events were observed and no hospitalisations occurred due to therapy-related side effects Conclusion These data are in concordance with prior studies of tofacitinib effectiveness and safety in real world practice. They demonstrate that, in a cohort of UC patients with significant prior therapy exposure, tofacitinib is an effective therapy with an acceptable safety profile.

Objectives Rates of nonalcoholic fatty liver disease (NAFLD) are increasing worldwide. The fatty liver index (FLI) is a noninvasive predictor of NAFLD. This prospective cohort study used the FLI to estimate the prevalence of NAFLD in patients attending an Irish Acute Medical Unit (AMU), and assessed the degree of fibrosis in this group using Fibroscan. Methods Patients attending the AMU over a 3-month period were invited to participate. Patients with excess alcohol consumption or pre-existing liver disease were excluded. Using established FLI cut-offs, 414 participants were grouped into low (FLI ≤ 30), medium (30 < FLI ≤ 60) and high (FLI > 60) risk of NAFLD. High-risk patients were offered review including liver stiffness measurement (LSM) and controlled attenuation parameter (CAP) score. Results A total of 134 patients were at low-risk, 96 at medium-risk and 184 at high-risk of NAFLD. Male sex (P < 0.0001) and increasing age (P < 0.0001) were associated with higher risk. Of the 120 high-risk patients who attended follow up, 13 participants had LSM > 7 kPa. Higher FLI scores were associated with higher CAP scores (P < 0.0001) but did not predict higher LSMs. Fasting glucose and HbA1c were found to be associated with higher LSM. Conclusion About 44.4% of patients presenting to the AMU were at high risk of NAFLD according to the FLI. Only 10.8% of the high-risk group, and 3% of all those recruited had a LSM > 7 kPa suggesting development of fibrosis.

Background Artificial intelligence (AI) has been shown to have benefits in helping detect polyps and in other areas of colonoscopy. However, for any system to be implemented to the fullest potential, we will need the acceptance of clinicians. Methods We designed a survey using SurveyMonkey. Invites were sent via email to respondents over 4 countries; Egypt, India, Malta and United Kingdom to assess clinicians' acceptance/attitude towards AI. We collected data regarding their KPIs (self-reported), experience, knowledge of capsule endoscopy. Endoscopists were asked to provide their opinions on AI regarding likely benefits in outcomes of colonoscopy such as ADR and improving quality of colonoscopy. Results A total of 145 respondents participated, among them were 105 consultants, 37 registrars and 5 clinical endoscopists. 45 respondents were from Egypt, 12 from Malta, 48 from India and 38 from UK. The mean years since in graduation was 14 years. Experience with capsule endoscopy increases the positive attitude towards AI. Attitude was more positive/hopeful amongst Maltese/Egyptian endoscopists and amongst consultant grades vs registrars/trainees. Colonoscopists who had higher numbers of colonoscopies per year/higher caecal intubation rates and adenoma detection rates had significant positive attitude towards AI. Conclusions There is a variation amongst colonoscopists in the attitude towards AI in colonoscopy. Colonoscopists with experience with capsule endoscopy have very positive attitude towards AI. Further studies, training and familiarisation will be required should AI be incorporated into regular clinical practice.

Introduction Cystic fibrosis (CF) is a common, multisystem genetic disorder, affecting over 10,000 people in the UK. The risk of colorectal cancer (CRC) is 5-10 times greater than the general population, and 25 times greater in those with a transplant. The life expectancy from lung related disease has significantly improved over recent years, necessitating recommendations for screening for CRC in this high-risk cohort. Bowel preparation (BP) for colonoscopy is often poor in patients with cystic fibrosis (PWCF). Matson et al. demonstrated that a more intensive regime than for standard colonoscopies can lead to better bowel clearance for PWCF. We describe the development of a screening service at a tertiary centre with a dedicated CF bowel preparation regime. Methods This service was developed at Sheffield Teaching Hospital NHS Foundation Trust using a Plan-Do-Study-Act (PDSA) approach. Firstly, a review of the cohort of PWCF was undertaken to calculate the number of patients eligible for screening. Fit patients over 40 years and post-transplant patients were deemed eligible. Prior screening investigations in this cohort were reviewed. A steering committee was established with a team of medical endoscopists and specialist CF doctor and nurse. Dieticians, patients, the clerical staff, endoscopy nurses, and colorectal cancer screening team were consulted in the development of the service and the BP regime. Tolerance of BP was recorded using a modified Mayo Clinic bowel prep tolerability questionnaire. BP quality was recorded using a categorical scale. Results 210 patients were under the care of STH with CF. There were 48 eligible for screening (41 over the age of 40; 7 had had a transplant). of the screening cohort 20/48 (42%) were female with a mean age 50 (2SD = 16.8). A dedicated CF nurse specialist was assigned the role of educating patients on the regime. 5 (10%) of the eligible cohort have attended the dedicated clinic and completed colonoscopy. A weekly CF endoscopy slot was secured in the department, which improved service provision, planning of appointments and provision of augmented BP. Feedback through PDSA from administrative staff highlighted the potential for duplicate BP planning of endoscopy for CF patients. Therefore, an administrative lead with responsibility for booking all CF colonoscopies was appointed. Patients provided feedback on the regime which consisting of 5 litres of Moviprep©, Laxido ©, Bisacodyl and a low residue. Tolerance was reported as good globally. Good/excellent preparation was recorded in 4/5 colonoscopies. One patient had inadequate views for polyp assessment but had only completed two-thirds of her preparation due to a clerking error while an inpatient. Conclusions CRC is an emerging concern within PWCF. Dedicated surveillance programmes may help to optimise care and minimise unsuccessful colonoscopies due to poor BP. We demonstrated the development a CF screening pathway at our trust using a PDSA approach. The patient-centred pathway records colonoscopy outcomes and prioritises PROMs regarding BP and procedure tolerance. It provides an opportunity to optimise the delivery of this service by tailoring the BP regime to improve tolerability and outcomes, in this difficult to prepare cohort.

Proactive therapeutic drug monitoring (proactive-TDM) to optimise maintenance infliximab (IFX) trough levels prior to loss of response reduces the risk of treatment failure, inflammatory bowel disease (IBD)-related surgery and hospitalisation when compared with reactive monitoring (reactive-TDM). The aim of this study is to investigate if proactive-TDM in a virtual biologic clinic (VBC) improves patient disease control determined by number of hospital admissions, surgeries, patient reported outcome measures (PROMs) and biomarkers of disease activity. We conducted a single-centre retrospective observational study. Data were collected from commencement of the VBC in June 2016 to September 2017. All IBD patients on IFX in the VBC were included. PROMs were recorded using the IBD-Control-8 sub-score and Visual Analogue Scale. One hundred and twenty-three patients were included in the study. A statistically significant improvement in faecal calprotectin was observed with proactive-TDM with a P -value <.001. There was a 59% reduction in crisis IBD admissions with the introduction of proactive-TDM in the VBC ( P -value <.005). Dose de-escalations in the first 3 months of the VBC lead to cost savings of €32 000 per annum. The introduction of proactive-TDM resulted in a significant reduction in hospital admissions, an increase in mean IFX trough levels, a significant improvement in faecal calprotectin and adjustment to therapy in 33% of patients. Proactive-TDM in the setting of a VBC is a method of managing IBD patients on IFX therapy with the potential for significant cost savings.

Question: A 42-year-old, nonsmoking, Caucasian man with no previous medical history presented with a history of severe, central abdominal pain over a few days. The pain was worst postprandially. He reported no other systemic symptoms. He was afebrile and tachycardic with a blood pressure of 160/86 mm Hg. Physical examination revealed mild abdominal tenderness, but was otherwise unremarkable. Laboratory findings revealed a white cell count of 13 × 109/L and a C-reactive protein of 15mg/L, and a computed tomography scan of the abdomen demonstrated narrowing of the superior mesenteric artery (SMA) with thrombosis. A subsequent CT angiogram showed thickening of the wall of the SMA. Serology for JAK-2, HIV, and hepatitis B and C virus was negative. Interferon-gamma release assay was negative for tuberculosis. A full vasculitic screen was negative, including perinuclear antineutrophil cytoplasmic antibody. Complement levels were normal. After consultations with rheumatology, hematology, and vascular surgery, treatment was commenced with high-dose intravenous hydrocortisone and low-molecular-weight heparin. Repeat imaging after two weeks confirmed ongoing thickening of SMA, SMA dissection (Figure A, sagittal view [orange arrow]; Figure C, axial view [red arrow]) with no flow through the artery (Figure A, red arrow), new celiac artery aneurysmal dilatation (Figure A, blue arrow), and dissection flap (Figure B, red arrow), with multiple collaterals supplying the gut. An MR angiogram confirmed these findings (celiac artery aneurysm indicated by red arrow, SMA dissection indicated by the orange arrow and occlusion indicated by the green arrow). Treatment was escalated to high-dose methylprednisolone, with methotrexate 25 mg intramuscularly and infliximab 5 mg/kg intravenously. Three weeks after commencing triple immune suppression, the patient developed severe, central abdominal pain with vomiting. Physical examination revealed a heart rate of 140 and blood pressure of 168/121 mm Hg. Lactate was 4.2 mg/dL, white cell count was 27 × 109/L, and C-reactive protein was 1 mg/L. A further abdominal CT scan showed an ischemic ileum and cecum. At emergency laparotomy, a right hemicolectomy and small bowel resection were performed with ileostomy formation. Histopathologic examination of the surgical specimen showed ischemic necrosis of mainly large bowel. There was no evidence of vasculitis or thrombosis on the specimen. Based on the clinical scenario and images presented, what is the most likely underlying cause for the patient’s presentation? Look on page 833 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. The images are highly suggestive of segmental arterial mediolysis (SAM). This is a rare, noninflammatory, nonatherosclerotic arteriopathy affecting medium to large vessels. CT angiography is the modality of choice to diagnose SAM,1Naidu S. Menias C. Oklu R. et al.Segmental arterial mediolysis: abdominal imaging of and disease course in 111 patients.Am J Roentgenol. 2018; 210Crossref PubMed Scopus (19) Google Scholar and segmental dissections involving the celiac, mesenteric, and/or renal arteries, as seen in this case, are the key distinguishing features of SAM.2Pillai A. Iqbal S. Liu R. et al.Segmental arterial mediolysis.Cardiovasc Intervent Radiol. 2014; 37: 604-612Crossref PubMed Scopus (40) Google Scholar As was the case with our patient, the presentation can be similar to medium vessel vasculitides, such as polyarteritis nodosa, and, owing to overlapping clinical features, patients are often treated with immunosuppressive agents, at least when they first present. These treatments are not thought to be effective in the clinical management of SAM.2Pillai A. Iqbal S. Liu R. et al.Segmental arterial mediolysis.Cardiovasc Intervent Radiol. 2014; 37: 604-612Crossref PubMed Scopus (40) Google Scholar The pathogenesis of SAM is poorly understood, but it is thought that disruption to the medial layer of the arterial wall predisposes to vessel dissection, hemorrhage, and ischemia.3Baker-LePain J. Stone D. Mattis A. et al.Clinical diagnosis of segmental arterial mediolysis: differentiation from vasculitis and other mimics.Arthritis Care Res. 2010; 62: 1655-1660Crossref PubMed Scopus (57) Google Scholar SAM can be difficult to differentiate from fibromuscular dysplasia, connective tissue diseases such as polyarteritis nodosa and Bechet’s, inherited defects in vessel wall structural proteins (eg, Marfan syndrome and type IV Ehlers-Danlos syndrome), and neurofibromatosis.3Baker-LePain J. Stone D. Mattis A. et al.Clinical diagnosis of segmental arterial mediolysis: differentiation from vasculitis and other mimics.Arthritis Care Res. 2010; 62: 1655-1660Crossref PubMed Scopus (57) Google Scholar The typical age of onset for SAM is 40–60 years and there is no ethnic predisposition. There are no constitutional symptoms, cutaneous manifestations, or laboratory markers. Patients with SAM are antineutrophil cytoplasmic antibody negative, as was the case with our patient. Effective control of blood pressure is important. Histopathology review in this case failed to identify any evidence of inflammation, vasculitis, or thrombosis. Although the surgical specimen represented vessels downstream from the abnormalities identified on imaging, the reviewing histopathologist indicated that a vasculitis severe enough to result in bowel infarction should be evident on the specimen, even in the setting of concomitant immunosuppression. There are no formal guidelines for the treatment of SAM. A high mortality has been associated with aneurysmal rupture in the early phase, but SAM is not thought to be a progressive disease and is generally managed conservatively.2Pillai A. Iqbal S. Liu R. et al.Segmental arterial mediolysis.Cardiovasc Intervent Radiol. 2014; 37: 604-612Crossref PubMed Scopus (40) Google Scholar

Introduction Accelerated dose infliximab (IFX) induction is associated with reduced short-term colectomy rate in acute severe ulcerative colitis (ASUC). Data on medium/long-term outcomes of this strategy are limited. Aims Evaluate medium/long-term outcomes in patients receiving IFX induction for ASUC, comparing accelerated dose (AD) and standard dose (SD) induction. Methods Retrospective study of consecutive patients admitted with corticosteroid-refractory ASUC in four tertiary referral centres within INITIative IBD research network (www. initiativeibd.ie). IFX rescue was given either as SD (weeks 0, 2, 6) or AD (<28 days) from January 2010 to September 2017. AD induction has been utilised in participating centres since 2014. Consequently SD patients were subdivided based on time period of IFX rescue: historical SD group (SD1) (2010-2013) and current SD group (SD2) (2014-2017). Primary endpoint was time to colectomy; secondary endpoint was time to IFX discontinuation if induction was complete. Results 145 patients received rescue IFX (AD=58, SD1=32, SD2=55). Disease severity at induction was comparable between AD and SD1 groups; however, SD2 group had less severe disease: median C-reactive protein (CRP) 39, 44 and 20 mg/L for AD, SD1 and SD2 groups, respectively (p=0.026, Kruskal-Wallis); median CRP: albumin ratio was 1.4, 1.8 and 0.6 (p=0.016). Median follow-up for AD, SD1 and SD2 groups was 1.6 (IQR 1.1-3.1), 4.9 (IQR 2.6-5.5) and 1.5 (IQR 0.9-2.3) years. Time to colectomy was shorter in SD1 (log rank p=0.0013); no significant difference in time to colectomy was observed comparing AD and SD2 groups (log rank p=0.32). 123 patients (84%) completed IFX induction and received maintenance therapy. Time to IFX discontinuation was shorter in SD1 (log rank p=0.009). Conclusion Time to colectomy is significantly prolonged with use of AD IFX in selected ASUC patients with more severe disease. Historical use of standard IFX induction for all ASUC patients is associated with inferior long-term outcomes.

Proactive therapeutic drug monitoring (P-TDM) to optimise maintenance Infliximab (IFX) levels prior to loss of response reduces risk of treatment failure, IBD-related surgery and hospitalisation when compared with reactive monitoring (R-TDM). The aim of this study was to investigate if P-TDM in a virtual biologic clinic (VBC) improves patient disease control as determined by patient reported outcome measures (PROMs) and to evaluate biomarkers of disease activity. Retrospective observational study with crossover design. Data were collected from commencement of VBC in June 2016 to September 2017. All IBD patients on IFX in the VBC were included. PROMs were recorded using the IBD-Questionnaire and Visual Analogue Scale (VAS). One hundred and twenty-three patients were included in the study – 51% were male (n = 63), 66% had Crohn’s disease (n = 81). 78% (n = 96) were receiving IFX prior to June 2016. IBD VAS scores improved from a median score of 80 of 100 with reactive monitoring (95% CI: 80, 85) to a median of 90 of 100 at 1 year with P-TDM (95% CI: 85, 90). No change was observed in the median score for IBD-Control (13/16) when patients switched from R-TDM to P-TDM (95% CI: 12, 14). Faecal calprotectin levels decreased from a median score of 109 (95% CI: 56.5, 167.6) with R-TDM to a median score of 41 (95% CI: 22, 55) with P-TDM. The median CRP for R-TDM was 2.3 (95% CI: 1.6, 3.1) with a range of 0.6–295, compared with a median value of 1.8 (95% CI: 1.4, 2.5) with a range of 0.6–43 for P-TDM. Twenty-five patients (20%) were dose escalated and 15 patients (12%) were dose de-escalated (Figure 2). At 1 year, the median IBD-VAS score was 90 of 100 (95% CI: 84.3, 90) in dose-escalated patients and 82.5 of 100 (95% CI: 75, 93.6) in de-escalated patients. There were 19 admissions in the R-TDM group. Seventeen of 19 (89%) were due IBD flares. The P-TDM group had 12 admissions. Six of 12 (50%) due to IBD flares. Five VBC patients (4%) proceeded to surgery. Only one serious infusion reaction was reported. Results for faecal calprotectin, CRP, IBD-Control and IBD-VAS. Dose adjustment results. There was a modest improvement in PROMs overall. The majority of patients with dose adjustments showed improvement in their median VAS score. The introduction of P-TDM resulted in a significant reduction in hospital admissions, in particular the number of crisis admissions for IBD flares.

We have shown that the use of accelerated dose (AD) induction of infliximab (IFX) reduces short-term colectomy rates in ASUC, but long-term data are limited. The aim of this study was to evaluate medium to long-term outcomes in patients receiving IFX induction for ASUC, comparing AD induction and standard dose (SD) induction. Retrospective study of all consecutive patients admitted with corticosteroid-refractory ASUC in 4 tertiary referral centres within the INITIative IBD research network (www.initiativeibd.ie). Patients received rescue IFX either as Standard dose (SD) induction (Weeks 0, 2, 6) or AD induction (<42 days) from January 2010 to September 2017. AD induction has been in routine clinical use since 2014. SD patients were sub-divided based on the time period of IFX rescue: historical SD group (SD1) [2010–2013] and current SD group (SD2) [2014–2017]. Demographics were collected at time of induction. Primary end-point was time to colectomy, with secondary end-point of time to IFX discontinuation in those completing induction. A total of 145 patients received rescue IFX for steroid refractory ASUC (AD = 58, SD1 = 32, SD2 = 55). Disease severity at induction was comparable between the AD group and SD1, but SD2 had less severe disease. Median CRP was 39, 44, and 20 mg/l for groups AD, SD1 and SD2, respectively (p = 0.026, Kruskal–Wallis). Median CRP: albumin ratio was 1.4, 1.8, and 0.6 for groups AD, SD1 and SD2, respectively (p = 0.016). Median follow-up for each group was 1.9, 4.9, and 1.5 years. Kaplan–Meier survival analysis (Figure 1) revealed a significant difference in time to colectomy across the groups, with higher rates of colectomy in SD1 original group (log-rank p = 0.0013). No significant difference was observed between AD and SD2 (log-rank p = 0.32).123 (84%) completed IFX induction, receiving maintenance therapy. Time to IFX discontinuation was significantly shorter in SD1 group, and comparable between AD and SD2 current (log-rank p = 0.009). Kaplan–Meier curve showing estimates of proportion of patients requiring colectomy with time, comparing patients who had SD1(blue), SD2 (green) and AD (red) IFX induction for steroid-refractory ASUC. Kaplan–Meier curve showing estimates of proportion of patients with loss of response to infliximab (IFX) with time, comparing patients who had SD1(blue), SD2 (green) and AD (red) IFX induction and received maintaenancefor steroid-refractory ASUC. Time to colectomy is significantly prolonged with use of accelerated dose IFX in selected ASUC patients with more severe disease. The historic use of standard IFX induction for all ASUC patients is associated with inferior long-term outcomes. These data further support the use of AD IFX induction in selected patients with corticosteroid-refractory ASUC.

Nonsteroidal anti-inflammatory drugs are a common cause of intestinal injury. A variety of NSAID-induced injuries may occur including ulcers, erosions, colitis, strictures, and diaphragm disease. Diaphragm disease refers to the development of multiple thin, concentric, stenosing strictures in the intestine. Strictures occur most often in the midintestine and are thought to be pathognomonic of NSAID damage. They can lead to intermittent or complete bowel obstruction. Diagnosis may be elusive as there is nothing specific about NSAID-induced injury at endoscopy and histology is also nonspecific. Even at laparotomy, the diagnosis of diaphragm disease may be missed as the serosa may appear normal and strictures can be difficult to palpate. While most NSAID-induced lesions tend to resolve quickly following withdrawal of the offending drug, diaphragm-like strictures usually require intervention such as stricturoplasty or surgical resection of the involved segment of bowel. Here we report the case of a 60-year-old male patient who presented with iron deficiency anaemia and recurrent subacute bowel obstruction. Following endoscopy and repeated CT scanning of his abdomen, he was diagnosed with Crohn's disease. He was treated with 5-ASAs and immune suppression until a perforated duodenal ulcer resulted in emergency laparotomy and the subsequent discovery of multiple intestinal diaphragms attributable to long-standing NSAID use.