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Bathroom blues: Inexpensive dye tracks digestive transit time
When it comes to measuring gut transit time, blue dye could be a cost-effective and simple alternative to other, more burdensome methods.
The approach, which only requires fasting followed by eating dyed food, revealed an association between microbiome composition and transit time in healthy individuals, according to authors led by Francisco Asnicar, PhD, of the University of Trento (Italy). The researchers chose the blue food coloring over carmine red dye partly because of its vegetable origin and because the blue color makes it unlikely the recipient would mistake the coloring in stool as originating from some other food, such as beetroot.
Gut motility is connected to digestion, the immune system, the endocrine system, and gut microbiota, according to the authors. For example, some have suggested that transit time may affect postprandial glycemia and lipemia through a potential effect on nutrient absorption and gut microbiome composition. “[This blue dye’s] use therefore has the potential to provide another piece of the puzzle to advance precision medicine,” the authors wrote.
Validated methods to measure transit time include scintigraphy, wireless motility capsule, radio-opaque markers and breath testing, but they require specialized equipment and staff, participants must make at least one in-person visit, and they can be expensive.
Transit time’s position in research
Those limitations may explain why the effect of transit time has been understudied, though it has gained momentum in recent years, according to Henrik Roager, PhD, who was asked to comment on the study. “I think it has become clear that it is probably one of the most important factors that explain the [microbiota] differences that we see from individual to individual,” said Dr. Roager, of the department of nutrition, exercise, and sports at the University of Copenhagen.
The relationship is complex, since gut microbes may be releasing metabolites that can affect motility, which in turn would affect the microbes. “The speed by which nutrients pass through a fermenter in the lab will have a huge impact on microbial physiology and metabolism. It’s basically the same principle in humans,” added Dr. Roager, who is engaged in research to identify such microbial metabolites.
To better understand those relationships will require epidemiological studies in healthy populations. Blue dye is one approach. Another is sweet corn, which individuals can obtain even more easily. Dye has one advantage in that it’s unlikely to impact transit time, while the quantity of sweet corn eaten could have an effect. “I definitely think that either this or sweet corn would be standard in many studies in the future,” said Dr. Roager.
Epidemiological studies made easier by dye or sweet corn could also reveal how diet interacts with the microbiome by including transit time as a variable. Transit time can vary from day to day, and Dr. Roager believes those variations may be linked to changes in the gut microbiome. With simpler techniques for measuring transit time, “I think we might be able to better identify effects of diets or drugs or lifestyle on the microbiome.”
How the blue dye fared
The researchers analyzed data from 866 twins and unrelated adults from the United States and the United Kingdom who were enrolled in the PREDICT 1 study, which quantified metabolic responses to standardized meals. Participants underwent fasting and then ate two blue muffins, along with a glass of chocolate milk, then logged the first sign of blue coloring in their stool using an app. Participants also answered a questionnaire detailing the frequency and consistency of bowel movements. The researchers also conducted sequencing of stool samples to determine microbiome profile.
There was a strong correlation between stool consistency and frequency, as well as microbial diversity and the composition of the gut microbiome. The dye measurement identified different fast and slow transit time clusters (area under the receiver operating characteristic curve, 0.82), which were associated with the composition of the gut microbiome, including species like Akkermansia muciniphila, Bacteroides species, and Alistipes species (false discovery rate–adjusted P values < .01). Transit times measured with the blue dye was a better predictor of gut function than either stool consistency and stool frequency, suggesting that the dye may be a more useful method for large cohorts of healthy individuals.
Although associations with diet and cardiometabolic factors were more modest, longer transit times appear predictive of greater visceral fat and higher postprandial responses, “which are key measures of health.”
The authors cited some limitations, including the fact that the blue-dye method has not yet been compared with other transit methodologies. However, the gut transit time in this study was found to be strongly correlated with stool consistency and frequency.
“To conclude, our findings indicate that the blue dye method is a novel, inexpensive and scalable method of gut transit assessment providing valuable gut health and metabolic insights,” they wrote. “Its wide use in both research and clinical settings could facilitate the advancement of our understanding of gut function and its determinants, as well as the complex interactions between gut physiology and health outcomes.”
The study authors received funding from a wide range of nonindustry sources. Dr. Roager had no relevant financial disclosures.
When it comes to measuring gut transit time, blue dye could be a cost-effective and simple alternative to other, more burdensome methods.
The approach, which only requires fasting followed by eating dyed food, revealed an association between microbiome composition and transit time in healthy individuals, according to authors led by Francisco Asnicar, PhD, of the University of Trento (Italy). The researchers chose the blue food coloring over carmine red dye partly because of its vegetable origin and because the blue color makes it unlikely the recipient would mistake the coloring in stool as originating from some other food, such as beetroot.
Gut motility is connected to digestion, the immune system, the endocrine system, and gut microbiota, according to the authors. For example, some have suggested that transit time may affect postprandial glycemia and lipemia through a potential effect on nutrient absorption and gut microbiome composition. “[This blue dye’s] use therefore has the potential to provide another piece of the puzzle to advance precision medicine,” the authors wrote.
Validated methods to measure transit time include scintigraphy, wireless motility capsule, radio-opaque markers and breath testing, but they require specialized equipment and staff, participants must make at least one in-person visit, and they can be expensive.
Transit time’s position in research
Those limitations may explain why the effect of transit time has been understudied, though it has gained momentum in recent years, according to Henrik Roager, PhD, who was asked to comment on the study. “I think it has become clear that it is probably one of the most important factors that explain the [microbiota] differences that we see from individual to individual,” said Dr. Roager, of the department of nutrition, exercise, and sports at the University of Copenhagen.
The relationship is complex, since gut microbes may be releasing metabolites that can affect motility, which in turn would affect the microbes. “The speed by which nutrients pass through a fermenter in the lab will have a huge impact on microbial physiology and metabolism. It’s basically the same principle in humans,” added Dr. Roager, who is engaged in research to identify such microbial metabolites.
To better understand those relationships will require epidemiological studies in healthy populations. Blue dye is one approach. Another is sweet corn, which individuals can obtain even more easily. Dye has one advantage in that it’s unlikely to impact transit time, while the quantity of sweet corn eaten could have an effect. “I definitely think that either this or sweet corn would be standard in many studies in the future,” said Dr. Roager.
Epidemiological studies made easier by dye or sweet corn could also reveal how diet interacts with the microbiome by including transit time as a variable. Transit time can vary from day to day, and Dr. Roager believes those variations may be linked to changes in the gut microbiome. With simpler techniques for measuring transit time, “I think we might be able to better identify effects of diets or drugs or lifestyle on the microbiome.”
How the blue dye fared
The researchers analyzed data from 866 twins and unrelated adults from the United States and the United Kingdom who were enrolled in the PREDICT 1 study, which quantified metabolic responses to standardized meals. Participants underwent fasting and then ate two blue muffins, along with a glass of chocolate milk, then logged the first sign of blue coloring in their stool using an app. Participants also answered a questionnaire detailing the frequency and consistency of bowel movements. The researchers also conducted sequencing of stool samples to determine microbiome profile.
There was a strong correlation between stool consistency and frequency, as well as microbial diversity and the composition of the gut microbiome. The dye measurement identified different fast and slow transit time clusters (area under the receiver operating characteristic curve, 0.82), which were associated with the composition of the gut microbiome, including species like Akkermansia muciniphila, Bacteroides species, and Alistipes species (false discovery rate–adjusted P values < .01). Transit times measured with the blue dye was a better predictor of gut function than either stool consistency and stool frequency, suggesting that the dye may be a more useful method for large cohorts of healthy individuals.
Although associations with diet and cardiometabolic factors were more modest, longer transit times appear predictive of greater visceral fat and higher postprandial responses, “which are key measures of health.”
The authors cited some limitations, including the fact that the blue-dye method has not yet been compared with other transit methodologies. However, the gut transit time in this study was found to be strongly correlated with stool consistency and frequency.
“To conclude, our findings indicate that the blue dye method is a novel, inexpensive and scalable method of gut transit assessment providing valuable gut health and metabolic insights,” they wrote. “Its wide use in both research and clinical settings could facilitate the advancement of our understanding of gut function and its determinants, as well as the complex interactions between gut physiology and health outcomes.”
The study authors received funding from a wide range of nonindustry sources. Dr. Roager had no relevant financial disclosures.
When it comes to measuring gut transit time, blue dye could be a cost-effective and simple alternative to other, more burdensome methods.
The approach, which only requires fasting followed by eating dyed food, revealed an association between microbiome composition and transit time in healthy individuals, according to authors led by Francisco Asnicar, PhD, of the University of Trento (Italy). The researchers chose the blue food coloring over carmine red dye partly because of its vegetable origin and because the blue color makes it unlikely the recipient would mistake the coloring in stool as originating from some other food, such as beetroot.
Gut motility is connected to digestion, the immune system, the endocrine system, and gut microbiota, according to the authors. For example, some have suggested that transit time may affect postprandial glycemia and lipemia through a potential effect on nutrient absorption and gut microbiome composition. “[This blue dye’s] use therefore has the potential to provide another piece of the puzzle to advance precision medicine,” the authors wrote.
Validated methods to measure transit time include scintigraphy, wireless motility capsule, radio-opaque markers and breath testing, but they require specialized equipment and staff, participants must make at least one in-person visit, and they can be expensive.
Transit time’s position in research
Those limitations may explain why the effect of transit time has been understudied, though it has gained momentum in recent years, according to Henrik Roager, PhD, who was asked to comment on the study. “I think it has become clear that it is probably one of the most important factors that explain the [microbiota] differences that we see from individual to individual,” said Dr. Roager, of the department of nutrition, exercise, and sports at the University of Copenhagen.
The relationship is complex, since gut microbes may be releasing metabolites that can affect motility, which in turn would affect the microbes. “The speed by which nutrients pass through a fermenter in the lab will have a huge impact on microbial physiology and metabolism. It’s basically the same principle in humans,” added Dr. Roager, who is engaged in research to identify such microbial metabolites.
To better understand those relationships will require epidemiological studies in healthy populations. Blue dye is one approach. Another is sweet corn, which individuals can obtain even more easily. Dye has one advantage in that it’s unlikely to impact transit time, while the quantity of sweet corn eaten could have an effect. “I definitely think that either this or sweet corn would be standard in many studies in the future,” said Dr. Roager.
Epidemiological studies made easier by dye or sweet corn could also reveal how diet interacts with the microbiome by including transit time as a variable. Transit time can vary from day to day, and Dr. Roager believes those variations may be linked to changes in the gut microbiome. With simpler techniques for measuring transit time, “I think we might be able to better identify effects of diets or drugs or lifestyle on the microbiome.”
How the blue dye fared
The researchers analyzed data from 866 twins and unrelated adults from the United States and the United Kingdom who were enrolled in the PREDICT 1 study, which quantified metabolic responses to standardized meals. Participants underwent fasting and then ate two blue muffins, along with a glass of chocolate milk, then logged the first sign of blue coloring in their stool using an app. Participants also answered a questionnaire detailing the frequency and consistency of bowel movements. The researchers also conducted sequencing of stool samples to determine microbiome profile.
There was a strong correlation between stool consistency and frequency, as well as microbial diversity and the composition of the gut microbiome. The dye measurement identified different fast and slow transit time clusters (area under the receiver operating characteristic curve, 0.82), which were associated with the composition of the gut microbiome, including species like Akkermansia muciniphila, Bacteroides species, and Alistipes species (false discovery rate–adjusted P values < .01). Transit times measured with the blue dye was a better predictor of gut function than either stool consistency and stool frequency, suggesting that the dye may be a more useful method for large cohorts of healthy individuals.
Although associations with diet and cardiometabolic factors were more modest, longer transit times appear predictive of greater visceral fat and higher postprandial responses, “which are key measures of health.”
The authors cited some limitations, including the fact that the blue-dye method has not yet been compared with other transit methodologies. However, the gut transit time in this study was found to be strongly correlated with stool consistency and frequency.
“To conclude, our findings indicate that the blue dye method is a novel, inexpensive and scalable method of gut transit assessment providing valuable gut health and metabolic insights,” they wrote. “Its wide use in both research and clinical settings could facilitate the advancement of our understanding of gut function and its determinants, as well as the complex interactions between gut physiology and health outcomes.”
The study authors received funding from a wide range of nonindustry sources. Dr. Roager had no relevant financial disclosures.
FROM GUT
Can laparoscopic lavage beat resection for acute perforated diverticulitis?
Severe complications at 5 years were no different for patients with perforated purulent diverticulitis who underwent laparoscopic peritoneal lavage or colon resection, according to data from 199 individuals treated at 21 hospitals in Norway and Sweden. But it may yet prove appropriate in the right patient.
Acute perforated diverticulitis with peritonitis remains a challenging complication with high morbidity and mortality among patients with diverticular disease, and bowel resection remains the standard of treatment, Najia Azhar, MD, of Skåne University Hospital, Malmö, Sweden, and colleagues wrote.
Short-term data suggest that laparoscopic lavage with drainage and antibiotics might be a viable alternative, but long-term data are lacking, they said.
In the Scandinavian Diverticulitis (SCANDIV) trial, published in JAMA Surgery, researchers randomized 101 patients to laparoscopic peritoneal lavage and 98 to colon resection. With 3 patients lost to follow-up, the final analysis included 73 patients who underwent laparoscopic lavage and 69 who underwent resection. The mean age of the lavage patients was 66.4 years, and 39 were men. The mean age of the resection patients was 63.5 years, and 36 were men. The primary outcome was severe complications – excluding stoma reversals and elective sigmoid resections because of recurrence – at an average of 5 years’ follow-up. Secondary outcomes included stoma prevalence, diverticulitis recurrence, and secondary sigmoid resection.
Severe complications were similar for the lavage and resection groups (36% and 35%, respectively), as were the overall mortality rates (32% and 25%, respectively).
The prevalence of stoma was significantly lower in the lavage group, compared with the resection group (8% vs. 33%, P = .002). However, secondary operations (including reversal of stoma) were similar between the lavage and resection groups, performed in 26 lavage patients (36%) versus 24 resection patients (35%).
Diverticulitis recurrence was significantly more common in the lavage, compared with the resection group (21% vs. 4%, P = .004), the researchers noted.
In the laparoscopic lavage group, 30% (n = 21) underwent a sigmoid resection; all but one of these occurred within a year of the index procedure, the researchers wrote. In addition, overall length of hospital stay was similar for both groups.
No significant differences in quality of life were noted between the groups, based on the EuroQoL-5D questionnaire or Cleveland Global Quality of Life scores.
Balance secondary pros and cons
Laparoscopic lavage is not common practice today in the United States, the researchers noted. In clinical practice guidelines issued in 2020, the American Society of Colon and Rectal Surgeons strongly recommend colectomy over laparoscopic lavage for the treatment of left-sided colonic diverticulitis. However, the European Society of Coloproctology’s guidelines state that laparoscopic lavage is feasible for patients with peritonitis at Hinchey stage III.
The findings of the current study were limited primarily by the exclusion of 50% of eligible patients because of challenges associated with conducting randomized trials in emergency settings, the researchers noted. However, the number of excluded patients and their baseline characteristics after exclusion were very similar in the two groups, and the study represents the largest randomized trial to date to examine long-term outcomes in patients with perforated diverticulitis.
“Laparoscopic lavage is faster and cost-effective but leads to a higher reoperation rate and recurrence rate, often requiring secondary sigmoid resection,” the researchers emphasized. Consequently, patients undergoing lavage should have consented for resection surgery.
The similar rates of severe complications and quality of life scores support laparoscopic lavage as an option for perforated purulent diverticulitis, but shared decision-making will be essential for better optimal patient management, the researchers concluded.
Similar outcomes, but unanswered questions
Even though the primary outcome of disease-related morbidity was similar for both groups, “the issue still remains regarding when and how, if ever, this therapeutic approach should be considered for purulent peritonitis,” Kellie E. Cunningham, MD, and Brian S. Zuckerbraun, MD, both of the University of Pittsburgh, wrote in an accompanying editorial.
Although laparoscopic lavage has the obvious advantages of avoiding a laparotomy and stoma, previous studies have shown a higher rate of early reoperations and recurrent diverticulitis, despite lower stoma prevalence and equal mortality rates, they said. In addition, “patients who are immunosuppressed or would be expected to have a higher mortality rate with failure to achieve definitive source control should likely not be offered this therapy.”
A “philosophical” argument could be made in favor of laparoscopic lavage based on the potential consequences of early treatment failure, they wrote.
“Although one may consider the need for early reoperation a complication, some would argue it affects the minority of patients, thus avoiding the more morbid procedure with creation of a stoma at the index operation in the majority of patients,” they noted. “Additionally, patients who underwent lavage that subsequently proceed to colectomy would have otherwise been offered this therapy initially at the time of the index operation.”
More research is needed to answer questions such as which, if any, operative findings are associated with failure. In addition, an analysis of long-term cost benefits between the two options should be explored, the authors wrote.
Based on current evidence, shared decision-making is necessary, with individualized care and short and long-term trade-offs taken into account, they wrote.
Gastroenterologist perspective: Study fills gap in follow-up data
In an interview, David A. Johnson, MD, professor of medicine and chief of gastroenterology at Eastern Virginia School of Medicine, Norfolk, said the study is important because data have been lacking on outcomes of a laparoscopic lavage without a resection.
The findings represent “a major shift” in the growing consensus among surgeons that laparoscopic lavage is a viable option in appropriate patients, he said.
A key issue is the high rate of morbidity in patients who undergo traditional diverticulitis surgery. Complications can include wound infection and poor quality of life associated with stoma, Dr. Johnson said. Consequently, “a nonoperative approach from a patient perspective is certainly refreshing.”
Dr. Johnson said he was surprised by how well the patients fared after lavage given the severity of the diverticulitis in the patient population. However, this may be in part because of the relatively small numbers of patients at highest risk for complications, such as those with diabetes or immunocompromising conditions.
Dr. Johnson also said he was struck by the fact that the adenocarcinomas in the lavage group were diagnosed within the first year after the procedure. “The cancer diagnosis shouldn’t reflect on the lavage group,” but emphasizes the importance of having an earlier colonoscopy, he noted.
Next steps for research might include identifying a standardized endpoint for lavage, and determining how expanded use of the procedure might impact community practice, Dr. Johnson said. In addition, more research is needed to more clearly define patients most likely to benefit from laparoscopic lavage.
The study was supported in part by the department of surgery at Skåne University Hospital, Akershus University Hospital, and a fellowship to one of the study coauthors from the Southeastern Norway Regional Health Authority. Lead author Dr. Azhar disclosed grants from the department of surgery of Skåne University Hospital. Dr. Cunningham and Dr. Zuckerbraun had no financial conflicts to disclose. Dr. Johnson had no relevant financial disclosures.
Severe complications at 5 years were no different for patients with perforated purulent diverticulitis who underwent laparoscopic peritoneal lavage or colon resection, according to data from 199 individuals treated at 21 hospitals in Norway and Sweden. But it may yet prove appropriate in the right patient.
Acute perforated diverticulitis with peritonitis remains a challenging complication with high morbidity and mortality among patients with diverticular disease, and bowel resection remains the standard of treatment, Najia Azhar, MD, of Skåne University Hospital, Malmö, Sweden, and colleagues wrote.
Short-term data suggest that laparoscopic lavage with drainage and antibiotics might be a viable alternative, but long-term data are lacking, they said.
In the Scandinavian Diverticulitis (SCANDIV) trial, published in JAMA Surgery, researchers randomized 101 patients to laparoscopic peritoneal lavage and 98 to colon resection. With 3 patients lost to follow-up, the final analysis included 73 patients who underwent laparoscopic lavage and 69 who underwent resection. The mean age of the lavage patients was 66.4 years, and 39 were men. The mean age of the resection patients was 63.5 years, and 36 were men. The primary outcome was severe complications – excluding stoma reversals and elective sigmoid resections because of recurrence – at an average of 5 years’ follow-up. Secondary outcomes included stoma prevalence, diverticulitis recurrence, and secondary sigmoid resection.
Severe complications were similar for the lavage and resection groups (36% and 35%, respectively), as were the overall mortality rates (32% and 25%, respectively).
The prevalence of stoma was significantly lower in the lavage group, compared with the resection group (8% vs. 33%, P = .002). However, secondary operations (including reversal of stoma) were similar between the lavage and resection groups, performed in 26 lavage patients (36%) versus 24 resection patients (35%).
Diverticulitis recurrence was significantly more common in the lavage, compared with the resection group (21% vs. 4%, P = .004), the researchers noted.
In the laparoscopic lavage group, 30% (n = 21) underwent a sigmoid resection; all but one of these occurred within a year of the index procedure, the researchers wrote. In addition, overall length of hospital stay was similar for both groups.
No significant differences in quality of life were noted between the groups, based on the EuroQoL-5D questionnaire or Cleveland Global Quality of Life scores.
Balance secondary pros and cons
Laparoscopic lavage is not common practice today in the United States, the researchers noted. In clinical practice guidelines issued in 2020, the American Society of Colon and Rectal Surgeons strongly recommend colectomy over laparoscopic lavage for the treatment of left-sided colonic diverticulitis. However, the European Society of Coloproctology’s guidelines state that laparoscopic lavage is feasible for patients with peritonitis at Hinchey stage III.
The findings of the current study were limited primarily by the exclusion of 50% of eligible patients because of challenges associated with conducting randomized trials in emergency settings, the researchers noted. However, the number of excluded patients and their baseline characteristics after exclusion were very similar in the two groups, and the study represents the largest randomized trial to date to examine long-term outcomes in patients with perforated diverticulitis.
“Laparoscopic lavage is faster and cost-effective but leads to a higher reoperation rate and recurrence rate, often requiring secondary sigmoid resection,” the researchers emphasized. Consequently, patients undergoing lavage should have consented for resection surgery.
The similar rates of severe complications and quality of life scores support laparoscopic lavage as an option for perforated purulent diverticulitis, but shared decision-making will be essential for better optimal patient management, the researchers concluded.
Similar outcomes, but unanswered questions
Even though the primary outcome of disease-related morbidity was similar for both groups, “the issue still remains regarding when and how, if ever, this therapeutic approach should be considered for purulent peritonitis,” Kellie E. Cunningham, MD, and Brian S. Zuckerbraun, MD, both of the University of Pittsburgh, wrote in an accompanying editorial.
Although laparoscopic lavage has the obvious advantages of avoiding a laparotomy and stoma, previous studies have shown a higher rate of early reoperations and recurrent diverticulitis, despite lower stoma prevalence and equal mortality rates, they said. In addition, “patients who are immunosuppressed or would be expected to have a higher mortality rate with failure to achieve definitive source control should likely not be offered this therapy.”
A “philosophical” argument could be made in favor of laparoscopic lavage based on the potential consequences of early treatment failure, they wrote.
“Although one may consider the need for early reoperation a complication, some would argue it affects the minority of patients, thus avoiding the more morbid procedure with creation of a stoma at the index operation in the majority of patients,” they noted. “Additionally, patients who underwent lavage that subsequently proceed to colectomy would have otherwise been offered this therapy initially at the time of the index operation.”
More research is needed to answer questions such as which, if any, operative findings are associated with failure. In addition, an analysis of long-term cost benefits between the two options should be explored, the authors wrote.
Based on current evidence, shared decision-making is necessary, with individualized care and short and long-term trade-offs taken into account, they wrote.
Gastroenterologist perspective: Study fills gap in follow-up data
In an interview, David A. Johnson, MD, professor of medicine and chief of gastroenterology at Eastern Virginia School of Medicine, Norfolk, said the study is important because data have been lacking on outcomes of a laparoscopic lavage without a resection.
The findings represent “a major shift” in the growing consensus among surgeons that laparoscopic lavage is a viable option in appropriate patients, he said.
A key issue is the high rate of morbidity in patients who undergo traditional diverticulitis surgery. Complications can include wound infection and poor quality of life associated with stoma, Dr. Johnson said. Consequently, “a nonoperative approach from a patient perspective is certainly refreshing.”
Dr. Johnson said he was surprised by how well the patients fared after lavage given the severity of the diverticulitis in the patient population. However, this may be in part because of the relatively small numbers of patients at highest risk for complications, such as those with diabetes or immunocompromising conditions.
Dr. Johnson also said he was struck by the fact that the adenocarcinomas in the lavage group were diagnosed within the first year after the procedure. “The cancer diagnosis shouldn’t reflect on the lavage group,” but emphasizes the importance of having an earlier colonoscopy, he noted.
Next steps for research might include identifying a standardized endpoint for lavage, and determining how expanded use of the procedure might impact community practice, Dr. Johnson said. In addition, more research is needed to more clearly define patients most likely to benefit from laparoscopic lavage.
The study was supported in part by the department of surgery at Skåne University Hospital, Akershus University Hospital, and a fellowship to one of the study coauthors from the Southeastern Norway Regional Health Authority. Lead author Dr. Azhar disclosed grants from the department of surgery of Skåne University Hospital. Dr. Cunningham and Dr. Zuckerbraun had no financial conflicts to disclose. Dr. Johnson had no relevant financial disclosures.
Severe complications at 5 years were no different for patients with perforated purulent diverticulitis who underwent laparoscopic peritoneal lavage or colon resection, according to data from 199 individuals treated at 21 hospitals in Norway and Sweden. But it may yet prove appropriate in the right patient.
Acute perforated diverticulitis with peritonitis remains a challenging complication with high morbidity and mortality among patients with diverticular disease, and bowel resection remains the standard of treatment, Najia Azhar, MD, of Skåne University Hospital, Malmö, Sweden, and colleagues wrote.
Short-term data suggest that laparoscopic lavage with drainage and antibiotics might be a viable alternative, but long-term data are lacking, they said.
In the Scandinavian Diverticulitis (SCANDIV) trial, published in JAMA Surgery, researchers randomized 101 patients to laparoscopic peritoneal lavage and 98 to colon resection. With 3 patients lost to follow-up, the final analysis included 73 patients who underwent laparoscopic lavage and 69 who underwent resection. The mean age of the lavage patients was 66.4 years, and 39 were men. The mean age of the resection patients was 63.5 years, and 36 were men. The primary outcome was severe complications – excluding stoma reversals and elective sigmoid resections because of recurrence – at an average of 5 years’ follow-up. Secondary outcomes included stoma prevalence, diverticulitis recurrence, and secondary sigmoid resection.
Severe complications were similar for the lavage and resection groups (36% and 35%, respectively), as were the overall mortality rates (32% and 25%, respectively).
The prevalence of stoma was significantly lower in the lavage group, compared with the resection group (8% vs. 33%, P = .002). However, secondary operations (including reversal of stoma) were similar between the lavage and resection groups, performed in 26 lavage patients (36%) versus 24 resection patients (35%).
Diverticulitis recurrence was significantly more common in the lavage, compared with the resection group (21% vs. 4%, P = .004), the researchers noted.
In the laparoscopic lavage group, 30% (n = 21) underwent a sigmoid resection; all but one of these occurred within a year of the index procedure, the researchers wrote. In addition, overall length of hospital stay was similar for both groups.
No significant differences in quality of life were noted between the groups, based on the EuroQoL-5D questionnaire or Cleveland Global Quality of Life scores.
Balance secondary pros and cons
Laparoscopic lavage is not common practice today in the United States, the researchers noted. In clinical practice guidelines issued in 2020, the American Society of Colon and Rectal Surgeons strongly recommend colectomy over laparoscopic lavage for the treatment of left-sided colonic diverticulitis. However, the European Society of Coloproctology’s guidelines state that laparoscopic lavage is feasible for patients with peritonitis at Hinchey stage III.
The findings of the current study were limited primarily by the exclusion of 50% of eligible patients because of challenges associated with conducting randomized trials in emergency settings, the researchers noted. However, the number of excluded patients and their baseline characteristics after exclusion were very similar in the two groups, and the study represents the largest randomized trial to date to examine long-term outcomes in patients with perforated diverticulitis.
“Laparoscopic lavage is faster and cost-effective but leads to a higher reoperation rate and recurrence rate, often requiring secondary sigmoid resection,” the researchers emphasized. Consequently, patients undergoing lavage should have consented for resection surgery.
The similar rates of severe complications and quality of life scores support laparoscopic lavage as an option for perforated purulent diverticulitis, but shared decision-making will be essential for better optimal patient management, the researchers concluded.
Similar outcomes, but unanswered questions
Even though the primary outcome of disease-related morbidity was similar for both groups, “the issue still remains regarding when and how, if ever, this therapeutic approach should be considered for purulent peritonitis,” Kellie E. Cunningham, MD, and Brian S. Zuckerbraun, MD, both of the University of Pittsburgh, wrote in an accompanying editorial.
Although laparoscopic lavage has the obvious advantages of avoiding a laparotomy and stoma, previous studies have shown a higher rate of early reoperations and recurrent diverticulitis, despite lower stoma prevalence and equal mortality rates, they said. In addition, “patients who are immunosuppressed or would be expected to have a higher mortality rate with failure to achieve definitive source control should likely not be offered this therapy.”
A “philosophical” argument could be made in favor of laparoscopic lavage based on the potential consequences of early treatment failure, they wrote.
“Although one may consider the need for early reoperation a complication, some would argue it affects the minority of patients, thus avoiding the more morbid procedure with creation of a stoma at the index operation in the majority of patients,” they noted. “Additionally, patients who underwent lavage that subsequently proceed to colectomy would have otherwise been offered this therapy initially at the time of the index operation.”
More research is needed to answer questions such as which, if any, operative findings are associated with failure. In addition, an analysis of long-term cost benefits between the two options should be explored, the authors wrote.
Based on current evidence, shared decision-making is necessary, with individualized care and short and long-term trade-offs taken into account, they wrote.
Gastroenterologist perspective: Study fills gap in follow-up data
In an interview, David A. Johnson, MD, professor of medicine and chief of gastroenterology at Eastern Virginia School of Medicine, Norfolk, said the study is important because data have been lacking on outcomes of a laparoscopic lavage without a resection.
The findings represent “a major shift” in the growing consensus among surgeons that laparoscopic lavage is a viable option in appropriate patients, he said.
A key issue is the high rate of morbidity in patients who undergo traditional diverticulitis surgery. Complications can include wound infection and poor quality of life associated with stoma, Dr. Johnson said. Consequently, “a nonoperative approach from a patient perspective is certainly refreshing.”
Dr. Johnson said he was surprised by how well the patients fared after lavage given the severity of the diverticulitis in the patient population. However, this may be in part because of the relatively small numbers of patients at highest risk for complications, such as those with diabetes or immunocompromising conditions.
Dr. Johnson also said he was struck by the fact that the adenocarcinomas in the lavage group were diagnosed within the first year after the procedure. “The cancer diagnosis shouldn’t reflect on the lavage group,” but emphasizes the importance of having an earlier colonoscopy, he noted.
Next steps for research might include identifying a standardized endpoint for lavage, and determining how expanded use of the procedure might impact community practice, Dr. Johnson said. In addition, more research is needed to more clearly define patients most likely to benefit from laparoscopic lavage.
The study was supported in part by the department of surgery at Skåne University Hospital, Akershus University Hospital, and a fellowship to one of the study coauthors from the Southeastern Norway Regional Health Authority. Lead author Dr. Azhar disclosed grants from the department of surgery of Skåne University Hospital. Dr. Cunningham and Dr. Zuckerbraun had no financial conflicts to disclose. Dr. Johnson had no relevant financial disclosures.
FROM JAMA SURGERY
Addressing an unmet need in IBD patients: Treatment of acute abdominal pain
In the acute care setting, providers of care for inflammatory bowel disease (IBD) patients are often faced with the dilemma of providing effective abdominal pain management in a population that has worse outcomes with both opioid and NSAID therapy. There is increased mortality associated with opioid use and risk of disease relapse with NSAID use in IBD patients.1,2 Due to this, patients often feel that their pain is inadequately addressed.3,4 There are multiple sources of abdominal pain in IBD, and understanding the mechanisms and presentations can help identify effective treatments. We will review pharmacologic and supportive therapies to optimize pain management in IBD.
Common pain presentations in IBD
Visceral pain is a dull, poorly localized, cramping pain from intestinal distension. It is associated with inflammation, dysmotility, obstruction, and visceral hypersensitivity. Somatic and parietal pain is sharp, intense, and often localizable. Somatic pain originates from surrounding skin or muscles, and parietal pain arises from irritation of the peritoneum.5 We will review two common pain presentations in IBD.
Case 1: Mr. A is a 32-year-old male with stricturing small bowel Crohn’s disease s/p small bowel resection, who presents to the ED with 3 days of abdominal pain, nausea, and vomiting. C-reactive protein is elevated to 6.8 mg/dL (normal 0.0 – 0.6 mg/dL), and CT is consistent with active small bowel inflammation, intraabdominal abscess at the anastomosis, and associated partial small bowel obstruction. He describes a sharp, intense abdominal pain with cramping. His exam is significant for diffuse abdominal tenderness and distension.
Case 2: Ms. B is a 28-year-old female with ulcerative colitis on mesalamine monotherapy who presents to the hospital for rectal bleeding and cramping abdominal pain. After 3 days of IV steroids her rectal bleeding has resolved, and CRP has normalized. However, she continues to have dull, cramping abdominal pain. Ibuprofen has improved this pain in the past.
Mr. A is having somatic pain from inflammation, abscess, and partial bowel obstruction. He also has visceral pain from luminal distension proximal to the obstruction. Ms. B is having visceral pain despite resolution of inflammation, which may be from postinflammatory visceral hypersensitivity.
Etiologies of pain
It’s best to group pain etiologies into inflammatory and noninflammatory causes. Inflammatory pain can be secondary to infection, such as abscess or enteric infection, active bowel inflammation, or disease complications (that is, enteric fistula). It is important to recognize that patients with active inflammation may also have noninflammatory pain. These include small bowel obstruction, strictures, adhesions, narcotic bowel syndrome, bacterial overgrowth, and visceral hypersensitivity. See figure 1.
The brain-gut connection matters
Abdominal pain in IBD patients starts from painful stimuli in the gut. In addition to direct pain pathways, multiple areas of the brain modulate perception of pain.6 Patients with psychiatric comorbidities have increased perception of abdominal pain.7 In fact, high perceived stress is associated with disease relapse.8 Treatment of psychiatric disorders improves these symptoms with lasting effects.9 Addressing psychological and psychosocial needs is essential to successful pain management with long-term effect on quality of life and pain perception in IBD patients.
What are my options?
When IBD patients present with acute abdominal pain, it is important to directly address their pain as one of your primary concerns and provide them with a management plan. While this seems obvious, it is not routinely done.3-4
Next, it is important to identify the cause, whether it be infection, obstruction, active inflammation, or functional abdominal pain. In the case of active disease, in addition to steroids and optimization of IBD therapies, acetaminophen and antispasmodics can be used for initial pain management. Supportive therapies include sleep hygiene, physical activity, and psychotherapy. If initial treatments are unsuccessful in the acute setting, and presentation is consistent with somatic pain, it may be necessary to escalate to tramadol, opioid, or NSAID therapy. For visceral pain, a neuromodulator, such as a tricyclic antidepressant or gabapentin, may have greater effect. Bupropion, SNRIs, and SSRIs are options; however, they may not be effective in the acute setting. More recent focus in the IBD community has questioned the role of cannabinoids on pain in IBD patients. Cannabis has been shown in a few small studies to provide pain relief in IBD patients with active inflammation.10-11 In patients with mechanical causes for pain, management of obstruction is an important part of the treatment plan.
Let’s talk about opioids in IBD patients
Chronic narcotic use in IBD is associated with worse outcomes. So when is it okay to use opioid therapies in IBD patients? Postoperative patients, patients with severe perianal disease, or those who fail alternative pain management strategies may require opioid medications. The association with mortality and opioids in IBD is with patients who require moderate to heavy use, which is defined as being prescribed opioids more than once a year. Opioid use in IBD patients is also associated with increased risk of readmissions and poor surgical outcomes.12-13 Tramadol does not have increased mortality risk.1 If selecting opioid therapy in managing pain in IBD, it is important to define the course of therapy, with a clear goal of discontinuation after the acute episode. Opioids should be used in tandem with alternative strategies. Patients should be counseled on the synergistic effect of acetaminophen with opioids, which may allow lower effective doses of opioids.
What about NSAID use in IBD patients?
NSAIDs have negative effects in the gastrointestinal tract due to inhibition of protective prostaglandins. They also alter the gut microbiome, although clinical implications of this are unknown.14 A small study showed that IBD patients who used NSAIDs had increased risk of disease relapse.2 Symptoms of relapse would present within 2-9 days of exposure; however, most had resolution of symptoms within 2-11 days of discontinuation.2 Follow-up studies have not reliably found that NSAIDs are associated with disease relapse.8 and thus NSAIDs may be used sparingly if needed in the acute setting.
Case Review: How do we approach Mr. A and Ms. B?
Mr. A presented with a partial small bowel obstruction and abscess. His pain presentation was consistent with both visceral and somatic pain etiologies. In addition to treating active inflammation and infection, bowel rest, acetaminophen, and antispasmodics can be initiated for pain control. Concomitantly, gabapentin, TCA, or SNRI can be initiated for neurobiological pain but may have limited benefit in the acute hospitalized setting. Social work may identify needs that affect pain perception and assist in addressing those needs. If abdominal pain persists, tramadol or hydrocodone-acetaminophen can be considered.
Ms. B presented with disease relapse, but despite improving inflammatory markers she had continued cramping abdominal pain, which can be consistent with visceral hypersensitivity. Antispasmodic and neuromodulating agents, such as a TCA, could be effective. We can recommend discontinuation of chronic ibuprofen due to risk of intestinal inflammation. Patients may inquire about adjuvant cannabis in pain management. While cannabis can be considered, further research is needed to recommend its regular use.
Conclusion
Acute abdominal pain management in IBD can be challenging for providers when typical options are limited in this population. Addressing inflammatory, mechanical, neurobiological, and psychological influences is vital to appropriately address pain. Having a structured plan for pain management in IBD can improve outcomes by decreasing recurrent hospitalizations and use of opioids.15 Figure 2 presents an overview.
Dr. Ahmed is a second-year internal medicine resident at the University of Michigan, Ann Arbor. Dr. Kinnucan is with the department of internal medicine and the division of gastroenterology and hepatology and is an assistant professor of medicine in the division of gastroenterology, both at the University of Michigan. They have no conflicts of interest.
References
1. Burr NE et al. Clin Gastroenterol Hepatol. 2018 Apr;16(4):534-41.e6.
2. Takeuchi K et al. Clin Gastroenterol Hepatol. 2006 Feb;4(2):196-202.
3. Bernhofer EI et al. Gastroenterol Nurs. 2017 May/Jun;40(3):200-7.
4. Zeitz J et al. PLoS One. 2016 Jun 22;11(6):e0156666.
5. Srinath A et al. Inflamm Bowel Dis. 2014 Dec;20(12):2433-49.
6. Docherty MJ et al. Gastroenterol Hepatol (N Y). 2011 Sep;7(9):592-601.
7. Elsenbruch S et al. Gut. 2010 Apr;59(4):489-95.
8. Bernstein CN et al. Am J Gastroenterol. 2010 Sep;105(9):1994-2002.
9. Palsson OS and Whitehead WE. Clin Gastroenterol Hepatol. 2013 Mar;11(3):208-16; quiz e22-3.
10. Swaminath A et al. Inflamm Bowel Dis. 2019 Mar; 25(3):427-35.
11. Naftali T et al. Clin Gastroenterol Hepatol. 2013 Oct;11(10):1276-80.e1.
12. Sultan K and Swaminath A. J Crohns Colitis. 2020 Sep 16;14(9):1188-89.
13. Hirsch A et al. J Gastrointest Surg. 2015 Oct;19(10):1852-61.
14. Rogers MAM and Aronoff DM. Clin Microbiol Infect. 2016;22(2):178.e1-178.e9.
15. Kaimakliotis P et al. Int J Colorectal Dis. 2021 Jun;36(6):1193-200.
In the acute care setting, providers of care for inflammatory bowel disease (IBD) patients are often faced with the dilemma of providing effective abdominal pain management in a population that has worse outcomes with both opioid and NSAID therapy. There is increased mortality associated with opioid use and risk of disease relapse with NSAID use in IBD patients.1,2 Due to this, patients often feel that their pain is inadequately addressed.3,4 There are multiple sources of abdominal pain in IBD, and understanding the mechanisms and presentations can help identify effective treatments. We will review pharmacologic and supportive therapies to optimize pain management in IBD.
Common pain presentations in IBD
Visceral pain is a dull, poorly localized, cramping pain from intestinal distension. It is associated with inflammation, dysmotility, obstruction, and visceral hypersensitivity. Somatic and parietal pain is sharp, intense, and often localizable. Somatic pain originates from surrounding skin or muscles, and parietal pain arises from irritation of the peritoneum.5 We will review two common pain presentations in IBD.
Case 1: Mr. A is a 32-year-old male with stricturing small bowel Crohn’s disease s/p small bowel resection, who presents to the ED with 3 days of abdominal pain, nausea, and vomiting. C-reactive protein is elevated to 6.8 mg/dL (normal 0.0 – 0.6 mg/dL), and CT is consistent with active small bowel inflammation, intraabdominal abscess at the anastomosis, and associated partial small bowel obstruction. He describes a sharp, intense abdominal pain with cramping. His exam is significant for diffuse abdominal tenderness and distension.
Case 2: Ms. B is a 28-year-old female with ulcerative colitis on mesalamine monotherapy who presents to the hospital for rectal bleeding and cramping abdominal pain. After 3 days of IV steroids her rectal bleeding has resolved, and CRP has normalized. However, she continues to have dull, cramping abdominal pain. Ibuprofen has improved this pain in the past.
Mr. A is having somatic pain from inflammation, abscess, and partial bowel obstruction. He also has visceral pain from luminal distension proximal to the obstruction. Ms. B is having visceral pain despite resolution of inflammation, which may be from postinflammatory visceral hypersensitivity.
Etiologies of pain
It’s best to group pain etiologies into inflammatory and noninflammatory causes. Inflammatory pain can be secondary to infection, such as abscess or enteric infection, active bowel inflammation, or disease complications (that is, enteric fistula). It is important to recognize that patients with active inflammation may also have noninflammatory pain. These include small bowel obstruction, strictures, adhesions, narcotic bowel syndrome, bacterial overgrowth, and visceral hypersensitivity. See figure 1.
The brain-gut connection matters
Abdominal pain in IBD patients starts from painful stimuli in the gut. In addition to direct pain pathways, multiple areas of the brain modulate perception of pain.6 Patients with psychiatric comorbidities have increased perception of abdominal pain.7 In fact, high perceived stress is associated with disease relapse.8 Treatment of psychiatric disorders improves these symptoms with lasting effects.9 Addressing psychological and psychosocial needs is essential to successful pain management with long-term effect on quality of life and pain perception in IBD patients.
What are my options?
When IBD patients present with acute abdominal pain, it is important to directly address their pain as one of your primary concerns and provide them with a management plan. While this seems obvious, it is not routinely done.3-4
Next, it is important to identify the cause, whether it be infection, obstruction, active inflammation, or functional abdominal pain. In the case of active disease, in addition to steroids and optimization of IBD therapies, acetaminophen and antispasmodics can be used for initial pain management. Supportive therapies include sleep hygiene, physical activity, and psychotherapy. If initial treatments are unsuccessful in the acute setting, and presentation is consistent with somatic pain, it may be necessary to escalate to tramadol, opioid, or NSAID therapy. For visceral pain, a neuromodulator, such as a tricyclic antidepressant or gabapentin, may have greater effect. Bupropion, SNRIs, and SSRIs are options; however, they may not be effective in the acute setting. More recent focus in the IBD community has questioned the role of cannabinoids on pain in IBD patients. Cannabis has been shown in a few small studies to provide pain relief in IBD patients with active inflammation.10-11 In patients with mechanical causes for pain, management of obstruction is an important part of the treatment plan.
Let’s talk about opioids in IBD patients
Chronic narcotic use in IBD is associated with worse outcomes. So when is it okay to use opioid therapies in IBD patients? Postoperative patients, patients with severe perianal disease, or those who fail alternative pain management strategies may require opioid medications. The association with mortality and opioids in IBD is with patients who require moderate to heavy use, which is defined as being prescribed opioids more than once a year. Opioid use in IBD patients is also associated with increased risk of readmissions and poor surgical outcomes.12-13 Tramadol does not have increased mortality risk.1 If selecting opioid therapy in managing pain in IBD, it is important to define the course of therapy, with a clear goal of discontinuation after the acute episode. Opioids should be used in tandem with alternative strategies. Patients should be counseled on the synergistic effect of acetaminophen with opioids, which may allow lower effective doses of opioids.
What about NSAID use in IBD patients?
NSAIDs have negative effects in the gastrointestinal tract due to inhibition of protective prostaglandins. They also alter the gut microbiome, although clinical implications of this are unknown.14 A small study showed that IBD patients who used NSAIDs had increased risk of disease relapse.2 Symptoms of relapse would present within 2-9 days of exposure; however, most had resolution of symptoms within 2-11 days of discontinuation.2 Follow-up studies have not reliably found that NSAIDs are associated with disease relapse.8 and thus NSAIDs may be used sparingly if needed in the acute setting.
Case Review: How do we approach Mr. A and Ms. B?
Mr. A presented with a partial small bowel obstruction and abscess. His pain presentation was consistent with both visceral and somatic pain etiologies. In addition to treating active inflammation and infection, bowel rest, acetaminophen, and antispasmodics can be initiated for pain control. Concomitantly, gabapentin, TCA, or SNRI can be initiated for neurobiological pain but may have limited benefit in the acute hospitalized setting. Social work may identify needs that affect pain perception and assist in addressing those needs. If abdominal pain persists, tramadol or hydrocodone-acetaminophen can be considered.
Ms. B presented with disease relapse, but despite improving inflammatory markers she had continued cramping abdominal pain, which can be consistent with visceral hypersensitivity. Antispasmodic and neuromodulating agents, such as a TCA, could be effective. We can recommend discontinuation of chronic ibuprofen due to risk of intestinal inflammation. Patients may inquire about adjuvant cannabis in pain management. While cannabis can be considered, further research is needed to recommend its regular use.
Conclusion
Acute abdominal pain management in IBD can be challenging for providers when typical options are limited in this population. Addressing inflammatory, mechanical, neurobiological, and psychological influences is vital to appropriately address pain. Having a structured plan for pain management in IBD can improve outcomes by decreasing recurrent hospitalizations and use of opioids.15 Figure 2 presents an overview.
Dr. Ahmed is a second-year internal medicine resident at the University of Michigan, Ann Arbor. Dr. Kinnucan is with the department of internal medicine and the division of gastroenterology and hepatology and is an assistant professor of medicine in the division of gastroenterology, both at the University of Michigan. They have no conflicts of interest.
References
1. Burr NE et al. Clin Gastroenterol Hepatol. 2018 Apr;16(4):534-41.e6.
2. Takeuchi K et al. Clin Gastroenterol Hepatol. 2006 Feb;4(2):196-202.
3. Bernhofer EI et al. Gastroenterol Nurs. 2017 May/Jun;40(3):200-7.
4. Zeitz J et al. PLoS One. 2016 Jun 22;11(6):e0156666.
5. Srinath A et al. Inflamm Bowel Dis. 2014 Dec;20(12):2433-49.
6. Docherty MJ et al. Gastroenterol Hepatol (N Y). 2011 Sep;7(9):592-601.
7. Elsenbruch S et al. Gut. 2010 Apr;59(4):489-95.
8. Bernstein CN et al. Am J Gastroenterol. 2010 Sep;105(9):1994-2002.
9. Palsson OS and Whitehead WE. Clin Gastroenterol Hepatol. 2013 Mar;11(3):208-16; quiz e22-3.
10. Swaminath A et al. Inflamm Bowel Dis. 2019 Mar; 25(3):427-35.
11. Naftali T et al. Clin Gastroenterol Hepatol. 2013 Oct;11(10):1276-80.e1.
12. Sultan K and Swaminath A. J Crohns Colitis. 2020 Sep 16;14(9):1188-89.
13. Hirsch A et al. J Gastrointest Surg. 2015 Oct;19(10):1852-61.
14. Rogers MAM and Aronoff DM. Clin Microbiol Infect. 2016;22(2):178.e1-178.e9.
15. Kaimakliotis P et al. Int J Colorectal Dis. 2021 Jun;36(6):1193-200.
In the acute care setting, providers of care for inflammatory bowel disease (IBD) patients are often faced with the dilemma of providing effective abdominal pain management in a population that has worse outcomes with both opioid and NSAID therapy. There is increased mortality associated with opioid use and risk of disease relapse with NSAID use in IBD patients.1,2 Due to this, patients often feel that their pain is inadequately addressed.3,4 There are multiple sources of abdominal pain in IBD, and understanding the mechanisms and presentations can help identify effective treatments. We will review pharmacologic and supportive therapies to optimize pain management in IBD.
Common pain presentations in IBD
Visceral pain is a dull, poorly localized, cramping pain from intestinal distension. It is associated with inflammation, dysmotility, obstruction, and visceral hypersensitivity. Somatic and parietal pain is sharp, intense, and often localizable. Somatic pain originates from surrounding skin or muscles, and parietal pain arises from irritation of the peritoneum.5 We will review two common pain presentations in IBD.
Case 1: Mr. A is a 32-year-old male with stricturing small bowel Crohn’s disease s/p small bowel resection, who presents to the ED with 3 days of abdominal pain, nausea, and vomiting. C-reactive protein is elevated to 6.8 mg/dL (normal 0.0 – 0.6 mg/dL), and CT is consistent with active small bowel inflammation, intraabdominal abscess at the anastomosis, and associated partial small bowel obstruction. He describes a sharp, intense abdominal pain with cramping. His exam is significant for diffuse abdominal tenderness and distension.
Case 2: Ms. B is a 28-year-old female with ulcerative colitis on mesalamine monotherapy who presents to the hospital for rectal bleeding and cramping abdominal pain. After 3 days of IV steroids her rectal bleeding has resolved, and CRP has normalized. However, she continues to have dull, cramping abdominal pain. Ibuprofen has improved this pain in the past.
Mr. A is having somatic pain from inflammation, abscess, and partial bowel obstruction. He also has visceral pain from luminal distension proximal to the obstruction. Ms. B is having visceral pain despite resolution of inflammation, which may be from postinflammatory visceral hypersensitivity.
Etiologies of pain
It’s best to group pain etiologies into inflammatory and noninflammatory causes. Inflammatory pain can be secondary to infection, such as abscess or enteric infection, active bowel inflammation, or disease complications (that is, enteric fistula). It is important to recognize that patients with active inflammation may also have noninflammatory pain. These include small bowel obstruction, strictures, adhesions, narcotic bowel syndrome, bacterial overgrowth, and visceral hypersensitivity. See figure 1.
The brain-gut connection matters
Abdominal pain in IBD patients starts from painful stimuli in the gut. In addition to direct pain pathways, multiple areas of the brain modulate perception of pain.6 Patients with psychiatric comorbidities have increased perception of abdominal pain.7 In fact, high perceived stress is associated with disease relapse.8 Treatment of psychiatric disorders improves these symptoms with lasting effects.9 Addressing psychological and psychosocial needs is essential to successful pain management with long-term effect on quality of life and pain perception in IBD patients.
What are my options?
When IBD patients present with acute abdominal pain, it is important to directly address their pain as one of your primary concerns and provide them with a management plan. While this seems obvious, it is not routinely done.3-4
Next, it is important to identify the cause, whether it be infection, obstruction, active inflammation, or functional abdominal pain. In the case of active disease, in addition to steroids and optimization of IBD therapies, acetaminophen and antispasmodics can be used for initial pain management. Supportive therapies include sleep hygiene, physical activity, and psychotherapy. If initial treatments are unsuccessful in the acute setting, and presentation is consistent with somatic pain, it may be necessary to escalate to tramadol, opioid, or NSAID therapy. For visceral pain, a neuromodulator, such as a tricyclic antidepressant or gabapentin, may have greater effect. Bupropion, SNRIs, and SSRIs are options; however, they may not be effective in the acute setting. More recent focus in the IBD community has questioned the role of cannabinoids on pain in IBD patients. Cannabis has been shown in a few small studies to provide pain relief in IBD patients with active inflammation.10-11 In patients with mechanical causes for pain, management of obstruction is an important part of the treatment plan.
Let’s talk about opioids in IBD patients
Chronic narcotic use in IBD is associated with worse outcomes. So when is it okay to use opioid therapies in IBD patients? Postoperative patients, patients with severe perianal disease, or those who fail alternative pain management strategies may require opioid medications. The association with mortality and opioids in IBD is with patients who require moderate to heavy use, which is defined as being prescribed opioids more than once a year. Opioid use in IBD patients is also associated with increased risk of readmissions and poor surgical outcomes.12-13 Tramadol does not have increased mortality risk.1 If selecting opioid therapy in managing pain in IBD, it is important to define the course of therapy, with a clear goal of discontinuation after the acute episode. Opioids should be used in tandem with alternative strategies. Patients should be counseled on the synergistic effect of acetaminophen with opioids, which may allow lower effective doses of opioids.
What about NSAID use in IBD patients?
NSAIDs have negative effects in the gastrointestinal tract due to inhibition of protective prostaglandins. They also alter the gut microbiome, although clinical implications of this are unknown.14 A small study showed that IBD patients who used NSAIDs had increased risk of disease relapse.2 Symptoms of relapse would present within 2-9 days of exposure; however, most had resolution of symptoms within 2-11 days of discontinuation.2 Follow-up studies have not reliably found that NSAIDs are associated with disease relapse.8 and thus NSAIDs may be used sparingly if needed in the acute setting.
Case Review: How do we approach Mr. A and Ms. B?
Mr. A presented with a partial small bowel obstruction and abscess. His pain presentation was consistent with both visceral and somatic pain etiologies. In addition to treating active inflammation and infection, bowel rest, acetaminophen, and antispasmodics can be initiated for pain control. Concomitantly, gabapentin, TCA, or SNRI can be initiated for neurobiological pain but may have limited benefit in the acute hospitalized setting. Social work may identify needs that affect pain perception and assist in addressing those needs. If abdominal pain persists, tramadol or hydrocodone-acetaminophen can be considered.
Ms. B presented with disease relapse, but despite improving inflammatory markers she had continued cramping abdominal pain, which can be consistent with visceral hypersensitivity. Antispasmodic and neuromodulating agents, such as a TCA, could be effective. We can recommend discontinuation of chronic ibuprofen due to risk of intestinal inflammation. Patients may inquire about adjuvant cannabis in pain management. While cannabis can be considered, further research is needed to recommend its regular use.
Conclusion
Acute abdominal pain management in IBD can be challenging for providers when typical options are limited in this population. Addressing inflammatory, mechanical, neurobiological, and psychological influences is vital to appropriately address pain. Having a structured plan for pain management in IBD can improve outcomes by decreasing recurrent hospitalizations and use of opioids.15 Figure 2 presents an overview.
Dr. Ahmed is a second-year internal medicine resident at the University of Michigan, Ann Arbor. Dr. Kinnucan is with the department of internal medicine and the division of gastroenterology and hepatology and is an assistant professor of medicine in the division of gastroenterology, both at the University of Michigan. They have no conflicts of interest.
References
1. Burr NE et al. Clin Gastroenterol Hepatol. 2018 Apr;16(4):534-41.e6.
2. Takeuchi K et al. Clin Gastroenterol Hepatol. 2006 Feb;4(2):196-202.
3. Bernhofer EI et al. Gastroenterol Nurs. 2017 May/Jun;40(3):200-7.
4. Zeitz J et al. PLoS One. 2016 Jun 22;11(6):e0156666.
5. Srinath A et al. Inflamm Bowel Dis. 2014 Dec;20(12):2433-49.
6. Docherty MJ et al. Gastroenterol Hepatol (N Y). 2011 Sep;7(9):592-601.
7. Elsenbruch S et al. Gut. 2010 Apr;59(4):489-95.
8. Bernstein CN et al. Am J Gastroenterol. 2010 Sep;105(9):1994-2002.
9. Palsson OS and Whitehead WE. Clin Gastroenterol Hepatol. 2013 Mar;11(3):208-16; quiz e22-3.
10. Swaminath A et al. Inflamm Bowel Dis. 2019 Mar; 25(3):427-35.
11. Naftali T et al. Clin Gastroenterol Hepatol. 2013 Oct;11(10):1276-80.e1.
12. Sultan K and Swaminath A. J Crohns Colitis. 2020 Sep 16;14(9):1188-89.
13. Hirsch A et al. J Gastrointest Surg. 2015 Oct;19(10):1852-61.
14. Rogers MAM and Aronoff DM. Clin Microbiol Infect. 2016;22(2):178.e1-178.e9.
15. Kaimakliotis P et al. Int J Colorectal Dis. 2021 Jun;36(6):1193-200.
Ustekinumab effective in treatment-refractory pediatric ulcerative colitis
Key clinical point: Ustekinumab induced and maintained steroid-free clinical remission to 1 year in a significant proportion of children with extensive and treatment-refractory ulcerative colitis (UC).
Major finding: At week 52, 44% of children who received ustekinumab achieved steroid-free remission. This included 69% of those previously treated with antitumor necrosis factor (anti-TNF) only vs. 17% of those who previously failed vedolizumab (P = .008). No adverse events were reported.
Study details: Data come from an open-label prospective cohort study of 25 children with anti-TNF refractory UC who were treated with intravenous ustekinumab. All patients had failed prior infliximab therapy, whereas 12 patients also failed vedolizumab.
Disclosures: The study was funded by the Canadian Institutes of Health Research and Children's Intestinal and Liver Disease Foundation. Some of the authors reported serving as a consultant, speaker, advisory board member for and receiving speaker/consultation fees, honoraria, and/or research support from multiple sources.
Source: Dhaliwal J et al. Aliment Pharmacol Ther. 2021 Apr 28. doi: 10.1111/apt.16388.
Key clinical point: Ustekinumab induced and maintained steroid-free clinical remission to 1 year in a significant proportion of children with extensive and treatment-refractory ulcerative colitis (UC).
Major finding: At week 52, 44% of children who received ustekinumab achieved steroid-free remission. This included 69% of those previously treated with antitumor necrosis factor (anti-TNF) only vs. 17% of those who previously failed vedolizumab (P = .008). No adverse events were reported.
Study details: Data come from an open-label prospective cohort study of 25 children with anti-TNF refractory UC who were treated with intravenous ustekinumab. All patients had failed prior infliximab therapy, whereas 12 patients also failed vedolizumab.
Disclosures: The study was funded by the Canadian Institutes of Health Research and Children's Intestinal and Liver Disease Foundation. Some of the authors reported serving as a consultant, speaker, advisory board member for and receiving speaker/consultation fees, honoraria, and/or research support from multiple sources.
Source: Dhaliwal J et al. Aliment Pharmacol Ther. 2021 Apr 28. doi: 10.1111/apt.16388.
Key clinical point: Ustekinumab induced and maintained steroid-free clinical remission to 1 year in a significant proportion of children with extensive and treatment-refractory ulcerative colitis (UC).
Major finding: At week 52, 44% of children who received ustekinumab achieved steroid-free remission. This included 69% of those previously treated with antitumor necrosis factor (anti-TNF) only vs. 17% of those who previously failed vedolizumab (P = .008). No adverse events were reported.
Study details: Data come from an open-label prospective cohort study of 25 children with anti-TNF refractory UC who were treated with intravenous ustekinumab. All patients had failed prior infliximab therapy, whereas 12 patients also failed vedolizumab.
Disclosures: The study was funded by the Canadian Institutes of Health Research and Children's Intestinal and Liver Disease Foundation. Some of the authors reported serving as a consultant, speaker, advisory board member for and receiving speaker/consultation fees, honoraria, and/or research support from multiple sources.
Source: Dhaliwal J et al. Aliment Pharmacol Ther. 2021 Apr 28. doi: 10.1111/apt.16388.
Sarcopenia predictive of clinical course in acute severe ulcerative colitis
Key clinical point: Sarcopenia is predictive of the clinical course and postoperative outcomes of acute severe ulcerative colitis (ASUC).
Major finding: Sarcopenia was an independent risk factor for intravenous corticosteroid failure (odds ratio [OR], 3.130; P = .001), colectomy after medical rescue therapy failure (OR, 3.401; P = .033), and postoperative complications after colectomy (OR, 4.157; P = .012).
Study details: Findings are from a retrospective cohort study of 233 patients with ASUC.
Disclosures: The work was supported by the National Natural Science Foundation of China and Zhejiang Provincial Natural Science Foundation. The authors declared no conflicts of interest.
Source: Ge X et al. Dig Liver Dis. 2021 Apr 29. doi: 10.1016/j.dld.2021.03.031.
Key clinical point: Sarcopenia is predictive of the clinical course and postoperative outcomes of acute severe ulcerative colitis (ASUC).
Major finding: Sarcopenia was an independent risk factor for intravenous corticosteroid failure (odds ratio [OR], 3.130; P = .001), colectomy after medical rescue therapy failure (OR, 3.401; P = .033), and postoperative complications after colectomy (OR, 4.157; P = .012).
Study details: Findings are from a retrospective cohort study of 233 patients with ASUC.
Disclosures: The work was supported by the National Natural Science Foundation of China and Zhejiang Provincial Natural Science Foundation. The authors declared no conflicts of interest.
Source: Ge X et al. Dig Liver Dis. 2021 Apr 29. doi: 10.1016/j.dld.2021.03.031.
Key clinical point: Sarcopenia is predictive of the clinical course and postoperative outcomes of acute severe ulcerative colitis (ASUC).
Major finding: Sarcopenia was an independent risk factor for intravenous corticosteroid failure (odds ratio [OR], 3.130; P = .001), colectomy after medical rescue therapy failure (OR, 3.401; P = .033), and postoperative complications after colectomy (OR, 4.157; P = .012).
Study details: Findings are from a retrospective cohort study of 233 patients with ASUC.
Disclosures: The work was supported by the National Natural Science Foundation of China and Zhejiang Provincial Natural Science Foundation. The authors declared no conflicts of interest.
Source: Ge X et al. Dig Liver Dis. 2021 Apr 29. doi: 10.1016/j.dld.2021.03.031.
IBD patients at higher risk for stroke
Key clinical point: Inflammatory bowel disease (IBD) may be a risk factor for stroke.
Major finding: IBD was associated with an increased risk for stroke (odds ratio/relative risk [OR/RR], 1.21; P less than .001). Additionally, both Crohn's disease (OR/RR, 1.25; P less than .001) and ulcerative colitis (OR/RR, 1.09; P = .051) were associated with an increased risk for stroke.
Study details: Findings are from a meta-analysis of 9 studies involving 791,010 patients with IBD or stroke.
Disclosures: The study was supported by the General Project of Chongqing Natural Science Foundation and the National Natural Science Foundation of China. All authors declared no conflicts of interest.
Source: Chen Y et al. Brain Behav. 2021 May 7. doi: 10.1002/brb3.2159.
Key clinical point: Inflammatory bowel disease (IBD) may be a risk factor for stroke.
Major finding: IBD was associated with an increased risk for stroke (odds ratio/relative risk [OR/RR], 1.21; P less than .001). Additionally, both Crohn's disease (OR/RR, 1.25; P less than .001) and ulcerative colitis (OR/RR, 1.09; P = .051) were associated with an increased risk for stroke.
Study details: Findings are from a meta-analysis of 9 studies involving 791,010 patients with IBD or stroke.
Disclosures: The study was supported by the General Project of Chongqing Natural Science Foundation and the National Natural Science Foundation of China. All authors declared no conflicts of interest.
Source: Chen Y et al. Brain Behav. 2021 May 7. doi: 10.1002/brb3.2159.
Key clinical point: Inflammatory bowel disease (IBD) may be a risk factor for stroke.
Major finding: IBD was associated with an increased risk for stroke (odds ratio/relative risk [OR/RR], 1.21; P less than .001). Additionally, both Crohn's disease (OR/RR, 1.25; P less than .001) and ulcerative colitis (OR/RR, 1.09; P = .051) were associated with an increased risk for stroke.
Study details: Findings are from a meta-analysis of 9 studies involving 791,010 patients with IBD or stroke.
Disclosures: The study was supported by the General Project of Chongqing Natural Science Foundation and the National Natural Science Foundation of China. All authors declared no conflicts of interest.
Source: Chen Y et al. Brain Behav. 2021 May 7. doi: 10.1002/brb3.2159.
Prenatal exposure to tobacco smoke and antibiotics increases IBD risk in offspring
Key clinical point: Prenatal exposure to tobacco smoke and antibiotics and early life otitis media were risk factors for inflammatory bowel disease (IBD).
Major finding: Prenatal exposure to tobacco smoke (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.17-1.90) and antibiotics (OR, 1.75; 95% CI, 1.22-2.51), and early life otitis media (OR, 2.11; 95% CI, 1.22-3.62) were positively associated with IBD.
Study details: Findings are from a meta-analysis of 39 studies that evaluated the association between early life (prenatal life to 5 years of age) exposures and subsequent risk for IBD.
Disclosures: The study did not receive any funding. Some of the authors reported receiving grants, speaker fees, advisory board fees, personal fees, consultancy, and/or lectures, and/or honoraria from multiple sources. All other authors had no disclosures.
Source: Agrawal M et al. EClinicalMedicine. 2021 May 15. doi: 10.1016/j.eclinm.2021.100884.
Key clinical point: Prenatal exposure to tobacco smoke and antibiotics and early life otitis media were risk factors for inflammatory bowel disease (IBD).
Major finding: Prenatal exposure to tobacco smoke (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.17-1.90) and antibiotics (OR, 1.75; 95% CI, 1.22-2.51), and early life otitis media (OR, 2.11; 95% CI, 1.22-3.62) were positively associated with IBD.
Study details: Findings are from a meta-analysis of 39 studies that evaluated the association between early life (prenatal life to 5 years of age) exposures and subsequent risk for IBD.
Disclosures: The study did not receive any funding. Some of the authors reported receiving grants, speaker fees, advisory board fees, personal fees, consultancy, and/or lectures, and/or honoraria from multiple sources. All other authors had no disclosures.
Source: Agrawal M et al. EClinicalMedicine. 2021 May 15. doi: 10.1016/j.eclinm.2021.100884.
Key clinical point: Prenatal exposure to tobacco smoke and antibiotics and early life otitis media were risk factors for inflammatory bowel disease (IBD).
Major finding: Prenatal exposure to tobacco smoke (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.17-1.90) and antibiotics (OR, 1.75; 95% CI, 1.22-2.51), and early life otitis media (OR, 2.11; 95% CI, 1.22-3.62) were positively associated with IBD.
Study details: Findings are from a meta-analysis of 39 studies that evaluated the association between early life (prenatal life to 5 years of age) exposures and subsequent risk for IBD.
Disclosures: The study did not receive any funding. Some of the authors reported receiving grants, speaker fees, advisory board fees, personal fees, consultancy, and/or lectures, and/or honoraria from multiple sources. All other authors had no disclosures.
Source: Agrawal M et al. EClinicalMedicine. 2021 May 15. doi: 10.1016/j.eclinm.2021.100884.
Crohn's disease: Ustekinumab more effective than vedolizumab in patients refractory to anti-TNF therapy
Key clinical point: Ustekinumab showed higher short- and long-term efficacy than vedolizumab in patients with Crohn's disease with prior antitumor necrosis factor (TNF) therapy failure.
Major finding: Ustekinumab vs. vedolizumab was more effective in achieving corticosteroid-free clinical remission at week 54 (50.6% vs. 40.6%; P = .047) and deep remission at week 14 (17.9% vs. 5.7%; P = .047). Patients treated with ustekinumab vs. vedolizumab had a lower rate of primary nonresponse (6.7% vs. 14.8%, P = .034), a longer time to therapeutic escalation (hazard ratio [HR], 1.35; P = .043), and lower risk for drug discontinuation (HR, 1.53; P = .029).
Study details: This was a retrospective cohort study of 312 patients with Crohn's disease treated with ustekinumab (n=224) or vedolizumab (n=88) after exposure to at least 1 anti-TNF agent.
Disclosures: No information on funding was available. A Buisson reported receiving consulting and lecture fees from multiple sources. The other authors had no disclosures.
Source: Manlay L et al. Aliment Pharmacol Ther. 2021 Apr 28. doi: 10.1111/apt.16377.
Key clinical point: Ustekinumab showed higher short- and long-term efficacy than vedolizumab in patients with Crohn's disease with prior antitumor necrosis factor (TNF) therapy failure.
Major finding: Ustekinumab vs. vedolizumab was more effective in achieving corticosteroid-free clinical remission at week 54 (50.6% vs. 40.6%; P = .047) and deep remission at week 14 (17.9% vs. 5.7%; P = .047). Patients treated with ustekinumab vs. vedolizumab had a lower rate of primary nonresponse (6.7% vs. 14.8%, P = .034), a longer time to therapeutic escalation (hazard ratio [HR], 1.35; P = .043), and lower risk for drug discontinuation (HR, 1.53; P = .029).
Study details: This was a retrospective cohort study of 312 patients with Crohn's disease treated with ustekinumab (n=224) or vedolizumab (n=88) after exposure to at least 1 anti-TNF agent.
Disclosures: No information on funding was available. A Buisson reported receiving consulting and lecture fees from multiple sources. The other authors had no disclosures.
Source: Manlay L et al. Aliment Pharmacol Ther. 2021 Apr 28. doi: 10.1111/apt.16377.
Key clinical point: Ustekinumab showed higher short- and long-term efficacy than vedolizumab in patients with Crohn's disease with prior antitumor necrosis factor (TNF) therapy failure.
Major finding: Ustekinumab vs. vedolizumab was more effective in achieving corticosteroid-free clinical remission at week 54 (50.6% vs. 40.6%; P = .047) and deep remission at week 14 (17.9% vs. 5.7%; P = .047). Patients treated with ustekinumab vs. vedolizumab had a lower rate of primary nonresponse (6.7% vs. 14.8%, P = .034), a longer time to therapeutic escalation (hazard ratio [HR], 1.35; P = .043), and lower risk for drug discontinuation (HR, 1.53; P = .029).
Study details: This was a retrospective cohort study of 312 patients with Crohn's disease treated with ustekinumab (n=224) or vedolizumab (n=88) after exposure to at least 1 anti-TNF agent.
Disclosures: No information on funding was available. A Buisson reported receiving consulting and lecture fees from multiple sources. The other authors had no disclosures.
Source: Manlay L et al. Aliment Pharmacol Ther. 2021 Apr 28. doi: 10.1111/apt.16377.
Crohn’s disease: Partial restoration of intestinal microbiome in anti-TNF responders
Key clinical point: Patients with Crohn’s disease (CD) who responded to antitumor necrosis factor (anti-TNF) treatment showed partial restoration of intestinal microbiome characteristics of healthy individuals.
Major finding: Patients with CD vs. healthy cohort showed a decrease in genera of the class Clostridia and an increase in the phylum Proteobacteria (P less than .01). Anti-TNF treatment allowed restoration of bacteria belonging to the class Clostridia in responders. The genus Escherichia/Shigella reduced significantly vs. baseline but did not reach statistical significance in responders vs. healthy control.
Study details: Data come from a prospective multicenter observational study of 27 patients with CD who initiated anti-TNF treatment and 16 healthy individuals. Based on inflammatory activity, patients were classified into responders and nonresponders.
Disclosures: No information on funding was available. The authors declared no conflicts of interest.
Source: Sanchis-Artero L et al. Sci Rep. 2021 May 11. doi: 10.1038/s41598-021-88823-2.
Key clinical point: Patients with Crohn’s disease (CD) who responded to antitumor necrosis factor (anti-TNF) treatment showed partial restoration of intestinal microbiome characteristics of healthy individuals.
Major finding: Patients with CD vs. healthy cohort showed a decrease in genera of the class Clostridia and an increase in the phylum Proteobacteria (P less than .01). Anti-TNF treatment allowed restoration of bacteria belonging to the class Clostridia in responders. The genus Escherichia/Shigella reduced significantly vs. baseline but did not reach statistical significance in responders vs. healthy control.
Study details: Data come from a prospective multicenter observational study of 27 patients with CD who initiated anti-TNF treatment and 16 healthy individuals. Based on inflammatory activity, patients were classified into responders and nonresponders.
Disclosures: No information on funding was available. The authors declared no conflicts of interest.
Source: Sanchis-Artero L et al. Sci Rep. 2021 May 11. doi: 10.1038/s41598-021-88823-2.
Key clinical point: Patients with Crohn’s disease (CD) who responded to antitumor necrosis factor (anti-TNF) treatment showed partial restoration of intestinal microbiome characteristics of healthy individuals.
Major finding: Patients with CD vs. healthy cohort showed a decrease in genera of the class Clostridia and an increase in the phylum Proteobacteria (P less than .01). Anti-TNF treatment allowed restoration of bacteria belonging to the class Clostridia in responders. The genus Escherichia/Shigella reduced significantly vs. baseline but did not reach statistical significance in responders vs. healthy control.
Study details: Data come from a prospective multicenter observational study of 27 patients with CD who initiated anti-TNF treatment and 16 healthy individuals. Based on inflammatory activity, patients were classified into responders and nonresponders.
Disclosures: No information on funding was available. The authors declared no conflicts of interest.
Source: Sanchis-Artero L et al. Sci Rep. 2021 May 11. doi: 10.1038/s41598-021-88823-2.
Crohn’s disease: Ustekinumab safe and effective in a real-world setting
Key clinical point: Ustekinumab was effective and relatively safe in a real-world cohort of patients with Crohn’s disease (CD).
Major finding: After 104 weeks of ustekinumab treatment, 34.0% of patients were in corticosteroid-free clinical remission (Cf-CR). Among patients who were in Cf-CR at week 24, 48.1% remained at Cf-CR at week 104. Lack of response (61.7%) and loss of response (18.3%) were the main reasons for treatment discontinuation. No new safety signals were identified.
Study details: Findings are from a cohort study of 252 patients with CD who initiated ustekinumab and completed at least 2 years of follow-up.
Disclosures: No information on funding was available. The authors declared serving as a speaker, consultant, principal investigator, advisory board member for and/or receiving sponsorship, grants/honoraria, advisory, and/or speaker fees from multiple sources.
Source: Straatmijer T et al. J Crohns Colitis. 2021 Apr 28. doi: 10.1093/ecco-jcc/jjab081.
Key clinical point: Ustekinumab was effective and relatively safe in a real-world cohort of patients with Crohn’s disease (CD).
Major finding: After 104 weeks of ustekinumab treatment, 34.0% of patients were in corticosteroid-free clinical remission (Cf-CR). Among patients who were in Cf-CR at week 24, 48.1% remained at Cf-CR at week 104. Lack of response (61.7%) and loss of response (18.3%) were the main reasons for treatment discontinuation. No new safety signals were identified.
Study details: Findings are from a cohort study of 252 patients with CD who initiated ustekinumab and completed at least 2 years of follow-up.
Disclosures: No information on funding was available. The authors declared serving as a speaker, consultant, principal investigator, advisory board member for and/or receiving sponsorship, grants/honoraria, advisory, and/or speaker fees from multiple sources.
Source: Straatmijer T et al. J Crohns Colitis. 2021 Apr 28. doi: 10.1093/ecco-jcc/jjab081.
Key clinical point: Ustekinumab was effective and relatively safe in a real-world cohort of patients with Crohn’s disease (CD).
Major finding: After 104 weeks of ustekinumab treatment, 34.0% of patients were in corticosteroid-free clinical remission (Cf-CR). Among patients who were in Cf-CR at week 24, 48.1% remained at Cf-CR at week 104. Lack of response (61.7%) and loss of response (18.3%) were the main reasons for treatment discontinuation. No new safety signals were identified.
Study details: Findings are from a cohort study of 252 patients with CD who initiated ustekinumab and completed at least 2 years of follow-up.
Disclosures: No information on funding was available. The authors declared serving as a speaker, consultant, principal investigator, advisory board member for and/or receiving sponsorship, grants/honoraria, advisory, and/or speaker fees from multiple sources.
Source: Straatmijer T et al. J Crohns Colitis. 2021 Apr 28. doi: 10.1093/ecco-jcc/jjab081.