t
ENDOSCOPY
admission to hospital – and furthermore, around 20% of first attacks in these patients are acute and severe in nature. “This has a particular impact on the individual involved and these patients haven’t really had a chance to really understand the nature of the disease, and indeed its implications and possible surgery,” Prof Hart explained. “Accute Severe Ulcerative Colitis (ASUC) is defined by the true level of its criteria: and this includes more than six stools a day with blood, with signs of systematic upset which includes fever, tachycardia and anaemia. It’s important to remember that ASUC is a medical emergency and requires prompt recognition and multidisciplinary management. It’s also important to remember the attention to detail in the management of these patients eg: adequate intravenous fluid replacement, particularly with potassium; adequate nutritional support; subcutaneous prophylactic low molecular weight heparin; prophylaxes against deep vein thrombosis (DVT); and a pulmonary embolism (PE).
“Investigations include an unprepared limited flexible sigmoidoscopy and biopsies, stool cultures – again, to exclude infection – and being careful not to give these patients drugs like opioids, NSAIDs, anti-cholinergics or anti-diarrhoeal agents.” Prof Hart noted that some patients they will be able to tolerate topical therapies and blood transfusion as required and said that this can be helpful in their management. She continued: “The mainstay of therapy is steroids and around two thirds of patients will respond as first line therapy. However, the flip side of the coin is that about one third will not respond to therapy after about three to five days and in these patients, rescue therapy with either Ciclosporin (CsA) or Infliximab (IFX) presents the next options for them. “Randomised trials comparing CsA and IFX show no major difference in outcomes between these drugs and decisions are based more on a number of factors - both patient driven and physician driven. For example, patients who are hypertensive, who have renal problems, who are old, or who have other co-morbities, may be less suitable for CsA. And the same with IFX – patients with risks of infection, such as tuberculosis, or heart failure may be less appropriate for IFX.” Stressing that careful monitoring of these patients is paramount, Prof noted that tools to assess, predict and prognosticate are important ways of assessing these patients. She explained: “The clinical parameters will include the number of bowel movements, rectal bleeding. Biochemical parameters will include markers such as the CRP/albumin ratio.
“Endoscopy can have a really important role, using the Ulcerative Colitis Endoscopic Index of Severity (UCEIS) Score to assess the severity of the disease - and radiological markers looking for toxic dilatation. “Optimal dosing strategies of IFX are still uncertain, with several retrospective studies
SEPTEMBER 2018
The National Endoscopy Database is an exciting innovation launched in 2018. This database hosted by JAG will work across all endoscopy reporting platforms and will collate data of endoscopies performed in the UK, in both NHS and private settings. Siwan Thomas-Gibson, St Mark’s Hospital.
suggesting the association between a better outcome with accelerated or intensified IFX induction. But, still, there’s no randomised data in this particular context. “In patients who don’t respond to rescue medical therapy it is important to think about the next step, and of course surgery plays a key role here. I think only with caution should
Testing protocol 1
GDH + CDT + PCR+
GDH EIA (or NAAT) positive, toxin EIA positive: CDI is likely to be present
2
GDH + CDT – PCR +
GDH EIA (or NAAT) positive, toxin EIA negative: C.difficile could be present – may need treatment transmission potential. Patient could be potential C.difficile excretor
3
GDH – / + CDT – PCR –
GDH EIA (or NAAT) negative, toxin EIA negative: C.difficile is very unlikely to be present, so may have transmission potential. Patient could have other potential pathogens.
a third line medical therapy be given, particularly in tertiary referral centres. It’s very important to interact with the surgeon and make sure that the surgeon plays a key role from early on in the disease – and that the patient knows the surgeon and vice versa, because surgery can have a key role in the patients who fail medical rescue therapy.” Considering the future options, Prof Hart suggested these might include optimised/ personalised dosing of anti-TNFs, particularly when point-of-care testing of drug levels are available. “Another potential could be using calcineurin inhibitors,” she added. “In the UK a trial is just starting using Anakinra – a biopharmaceutical drug used to treat rheumatoid arthritis - in this particular setting.”
Non-alcoholic fatty liver disease
Dr Stuart McPherson, consultant hepatologist, The Newcastle upon Tyne Hospitals NHS Foundation Trust, asked the question: “Non-alcoholic fatty liver disease: the patient hasn’t lost weight – now what?” Non-alcoholic fatty liver disease (NAFLD) is associated with central obesity and the metabolic syndrome, and now affects approximately 20% to 30% of the UK population. Fatty liver is present when more than 5% of hepatocytes contain fat droplets. Approximately 10% to 30% of patients with NAFLD have steatohepatitis, where liver fat is associated with hepatocyte injury and liver inflammation. And 20% of these individuals progress onto cirrhosis. “The development of cirrhosis is associated with a significant risk of related complications, such as hepatic
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