Capsule Endoscopy in Crohn’s Disease—From a Relative Contraindication to Habitual Monitoring Tool

Crohn’s disease (CD) is a chronic inflammatory disorder that may involve the gastrointestinal tract from the mouth to the anus. Habitual disease monitoring is highly important during disease management, aiming to identify and treat disease exacerbations, in order to avoid immediate and future complications. Currently, ilio-clonoscopy is the gold standard for mucosal assessment. However, the procedure is invasive, involves sedation and allows for visualization of the colon and only a small part of the terminal ileum, while most of the small bowel is not visualized. Since CD may involve the whole length of the small bowel, the disease extent might be underestimated. Capsule endoscopy (CE) provides a technology that can screen the entire bowel in a non-invasive procedure, with minimal side effects. In recent years, this technique has gained in popularity for CD evaluation and monitoring. When CE was first introduced, two decades ago, the fear of possible capsule retention in the narrowed inflamed bowel lumen limited its use in CD patients, and a known CD located at the small bowel was even regarded as a relative contraindication for capsule examination. However, at present, as experience using CE in CD patients has accumulated, this procedure has become one of the accepted tools for disease diagnosis and monitoring. In our current review, we summarize the historic change in the indications and contraindications for the usage of capsule endoscopy for the evaluation of CD, and discuss international recommendations regarding CE’s role in CD diagnosis and monitoring.

A Patient With Graves’ Disease And Thyroid-Associated Orbitopathy Undergoing Radioactive Iodine in Dr. Soetomo General Academic Hospital, Surabaya

Graves’ Disease (GD) is the most common etiology of thyrotoxicosis, followed by toxic multinodular goiter and toxic adenoma. GD can be managed with anti-thyroid drugs (ATDs), surgery, or radioactive iodine (RAI). Thyroid-associated orbitopathy (TAO) or Graves’ Ophthalmopathy (GO) affects 25%-50% patients with GD, and its presence usually dissuade clinicians to use RAI in treating hyperthyroidism. The presence of GO is a relative contraindication use of RAI in patients with GD, as RAI can worsen existing GO. Corticosteroid prophylaxis can be given to such patients to reduce likelihood of worsening of GO. However, patient with moderate to severe active GO is currently advised against undergoing RAI. Established guidelines recommend the use of corticosteroid prophylaxis in these patients. We reported a patients with GD and orbitopathy who was treated with RAI and was given steroid prophylaxis to prevent worsening of GO.

Reappraisal of an Intraoperative Resource for Performing Vaginal Hysterectomy in Patients with Prior Pelvic Surgery

Prior pelvic surgery is a relative contraindication for vaginal hysterectomy. The authors describe a procedure to be used as an Intraoperative resource, which helps in clearing any doubt for performing this surgical procedure, offering greater safety for the surgeon and preserving the patient’s bodily integrity. The aforementioned procedure was performed in two hundred and ten patients, who all underwent vaginal hysterectomy. *Obstetrics and Gynecology Professor, Universidad Peruana Cayetano Heredia; former Head of the Gynecology and Obstetrics Department, Arzobispo Loayza National Hospital **Physician, GP

Neuraxial and regional anesthesia in surgical patients with osteogenesis imperfecta: a narrative review of literature

Background and objectivesRegional and neuraxial anesthesia techniques have become instrumental in the perioperative period yet have not been well described in patients with osteogenesis imperfecta (OI), a congenital connective tissue disorder characterized by skeletal dysplasia and fragility. Patients with skeletal dysplasia present unique perioperative challenges that warrant consideration of these techniques despite their relative contraindication in this population due to reports of increased bleeding with surgery, skeletal fragility concerns with positioning, and risk of spinal cord injury with continuous neuraxial catheters. The aim of this narrative review was to evaluate literature describing the use of regional and neuraxial techniques in patients with OI and any associated clinical outcomes.MethodsAll available literature from inception to July 2020 was retrieved, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, from MEDLINE, Embase, Google Scholar and The Cochrane Library. Three authors reviewed all references for eligibility, abstracted data, and appraised quality.ResultsOf 412 articles initially identified, 42 met our inclusion criteria, yielding 161 cases with regional and/or neuraxial techniques described. In 117 (72.6%) of the 161 cases, neuraxial technique was performed, including 76 (64.9%) epidural, 7 (5.9%) caudal, 5 (4.2%) combined spinal epidural, and 29 (24.7%) spinal procedures. In 44 (27.4%) of the 161 cases, the use of regional anesthesia was described. Our review was confounded by incomplete data reporting and small sample sizes, as most were case reports. There were no randomized controlled trials, and the two single-center retrospective data reviews lacked sufficient data to perform meta-analysis. While complications or negative outcomes related to these techniques were not reported in any of the cases, less than half specifically discuss outcomes beyond placement and immediate postoperative course.ConclusionsThere is insufficient evidence to validate or refute the potential risks associated with the use of regional and neuraxial techniques in patients with OI. This review did not uncover any reports of negative sequelae related to the use of these modalities to support relative contraindication in this population; however, further research is needed to adequately assess clinically relevant outcomes such as complications and opioid-sparing effect.

Modified Very Low Calorie Diet for Weight Loss to Improve Lung Transplantation Candidacy in a Medical Intensive Care Unit: A Case Report (P12-048-19)

Objectives The prevalence of adults with obesity in the United States continues to increase [1]. Obesity remains a relative contraindication to lung transplantation due to the potential for negative effects on post-transplant survival, including primary graft dysfunction [2]. We report a case of implementing a modified very low calorie diet for weight loss in an inpatient setting to improve candidacy for lung transplantation. Methods A 47 year-old male with morbid obesity, chronic hypercapneic respiratory failure status post tracheostomy seven years prior, and progressive pulmonary fibrosis was admitted to the intensive care unit for worsening hypoxia at home. On admission his weight was 108.9 kilograms with body mass index of 37 kg/m², making him ineligible for lung transplantation listing and evaluation. Due to persistently high oxygen requirements and nocturnal ventilator dependence, care for the patient could not safely be transitioned outside of an acute care setting. To achieve weight loss, we implemented a modified very low calorie diet to provide 800 kilocalories and 90–100 grams of protein per day. At the time of this report, the patient has achieved a 10.9 kilogram decrease in body weight over four weeks with stable clinical status and without new adverse events during the period on the calorie restricted diet. Results Median survival after lung transplantation is approximately five years. In transplant recipients, a BMI > 30 may be associated with increased short-term and long-term mortality and is a relative contraindication to transplantation [2,3]. Importantly, in patients with obesity, weight loss prior to lung transplantation may improve survival and decrease peri-operative morbidity [4]. While this is difficult in patients with limited exercise capacity and urgent indications for transplantation, utilizing a very low calorie diet for weight loss can be effective in the proper setting, especially a monitored inpatient unit [5]. This is important because it may allow for transplant eligibility and the possibility of transplantation for a patient that would otherwise have a limited survival period. Conclusions The use of a calorie restricted diet should be considered as a safe and effective method for rapid weight loss in an inpatient, monitored setting to allow for lung transplantation eligibility. Funding Sources None.