Nasobiliary drainage: an effective treatment for pruritus in cholestatic liver disease

IntroductionNasobiliary drains (NBDs) have been successfully used to manage intrahepatic cholestasis, bile leaks and obstructive cholangitis. It allows external drainage of bile, bypassing the ileum where bile salts are reabsorbed. We assessed the utility of placement with effect on markers of cholestasis and patient symptoms.MethodsConsecutive patients undergoing NBD over 12 years for the management of pruritus were retrospectively analysed. Recorded variables included patient demographics, procedural characteristics and response to therapy.ResultsTwenty-three patients (14, 61% male) underwent 30 episodes of NBD. The median age was 26 years old (range 2–67 years old). A single procedure was carried out in 20. One patient each had two, three and five episodes of NBD. The most common aetiologies were hereditary cholestatic disease (n=17, 74%) and drug-induced cholestasis (n=5, 22%),NBD remained in situ for a median of 8 days (range 1–45 days). Significant improvement in bilirubin was seen at 7 days post-NBD (p=0.0324), maintained at day 30 (335 μmol/L vs 302 µmol/L vs 167 µmol/L). There was symptomatic improvement in pruritus in 20 (67%, p=0.0494) episodes. One patient underwent NBD during the first trimester of pregnancy after medical therapy failure with a good symptomatic response. The catheters were well tolerated in 27 (90%) of cases. Mild pancreatitis occurred in 4 (13%) cases.ConclusionNBD can be used to provide symptomatic improvement to patients with pruritus associated with cholestasis. It is well tolerated by patients. They can be used in pregnancy where medical management has failed.

Comparative effectiveness of a second-line biologic in patients with ulcerative colitis: vedolizumab followed by an anti-TNF versus anti-TNF followed by vedolizumab

BackgroundSequential drug treatment with biological agents in ulcerative colitis (UC) is becoming increasingly complex. There are few studies comparing head-to-head outcomes in second-line treatments. The study assesses whether using anti-tumour necrosis factor (anti-TNF)-α therapy following the α4β7 integrin blocker vedolizumab (VDZ) or VDZ after an anti-TNF has more favourable clinical outcomes in UC in a real-world outpatient setting.MethodsPatients with UC who were exposed to first-line anti-TNF (adalimumab or infliximab) or VDZ who subsequently switched to the alternate class between May 2013 and August 2020 were identified by reviewing patient databases at 10 hospitals. Data were collected retrospectively using patient records. Baseline demographics, disease activity indices, biochemical markers, endoscopic Mayo score, colectomy rates, treatment persistence and urgent hospital utilisation composite endpoint (UHUC) rates were examined over a 52-week period.ResultsSecond-line week 52 treatment persistence was higher in the VDZ group (71/81, 89%) versus the anti-TNF group (15/34, 44%; p=0.0001), as were week 52 colectomy-free survival (VDZ: 77/80, 96%, vs anti-TNF: 26/32, 81%; p=0.009), week 52 UHUC survival (VDZ: 68/84, 81%, vs anti-TNF: 20/34, 59%; p=0.002) and week 52 corticosteroid-free clinical remission (CFCR) rates (VDZ: 22/34, 65%, vs anti-TNF: 4/20, 20%; p=0.001).ConclusionCompared with second-line anti TNF usage, the VDZ second-line cohort had significantly higher 52-week treatment persistence, UHUC survival, higher colectomy-free survival rates and higher week 52 CFCR. These data suggest that VDZ is an effective biologic in UC as a second-line therapy after anti-TNF exposure. It highlights the effect of biological order on clinically important outcomes.

UK-wide study of the opinions of gastroenterology trainees: COVID-19, Shape of Training and the future workforce

IntroductionThe COVID-19 pandemic has disrupted training. Gastroenterology higher specialty training is soon to be reduced from 5 years to 4. The British Society of Gastroenterology Trainees Section biennial survey aims to delineate the impact of COVID-19 on training and the opinions on changes to training.MethodsAn electronic survey allowing for anonymised responses at the point of completion was distributed to all gastroenterology trainees from September to November 2020.ResultsDuring the first wave of the COVID-19 pandemic, 71.0% of the respondents stated that more than 50% of their clinical time was mostly within general internal medicine. Trainees reported a significant impact on all aspects of their gastroenterology training due to lost training opportunities and increasing service commitments. During the first wave, 88.5% of the respondents reported no access to endoscopy training lists. Since this time, 66.2% of the respondents stated that their endoscopy training lists had restarted. This has resulted in fewer respondents achieving endoscopy accreditation. The COVID-19 pandemic has caused 42.2% of the respondents to consider extending their training to obtain the skills required to complete training. Furthermore, 10.0% of the respondents reported concerns of a delay to completion of training. The majority of respondents (84.2%) reported that they would not feel ready to be a consultant after 4 years of training.ConclusionsReductions in all aspects of gastroenterology training were reported. This is mirrored in anticipated concerns about completion of training in a shorter training programme as proposed in the new curriculum. Work is now required to ensure training is restored following the pandemic.

Nivolumab-induced exocrine pancreatic insufficiency

Immune checkpoint inhibition is the standard-of-care for many advanced cancers. Side effects of therapy may prevent optimal treatment of the cancer. Management of side effects is dominated by recommendations derived from oncological, not gastroenterological practice. We report a patient who developed pancreatic insufficiency during checkpoint inhibitor therapy with a programmed cell death receptor 1 inhibitor, nivolumab, which if not diagnosed would have prevented ongoing treatment. This is a problem which affects approximately 1 in 100 patients treated with this agent but is rarely recognised. Gastroenterologists need to be aware of the spectrum of gastrointestinal disorders which occur after immunotherapy to treat cancer.

Improved outcomes following the implementation of a decompensated cirrhosis discharge bundle

IntroductionMortality from liver disease is increasing and management of decompensated cirrhosis (DC) is inconsistent across the UK. Patients with DC have complex medical needs when discharged from hospital and early readmissions are common. Our aims were: (1) to develop a Decompensated Cirrhosis Discharge Bundle (DCDB) to optimise ongoing care and (2) evaluate the impact of the DCDB.MethodsA baseline review of the management of patients with DC was conducted in Newcastle in 2017. The DCCB was developed and implemented in 2018. Impact of the DCDB was evaluated in two cycles, first a paper version (November 2018–October 2019) and then an electronic version (November 2020–March 2021). Key clinical data were collected from the time of discharge.ResultsOverall, 192 patients (62% male; median age 55; median model for end-stage liver disease 17; 72% alcohol related) were reviewed in three cycles. At baseline, management was suboptimal, particularly ascites/diuretic management and provision of follow-up for alcohol misuse and 12% of patients had a potentially avoidable readmission within 30 days. After DCDB introduction, care improved across most domains, particularly electrolyte monitoring (p=0.012) and provision of community alcohol follow-up (p=0.026). Potentially preventable readmissions fell to 5% (p=0.055).ConclusionsUse of a care bundle for patients with DC can standardise care and improve patient management. If used more widely this could improve outcomes and reduce variability in care for patients with DC.

Artificial intelligence and inflammatory bowel disease: practicalities and future prospects

Artificial intelligence (AI) is an emerging technology predicted to have significant applications in healthcare. This review highlights AI applications that impact the patient journey in inflammatory bowel disease (IBD), from genomics to endoscopic applications in disease classification, stratification and self-monitoring to risk stratification for personalised management. We discuss the practical AI applications currently in use while giving a balanced view of concerns and pitfalls and look to the future with the potential of where AI can provide significant value to the care of the patient with IBD.