Background. Treatment options are limited for patients with refractory cirrhotic ascites (RCA). As such, we assessed the safety and effectiveness of the PleurX catheter for RCA. Methods. A retrospective analysis was performed on all patients with RCA who have undergone insertion of the PleurX catheter between 2007 and 2014 at our clinic. Results. Thirty-three patients with RCA were included in the study; 4 patients were lost to follow-up. All patients were still symptomatic despite bimonthly large volume paracentesis and were not candidates for TIPS or PV shunt. Technical success was achieved in 100% of patients. The median duration the catheter remained in situ was 117.5 days, with 95% CI of 48–182 days. Drain patency was maintained in 90% of patients. Microorganisms consistent with spontaneous bacterial peritonitis (SBP) from a catheter source were isolated in 38% of patients. The median time to infection was 105 days, with 95% CI of 34–233 days. All patients were treated for SBP successfully with antibiotics. Conclusion. Use of the PleurX catheter for the management of RCA carries a high risk for infection when the catheter remains in situ for more than 3 months but has an excellent patency rate and did not result in significant renal injury.

Important deteriorations in body composition and strength occur and need to be accurately measured in advanced cancer patients (ACPs). The aim of this study was to establish the relationship between a single-frequency bioimpedance analyzer (BIA) and the dual-energy X-ray absorptiometer (DXA), as well as the Jamar handgrip dynometer and the Biodex handgrip attachment, and to determine the precision of each of these instruments in ACPs. Eighty-one ACPs with non-small-cell lung cancer and gastrointestinal cancer were recruited from the McGill University Health Centre (Montreal, Que.). Consecutive paired measurements, with repositioning between measurements, were obtained for total-body DXA, BIA, Biodex handgrip, and BIA plus Jamar handgrip. The total-body percent coefficient of variation (%CV) for the BIA and DXA were 1.34 and 1.56 for fat mass (FM), respectively, and 0.42 and 0.72 for fat free mass (FFM), respectively. The %CV for the Jamar and Biodex handgrips were 6.3 and 16.7, respectively. Bland-Altman plots were used to characterize the limits of agreement between DXA and BIA for FM (4.60 +/- 7.80 (-3.19 to 12.39) kg) and FFM (-1.87 +/- 7.16 (-9.03 to 5.29) kg). Both DXA and BIA demonstrate good short-term precision in ACPs. However, given its poor accuracy, it remains to be determined if BIA can be used to monitor ACPs for changes in total-body tissue composition as a function of time, whether for observation or response to treatment. Furthermore, because of wide limits of agreement, the DXA and BIA cannot be used interchangeably in research or clinical settings. The Jamar handgrip dynamometer shows more consistency than the Biodex handgrip attachment in ACPs, and should therefore be the preferred measure of changes in strength over time.

Lymphangiomatosis is a rare and fatal congenital lymphatic malformation. Because the natural course of the disease affects multiple body systems, the management can be challenging. This article presents a novel approach to the treatment of diffuse lymphangiomatosis using sirolimus. The reported case involves a 4-month-old male with a known lymphatic malformation who presented to the emergency department with respiratory difficulties. Sirolimus was successful at significantly reducing our patient's mass at a relatively low target level of 5 to 10 μg/L. The use of sirolimus for the treatment of lymphangiomatosis should be studied further in the setting of a formal trial.

Symptomatic intestinal strictures develop in more than one third of patients with Crohn’s disease (CD) within 10 years of disease onset. Strictures can be inflammatory, fibrotic or mixed and result in a significant decline in quality of life, frequently requiring surgery for palliation of symptoms. Patients under the age of 40 with perianal disease are more likely to suffer from disabling ileocolonic disease thus may have a greater risk for fibrostenotic strictures. Treatment options for fibrostenotic strictures are limited to endoscopic and surgical therapy. Endoscopic balloon dilatation (EBD) appears to be a safe, less invasive and effective alternative modality to replace or defer surgery. Serious complications are rare and occur in less than 3% of procedures. For non-complex strictures without adjacent fistulizaation or perforation that are less than 5 cm in length, EBD should be considered as first-line therapy. The aim of this review is to present the current literature on the endoscopic management of small bowel and colonic strictures in CD, which includes balloon dilatation, adjuvant techniques of intralesional injection of steroids and anti-tumor necrosis factor, and metal stent insertion. Short and long-term outcomes, complications and safety of EBD will be discussed.

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There are opportunities to optimize quality of care among hospitalized patients with IBD.

The past decade has brought substantial advances in the management of inflammatory bowel diseases (IBD). The introduction of tumor necrosis factor (TNF) antagonists, evidence for the value of combination therapy, the recognition of targeting lymphocyte trafficking and activation as a viable treatment, and the need for early treatment of high-risk patients are all fundamental concepts for current modern IBD treatment algorithms. In this article, authors review the existing data on approved biologicals and small molecules as well as provide insight on the current positioning of approved therapies. Patient stratification for the selection of specific therapies, therapeutic targets and patient monitoring will be discussed as well. The therapeutic armamentarium for IBD is expanding as novel and more targeted therapies become available. In the absence of comparative trials, positioning these agents is becoming difficult. Emerging concepts for the future will include an emphasis on the development of algorithms which will facilitate a greater understanding of the positioning of novel biological drugs and small molecules in order to best tailor therapy to the patient. In the interim, anti-TNF therapy remains an important component of IBD therapy with the most real-life evidence and should be considered as first-line therapy in patients with complicated Crohn’s disease and in acute-severe ulcerative colitis. The safety and efficacy of these ‘older’ anti-TNF therapies can be optimized by adhering to therapeutic algorithms which combine clinical and objective markers of disease severity and response to therapy.

Background Patients with Crohn’s disease [CD] and ulcerative colitis [UC] are at increased risk for colorectal dysplasia [CRD] and colorectal cancer [CRC]. Adherence to CRC surveillance guidelines is reportedly low internationally. Aim To evaluate surveillance practices at the tertiary IBD Center of the McGill University Health Center [MUHC] and to determine CRD/CRC incidence. Methods A representative inflammatory bowel disease cohort with at least 8 years of disease duration [or with primary sclerosing cholangitis] who visited the MUHC between July 1 and December 31, 2016 were included. Adherence to surveillance guidelines was compared to modified 2010 British Society of Gastroenterology guidelines. Incidence rates of CRC, high-grade dysplasia [HGD], low-grade dysplasia [LGD] and colorectal adenomas [CRA] were calculated based on pathology. Results In total, 1356 CD and UC patients (disease duration: 12 [interquartile range: 6–22) and 10 [interquartile range: 5–19] years) were identified. The surveillance cohort consisted of 680 patients [296 UC and 384 CD]. Adherence to surveillance guidelines was 76/82% in UC/colonic CD. An adequate number of biopsies were taken in 54/54% of UC/colonic CD patients. The incidence of CRC/HGD in UC and CD with colonic involvement was 19.5/58.5 and 25.1/37.6 per 100,000 patient-years, respectively. The incidence of dysplasia before 8 years of disease duration was low in both UC/CD [19.5 and 12.5/100,000 patient-years] with no CRC detected. The CRA rate was 30/38% in UC/colonic CD. Conclusion High adherence to surveillance guidelines and low CRC and dysplasia, but not CRA rates were found, suggesting that adhering to updated, stratified, surveillance recommendations may result in low advanced neoplasia rates. The incidence of dysplasia before the start of surveillance was low.