Background A clinical decision support tool (CDST) has been developed and validated for predicting outcomes of vedolizumab (VDZ) therapy for patients with Crohn’s disease (CD) and ulcerative colitis (UC), respectively. We aimed to validate each CDST for predicting outcomes and need for drug optimisation in patients with inflammatory bowel disease (IBD). Methods We retrospectively analysed 166 patients with IBD (71 with CD, and 95 with UC) treated with VDZ from January 2017 through November 2021 at 6 tertiary referral centres in Korea. We assessed clinical remission (CREM) and response (CRES), corticosteroid-free clinical remission (CfCREM) and response (CfCRES), biochemical response (BioRES), endoscopic healing (EH), and need for drug optimisation by CDST-defined response groups (low vs. intermediate to high probability group with a cut-off of 13 points in CD, Table 1A, and 26 points in UC, Table 2A, respectively). CDST was evaluated by area under the receiver operating characteristics curve (AUC) and test performance. Results Patients were classified as low (27 with CD, and 28 with UC) and intermediate to high probability group (44 with CD, and 67 with UC). Among CD patients, there showed no significant difference in the response rate of any outcomes between CDST-defined groups. Among UC patients, the rates of CREM (41.0 vs. 18.5%, p=0.040) and EH (56.5 vs. 33.3%, p=0.045) at week 14 were higher among intermediate to high probability group. The rate of drug optimisation during maintenance therapy was also higher in low probability group (54.2 vs. 30.2%, p=0.038). At week 26, CDST for CD discriminated CfCREM with an AUC of 0.656 (sensitivity 87.5%, specificity 43.8%) (Table 1B). Meanwhile, CDST for UC identified CREM with an AUC of 0.606 (sensitivity 83.3%, specificity 37.9%) at week 14 (Table 2B). BioRES of FC was identified with an AUC of 0.649 (sensitivity 84.6%, specificity 45.2%) at week 26. BioRES of CRP was identified with an AUC of 0.660 (sensitivity 68.8%, specificity 63.2%) at week 26, and with an AUC of 0.642 (sensitivity 70.0%, specificity 58.3%) at week 54. Drug optimisation during maintenance therapy was identified with an AUC of 0.620 (sensitivity 54.2%, specificity 69.8%). Conclusion Both CDST for CD and UC can be used to help guide VDZ therapy for Korean patients to predict BioRES with a fair discriminant function and moderate sensitivity.
Hepatobiliary and Pancreatic: Hepatic portal vein gas accompanied by acute enterocolitis improved with non-surgical treatment A 72-year-old woman presented with 3-day history of abdominal pain, watery diarrhea, hematochezia, and fever. This patient had history of hypertension, diabetes mellitus, and chronic hepatitis B. Vitals at presentation were pulse rate 88/min, blood pressure 130/80 mmHg, respiratory rate 18/min, temperature 38.1°C. Physical examination revealed grossly distended abdomen with mild tenderness on right lower quadrant but without rebound tenderness or rigidity. Bowel sounds were sluggish. Laboratory data revealed an elevated white blood cell count (24 520/uL) and C-reactive protein level (19.448 mg/dL), but liver function, kidney function, anion gap, and lactate were within normal limit. Abdominal X-ray showed diffuse distended small bowel without remarkable evidence of obstruction ( Fig. 1a). Abdominal computed tomography (CT) revealed multiple tubular tree-like branching lucencies in bilateral hepatic lobes regarded as hepatic portal venous gas (HPVG) and inflammatory change in distal ileum and cecum base (Fig. 1b,c). Colonoscopy showed changes of moderate colitis at the rectosigmoid colon. Supportive care with intravenous piperacillin/ tazobactam (4.5 g q 8 h) and nutritional support were given. On the fifth day, fever subsided, and bowel sound returned. Oral intake was permitted on the ninth day. On the 14th day, repeat colonoscopy showed whitish exudate and edematous mucosa on cecum and terminal ileum ( Fig. 1d) and normal mucosa on descending colon. Patient's condition improved gradually with conservative management and discharged on 17th day with advice for regular follow-up. On the 48th day at outpatient, abdominal CT revealed loss of HPVG and improving enterocolitis (Fig. 2).Hepatic portal venous gas was first reported in 1955 in patient with neonatal necrotizing enterocolitis. HPVG was regarded as a sign of mesenteric ischemia or bowel necrosis that requires emergent operation. A wide use of abdominal CT enabled to detect HPVG at the early stage: characteristic finding of branching radiolucency extending to liver periphery, within 2 cm beneath the liver capsule. Recently, HPVG has been recognized to be associated with not only ischemic but also non-ischemic causes, such as bowel ileus, intra-abdominal infection, peptic ulcer, and iatrogenic events, after intra-abdominal operation or procedure. In our case, the cause of HPVG is presumed to be originated from enterocolitis on terminal ileum to cecum. The inflammation of bowel lesion might lead to ileus and intestinal distention with mucosal damage and migration of gas into portal venous circulation. In summary, the presence of HPVG itself is not an indicator of poor prognosis so that finding the pathophysiology of HPVG and consideration of patient's overall clinical, radiological, and laboratory findings are utmost important for decision-making for optimal treatment. Figure 1 Abdominal X-ray revealed diffuse distended small bowel withou...
Background Tofacitinib is a small molecule which inhibits janus kinase and has been shown to be effective for patients with active ulcerative colitis (UC). We investigated the real-life therapeutic effectiveness and safety of tofacitinib treatment for Korean patient with UC. Methods We retrospectively analyzed the data of patients with UC who received tofacitinib treatment at 10 hospitals in Korea. The primary outcome was clinical remission at week 16 which was defined as a partial Mayo score ≤2 with a combined rectal bleeding subscore and stool frequency subscore ≤1. The secondary outcome was endoscopic remission (Mayo endoscopic subscore ≤1) at week 16. Adverse events including herpes zoster and deep vein thrombosis were also evaluated. Results Between January 2018 and November 2020, a total of 123 patients with UC received tofacitinib treatment (Table 1). Clinical effectiveness was evaluated for those who had completed or stopped the tofacitinib therapy by week 16, week 24 and week 52, respectively (Figure 1). Clinical remission and response rates at week 16 were 65.3% and 73.7%, respectively (Figure 2A). Ninety-one out of 123 patients (74.0%) were followed up to week 52. Their clinical remission and response rates at week 52 were 49.5% and 58.2%, respectively (Figure 2A). Among 117 patients with baseline Mayo endoscopic subscore ≥2, endoscopic remission rate at week 16 was 55.6% (Figure 2C). Any adverse events occurred in 15 patients (12.2%) and serious adverse events occurred in 9 patients (7.3%). Herpes zoster occurred in 4 patients (3.3%) and one patient (0.8%) suffered from deep vein thrombosis (Table 2). Conclusion Tofacitinib was effective with an acceptable safety profile for Korean patients with UC in the real world.
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