Ulcerative colitis and Crohn’s disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn’s and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn’s disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn’s disease, including patients, their families and friends.

https://gut.bmj.com/content/gutjnl/68/Suppl_3/s1.full.pdf

British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults

/pdf/second-european-evidence-based-consensus-on-the-diagnosis-hg0loy9hft.pdf

Second European evidence-based consensus on the diagnosis and management of ulcerative colitis Part 2: Current management

Endometriosis

ACG Clinical Guideline: Ulcerative Colitis in Adults

Objective The aim of this study was to assess the efficacy and safety of adalimumab (ADA), a recombinant human monoclonal antibody against tumour necrosis factor a (TNF), for the induction of clinical remission in anti-TNF nao¨ve patients with moderately to severely active ulcerative colitis. Methods This 8-week, multicentre, randomised, doubleblind, placebo-controlled study (NCT00385736), conducted at 94 centres in North America and Europe, enrolled ambulatory adult patients with Mayo score of $6 points and endoscopic subscore of $2 points despite treatment with corticosteroids and/or immunosuppressants. Under the original study protocol, 186 patients were randomised (1:1) to subcutaneous treatment with ADA160/80 (160 mg at week 0, 80 mg at week 2, 40 mg at weeks 4 and 6) or placebo. Subsequently, at the request of European regulatory authorities, the protocol was amended to include a second induction group (ADA80/40: 80 mg at week 0, 40 mg at weeks 2, 4 and 6). The primary efficacy endpoint was clinical remission (Mayo score #2 with no individual subscore >1) at week 8, assessed in 390 patients randomised (1:1:1) to ADA160/80, ADA80/40, or placebo. Safety was assessed in all enrolled patients. Patients, study site personnel, investigators, and the sponsor were blinded to treatment assignment. Results At week 8, 18.5% of patients in the ADA160/80 group (p¼0.031 vs placebo) and 10.0% in the ADA80/40 group (p¼0.833 vs placebo) were in remission, compared with 9.2% in the placebo group. Serious adverse events occurred in 7.6%, 3.8% and 4.0% of patients in the placebo, ADA80/40, and ADA160/80 groups, respectively. There were two malignancies in the placebo group, none in the ADA groups. There were no cases of tuberculosis and no deaths. Conclusions ADA160/80 was safe and effective for induction of clinical remission in patients with moderately to severely active ulcerative colitis failing treatment with corticosteroids and/or immunosuppressants. Clinical trial NCT00385736.

/pdf/adalimumab-for-induction-of-clinical-remission-in-moderately-2oek2adx4o.pdf

Adalimumab for induction of clinical remission in moderately to severely active ulcerative colitis: results of a randomised controlled trial

Clinical trials evaluating the protective effect of nonsteroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) have yielded inconclusive results. Our objective was to conduct a meta-analysis of the data to date to evaluate the efficacy and safety of rectal NSAIDs for PEP prophylaxis. We did a systematic search of PubMed/MEDLINE, Embase, and Web of Science databases and the Cochrane Central Register of Controlled Trials. The meta-analysis was performed using a fixed-effect method because of the absence of significant heterogeneity in the included trials. Seven randomized, controlled trials involving 2133 patients were included. The meta-analysis showed that rectal NSAIDs decreased the overall incidence of PEP (risk ratio, 0.44; 95% confidence interval, 0.34-0.57; P < 0.01). The number needed to treat was 11. The NSAID prophylaxis also decreased the incidence of moderate to severe PEP (risk ratio, 0.37; 95% confidence interval, 0.27-0.63; P < 0.01). The number needed to treat was 34. No differences of the adverse events attributable to NSAIDs were observed. In conclusion, prophylactic use of rectal NSAIDs reduces the incidence and severity of PEP. There is neither a difference in efficacy between rectal indomethacin and diclofenac nor a difference in efficacy between the timing of administration of rectal NSAIDs, that is, immediate pre-ERCP and post-ERCP.

A meta-analysis on the role of rectal diclofenac and indomethacin in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis.

Background Cyclosporine (CSA) is effective in the short-term for severe, steroid refractory ulcerative colitis; but its use has been limited by concerns about safety and colectomy-sparing rates. The aim of this study was to assess the long-term colectomy-sparing effects and safety of CSA in patients hospitalized for ulcerative colitis. Methods Review of the patients who underwent intravenous CSA for ulcerative colitis between 1989 and 2003. Results A total of 71 patients with severe ulcerative colitis were treated with IV CSA. The median length of follow-up was 1.5 years (mean=3 y) (range 1 mo to 14 y) (IQR 0.6 to 4.6). Eighty-five percent (60/71) of patients responded to IV CSA and were discharged on oral CSA. Of these 60 patients, 26 were transitioned from CSA to 6MP. Of the 26 patients who were transitioned from CSA to 6MP, only 1 patient (4%) ultimately required colectomy; whereas colectomy was carried out in 76% (26/34) of the patients who were not transitioned from CSA to 6MP. Only concomitant 6MP therapy was associated with a reduced risk of colectomy (OR 0.01, 95% CI 0.001, 0.09, P Conclusion CSA is an effective therapy for severe ulcerative colitis. Long-term efficacy is improved with transition to 6MP. Adverse events with CSA are frequent, but most are mild.

Cyclosporine is Safe and Effective in Patients With Severe Ulcerative Colitis

Ulcerative colitis (UC) is a disease of unknown etiology characterized by inflammation of the mucosa and occasionally the submucosa of the colon. Conventional drug therapy for UC involves use of aminosalicylates, corticosteroids, azathioprine/6-mercaptopurine, cyclosporine and anti-tumor necrosis factor therapy. Alternative therapies include probiotics, nicotine and fish oil. Drugs like tacrolimus, rosiglitazone and Trichuris suis ova are being evaluated for use in UC patients. With the new biologic agents, new treatment options for UC continue to evolve. In this article we will discuss the conventional drugs, the alternative therapies and the management strategies according to the severity and extent of UC.

https://journals.sagepub.com/doi/pdf/10.1177/1756283X09102329

Review: Ulcerative colitis: current treatment strategies and future prospects:

Background and study aim: Cannulation of the native papilla in surgically altered anatomy is difficult in endoscopic retrograde cholangiography (ERC). There are limited data regarding the success of single-balloon enteroscopy-assisted ERC (SBE-ERC) in patients with a native papilla and Roux-en-Y gastric bypass. Use of a plastic cap may assist cannulation in these cases. The aim of the current study was to investigate the use of SBE-ERC with a cap (Cap-SBE-ERC) in patients with surgically altered anatomy referred for ERC. Patients and methods: Patients with surgically altered anatomy (hepaticojejunostomy, gastric bypass surgery, and Whipple’s surgery) who underwent Cap-SBE-ERC were identified from a prospectively maintained database. Outcomes were diagnostic and procedural success. Patients with a native papilla were compared with those with a biliary-enteric anastomosis. Results: Among 56 patients with surgically altered anatomy, high rates of diagnostic and procedural success were observed (78.6 % and 71.4 %, respectively). High diagnostic and procedural success rates of 72.7 % and 65.9 %, respectively, were also observed for patients with Roux-en-Y gastric bypass anatomy with a native papilla (n = 44). Conclusion: High rates of diagnostic and procedural success were reported for SBE-ERC with the use of a cap, including a large subgroup of patients with Roux-en-Y gastric bypass and a native papilla.

Use of a cap in single-balloon enteroscopy-assisted endoscopic retrograde cholangiography.

Purpose The placebo response rate in randomized controlled trials (RCTs) in ulcerative colitis (UC) varies from 0 to 76% The aims of this study were to quantify the pooled placebo response rate and identify the factors affecting it Methods We performed a meta-analysis of 110 RCTs carried out between 1955 and 2005 and published in English Regression analysis was used to identify factors significantly modifying placebo response Results The pooled placebo remission rate was 23% (95%CI: 184–28%) and the pooled placebo improvement rate was 321% (95%CI: 281–363%) Multivariate analysis showed that the country where the study was performed (P = 0025 for placebo remission and P = 00083 for placebo response rates) significantly influenced the placebo remission and response rates Conclusion Placebo remission and response rates in RCTs of UC are highly variable and are significantly influenced by the country in which the RCT is performed

Meta-Analysis of the Placebo Response in Ulcerative Colitis

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