Ileal Stricture Research Articles

Incidental small bowel malignancy in a chronic ileal stricture in a patient with Crohn's disease: an interesting case.

Incidental small bowel malignancy in a chronic ileal stricture in a patient with Crohn's disease: an interesting case.

In-utero segmental volvulus around vitellointestinal duct remnants leading to ileal atresia and stenosis: A case series

Background: The etiology of intestinal atresia is multifactorial with vascular accidents being the most common event in its development. In-utero volvulus is a well-known type of vascular accident leading to intestinal atresia. Segmental volvulus around vitellointestinal duct remnants is rarely described vascular accident leading to ileal atresia. Case Series: We report two cases of segmental ileal volvulus around vitellointestinal duct remnants in neonates leading to ileal atresia in one case and intestinal stenosis in the other one. Both neonates presented with signs of neonatal intestinal obstruction. X-ray abdomen performed in both neonates showed air-fluid levels. Both neonates were operated with suspicion of intestinal atresia. At surgery, a segment of the small bowel was found twisted around vitellointestinal duct remnants in both cases. The first case also had intestinal atresia whereas the second one had intestinal stenosis secondary to the segmental volvulus. Conclusion: Segmental volvulus around vitellointestinal duct remnants can also cause ileal atresia or stenosis.

Development of a uniform, very aggressive disease phenotype in all homozygous carriers of the NOD2 mutation p.Leu1007fsX1008 with Crohn's disease and active smoking status resulting in ileal stenosis requiring surgery.

BackgroundNOD2 variants are the strongest genetic predictors for susceptibility to Crohn’s disease (CD). However, the clinical value of NOD2 on an individual patient level remains controversial. We aimed to define the predictive power of the major NOD2 mutations regarding complicated CD in a large single center cohort.Methods1076 CD patients were prospectively genotyped for the three common CD-associated NOD2 mutations rs2066844, rs2066845, and rs2066847, followed by detailed genotype-phenotype analyses.ResultsOverall, 434 CD patients (40.3%) carried at least one of the three main NOD2 mutations. A significantly higher minor allele frequency (15.6%) of the NOD2 frameshift mutation p.Leu1007fsX1008 (rs2066847) was seen in patients with aggressive disease compared to 8.2% in patients with mild disease (p = 2.6 x 10−5). Moreover, a total of 54 CD patients (5.0%) were homozygous for this NOD2 frameshift mutation. 100% of these patients had ileal disease compared to 82% of NOD2 wild-type carriers (p<0.0001). In homozygous carriers of the NOD2 frameshift mutation, 87% presented with ileal stenosis, 68.5% had fistulas, and 72.2% required CD-related surgery despite immunosuppressive therapy in 87% of these patients. All homozygous carriers of the 1007fs mutation who were active smokers had ileal stenosis and required CD-related surgery.ConclusionHomozygosity for Leu1007fsX1008 is an excellent biomarker for predicting complicated CD on an individual patient level. Active smoking and homozygosity for this mutation is associated with a 100% risk for developing ileal stenosis requiring CD-related surgery. In these patients, smoking cessation and early initiation of immunosuppressive strategies may be beneficial.

Small bowel obstruction caused by primary adenocarcinoma arising from an ileal tubular type foregut duplication cyst

Small bowel obstruction is a surgical emergency commonly caused by adhesions, hernia, intussusception and volvulus. Less often, it can be caused by neoplasms. Small intestine adenocarcinoma is an uncommon malignancy, while its occurrence from foregut duplication cyst is extremely rare. Herein we reported a case of complete small bowel obstruction caused by ileal adenocarcinoma arising from a tubular-type foregut duplication cyst. A 49-year-old man with history of inguinal hernia presented with vomiting, abdominal pain and distention, and constipation for 3 days. Abdominal computed tomography (CT) scan showed high-grade distal small bowel obstruction with a transition point in the terminal ileum near the ileocecal valve. Emergency exploratory laparotomy revealed a 4 × 5 cm circumferential mass at the terminal ileum. Right hemicolectomy was performed. Gross examination demonstrated a 2.5 cm long circumferential ileal stricture. Histologically, the stricture contained moderately to poorly differentiated invasive adenocarcinoma arising from ectopic foregut duplication cysts lined by mixed cuboidal and ciliated respiratory epithelial cells with focal low- and high-grade dysplasia. Peritoneal implants developed four months post surgery despite post-operative chemotherapy. Foregut duplication cyst and its derivative neoplasm should be taken into consideration in encountering adult patients with small bowel obstruction.

Role of Computed Tomography Scan in the Assessment of Subacute Intestinal Obstruction at Bhuj, Kutch: A Prospective Study

Background: Bowel obstruction occurs when the normal flow of intraluminal contents is interrupted. Obstruction can be functional or due to a mechanical obstruction. Now a day’s CT is considered to be the most efficacious imaging technique for determining the cause of intestinal obstruction. However, the indications for the use of CT in patients with Sub-Acute Intestinal Obstruction (SAIO) have not been fully defined. Objectives of the present study are to study the role of CT in Diagnosis of patients with suspected subacute intestinal obstruction (SAIO), to find out site &amp; cause of obstruction and to diagnose complications of obstruction. Subjects and Methods: This study was conducted at Department of Radiodiagnosis, Gujarat Adani institute of Medcial Science, Bhuj, Kutch, Gujarat. Total number of 22 patients with SAIO having equivocal findings on USG was included in this study. Detailed clinical evaluation of the patients was done. Plain x-ray of abdomen in erect posture &amp; abdominopelvic ultrasound were performed before CT scan. CT scans were performed on a GE lightspeed VCT 64 slice scanner and acquired in precontrast &amp; portovenous phase at 60sec after i.v. contrast administration. Results: Age of the patients in the study range between 14 to 76 years. Out of 22 were 12 male &amp; 10 female patients. On CT scan all 22 patients were found to have obstruction with 19 patients having mechanical obstruction &amp; 3 patients having pseudo obstruction secondary to appendicitis, jejunal perforation. Most common cause of SAIO was ileal stricture 38% followed by intussusceptions 23%. Conclusion: CT is not only useful in distinguishing mechanical obstruction from paralytic ileus but also it often establishes the cause of obstruction &amp; presence of complications like strangulation &amp; perforation.

Therapeutic resolution of focal, predominantly anastomotic Crohn’s disease strictures using removable stents: outcomes from a single-center case series in the United Kingdom

Intestinal and anastomotic strictures in Crohn's disease (CD) produce considerable morbidity. The development of surgery-sparing, endoscopic modalities for stricture resolution is essential. Removable stent therapy is emerging as an efficacious and safe means of stricture resolution. We present outcomes from the largest, single-center series of patients with CD undergoing removable self-expanding metal stent (SEMS) therapy to resolve focal intestinal strictures. Patients with symptomatic CD were assessed with magnetic resonance enterography. Short (≤6 cm), fibrostenotic strictures of the terminal ileum or ileocolonic anastomoses were considered by a multidisciplinary team and put forward for stent therapy. Strictures were examined endoscopically and impassable strictures were treated with SEMSs. The Hanaro HRC-20-080-230 partially covered SEMS was used for all patients. Endoscopically inaccessible or inflammatory strictures were excluded. Stent retrieval was scheduled for 7 days after insertion. Therapeutic benefit was assessed with validated inflammatory bowel disease scoring tools. Twenty-one patients underwent 23 stent episodes, with 2 patients requiring repeat therapy in the follow-up period. Most treated strictures were anastomotic (19 of 21); 2 of 21 were de novo. Of those patients attending follow-up, 81% (13 of 16) reported symptom improvement or resolution; 88% (14 of 16) were in clinical remission at follow-up. Across all stent episodes, only 5 adverse events were noted (2 episodes of stent-related discomfort, 3 asymptomatic stent migrations). There were no direct stent-related adverse events such as perforation, impaction, or bleeding. No patient has required stricture-related surgery in the follow-up period (range, 3-50 months). In this series, removable SEMS therapy for ileal and anastomotic strictures was found to be clinically efficacious. The absence of perforation events and need for stricture-related surgery are noteworthy. These results suggest that the efficacy of stent therapy in this context merits powered, head-to-head investigation with other modalities for stricture resolution.

P084 DEEP REMISSION WITH DOUBLE BIOLOGIC THERAPY: A SUCCESSFUL CASE OF COMBINATION USTEKINUMAB AND VEDOLIZUMAB FOR SEVERE REFRACTORY CROHN’S DISEASE

Abstract Background Stricturing Crohn’s disease (CD) constitutes a severe phenotype often associated with a high degree of morbidity (3). Surgical resection is first-line therapy for symptomatic strictures, but most patients relapse without subsequent medical therapy (4–5). Biologics are the mainstay for inducing and maintaining remission, but some cases are refractory despite maximum dosage of therapy. Reports of dual biological therapy (DBT) in refractory, stricturing CD are sparse, and prior case reports document only clinical remission (1). To contribute further knowledge regarding the use of DBT in stricturing CD, we present the case of a refractory CD patient who achieved deep remission with ustekinumab and vedolizumab. Case Presentation A 35 year old non-smoking, Caucasian male was referred to our clinic in 2014 for refractory CD complicated by multiple strictures. Prior to establishing care with us, he received two jejunal resections and a sigmoid resection. Previously failed therapies included azathioprine with infliximab, adalimumab, and certolizumab. He continued to progress under our care despite combination methotrexate/certolizumab, as well as methotrexate/golimumab. He underwent proctocolectomy with end ileostomy in 2015 and initiated vedolizumab q8weeks post-operatively. He reoccurred in 2018, when he presented with an ulcerated ileal stricture. He was switched from vedolizumab to ustekinumab q8weeks and placed on prednisone, but continued to progress, developing significant hematochezia requiring hospitalization and blood transfusions. Ileoscopy performed during hospital admission confirmed severe, ulcerating disease in the ileum with stricture. Ustekinumab dosing was increased to q4weeks, azathioprine was initiated, and he underwent stricturoplasty. Follow-up ileoscopy three months later revealed two ulcers in the neo- TI (Figure 1). Vedolizumab q8weeks was initiated in addition to ustekinumab q4weeks and azathioprine 125mg. After four months on this regimen the patient felt better, but follow-up ileoscopy showed two persistent ulcers in the neo-TI. Vedolizumab dosing interval was increased to q4weeks. After four months, subsequent ileoscopy demonstrated normal neo-TI (Figure 2). Histologic evaluation of biopsies confirmed deep remission of crohn’s disease. No adverse side effects have occurred with maximum doses of both ustekinumab and vedolizumab combination therapy. Discussion This case supports both the safety and efficacy of ustekinumab and vedolizumab dual biologic therapy for treatment of severe, refractory Crohn’s disease. While there are reports of DBT inducing clinical remission, this case supports efficacy for vedolizumab and ustekinumab combination therapy to induce deep histologic remission. Large practical clinical trials are needed to better investigate the safety and efficacy of DBT with vedolizumab and ustekinumab, but our case suggests this combination may be a safe and efficacious therapy for refractory CD patients.

Imaging Findings of Ileal Inflammation at Computed Tomography and Magnetic Resonance Enterography: What do They Mean When Ileoscopy and Biopsy are Negative?

Our goal was to determine the importance of ileal inflammation at computed tomography or magnetic resonance enterography in Crohn's disease patients with normal ileoscopy. Patients with negative ileoscopy and biopsy within 30 days of CT or MR enterography showing ileal inflammation were included. The severity [0-3 scale] and length of inflammation within the distal 20 cm of the terminal ileum were assessed on enterography. Subsequent medical records were reviewed for ensuing surgery, ulceration at ileoscopy, histological inflammation, or new or worsening ileal inflammation or stricture on enterography. Imaging findings were classified as: Confirmed Progression [subsequent surgery or radiological worsening, new ulcers at ileoscopy or positive histology]; Radiologic Response [decreased inflammation with medical therapy]; or Unlikely/Unconfirmed Inflammation. Of 1471 patients undergoing enterography and ileoscopy, 112 [8%] had imaging findings of inflammation with negative ileoscopy, and 88 [6%] had negative ileoscopy and ileal biopsy. Half [50%; 44/88] with negative biopsy had moderate/severe inflammation at enterography, with 45%, 32% and 11% having proximal small bowel inflammation, stricture or fistulas, respectively. Two-thirds with negative biopsy [67%; 59/88] had Confirmed Progression, with 68%, 70% and 61% having subsequent surgical resection, radiological worsening or ulcers at subsequent ileoscopy, respectively. Mean length and severity of ileal inflammation in these patients was 10 cm and 1.6. Thirteen [15%] patients had Radiologic Response, and 16 [18%] had Unlikely/Unconfirmed Inflammation. Crohn's disease patients with unequivocal imaging findings of ileal inflammation at enterography despite negative ileoscopy and biopsy are likely to have active inflammatory Crohn's disease. Disease detected by imaging may worsen over time or respond to medical therapy.

P169 Balloon enteroscopy in small bowel Crohn’s disease (CD) with suspected bleeding

Abstract Background Deep enteroscopy with Single Balloon Enteroscopy (SBE) has been used in the evaluation of small bowel diseases and could be performed by a single operator. The role and safety of SBE in suspected small bowel CD with bleeding remained uncertain. Our primary aim was to evaluate the role of SBE in the management of suspected small bowel Crohn’s Disease (CD) with bleeding. The secondary aim was to find out whether SBE could provide definitive diagnosis and therapeutic intervention. Methods Hospitalised patients with iron deficiency anaemia (IDA) and/or overt GI bleeding were studied. All had prior negative oesophagogastro-duodenoscopy (OGD) and colonoscopy followed by single operator SBE. The indications were IDA in 28 patients, overt GI bleeding in 18 patients and IDA with abdominal pain and/or weight loss in 6 patients. Twenty and six patients had CT scan and capsule endoscopy done respectively with normal or unconfirmed small bowel lesions. Results Fifty-two patients with suspected small bowel bleeding were studied with mean age of 51 (range 20 -84) years. Small bowel Crohn’s disease were diagnosed in 7 patients with jejunal and ileal involvement in 2 and 5 patients respectively. All patients had subsequent histopathology confirmation from biopsies taken during the procedures. In addition, SBE allowed the retrieval of a stuck capsule scope in a patient with proximal ileal stricture. Repeated balloon dilatation through SBE was done successfully in one patient with distal ileal stricture without complication. Conclusion Small bowel Crohn’s disease was found in 21% of our patients with suspected small bowel bleeding. SBE is the preferred method of small bowel evaluation after negative upper and lower GI evaluation in this selected patients. Definitive diagnosis and targeted biopsies confirmed the diagnosis of CD as compared with radiological imaging and capsule endoscopy. SBE also provided safe therapeutic intervention in those patients with small bowel stricture from CD through endoscopic dilatation.

P730 Effectiveness and safety of endoscopic balloon dilation of colorectal strictures in Crohn’s disease

Abstract Background Endoscopic balloon dilation (EBD) is widely used to manage Crohn’s disease (CD) ileal stricture. However, data of EBD on inflammatory bowel diseases (IBD) colorectal strictures are scarce. Methods We performed a retrospective study in 9 tertiary centres, including all consecutive IBD patients who underwent EBD for native or anastomotic colorectal stricture between 1999 and 2018. Outcomes were rate of technical success defined by a passable stricture at the end of the EBD, clinical success defined by a passable and asymptomatic stricture and colonic resection at the end of follow-up. Factors associated with EBD success were also investigated by logistic regression. Results Fifty-seven patients (25 women, median age: 36 years, InterQuartile Range, 31–48) were included. All patients had CD and 42 (74%) had symptomatic stricture. Regarding the 60 strictures, 52 (87%) were native and the most frequent location was left colon (27%). 39 (65%) measured less than 5 cm, 57 (95%) were non-passable by the scope and 35 (58%) ulcerated. Among the 161 EBD performed (median number of dilatations per strictures: 1, IQR 1–3), technical success was observed in 123 (76%) EBD. One perforation occurred (0.6% per EDB and 2% per patient). After a median follow-up of 4.3 years [IQR 2.0–8.4], 24 patients (42%) underwent colonic resection, 9 (16%) had symptomatic strictures non-passable by the scope, 11 (19%) had asymptomatic non-passable strictures and 13 (23%) had asymptomatic strictures passable by the scope. One colon lymphoma and one colorectal cancer were diagnosed (3.5% of patients), respectively on endoscopic biopsies and at the time of surgery. None factor was associated with technical, clinical success, or surgery including therapeutic modification. Conclusion EBD of CD-associated colorectal strictures is feasible, efficient and safe as more than 50% of patients avoid surgery.

P833 Bacterial mucosa-associated microbiome in inflamed and proximal non-inflamed ileum of patients with Crohn’s disease

Abstract Background The microbiota most likely has an essential role in the pathogenesis of Crohn’s disease (CD). While faecal diversion after ileocecal resection (ICR) protects against CD recurrence, re-exposure triggers inflammation. After ICR, the majority of patients develop recurrence in the neoterminal ileum and the ileal microbiome is of particular interest. We have therefore assessed the mucosa-associated bacterial microbiome in the inflamed and non-inflamed ileum of patients with CD. Methods Patients with an established diagnosis of CD undergoing ileocolonoscopy and healthy controls (HC) referred for colonoscopy due to rectal bleeding or screening for disease, but without any detected gastrointestinal pathology were invited to participate. Exclusion criteria included use of antibiotic treatment for the past 2 months. Mucosal pinch biopsies were sampled 5 cm and 15 cm orally of the ileocecal valve or ileocolic anastomosis for comparisons within the same patients. The biopsies were analysed by 16S rRNA sequencing, α- and β-diversity was assessed by Shannon entropy and Bray-Curtis dissimilarity index respectively. Histologic inflammation was graded. Results Fifty-one CD patients, where of 32 with previous ICR, and 40 HC were included in the study. Of the 51 CD patients, 20 had terminal ileitis, with endoscopically inflamed mucosa at 5 cm and normal appearing mucosa at 15 cm and no history of upper GI disease involvement. Seven CD patients had ileal stenosis. CD patients (n = 51) had lower α-diversity and separated clearly from HC on β-diversity plots (Figure 1). Twenty-three bacterial taxa were differentially represented in CD patients and HC, among these Tyzzerella 4 was found to be profoundly overrepresented in CD (p = 4.1 × 10–68). When comparing the microbiome in the inflamed ileal mucosa with the proximal non-inflamed mucosa within CD patients (n = 20) neither α- or β-diversity differed (Figure 2). Furthermore, no bacterial taxa were differentially represented in the inflamed vs. proximally non-inflamed mucosa. CD patients operated with ICR had lower α-diversity (p = 0.021), but β-diversity did not differ from CD patients without ICR. CD patients with stenosis had lower abundances of Bacteroides, Sutterella and Akkermansia species. Conclusion 23 taxa were differentially expressed in CD compared with HC. The ileal mucosa-associated microbiome is similar assessed by both α- and β-diversity in the inflamed mucosa and the proximal non-inflamed mucosa within the same patients. Our results support the concept of CD specific microbiota alterations and demonstrate that neither ileal sub-location nor endoscopic inflammation itself influence the mucosa-associated microbiome.

P847 A pilot trial on the effect of a fibre-enriched nutritional supplement on the gut microbiota of stricturing Crohn’s disease patients

Abstract Background Diet is a potential factor that could influence the pathogenesis and activity of Inflammatory Bowel Disease(IBD). Soluble fibre is the best way to generate short-chain fatty acids such as butyrate, which has anti-inflammatory effects. Around 1/3 of Crohn’s disease (CD) patients will present with stricturing disease, most frequently in the terminal ileum. These patients often follow a very low-residue diet. CD patients present significant changes in the structure of their microbiota with a decreased prevalence of butyrate-producing bacteria such as Clostridiales species, particularly Faecalibacterium prausnitzii. Depletion of F. prausnitzii might be further enhanced in patients with a very low-residue diet. The aim of this study was to evaluate the effect of a nutritional supplement enriched with soluble fibre on the abundance of F. prausnitzii in stricturing CD. Methods We performed a single arm, pilot trial in CD patients with ileal stricturing disease who followed a very low-residue diet as assessed by a dietician. The fibre-enriched nutritional supplement (reg#26.06141/BA-72556) consisted of a 200ml vanilla-flavoured shake that included 3.4 gr of soluble fibre, omega-3 and oleic fatty acids. Patients received 2 supplements per day for 6 weeks, and were followed for 6 months. We obtained frozen faecal samples at time-points 0, 3, 6, 12 and 24 weeks. Total bacteria and F. prausnitzii counts were assessed by qPCR. Weight, BMI, CD activity index (CDAI), CRP, fatty acids, urine F2-isoprostanes and faecal calprotectin were also determined. Tolerance, palatability and acceptability of the supplement were assessed with validated questionnaires at weeks 3 and 6. Results Ten patients were included in the study with a median age of 38 [36–50] years, 60% were male, median BMI 25.2 [24.3–28.4] and 40% were current smokers. Six patients completed the 6 weeks of the supplement. Two patients did not receive the supplement because they underwent ileocecal resection, 1 patient was lost to follow-up and 1 patient dropped-out early because of poor palatability of the supplement. At baseline, all patients had F. prausnitzii levels below 109 CFU/g (median 2.02 × 106). Supplement intake did not significantly increase F. prausnitzii levels (p = 0.73) and had no effect on CDAI, CRP, urine F2-isoprostanes or faecal calprotectin. Most usual complaints associated with the supplement were abdominal bloating and flatulence. Conclusion CD patients with structuring disease and who follow a very low-residue diet have a markedly reduced abundance of F. prausnitzii. Intake of a 6.8 g/day fibre-enriched nutritional supplement was unable to significantly increase F. prausnitzii abundance in these patients. Fibre supplement was not associated with adverse events.

3153 Occult Adenocarcinomas in Crohn's Disease Related Strictures: A Case Series

INTRODUCTION: Small bowel tumors account for ∼2.3% of all gastrointestinal cancers. Strictures are frequent complications of Crohn's disease, but malignant ileal strictures are uncommon and their diagnosis is often challenging. CASE DESCRIPTION/METHODS: We retrospectively reviewed three cases of terminal ileum adenocarcinomas that developed in ileal strictures. In this case series, three patients with CD developed occult adenocarcinoma within an ileal stricture diagnosed only after surgery. In all of the patients, an underlying stricture was thought to have caused obstructive symptoms but there were no imaging or endoscopic findings suggestive of underlying malignancy. Subsequently, all patients underwent surgery and, unexpectedly, one patient was found to have a tumor within the ileal stricture intra-operatively and the remaining two were diagnosed post-operatively after histopathological examination. Though the findings of adenocarcinomas were unexpected, two of the three patients were over 60 years of age and had over 30 years of disease prior to their diagnosis. DISCUSSION: Conclusions: The diagnosis of adenocarcinomas arising within ileal strictures is uncommon and often challenging for clinicians. 2. Many cases are diagnosed only intra-operatively or post-operatively after histopathological examination in the absence of imaging studies or endoscopy that suggest the presence of underlying malignancy.

808 Clinical Course of Patients With Concomitant Eosinophilic Esophagitis and Inflammatory Bowel Disease

INTRODUCTION: An overlap between eosinophilic esophagitis (EoE) and inflammatory bowel disease (IBD), both immune-mediated diseases of the gastrointestinal tract, is gaining recognition. However, the natural history and clinical implications of concurrent EoE and IBD remain to be characterized. We describe an institutional experience of patients with concurrent EoE and IBD. METHODS: We conducted a retrospective single-center case series of patients with diagnoses of EoE and either Crohn’s disease (CD) or ulcerative colitis (UC) seen between 01/01/2008 and 12/01/2018. Clinical data were analyzed for demographics, diagnostic findings, medical treatments, and disease outcomes. RESULTS: In our cohort, the prevalence (per 100,000 patients) of EoE, CD, and UC was 58.9, 111.4, 159.5, respectively. We identified 7 patients with both IBD (4 CD, 3 UC) and EoE. All were Caucasian, with median age 52 (SD 15.9), and 86% male. Median age at diagnosis of IBD was 25.5 (SD 17.4), and EoE was 50 (SD 15.9). Diagnosis of IBD preceded EoE in 6/7 patients, by an average of 14.3 years (range, 2-30 years). At the time of EoE diagnosis, IBD therapies included no therapy (29%), mesalamine (29%), ustekinumab (14%), or adalimumab/6-mercaptopurine (14%). EoE was treated with proton-pump inhibitor (PPI) in 4 patients (43%), elimination diet in 2 (29%), and/or swallowed fluticasone in 1 (14%). EoE complications, identified at time of EoE diagnosis, included 2/7 (29%) requiring esophageal stricture dilation. No further EoE complications developed following EoE treatment. CD complications preceded diagnosis of EoE, with 2 patients with perianal fistula, one with both ileal stricture and perianal fistula. No UC-associated or additional CD complications were identified after EoE diagnosis. Co-existing immune-mediated conditions included allergic rhinitis (43%), primary sclerosing cholangitis (14%), and rheumatoid arthritis (14%). CONCLUSION: In our cohort, diagnosis of IBD preceded EoE diagnosis by more than one decade, with EoE median age at diagnosis occurring later in IBD than that reported in non-IBD patients. Majority of disease-related complications in either IBD or EoE appear unrelated to concomitant diagnosis or treatment. Further studies are needed to examine immune-mediated pathways resulting in these concomitant diagnoses

843 Crohn’s Strictures Open With Anti-Mycobacterial Antibiotic Therapy (AMAT): A Retrospective Review

INTRODUCTION: Approximately one third of patients with Crohn’s disease (CD) will develop strictures within 10 years of diagnosis, commonly in the terminal ileum and ileocecal valve (ICV). Strictures often lead to abdominal pain, obstruction and are a risk factor for developing internal fistulae and cancer. Current treatment involves endoscopic balloon dilatation or strictureplasty. However, this may result in postoperative complications or recurrence. Recent evidence suggests that Mycobacterium avium ssp paratuberculosis may be a causative agent of CD and anti-mycobacterial antibiotic therapy (AMAT) has been shown to induce remission significantly better than placebo. The effects of AMAT on strictures has not been reported. AIM: To report the outcomes of AMAT in patients with CD and an ileal stricture/s. METHODS: This is a single centre retrospective (January 1995-December 2018) case review of patients diagnosed with CD, who had ileal stricture on colonoscopy and were treated with AMAT which comprised a combination of clarithromycin, rifabutin, and clofazimine, some with added ethambutol, ciprofloxacin, metronidazole or tinidazole. Symptoms, colonoscopy reports, biochemistry and concurrent medications were reviewed and recorded at pre-treatment and 6, 12, 18 and &gt;24 months on treatment. RESULTS: Forty-three patients (24 male, 16-56 yrs) with an average age of 31 yrs, and 5 yrs (0-27 yrs) after diagnosis were included. At pre-treatment, 17 patients had stricturing of the ICV, 25 had stricturing of the ileum and one had stricturing in both the ileum and ICV. Of the patients who had follow up colonoscopy data (N = 32), after &gt;24 months of AMAT, 22/32 patients (69%) had complete resolution and 2/32 patients had partial resolution of their strictures. Interestingly, after resolution of stricture on AMAT one patient ceased treatment. At 36 month follow up post cessation of AMAT the patient’s ileocecal stricture had returned. Further treatment with AMAT resulted in resolution of the stricture. CONCLUSION: AMAT for CD is effective in opening Crohn’s strictures avoiding the need for repeated dilatations or surgery. These observations suggest that stricturing in CD may be mediated by mycobacterial infection, as reported in tuberculosis strictures. To our knowledge, CD strictures have not previously been reported to open using medical therapy. Further prospective documentation is required to better define this positive effect of AMAT, including rate of resolution.

Association of Crohn’s Disease with Aryl Hydrocarbon Receptor Gene Polymorphisms in Patients from Southeast China

ABSTRACTAims The aryl hydrocarbon receptor (AhR) plays a pivotal role in regulating the innate and the acquired immune systems. The present study aimed to investigate the association of Crohn’s disease (CD) with AhR polymorphisms in a cohort of patients from Southeast China.Methods An improved multiple ligase detection reaction technique was applied to examine the polymorphisms of rs2158041, rs2066853, and rs10249788 in 310 patients with CD and 573 controls.Results Compared to the controls, the variant allele (T) and genotype (CT+TT) of rs2158041 were less frequent in patients with CD (both p < 0.05). Similar conclusions were drawn from patients with ileal CD and with stricture CD as compared to the controls (all p < 0.0083). However, no significant differences were observed in allele and genotype frequencies of rs2066853 and rs10249788 between patients with CD and the controls (all p > 0.05). Although rs2158041 and rs10249788 were in complete linkage disequilibrium with rs2066853, respectively, only the frequency of haplotype (TG) formed by rs2158041 and rs2066853 was significantly lower in patients with CD than that in the controls (p < 0.05).Conclusions AhR (rs2158041) might be a susceptible locus for CD, especially for the two subtypes: ileal CD and stricture CD.

Role of CT scan in Diagnosis of Patients with Suspected Subacute Intestinal Obstruction

Background: Intestinal obstruction is defined as mechanical or functional obstruction of the intestines which prevents the normal passage of the products of digestion. Present study was performed to study the role of Computerized Tomography (CT) in Diagnosis of patients with suspected subacute intestinal obstruction (SAIO), to find out site & cause of obstruction and to diagnose complications of obstruction. Subjects and Methods: This study was conducted at Department of Radiodiagnosis, Gujarat Adani Institute of Medical Science, Bhuj, Kutch, Gujarat. Total number of 15 patients with SAIO having equivocal findings on USG was included in this study. All the statistical tests were performed in SPSS version 15 software. Results: Age of the patients in the study range between 14 to 70 years. Out of 15 were 8 male & 7 female patients. On CT scan all 15 patients were found to have obstruction with 12 patients having mechanical obstruction & 3 patients having pseudo obstruction secondary to appendicitis, jejunal perforation. CT scan correctly diagnosed intestinal obstruction with its cause in 14 out of 15 patients. Most common cause of SAIO was ileal stricture followed by intussusceptions. Conclusion: The findings of the study show that CT is a valuable diagnostic procedure in patients with subacute intestinal obstruction with high sensitivity. It is a problem-solving tool in equivocal cases.

Clinico-pathological profile and surgical management of tubercular small intestinal obstruction

Background: Small intestinal obstruction is one of the most common abdominal emergencies faced by surgery resident in emergency department. Diagnosis and management of tubercular intestinal obstruction is challenging as underlying pathology is usually obscure and disease is associated with significant morbidity and mortality. The aim of this study is to know the various clinical features; different types of treatment and prognosis of tubercular intestinal obstruction in adult patients in our setting. Our centre is the only tertiary care centre belongs to Kumauni region at present, most of our patient are from low socioeconomical strata of their region.Methods: Our study was a retrospective analytic study. Medical record of all patients who were operated between 2011 and 2016 for intestinal obstruction due to abdominal tuberculosis at Surgery Department of Dr. Sushila Tiwari Government Hospital attached to GMC Haldwani were retrospectively analysed. The patients who were above 14 years of age and operated for obstruction of small bowel and whose complete medical record was available, were included in the study.Results: There were total 59 patients operated during this time span, out of these, 19 were female and 40 were male. Patients from 3’rd decades (37.29%) of their life were most commonly affected. Abdomen pain was most common symptom found in all 59 patients. Ileal Stricture was most common gross finding. Resection anastomosis was done in 71.19%.Conclusions: Most of the cases of abdominal tuberculosis presents with non-specific clinical features, inconclusive laboratory and radiography findings.

Long Term Teduglutide for the Treatment of Crohnʼs Disease

Traditional therapies for inflammatory bowel disease are focused on altering inflammatory pathways. However, tedeglutide, an amino acid analog of glucagon-like peptide-2 (GLP2), has been shown to have enterogastrone properties, decreasing gastric motility and intestinal permeability while enhancing the intestinal epithelial barrier. We present the case of a 66 year old woman with a history of congestive heart failure (CHF) who was diagnosed with Crohn's disease (CD) after presenting with diarrhea. The patient was initially treated with Pentasa without any effect and later transitioned to adalimumab, which was stopped due to side effects. One year later, she presented to the emergency room with abdominal pain and vomiting and was found to have an ileal stricture. The patient underwent a side-to-side isoperistaltic stricturoplasty; however, post-operatively she continued to have watery diarrhea. She was subsequently started on teduglutide injections (0.265 mg) without any other CD therapies. After 3 months, she noted improvement in the consistency of her stools and less abdominal pain. A colonoscopy performed after 6 months of therapy showed no active inflammation in the colon or terminal ileum. Over the next 3 years, she continued to have improvement in her CD symptoms, with formed stools, improved appetite and weight gain. During this time, she had an episode of dark urine and a CHF exacerbation, which improved with reduction of the dose of the teduglutide. While the etiology of CD remains unclear, some clinicians believe that the disease is triggered by increased intestinal permeability. Tedeglutide, an analog of GLP2, has been shown to decrease intestinal permeability and stimulate epithelial cell proliferation. Although teduglutide is only approved for short bowel syndrome, a small number of case reports and a single randomized trial have been published evaluating its use in CD. In this trial, patients were treated with tedeglutide in addition to biologics. While roughly 40% of patients treated with tedeglutide had remission, this was not maintained at 20 weeks in one third of these patients1. In comparison to this study, our case report illustrates the use of of tedeglutide as monotherapy for CD with documented endoscopic remission and continued symptom control for over 3 years. With further studies, tedeglutide has the potential to be a novel, gut-specific therapy for patients with CD. 1. Buchman et al. IBD; June, 2010

Crohnʼs Disease Masquerading Ileal Signet Ring Cell Carcinoma: Case Report

Introduction: Signet ring cell carcinoma (SRCC) is a rare highly malignant adenocarcinoma that mainly originates in the stomach. Small bowel malignancies are rare, accounting for only 3% of all gastrointestinal tract neoplasms. We report a case of SRCC of the terminal ileum (TI) that was masqueraded by the presence of Crohn's disease (CD). Case Presentation: A 67-year-old man with a 49 year history of ileal CD, symptomatically controlled with Mesalamine, had recent changes in bowel habits. Endoscopy revealed normal-appearing colon and proximal ileal stricture at 10-15 cm from the Ileocecal valve. Six months later, computed tomography enterography demonstrated 2 long segments of ileal wall thickening and enhancement, suspicious of active disease. Over the next 4 months, he continued to have intermittent attacks of abdominal cramping, bloating, and borborygmus. He was treated with oral prednisone for suspected partial inflammatory small-bowel obstruction. Due to lack of improvement and weight loss, he underwent laparoscopic ileocecectomy with ileocolic anastomosis. Histopathological demonstrated 2.5 cm mucin-producing, moderate/poorly differentiated ileal adenocarcinoma with signet ring cell features as well as 6 cm tubulovillous adenoma in the setting of active stricturing CD. Unfortunately, the tumor was metastatic, and chemotherapy was initiated. Discussion: Adenocarcinomas represent 25-40% of small bowel neoplasms and may be associated with longstanding inflammation. It is extremely rare for SRCC to originate from the TI. It is likely that in our patient, SRCC arose, in part, because of longstanding inflammation due to CD. Routine screening for small bowel malignancies should be considered in patients with CD even with symptomatic remission. Aggressive medical therapy (i.e. biologics) to control subclinical inflammation may be warranted.