Terminal Ileal Resection Research Articles

The improvement of a refractory enterocutaneous fistula with colchicine in a patient with Crohn's disease who had an MEFV gene mutation.

Enterocutaneous fistulas (ECFs) occurring in the setting of Crohn's disease (CD) are difficult to cure with medical treatment alone and affects a patient's quality of life. A 39-year-old man was diagnosed with an ileocolitis-type CD in 2007. His inflammation was insufficiently controlled despite the administration of an anti-tumor necrosis factor-alpha antibody. Therefore, he underwent subtotal colectomy, terminal ileal resection, and ileostomy for multiple colon and anal stenoses in Dec 2015. The patient subsequently received ustekinumab; however, purulent discharge was observed from a postoperative scar around the umbilicus in July 2019. In July 2021, enteroscopy and magnetic resonance imaging (MRI) showed an ECF extending from the small intestine to the umbilicus. Upon referral to our hospital, laboratory data showed elevated C-reactive protein (CRP) and serum amyloid A (SAA). After receiving colchicine, his purulent discharge disappeared, and his CRP and SAA levels rapidly decreased. Enteroscopy and MRI performed 1year and 5months after the administration of colchicine revealed ECF closure. Genetic analysis revealed that the patient harbored an MEFV exon 1 (E84K) mutation.

The Effect of Colesevelam on the Microbiome in Postoperative Crohn's Disease.

While surgery plays a pivotal role in the management of ileal Crohn's disease, the risk of endoscopic recurrence following an ileocaecal resection can be greater than 65% within 12 months of surgery. More than 90% of patients with Crohn's disease have a concomitant diagnosis of bile acid diarrhea following an ileal resection. This pilot study aimed to assess whether the use of bile acid sequestrants in patients with Crohn's disease who have undergone a primary terminal ileal resection with concomitant bile acid diarrhea can alter the microbiome and prevent disease recurrence. Patients with Crohn's disease who underwent a primary terminal ileal resection and had symptoms of diarrhea within 1-3 months of surgery underwent 75SeHCAT testing for bile acid diarrhea. If positive (75SeHCAT ≤ 15%), patients were treated with colesevelam and stool samples were collected at 4 weeks, 8 weeks, and 6-12 months posttreatment. If negative (75SeHCAT > 15%), treatment was not given and were reviewed in the clinic as per local guidelines. All patients underwent a 6-12 month postoperative colonoscopy where further stool samples and mucosal biopsies were taken. Disease activity was established using the endoscopic Rutgeert's score, with disease remission defined as Rutgeert's score <i2 and disease recurrence ≥i2. 16S ribosomal RNA gene analysis was undertaken for the collected fecal and mucosal samples to assess α/β-diversity and microbial composition. A total of 14 patients who completed the study, 10 of whom had a 75SeHCAT positive diagnosis of bile acid diarrhea and were started on treatment with colesevelam. Four patients did not require treatment as 3 were asymptomatic and 1 had a negative 75SeHCAT scan. Three of the fourteen patients had disease recurrence at their 6-12 month postoperative colonoscopy assessment, of which 1 patient was taking colesevelam and 2 patients were not taking colesevelam. A total of 44 fecal samples and 44 mucosal biopsies underwent 16S ribosomal RNA gene analysis to assess α/β-diversity and microbial composition. In the colesevelam treated patients there was no significant difference in α/β-diversity pre- and posttreatment. Pretreatment, the 3 most abundant bacterial classes in all patients were Bacteroidia, Clostridia, and Gammaproteobacteria. Following 6-12 months of treatment, out of the 9 patients on colesevelam, 5/9 (55.6%) had a reduction in Bacteroidia, 9/9 (100%) had an increase in Clostridia, and 7/9 (77.8%) had a reduction in Gammaproteobacteria. Of the 2 patients not given colesevelam, one showed a reduction in Bacteroidia, increase in Clostridia and a reduction in Gammaproteobacteria. This small pilot study demonstrated that patients who were given colesevelam, were more likely to be in disease remission at their 6-12 months colonoscopy review compared with those not treated. Furthermore, treatment with colesevelam may have a role in altering the microbiome to help maintain remission states in postoperative Crohn's disease. Larger mechanistic studies are now needed to confirm these findings and demonstrate statistical significance as well as investigate whether this benefit may be present even in those patients with 75SeHCAT negative disease.

EP-565 Four different causes of bowel obstruction in single patient – case report and review of management of small bowel obstruction

Abstract Introduction The most common causes of Small bowel obstruction (SBO) in adults are adhesions, hernias, cancer, Crohn's, Diverticulitis, volvulus, etc; in children, intussusception. Overall mortality is 10%, increasing to 30% with complications. Urgent investigation, aggressive medical management and appropriate timely surgery are key to successful outcome. Aim We present a patient with 4 causes of bowel obstruction due to a single pathology, to highlight different causes and management of SBO with the aim of improving patient outcomes. Case presentation A 55 year old lady presented with SBO, and mass RIF. CT demonstrated subacute SBO. Four causes of obstruction were found at laparotomy 1. intraluminal lesion proximal jejunum 2. intussuscepting ileal lesion 3. terminal - ileal lesion perforated /adherent to pelvic side wall, and 4. RIF mass lesion from ascending colon. Right hemicolectomy + terminal ileal resection (lesions 2, 3, 4) and jejunal resection-anastomosis (lesion 1) were performed. She made a good post- operative recovery. Histology found the morphological appearances and immunoprofile were soft tissue sarcoma arising in the GIT: gastrointestinal clear cell sarcoma/ malignant gastrointestinal neuroectodermal tumour. She is under review with the specialist regional sarcoma team. Conclusion There are over 22 000 admissions for bowel obstruction in England/Wales each year; 6.4% result in death within 90 days. Depending on the cause, SBO may resolve with medical therapy but timely surgery is needed for total obstruction, complications such as bowel perforation, ischaemia, or failure of conservative therapy. Our case report highlights the importance of urgent investigations and appropriate management of SBO.

Functional, Diagnostic and Therapeutic Aspects of Bile.

Bile is a unique body fluid synthesized in our liver. Enterohepatic circulation preserves bile in our body through its efficient synthesis, transport, absorption, and reuptake. Bile is the main excretory route for bile salts, bilirubin, and potentially harmful exogenous lipophilic substances. The primary way of eliminating cholesterol is bile. Although bile has many organic and inorganic contents, bile acid is the most physiologically active component. Bile acids have a multitude of critical physiologic functions in our body. These include emulsification of dietary fat, absorption of fat and fat-soluble vitamins, maintaining glucose, lipid, and energy homeostasis, sustenance of intestinal epithelial integrity and epithelial cell proliferation, reducing inflammation in the intestine, and prevention of enteric infection due to its antimicrobial properties. But bile acids can be harmful in certain altered conditions like cholecystectomy, terminal ileal disease or resection, cholestasis, duodenogastric bile reflux, duodenogastroesophageal bile reflux, and bile acid diarrhea. Bile acids can have malignant potentials as well. There are also important diagnostic and therapeutic roles of bile acid and bile acid modulation.

Masked polycythemia vera manifested by splanchnic venous thrombosis during pregnancy: a clinical case

Ph-negative myeloproliferative disorders such as polycythemia vera (PV), essential thrombocythemia, and primary myelofibrosis are rare clonal hematopoietic diseases that typically occur at age over 50. Only 10–15% of PV cases are diagnosed during the reproductive years, most commonly manifested as splanchnic venous thrombosis (SVT). Here, we demonstrate a case of a 6-weeks pregnant woman with a history of stillbirth and miscarriage presented with SVT. A terminal ileal resection and right hemicolectomy were performed, as well as the appointment of low molecular weight heparin in the postoperative period was initiated that allowed the patient to continue the pregnancy and deliver a child. The JAK2 V617F mutation was detected and masked PV was diagnosed according to bone marrow findings. In this article, we discuss the etiology of SVT in adults and effect of JAK2 V617F mutation on pregnancy outcomes as well as summarize current knowledge about pregnancy outcomes in PV.

Canadian Association of Gastroenterology Clinical Practice Guideline on the Management of Bile Acid Diarrhea.

Background and AimsChronic diarrhea affects about 5% of the population overall. Altered bile acid metabolism is a common but frequently undiagnosed cause.MethodsWe performed a systematic search of publication databases for studies of assessment and management of bile acid diarrhea (BAD). The certainty (quality) of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation approach. Patient population, intervention, comparator and outcome questions were developed through an iterative process and were voted on by a group of specialists.ResultsThe certainty of evidence was generally rated as very low. Therefore, 16 of 17 recommendations are conditional. In patients with chronic diarrhea, consideration of risk factors (terminal ileal resection, cholecystectomy or abdominal radiotherapy), but not additional symptoms, was recommended for identification of patients with possible BAD. The group suggested testing using 75selenium homocholic acid taurine (where available) or 7α-hydroxy-4-cholesten-3-one, including patients with irritable bowel syndrome with diarrhea, functional diarrhea and Crohn’s disease without inflammation. Testing was suggested over empiric bile acid sequestrant therapy (BAST). Once remediable causes are managed, the group suggested cholestyramine as initial therapy, with alternate BAST when tolerability is an issue. The group suggested against BAST for patients with extensive ileal Crohn’s disease or resection and suggested alternative antidiarrheal agents if BAST is not tolerated. Maintenance BAST should be given at the lowest effective dose, with a trial of intermittent, on-demand administration, concurrent medication review and reinvestigation for patients whose symptoms persist despite BAST.ConclusionsBased on a systematic review, BAD should be considered for patients with chronic diarrhea. For patients with positive results from tests for BAD, a trial of BAST, initially with cholestyramine, is suggested.

2080 The Curious Case of the Belly Button: Penetrating Crohn’s Disease Presenting as Umbilical Drainage

INTRODUCTION: Crohn’s disease is an inflammatory condition that can present with fistulous communications with extraluminal structures. The presence of urachal remnants that do not communicate with the skin account for 50% of urachal malformations and are generally asymptomatic and benign. CASE DESCRIPTION/METHODS: We present a case of an active duty soldier, with no previous medical history, found to have Crohn’s disease presenting as an enterourachocutaneous fistula. The patient presented to primary care with persistent umbilical drainage that did not resolve with antibiotics given. Computed tomography showed a mass on the dome of the bladder with surrounding inflammation but no extravasation of contrast outside of the bladder during cystography. Ileocolonoscopy revealed a narrowed ileocecal valve with biopsies consistent with active Crohn’s disease. Magnetic resonance enterography showed a fistulous communication from the terminal ileum to a urachal cyst which drained to the skin via the umbilicus. After multi-disciplinary discussion with urology and colorectal surgery, patient will undergo planned cyst, fistula, and terminal ileal resection. DISCUSSION: This case represents a rare presentation of Crohn’s disease. The true prevalence of urachal malformations is unclear; a large number remain undiagnosed until noted on imaging when asymptomatic. Enterourachal fistulas are rare, with only 13 cases reported; cutaneous communication has occurred in only 4 of the 13 reported cases. Cutaneous fistulas are more commonly seen in penetrating Crohn’s Disease given proximity of the bowel to the abdominal wall. In our case, the involved segment of bowel created a cutaneous fistula by way of a patent urachal remnant. This case highlights the ability of Crohn’s disease to mimic more benign conditions. A diagnosis of Crohn’s disease should be considered in patients with umbilical drainage that fails to resolve with antibiotics.

Canadian Association of Gastroenterology Clinical Practice Guideline on the Management of Bile Acid Diarrhea

Chronic diarrhea affects about 5% of the population overall. Altered bile acid metabolism is a common but frequently undiagnosed cause. We performed a systematic search of publication databases for studies of assessment and management of bile acid diarrhea (BAD). The certainty (quality) of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation approach. Patient population, intervention, comparator, and outcome questions were developed through an iterative process and were voted on by a group of specialists. The certainty of evidence was generally rated as very low. Therefore, 16 of 17 recommendations are conditional. In patients with chronic diarrhea, consideration of risk factors (terminal ileal resection, cholecystectomy, or abdominal radiotherapy), but not additional symptoms, was recommended for identification of patients with possible BAD. The group suggested testing using 75selenium homocholic acid taurine (where available) or 7α-hydroxy-4-cholesten-3-one, including patients with irritable bowel syndrome with diarrhea, functional diarrhea, and Crohn's disease without inflammation. Testing was suggested over empiric bile acid sequestrant therapy (BAST). Once remediable causes are managed, the group suggested cholestyramine as initial therapy, with alternate BAST when tolerability is an issue. The group suggested against BAST for patients with extensive ileal Crohn's disease or resection and suggested alternative antidiarrheal agents if BAST is not tolerated. Maintenance BAST should be given at the lowest effective dose, with a trial of intermittent, on-demand administration, concurrent medication review, and reinvestigation for patients whose symptoms persist despite BAST. Based on a systematic review, BAD should be considered for patients with chronic diarrhea. For patients with positive results from tests for BAD, a trial of BAST, initially with cholestyramine, is suggested.

Prevalence of, and predictors of, bile acid diarrhea in outpatients with chronic diarrhea: A follow-up study.

23-seleno-25-homo-tauro-cholic acid (SeHCAT) scanning to rule out bile acid diarrhea (BAD) in patients with chronic diarrhea has a high yield. Our previous study showed that patients with terminal ileal (TI) Crohn's disease, TI resection, or cholecystectomy were highly likely to have an abnormal scan. As a result, we encouraged clinicians to use a therapeutic trial of a bile acid sequestrant in these patients, instead of scanning. This may have reduced diagnostic yield of the test, so we examined this issue, as well as factors predicting an abnormal scan, in a large cohort of patients referred subsequently. We retrospectively identified 1,071 consecutive patients with chronic diarrhea undergoing SeHCAT scanning at Leeds Teaching Hospitals Trust from 2012 to 2016. We reviewed electronic patient records to obtain information on presenting gastrointestinal symptoms and any proposed risk factors for BAD. BAD was categorized according to subtype and severity. As expected, indications for scanning changed between 2012 and 2016, with a significant reduction in referrals with TI Crohn's disease or resection year-on-year (P<0.001). Despite this, 457 (42.7%) patients had BAD and there was no downward trend in yield of SeHCAT during the 5year period (P=0.39). Overall, 51.6% had type II BAD, 36.1% type III, and 12.3% type I. BAD was mild in 31.7%, moderate in 34.4%, and severe in 33.9%. In total, 653 (61.0%) patients had no known risk factors, other than chronic diarrhea, but 233 (35.7%) of these individuals had BAD, and in 143 (61.4%), this was moderate or severe. Despite reduced referrals for SeHCAT scanning in those with clear risk factors for BAD, the yield remained >40%. One-third of those without known risk factors had BAD.

Surgery and peptide receptor radionuclide therapy: An effective multimodal approach for metastatic neuroendocrine tumors.

4113 Background: Neuroendocrine neoplasia (NEN) of the pancreas (PanNEN) or small bowel (SBNEN) frequently present with metastases at initial diagnosis, undermining the efficacy of surgical treatment. Peptide receptor radionuclide therapy (PRRT) with radiolabelled somatostatin analogues, 90Y-DOTATOC and 177Lu-DOTATATE, has been shown to achieve prolonged progression-free survival (PFS) and overall survival (OS) in a substantial number of non-surgical patients with advanced NEN. Our aim was to prospectively determine the efficacy of a combination of radical loco-regional surgery and 177Lu PRRT in patients with metastasised NEN. Methods: A set of inclusion criteria was defined (e.g. PanNEN or SBNEN, G1/G2 NEN, initial tumour diagnosis, treatment naïve patient, stage IV NEN, positivity on 68Ga DOTATATE or DOTATOC PET/CT, eligibility for surgery and PRRT). Patients underwent PRRT within 3 months following surgery. Follow-up included biochemistry and imaging. Outcome measures included 1-, 3-, and 5-year OS and PFS from initial diagnosis. Results: Forty-one patients met eligibility criteria and were included. There were 26 males (63.4%) and median age at surgery was 58.8 years (range 32.1-78.3). All patients with SBNEN underwent right hemicolectomy, terminal ileal resection and mesenteric lympadenectomy. In PanNEN patients either Whipple procedure or distal pancreatectomy and peripancreatic lymphadenectomy were performed. The median number of PRRT cycles was 4 (range 2-6). Post-treatment mortality was 0%. Surgical morbidity was 12% (all grade 1 according Clavien-Dindo) and transient grade 1 toxicity occurred post PRRT in 40%. There was no grade 3 toxicity. Median follow-up was 5.48 years (range 0.53 – 11.98). Median PFS and OS were 3.33 years and 9.07 years, respectively. Progression-free survival (with 95% CI) was at 1-, 3-, and 5-years 80% (68.7-92.6), 60.9% (45.9-75.9) and 43.3% (27.4-59.3), respectively. Overall survival (with 95% CI) at 1-, 3-, and 5-years was 97.6% (93-100), 97.6% (93-100), and 95% (87-100), respectively. Conclusions: Radical loco-regional surgery for primary tumours combined with PRRT provides a novel, highly efficacious approach in metastasised NEN.

Abdominal tuberculosis: An old disease surprising young surgeons

A 21-year-old male with no prior illnesses presented to the emergency department with features of small bowel obstruction. Contrast-enhanced computed tomography of the abdomen showed features of ileal obstruction and contained perforation secondary to probable Crohn's disease. However, on exploratory laparotomy, he underwent adhesiolysis, terminal ileal resection, and end ileostomy. The biopsy showed multiple tubercles and other pathognomic characteristics of tuberculosis (TB). The findings were conclusive of abdominal TB involving the peritoneum and terminal ileum. On initiation of antitubercular therapy, his condition improved symptomatically, and he was subsequently discharged. Although the prevalence of TB has been declining in recent times, it still remains a major public health problem in our country. Abdominal TB is known to mimic multiple other conditions, and a high index of suspicion is needed to initiate appropriate therapy, thereby preventing morbidity and mortality. It is therefore crucial that young surgeons familiarize themselves with all the different manifestations of abdominal TB.

A Rare Case of Sigmoid Adenocarcinoma Presenting with Coloenteric, Colosubcutaneous, and Colovesicular Fistulas

Fistulous complications occur in less than 10% of colon cancers as a result of locally advanced disease. We present an unusual case of a patient presenting with multiple fistulous tracts extending from the sigmoid colon to the small intestine, urinary bladder and skin, who was subsequently found to have locally advanced adenocarcinoma of the sigmoid colon. A 67-year old female presented to the emergency department with generalized fatigue and left-sided flank pain. Medical history included: breast cancer treated with chemoradiation and right radical mastectomy 3 years prior, chronic iron deficiency anemia and morbid obesity. Physical exam was notable for normal vitals and diffuse non-tender fluctuance along her left flank. Computed tomography imaging revealed a large subcutaneous air/fluid collection that extended along the left lateral abdominal wall that communicated with an inflamed sigmoid colon via a fistulous tract. There were also fistulous tracts extending from the sigmoid colon to the ileum and urinary bladder. Flexible sigmoidoscopy showed an obstructing, circumferential exophytic and friable mass. Urgent incision and drainage of the left flank fluid collection yielded feculent material. Left hemicolectomy with transverse colostomy and terminal ileal resection with primary anastomosis performed a few days later. Histopathology confirmed a 6cm x 5cm invasive adenocarcinoma with invasion of viscera, peritoneum, abdominal wall with clear surgical margins and 0/19 lymph nodes (pT4bN0M0). Following multiple washout and debridement procedures, her flank wound was eventually closed. Post-operatively she did well and adjuvant chemotherapy was initiated. Fistulas are an uncommon complication of locally advanced colonic adenocarcinoma, in part due to earlier diagnosis of colon cancer, and occur most frequently in sigmoid colon cancers. Rarely do patients have fistulous complications as an initial presentation of their colon cancer. We speculate that this patient's malignancy had an exuberant inflammatory component given the extensive fistulizing disease without lymph node nor distant organ involvement. To our knowledge this is the first reported case of a patient initially presenting with multiple fistulous complications as a result of a locally advanced sigmoid adenocarcinoma.1520_A Figure 1. Endoscopic view of sigmoid mass1520_B Figure 2. Computerized tomography of colosubcutaneous fistula1520_C Figure 3. Computerized tomography of colovesicular fistula

Surgery in combination with peptide receptor radionuclide therapy is effective in metastatic neuroendocrine tumors and is definable by blood gene transcript analysis.

e15697 Background: Neuroendocrine tumours (NET) of the pancreas (PNET) or small bowel (SBNET) frequently present with metastases at initial diagnosis, undermining the efficacy of surgical treatment. Peptide receptor radionuclide therapy (PRRT) with radiolabelled somatostatin analogues, 90Y-DOTATOC and 177Lu-DOTATATE, has been shown to achieve prolonged progression-free survival (PFS) in a substantial number of non-surgical patients with advanced NET. Our aim was to prospectively determine the efficacy of a combination of radical loco-regional surgery and PRRT in patients with metastasised NET. Methods: A set of inclusion criteria was defined (e.g. G1/G2 NET, initial tumour diagnosis, treatment naïve patient, stage IV NET, positivity on 68Ga DOTA- PET/CT, eligibility for surgery and PRRT). Patients underwent PRRT within 3 months following surgery. Follow-up included biochemistry and imaging. In a sub-cohort, blood-based neuroendocrine gene transcript analysis of 51 genes (NETest) was used to define the effectiveness of treatment. Outcome measures included 5-year overall survival (OS) and PFS from initial diagnosis. Results: Twenty-five patients (5 PNET, 20 SBNET) met eligibility criteria and were included. There were 13 men (52%) and mean age was 57.1 years. All patients with SB NET underwent right hemicolectomy, terminal ileal resection and mesenteric lympadenectomy. In all PNET patients only limited pancreatic resection was required. The median number of PRRT cycles was 4 (range 2-6). Post-treatment mortality was 0%. Surgical morbidity was 12% (all Clavien-Dindo grade 1). Transient grade 1 toxicity occurred post-PRRT in 40%. NETest scores were increased in 8 patients (100%) pre-operatively and decreased in all following treatment. NETest decreases correlated with diminished tumour volume (R2=0.37, p=0.02). Median follow-up was 48 months (range 12-72months). Five-year OS was 90% and 5-year PFS was 84.3%. Conclusions: Radical loco-regional surgery for primary tumours combined with PRRT provides a novel, highly efficacious approach in metastasised NET. The NETest accurately measures the effectiveness of treatment.

PTH-084 Bullous cutaneous vasculitis-a rare side effect to adalimumab therapy

Introduction Anti-TNF(tumour necrosis factor) therapy is an effective treatment for Crohn’s disease. As the usage of anti-TNF drugs increase worldwide, the proportion of reported serious side effects are expected to rise. We present a serious adverse reaction to Adalimumab. Method Case A 20 year old gentleman with background of Crohn’s disease with previous terminal ileal resection and Juvenile Idiopathic arthritis (JIA) had been on Adalimumab (Humira, Abbvie, USA), for dual indication, on a dose of 40mg per week since 2010 and was in remission. He presented to hospital in September 2014 with an erythematous maculo-papular rash distributed over his lower limbs, trunk and upper limbs. Initial blood tests showed raised inflammatory markers with no other abnormality and a vasculitis screen was negative. He had dramatic worsening of the rash while in hospital with rapid development of new lesions and bullous transformation of some of the existing lesions with necrotic areas. A skin biopsy showed severe cutaneous leucocytoclastic vasculitis. Results He was treated with high-dose intravenous Methyl-Prednisolone and was later switched to oral therapy. He improved over the next 8 weeks with reducing dose of Prednisolone. Anti-TNF drug therapy was the likely cause of the cutaneous vasculitis in absence of another specific trigger and based on existing literature, cutaneous vasculitis secondary to anti-TNF therapy is one of the side effects which may require drug withdrawal, and can be potentially serious and debilitating. There have been very few case reports worldwide of cutaneous vasculitis secondary to anti-TNF therapy, with fewer cases reported secondary to Adalimumab. According to current literature, the average duration of treatment before patients developed a major cutaneous reaction was noted to be 36 months, with all responding to drug withdrawal. Conclusion We believe this is the first reported case of bullous vasculitis of this degree of severity, secondary to Adalimumab, involving nearly 63% of body surface area (Rule of 9s) with full thickness involvement. (Picture) As the use of anti-TNF drugs increases worldwide, it is worth considering them as a possible cause of cutaneous lesions. Our experience suggests that withdrawal of the drug and high dose corticosteroids is an effective treatment strategy. Disclosure of interest None Declared.

High Prevalence of Idiopathic Bile Acid Diarrhea Among Patients With Diarrhea-Predominant Irritable Bowel Syndrome Based on Rome III Criteria

Some studies have found that patients with idiopathic bile acid diarrhea (BAD) present with symptoms of diarrhea-predominant irritable bowel syndrome (D-IBS). However, these studies either were retrospective, did not define D-IBS according to current criteria, or included patients with chronic functional diarrhea. We performed a prospective study of the prevalence of idiopathic BAD in consecutive patients fulfilling the Rome III criteria for D-IBS. We analyzed data from 118 consecutive adult patients who fulfilled the Rome III criteria for D-IBS (mean age, 41.7 y; 72.9% female), seen at 2 gastroenterology clinics in the United Kingdom. We excluded patients with risk factors for BAD (previous history of cholecystectomy, terminal ileal Crohn's disease, terminal ileal resection or right hemicolectomy, pelvic or abdominal radiotherapy, celiac disease, or microscopic colitis). Participants completed questionnaires at baseline (on demographics, hospital anxiety, somatization, and depression, as wellas the patient health questionnaire-12 and the Short Form-36), and then received the (75)selenium homocholic acid taurine retention test. Retention of (75)selenium homocholic acid taurine 7days after administration was used to identify patients with idiopathic BAD (mild BAD, 10%-14.9%; moderate BAD, 5.1%-9.9%; and severe BAD, ≤5%). Twenty-eight patients were found to have BAD (23.7% of total), with similar percentages at each study site (25.3% and 20%; P= .54). Eight patients had mild BAD (28.6%), 8 patients had moderate BAD (28.6%), and 12 patients had severe BAD (42.8%). There was no statistical difference in age, sex, depression, patient health questionnaire-12 responses, or SF-36 scores between individuals with vs without BAD. However, patients with BAD had a higher mean body mass index than patients without BAD (31.6 vs 26.4; P= .003). Physical activity (based on the Short Form-36) was significantly lower in subjects with moderate (43.8) or severe BAD (41.7), compared with patients with mild BAD (87.5) (P= .046). Almost 25% of patients presenting with D-IBS have idiopathic BAD; most cases are moderate to severe. Guidelines should advocate testing to exclude BAD before patients are diagnosed with D-IBS.

PTH-106 Bile Acid Diarrhoea Masquerades As Diarrhoea-predominant Irritable Bowel Syndrome: Results From A Dual Centre Prospective Study

IntroductionSeveral studies have suggested that bile acid diarrhoea (BAD) can present with symptoms that are compatible with diarrhoea-predominant irritable bowel syndrome (IBS-D). However, uncertainty exists as these have often been...

PTH-110 Factors Predictive Of Bile Acid Diarrhoea And Long Term Treatment Outcomes

IntroductionBile acid diarrhoea (BAD) is a recognised cause of chronic diarrhoea, however detection remains sub-optimal. Knowledge of factors predictive of BAD could help improve detection. This study evaluates factors predictive...

Su2076 Bile Acid Diarrhoea Masquerades As Diarrhoea-Predominant Irritable Bowel Syndrome: Results From a Dual Centre Prospective Study

Introduction Several studies have suggested that bile acid diarrhoea (BAD) can present with symptoms that are compatible with diarrhoea-predominant irritable bowel syndrome (IBS-D). However, uncertainty exists as these have often been retrospective, have not defined IBS-D according to accepted diagnostic criteria, or have included patients with chronic diarrhoea in the analysis. We have examined this issue in a well-characterised cohort of patients with rigorously defined IBS-D. Methods This was a prospective cross-sectional survey conducted among consecutive patients with IBS-D attending Gastroenterology clinics in two hospitals in Sheffield and Leeds, UK. All patients underwent 23-seleno-25-homo-tauro-cholic acid (SeHCAT) scanning according to local protocol, with a retention of 9.9%, and mild if 10.0 >14.9%. Presence of IBS-D was defined according to the Rome III criteria. Patients with other known risk factors for BAD, including previous cholecystectomy, terminal ileal Crohn’s disease, terminal ileal resection, pelvic or abdominal radiotherapy, coeliac disease, or microscopic colitis, were excluded. Participants completed the patient health questionnaire-15, a validated somatisation score, and the hospital anxiety and depression score. Demographic data, including age, gender, lifestyle, and body mass index (BMI) were collected. The effect of all these factors on presence or absence of BAD was examined by multivariate logistic regression analysis, with results expressed as odds ratios (ORs) with 99% confidence intervals. Results This is an interim analysis of an ongoing study. In total, 51 patients with IBS-D according to the Rome III criteria have been recruited to date (37 (72.5%) female, mean age 47.0 years). In total, 14 (27.5%) were found to have BAD following SeHCAT scanning. Of these, nine (17.6%) had severe BAD, four moderate, and one mild. Mean age, BMI, anxiety, depression, and somatisation scores were not significantly different among those with, compared with those without, BAD. No predictors of presence of BAD were identified following multivariate logistic regression. Conclusion Our data suggest that more than one-in-four IBS-D patients, if investigated, have definite evidence of BAD. In the majority, this is severe. Failure to investigate patients to exclude BAD as an underlying cause of symptoms compatible with IBS-D results in misdiagnosis and a failure to institute effective therapy, in the form of bile acid sequestrants. This suggests that future IBS management guidelines should advocate diagnostic testing to exclude BAD before a diagnosis of IBS-D is made. Disclosure of Interest None Declared.

Mo1972 Role of SeHCAT Scanning in Diagnosis of Bile Salt Malabsorption: a University Hospital Experience

Introduction: Chronic diarrhoea is a very common presentation in the gastroenterology clinics. Majority of patients with negative investigations for organic disease are often labelled with a diagnosis of irritable bowel syndrome with diarrhoea (IBS-D). Bile salt malabsorption (BMA) is not an uncommon cause of chronic diarrhoea. In clinical practice mostly an empirical trail of bile acid sequestrants is used to diagnose this condition which lacks diagnostic accuracy. 23-seleno-25-homo-tauro-cholic acid (SeHCAT) scan is a reliable, simple and non invasive investigation to detect and treat this condition but has been underutilized in most centres in the United Kingdom (UK). Aims & Methods: We aimed to evaluate the usefulness of SeHCAT scan in evaluating patients with chronic diarrhoea. We retrospectively reviewed all patients who had SeHCAT scan over a two year period in a University Hospital. The integrated hospital electronic database system was reviewed and analysed for the following: clinical details, radiology, biochemistry, endoscopy and histology. BMA was defines as SeHCAT retention of less than 15% (mild 10-15%; moderate 5-10% and severe <5%). Results: 118 patients referred to gastroenterology clinic for chronic diarrhoea underwent SeHCAT testing over the review period. 42 M; 76 F, mean age 51 y (range 16-89). SeHCAT test was positive for BMA in 51/118(43%) of patients. Among positive SeHCAT tests, 27 (53%) had severe, 15 (29%) had moderate and, 9 (17%) had mild BAM. 12 (23%) had type 1 (6 terminal ileal resection and 6 Crohn's Disease), 28 (55%) had type 2 (Idiopathic) and 11 (21.5%) had type 3 (7 cholecystectomy, 2 diabetes, 2 coeliac) BAM. Out of 51 with confirmed BMA on SeHCAT testing, treatment information in the notes was available for 35(68%) of the patients. These patients were treated with bile acid sequestrants, either with colesevalam (n=7) or with cholestyramine (n=28). Colesevalam was well tolerated with 100% good response. In cholestyramine group 12(43%) had good response, 4(7%) partial and 7(25%) showed poor response. All patients with poor response discontinued treatment and 4 (57%) of this group stopped cholestyramine early due to unpleasant side effects. No treatment response was documented in the notes for 5 patients. Overall, colesevalam had excellent response rates with no reported side effects. Conclusion: SeHCAT scan is probably an underutilized test for diagnosing bile salt malabsorption. In patients presenting with chronic diarrhoea SeHCAT scanning must be considered to diagnose this probably under recognised cause of chronic diarrhoea. Colesevalam has better tolerability and response rates and must be considered in group of patients intolerant to cholestyramine.

The Influence of CTGF Single-Nucleotide Polymorphisms on Outcomes in Crohn's Disease

To examine the association between single-nucleotide polymorphisms (SNPs) in CTGF (connective tissue growth factor) and patient outcomes after terminal ileal resection for Crohn's disease. The primary indication for intestinal resection in Crohn's disease is fibrostenotic terminal ileal disease. CTGF is a cytokine overexpressed in the intestine of patients with Crohn's disease that influences outcomes in other disease processes. DNA was extracted from formalin-fixed, paraffin-embedded tissue from 147 patients with Crohn's disease who had undergone terminal ileal resection between 1981 and 2009. Genotyping was performed for 4 CTGF SNPs (rs9402373, rs12526196, rs6918698, and rs9399005), which modulate nuclear factor binding and CTGF production, and a smad3 SNP (rs17293632) involved in the CTGF pathway. Patients were phenotyped using the Montreal Disease Classification. Sixty-seven of 147 patients (45.6%) were male; the mean age at diagnosis was 30.3 ± 12.6 years and the mean follow-up duration was 8.3 ± 7.1 years. Genotype-phenotype analysis demonstrated that the rs6918698GG genotype was associated with an older age of disease onset [>40 years; 30.6% vs 13.2%; odds ratio (OR): 2.891; 95% confidence interval (CI): 1.170-7.147). The rs9402373CC genotype was positively associated with type B1 disease (50.7% vs 26.3%; OR: 2.876; 95% CI: 1.226-6.743) and negatively associated with B2 disease (37.0% vs 65.0%; OR: 0.317; 95% CI: 0.144-0.699). None of the 5 SNPs assessed influenced clinical or surgical recurrence of Crohn's disease after intestinal resection. On multivariate analysis, male sex odds ratio (OR): 0.235; 95% CI: 0.073-0.755; P = 0.015] and never having smoked tobacco (OR: 0.249; 95% CI: 0.070-0.894; P = 0.033) reduced the risk, whereas having a prior appendectomy increased the risk (OR: 5.048; 95% CI: 1.632-15.617; P = 0.005) of surgical recurrence. These data implicate the rs6918698GG genotype with an age of disease onset of greater than 40 years in Crohn's disease whereas the rs9402373CC genotype is associated with a nonstricturing, nonpenetrating disease phenotype. CTGF SNPs do not influence the rate of recurrence after terminal ileal resection for Crohn's disease.