Specific Oral Manifestations in Adults with Crohn's Disease.

Background: Oral manifestations of Crohn's disease (CD) include non-specific lesions and specific lesions directly related to intestinal inflammation. Oral lesions that can be overlooked in CD are sometimes challenging to treat. Methods: In this retrospective single-center study, patients with CD aged over 18 years who complied with follow-up and treatment were included. Clinical definitions of specific oral lesions included pyostomatitis vegetans, glossitis with fissuring, lip swelling with fissuring, cobblestoning, and orofacial granulomatosis. Experienced dentists confirmed the specific lesions in each case. Three groups of patients were identified: those without oral lesions, those with non-specific oral lesions, and those with specific oral lesions. The groups were compared based on demographics, disease extent and behavior (based on the Montreal classification), extraintestinal involvement, biologic and steroid treatment, and the requirement of resective surgery. Results: A total of 96 patients (14.2%) with oral lesions were found among the 676 patients with CD (59.7% male, median age 38 years) who were followed for 6.83 years (IQR 0.5-29.87 years). Eight patients (1.2%, 9 lesions) had specific oral lesions, while eighty-eight patients (13%) had non-specific lesions. Orofacial granulomatosis (n = 3), cobblestoning (n = 2), glossitis with fissuring (n = 2), and lip swelling with fissuring (n = 2) were among the specific lesions. The majority of patients (75%) with specific lesions were male, and their median age was 46.5 years (range: 23-68 years). Disease localization was commonly ileocolonic (50%), and perianal disease was present in 25% of patients. Three patients were active smokers. Extraintestinal manifestations were peripheral arthritis/arthralgia (n = 7) and sacroiliitis (n = 1). All specific lesions were associated with moderate-to-severe disease. Five patients improved with biologic therapy, and two patients with immunomodulatory therapy. Conclusions: Specific oral lesions in CD were associated with active disease and improved with immunomodulators or biologic therapy. Close cooperation between gastroenterologists and dentists is essential for early diagnosis and optimal management of CD.

Clinical Outcomes of Older Patients with Non-Variceal Upper Gastrointestinal Bleeding Taking Anti-Thrombotic or Non-Steroidal Anti-Inflammatory Agents.

BACKGROUND/AIMS: Non-variceal upper gastrointestinal bleeding is a well-established complication of non-steroidal anti-inflammatory drugs and anti-thrombotics. Both medication groups are frequently used by older populations and increase the incidence of non-var- iceal upper gastrointestinal bleeding; however, their impact on etiology and outcomes of non-variceal upper gastrointestinal bleeding has not been well defined. We aimed to compare the etiology and outcomes of non-variceal upper gastrointestinal bleeding in older patients who use anti-thrombotics and non-steroidal anti-inflammatory drugs or do not use either of them. MATERIALS AND METHODS: This is a single-center prospective study of patients older than 65 years with non-variceal upper gastrointesti- nal bleeding. Endoscopic findings, laboratory values, blood transfusion, endoscopic treatment, re-bleeding, and 30-day mortality rates were recorded. RESULTS: A total of 257 patients (median age 77.7 ± 8.2, 59% male) were included. Re-bleeding occurred in 25 (10%) and the 30-day mortality rate was 40 (16%). There was no statistically significant difference between patients using anti-thrombotics, non-steroidal anti-inflammatory drugs or non-users for blood transfusion (P = .46), endoscopic hemostasis (P = .39), re-bleeding (P = .09), and 30-day mortality (P = .45). Peptic ulcer was the most common etiology in all groups (124, 48%). Although the incidence of peptic ulcer was similar between drug users and anti-thrombotic users (P = .75), the incidence of peptic ulcer was significantly higher in patients using non-steroidal anti-inflammatory drugs than in patients who did not use drugs (P = .05). When the patients were analyzed as using anti- thrombotic drugs or non-steroidal anti-inflammatory drugs or neither, no statistically significant difference was found between ulcer location, ulcer number, and ulcer size. CONCLUSION: Non-variceal upper gastrointestinal bleeding increasingly occurs in older populations with several comorbidities; non- steroidal anti-inflammatory drugs or anti-thrombotics do not seem to change the clinical outcomes among older patients with non- variceal upper gastrointestinal bleeding.

A Step-Up Approach Using Alternative Endoscopic Modalities Is an Effective Strategy for Postoperative and Traumatic Pancreatic Duct Disruption.

BACKGROUND AND AIMS: Standard endotherapy for pancreatic duct (PD) disruption is pancreatic stenting and sphincterotomy. In patients refractory to standard treatment, treatment algorithm is currently not standardized. This study aims to report the 10-year experience with the endoscopic treatment of postoperative or traumatic PD disruption and to share our algorithmic approach. METHODS: This retrospective study was conducted on 30 consecutive patients who underwent endoscopic treatment for postoperative (n = 26) or traumatic (n = 4) PD disruption between 2011 and 2021. Standard treatment was initially applied to all patients. Endoscopic modalities used with a step-up approach in patients unresponsive to standard treatment were stent upsizing and N-butyl-2-cyanoacrilate (NBCA) injection for partial disruption, and the bridging of the disruption with a stent and cystogastrostomy for complete disruption. RESULTS: PD disruption was partial in 26 and complete in 4 patients. Cannulation and stenting of PD was successful in all patients and sphincterotomy was performed in 22 patients. Standard treatment was successful in 20 patients (66.6%). The resolution of PD disruption in 9 of 10 patients refractory to standard treatment was achieved with stent upsizing in 4, NBCA injection in 2, the bridging of the complete disruption in one, and cystogastrostomy after spontaneously and intentionally developed pseudocyst in one patient each. Overall, therapeutic success rate was 96.6% (100% for partial, 75% for complete disruption). Procedural complications occurred in 7 patients. CONCLUSIONS: Standart treatment for PD disruption is usually effective. In patients refractory to standard treatment, the outcome may be improved by step-up approach using alternative endoscopic modalities.

Ileocecal valve that cannot be intubated in Crohn's disease: is this a sign of poor prognosis?

BACKGROUND: In Crohn's disease (CD), the inability to intubate the ileocecal valve during colonoscopy may be associated with a poor disease prognosis. In this study, we aimed to compare the long-term outcomes of CD patients with and without ileocecal valve intubation during colonoscopy to assess its value as a prognostic parameter. METHODS: This retrospective study involved CD patients with isolated ileal involvement who underwent colonoscopy between 1993 and 2022. We compared the basic characteristics and long-term clinical outcomes of two groups of patients: those with intubated and non-intubated ileocecal valves during colonoscopy. RESULTS: Of the 155 participants, 97 (62.5%) patients' ileum could be intubated and 58 (37.5%) could not be intubated. The non-intubated group was younger at diagnosis (39 years versus 30.5 years, p = 0.002), but other baseline characteristics such as sex, smoking status, disease duration, perianal disease, and upper gastrointestinal involvements were similar. The non-intubated group had higher rates of steroid dependence (67.2% versus 46.4%; p = 0.012), biologic treatment (89.7% versus 58.8%; p < 0.001), CD-related hospitalization (81% versus 24.7%; p < 0.001), and major abdominal surgery (58.6% versus 15.5%; p < 0.001). In the logistic regression analysis, the positive predictors of successful ileum intubation were inflammatory type CD (OR: 14.821), high serum albumin level (OR: 5.919), and older age (OR: 1.069), while the negative predictors were stenosing (OR: 0.262) and penetrating (OR: 0.247) CD behavior. CONCLUSIONS: In Crohn's disease patients with isolated ileal involvement, ileocecal valve cannot be intubated during colonoscopy may indicate the severity of the disease.

Comparison of urgent and early endoscopy for acute non-variceal upper gastrointestinal bleeding in high-risk patients.

OBJECTIVE: Data regarding early (within 24h) and urgent endoscopy (within 12h) in non-variceal upper gastrointestinal bleeding (NV-UGIB) revealed conflicting results. This study aimed to investigate the impact of endoscopy timing on the outcomes of high-risk patients with NV-UGIB. PATIENTS AND METHODS: From February 2020 to February 2021, consecutive high-risk (Glasgow-Blatchford score ≥12) adults admitted to the emergency department with NV-UGIB were analyzed retrospectively. The primary composite outcome was 30-day mortality from any cause, inpatient rebleeding, need for endoscopic re-intervention, need for surgery or angiographic embolization. RESULTS: 240 patients were enrolled: 152 (63%) patients underwent urgent endoscopy (<12h) and 88 (37%) patients underwent early endoscopy (12-24h). One or more components of the composite outcome were observed in 53 (22.1%) patients: 30 (12.5%) had 30-day mortality, rebleeding occurred in 27 (11.3%), 7 (2.9%) underwent endoscopic re-intervention, and 5 (2.1%) required surgery or angiographic embolization. The composite outcome was similar between the groups. Multivariate analysis showed only hemodynamic instability on admission (OR: 3.05, p=0.006), and the previous history of cancer (OR: 2.42, p=0.029) were significant in predicting composite outcome. In terms of secondary outcomes, the endoscopic intervention was higher in the urgent endoscopy group (p=0.006), whereas the number of transfused erythrocyte suspensions and the length of hospital stay was higher in the early endoscopy group (p=0.002 and p=0.040, respectively). CONCLUSIONS: Urgent endoscopy leads to a significant reduction in the length of hospitalization and the number of transfused erythrocyte suspensions in NV-UGIB, which can contribute to patient satisfaction, reduce healthcare expenditure, and improve hospital bed availability. The composite outcome and its sub-outcomes were the same among both groups.