A prospective cohort study of the use of the fatty liver index and Fibroscan to determine the prevalence of fatty liver disease in an Irish population.

OBJECTIVES: Rates of nonalcoholic fatty liver disease (NAFLD) are increasing worldwide. The fatty liver index (FLI) is a noninvasive predictor of NAFLD. This prospective cohort study used the FLI to estimate the prevalence of NAFLD in patients attending an Irish Acute Medical Unit (AMU), and assessed the degree of fibrosis in this group using Fibroscan. METHODS: Patients attending the AMU over a 3-month period were invited to participate. Patients with excess alcohol consumption or pre-existing liver disease were excluded. Using established FLI cut-offs, 414 participants were grouped into low (FLI ≤ 30), medium (30 < FLI ≤ 60) and high (FLI > 60) risk of NAFLD. High-risk patients were offered review including liver stiffness measurement (LSM) and controlled attenuation parameter (CAP) score. RESULTS: A total of 134 patients were at low-risk, 96 at medium-risk and 184 at high-risk of NAFLD. Male sex (P < 0.0001) and increasing age (P < 0.0001) were associated with higher risk. Of the 120 high-risk patients who attended follow up, 13 participants had LSM > 7 kPa. Higher FLI scores were associated with higher CAP scores (P < 0.0001) but did not predict higher LSMs. Fasting glucose and HbA1c were found to be associated with higher LSM. CONCLUSION: About 44.4% of patients presenting to the AMU were at high risk of NAFLD according to the FLI. Only 10.8% of the high-risk group, and 3% of all those recruited had a LSM > 7 kPa suggesting development of fibrosis.

Comparison of medium to long-term outcomes of acute severe ulcerative colitis patients receiving accelerated and standard infliximab induction.

INTRODUCTION: Accelerated dose infliximab (IFX) induction is associated with reduced short-term colectomy rate in acute severe ulcerative colitis (ASUC). Data on medium/long-term outcomes of this strategy are limited. AIMS: Evaluate medium/long-term outcomes in patients receiving IFX induction for ASUC, comparing accelerated dose (AD) and standard dose (SD) induction. METHODS: Retrospective study of consecutive patients admitted with corticosteroid-refractory ASUC in four tertiary referral centres within INITIative IBD research network (www.initiativeibd.ie). IFX rescue was given either as SD (weeks 0, 2, 6) or AD (<28 days) from January 2010 to September 2017. AD induction has been utilised in participating centres since 2014. Consequently SD patients were subdivided based on time period of IFX rescue: historical SD group (SD1) (2010-2013) and current SD group (SD2) (2014-2017). Primary endpoint was time to colectomy; secondary endpoint was time to IFX discontinuation if induction was complete. RESULTS: 145 patients received rescue IFX (AD=58, SD1=32, SD2=55). Disease severity at induction was comparable between AD and SD1 groups; however, SD2 group had less severe disease: median C-reactive protein (CRP) 39, 44 and 20 mg/L for AD, SD1 and SD2 groups, respectively (p=0.026, Kruskal-Wallis); median CRP: albumin ratio was 1.4, 1.8 and 0.6 (p=0.016). Median follow-up for AD, SD1 and SD2 groups was 1.6 (IQR 1.1-3.1), 4.9 (IQR 2.6-5.5) and 1.5 (IQR 0.9-2.3) years. Time to colectomy was shorter in SD1 (log rank p=0.0013); no significant difference in time to colectomy was observed comparing AD and SD2 groups (log rank p=0.32). 123 patients (84%) completed IFX induction and received maintenance therapy. Time to IFX discontinuation was shorter in SD1 (log rank p=0.009). CONCLUSION: Time to colectomy is significantly prolonged with use of AD IFX in selected ASUC patients with more severe disease. Historical use of standard IFX induction for all ASUC patients is associated with inferior long-term outcomes.

A Curious Case of Intestinal Diaphragm Disease Unmasked by Perforation of a Duodenal Ulcer.

Nonsteroidal anti-inflammatory drugs are a common cause of intestinal injury. A variety of NSAID-induced injuries may occur including ulcers, erosions, colitis, strictures, and diaphragm disease. Diaphragm disease refers to the development of multiple thin, concentric, stenosing strictures in the intestine. Strictures occur most often in the midintestine and are thought to be pathognomonic of NSAID damage. They can lead to intermittent or complete bowel obstruction. Diagnosis may be elusive as there is nothing specific about NSAID-induced injury at endoscopy and histology is also nonspecific. Even at laparotomy, the diagnosis of diaphragm disease may be missed as the serosa may appear normal and strictures can be difficult to palpate. While most NSAID-induced lesions tend to resolve quickly following withdrawal of the offending drug, diaphragm-like strictures usually require intervention such as stricturoplasty or surgical resection of the involved segment of bowel. Here we report the case of a 60-year-old male patient who presented with iron deficiency anaemia and recurrent subacute bowel obstruction. Following endoscopy and repeated CT scanning of his abdomen, he was diagnosed with Crohn's disease. He was treated with 5-ASAs and immune suppression until a perforated duodenal ulcer resulted in emergency laparotomy and the subsequent discovery of multiple intestinal diaphragms attributable to long-standing NSAID use.