Sarcopenia and frailty in inflammatory bowel disease: Emerging concepts and evidence.

Sarcopenia is a condition marked by progressive loss of skeletal muscle mass and function while frailty is a multidimensional concept characterized by diminished physiological reserve and increased vulnerability to stressors. Both of these were previously considered as related to aging and shown to impact the quality of life and carry prognostic significance. Emerging data show that both sarcopenia and frailty carry similar relevance in chronic illness. Inflammatory bowel disease (IBD) is characterized by chronic inflammation of the gastrointestinal tract and malnourishment, both of which contribute to the development of sarcopenia by increasing protein breakdown and reducing protein synthesis. The coexistence of frailty further compounds the clinical complexity of IBD patients. Published evidence suggests a bidirectional association with IBD contributing to muscle wasting, while the resultant sarcopenia and frailty could further exacerbate the disease course. Sarcopenia and frailty are independently associated with adverse outcomes, including hospitalizations, increased surgical interventions, and surgical complications. As therapeutic strategies for IBD evolve, understanding the nuanced relationship between inflammatory bowel disease, sarcopenia, and frailty is crucial for devising holistic management. Comprehensive care should encompass not only disease-modifying therapies but also interventions targeting frailty and sarcopenia, as they have been shown to have a significant impact not only on the disease course but also on the quality of life. Future research could focus on further elucidating underlying mechanisms, simple screening strategies, and developing targeted interventions to improve the overall quality of life for individuals grappling with the complex interplay of IBD, sarcopenia, and frailty.

Sarcopenia is common in ulcerative colitis and correlates with disease activity.

BACKGROUND/AIMS: Association of sarcopenia with disease severity in ulcerative colitis (UC) is not clearly defined. We planned to estimate the prevalence of sarcopenia in patients with UC as per the revised definition and its relation with the disease severity. METHODS: A cross-sectional assessment of sarcopenia in patients with UC was performed. Disease activity was graded according to complete Mayo score. Hand grip strength was assessed with Jamar hand dynamometer, muscle mass using a dual energy X-ray absorptiometry scan, and physical performance with 4-m walk test. Sarcopenia was defined as a reduction of both muscle mass and strength. Severe sarcopenia was defined as reduced gait speed in presence of sarcopenia. RESULTS: Of 114 patients (62 males, mean age: 36.49±12.41 years), 32 (28%) were in remission, 46 (40.4%) had mild-moderate activity, and 36 (31.6%) had severe UC. Forty-three patients (37.7%) had probable sarcopenia, 25 (21.9%) had sarcopenia, and 14 (12.2%) had severe sarcopenia. Prevalence of sarcopenia was higher in active disease (2 in remission, 6 in active, and 17 in severe, P<0.001). Of 14 with severe sarcopenia, 13 had severe UC while 1 had moderate UC. On multivariate analysis, lower body mass index and higher Mayo score were associated with sarcopenia. Of 37 patients with acute severe colitis, 16 had sarcopenia. Requirement of second-line therapy was similar between patients with and without sarcopenia. On follow-up (median: 18 months), there was a non-significant higher rate of major adverse events in those with sarcopenia (47.4% vs. 33.8%, P=0.273). CONCLUSIONS: Sarcopenia and severe sarcopenia in UC correlate with the disease activity.

Clinical and Radiological Parameters to Discriminate Tuberculous Peritonitis and Peritoneal Carcinomatosis.

It is challenging to differentiate between tuberculous peritonitis and peritoneal carcinomatosis due to their insidious nature and intersecting symptoms. Computed tomography (CT) is the modality of choice in evaluating diffuse peritoneal disease. We conducted an ambispective analysis of patients suspected as having tuberculous peritonitis or peritoneal tuberculosis between Jan 2020 to Dec 2021. The study aimed to identify the clinical and radiological features differentiating the two entities. We included 44 cases of tuberculous peritonitis and 45 cases of peritoneal carcinomatosis, with a median age of 31.5 (23.5-40) and 52 (46-61) years, respectively (p ≤ 0.001). Fever, past history of tuberculosis, and loss of weight were significantly associated with tuberculous peritonitis (p ≤ 0.001, p = 0.038 and p = 0.001). Pain in the abdomen and history of malignancy were significantly associated with peritoneal carcinomatosis (p = 0.038 and p ≤ 0.001). Ascites was the most common radiological finding. Loculated ascites, splenomegaly and conglomeration of lymph nodes predicted tuberculous peritonitis significantly (p ≤ 0.001, p = 0.010, p = 0.038). Focal liver lesion(s) and nodular omental involvement were significantly associated with peritoneal carcinomatosis (p = 0.011, p = 0.029). The use of clinical features in conjunction with radiological findings provide better diagnostic yields because of overlapping imaging findings.

Effectiveness and safety of thioguanine as a maintenance therapy of inflammatory bowel disease: Systematic review, meta-analysis and meta-regression.

INTRODUCTION: Thiopurines are an important therapy for the maintenance of remission in inflammatory bowel disease (IBD). However, the use of thioguanine has been limited by concerns regarding its toxicity. We performed a systematic review to evaluate its effectiveness and safety in IBD. METHODS: Electronic databases were searched to identify studies reporting clinical responses and/or adverse events of thioguanine therapy in IBD. We calculated the pooled clinical response and clinical remission rates of thioguanine in IBD. Subgroup analyses were done for the dosage of thioguanine and the type of studies (prospective or retrospective). Meta-Regression was used to analyze the impact of dose on clinical efficacy and occurrence of nodular regenerative hyperplasia. RESULTS: A total of 32 studies were included. The pooled clinical response rate of thioguanine therapy in IBD was 0.66 (95% C.I. 0.62 - 0.70; I2 = 16%). The pooled clinical response rate with low-dose was similar to high-dose thioguanine therapy [0.65 (95% C.I. 0.59 - 0.70; I2 = 24%) and 0.68 (95% C.I. 0.61 - 0.75; I2 = 18%) respectively]. The pooled remission maintenance rate was 0.71 (95% C.I. 0.58 - 0.81; I2 = 86%). The pooled rates of occurrence of nodular regenerative hyperplasia, liver function tests abnormalities and cytopenia were 0.04 (95% C.I. 0.02 - 0.08; I2 = 75%), 0.11 (95% C.I. 0.08 - 0.16; I2 = 72%) and 0.06 (95% C.I. 0.04 - 0.09; I2 = 62%) respectively. Meta-regression suggested that the risk of nodular regenerative hyperplasia is related to the dose of thioguanine. CONCLUSION: TG is an efficacious and well-tolerated drug in most patients with IBD. Nodular regenerative hyperplasia, cytopenias, and liver function abnormalities occur in a small subset. Future studies should look into TG as primary therapy in IBD.

Frequency, outcomes, and need for intervention in stricturing gastrointestinal tuberculosis: a systematic review and meta-analysis.

BACKGROUND: Gastrointestinal strictures impact clinical presentation in abdominal tuberculosis and are associated with significant morbidity. AIM: To conduct a systematic review of the prevalence of stricturing disease in abdominal and gastrointestinal tuberculosis and response to antitubercular therapy (ATT). METHODS: We searched Pubmed and Embase on 13th January 2022, for papers reporting on the frequency and outcomes of stricturing gastrointestinal tuberculosis. The data were extracted, and pooled prevalence of stricturing disease was estimated in abdominal tuberculosis and gastrointestinal (intestinal) tuberculosis. The pooled clinical response and stricture resolution (endoscopic or radiologic) rates were also estimated. Publication bias was assessed using the Funnel plot and Egger test. The risk of bias assessment was done using a modified Newcastle Ottawa Scale. RESULTS: Thirty-three studies reporting about 1969 patients were included. The pooled prevalence of intestinal strictures in abdominal tuberculosis and gastrointestinal TB was 0.12 (95%CI 0.07-0.20, I2 = 89%) and 0.27 (95% CI 0.21-0.33, I2 = 85%), respectively. The pooled clinical response of stricturing gastrointestinal tuberculosis to antitubercular therapy was 0.77 (95%CI 0.65-0.86, I2 = 74%). The pooled stricture response rate (endoscopic or radiological) was 0.66 (95%CI 0.40-0.85, I2 = 91%). The pooled rate of need for surgical intervention was 0.21 (95%CI 0.13-0.32, I2 = 70%), while endoscopic dilatation was 0.14 (95%CI 0.09-0.21, I2 = 0%). CONCLUSION: Stricturing gastrointestinal tuberculosis occurs in around a quarter of patients with gastrointestinal tuberculosis, and around two-thirds of patients have a clinical response with antitubercular therapy. A subset of patients may need endoscopic or surgical intervention. The estimates for the pooled prevalence of stricturing disease and response to ATT had significant heterogeneity.