Modeling-Based Response-Guided Hepatitis C Treatment During Pregnancy and Postpartum.

Treating hepatitis C virus (HCV) in pregnancy would address HCV during prenatal care and potentially reduce the risk of vertical transmission. Response-guided therapy could provide a means to individualize and the reduce duration of HCV treatment during pregnancy. Data from a 27-year-old woman indicated that, pretreatment, HCV was stable and that it dropped in a biphasic manner during sofosbuvir/velpatasvir therapy, reaching target not detected at time of delivery-16 days post-initiation of therapy. Mathematical modeling of measured HCV at days 0, 7, and 14 predicted that cure could have been achieved after 7 weeks of sofosbuvir/velpatasvir, reducing the duration of therapy by 5 weeks.

Adjunctive Pharmacotherapy Use in Patients With Ileal Pouch-Anal Anastomosis (IPAA).

Background: This study evaluated the prevalence of adjunctive pharmacotherapies use among ileal pouch-anal anastomosis (IPAA) patients. Methods: The IBD Partners database was queried to compare IPAA patients with and without pouch-related symptoms (PRS). Within the cohort of patients with PRS, patient reported outcomes were compared among opioid, nonsteroidal anti-inflammatory drug (NSAID), and probiotic users. Results: There were no differences in patient reported outcomes based on NSAID or probiotic usage. Opioid users reported increased bowel frequency, urgency, poor general well-being, abdominal pain, and depression (P < 0.05 for all variables). Conclusions: In IPAA patients with PRS, opioid use, but not NSAIDs or probiotics, was associated with a higher burden of PRS.

Endoscopic Treatment of Bleeding Diversion Pouchitis with High-Concentration Dextrose Spray.

Surgical closure of stoma with the reestablishment of gut continuity is the only curative intervention available for inflammatory bowel disease patients with diversion pouchitis, proctitis, or colitis. For patients who are not candidates for surgical reestablishment of bowel continuity, the alternative nonsurgical approaches, such as topical therapy with mesalamine, corticosteroids, or short-chain fatty acids, have only shown modest efficacy. The management of massive bleeding from diversion pouchitis has not been described. We present a patient with ulcerative colitis with severe hematochezia and diffuse mucosal bleeding in a diverted ileal pouch, which was successfully treated with endoscopic spray of hypertonic glucose.

Hyperbaric oxygen therapy for chronic antibiotic-refractory ischemic pouchitis.

Hyperbaric oxygen therapy (HBOT) has been shown to be efficacious in treating various conditions, including perianal Crohn's disease. Here we present a case of a 59-year-old male with a history of ulcerative colitis, who underwent a total proctocolectomy and two-stage J-pouch construction. He later developed chronic antibiotic-refractory pouchitis with endoscopic features of ischemia. At the completion of HOBT-a total of 20 sessions of 100% oxygen at 2.5-3.0 atmospheres absolute for 60-90 minutes per session-a repeat pouchoscopy showed marked improvement of endoscopic mucosal inflammation. HBOT is known to increase tissue oxygenation, reduce tissue hypoxia, alter inflammatory pathways and promote tissue healing. This case demonstrated the therapeutic role of HBOT as well as the possible disease mechanism in chronic antibiotic-refractory pouchitis.

Management of Crohn's Disease in the New Era of Gut Rehabilitation and Intestinal Transplantation.

Despite recent therapeutic advances, patients with Crohn's disease (CD) continue to experience high recurrence with cumulative structural damage and ultimate loss of nutritional autonomy. With short bowel syndrome, strictures, and enteric fistulae being the underlying pathology, CD is the second common indication for home parenteral nutrition (HPN). With development of intestinal failure, nutritional management including HPN is required as a rescue therapy. Unfortunately, some patients do not escape the HPN-associated complications. Therefore, the concept of gut rehabilitation has evolved as part of the algorithmic management of these patients, with transplantation being the ultimate life-saving therapy. With type 2 intestinal failure, comprehensive rehabilitative measures including nutritional care, pharmacologic manipulation, autologous reconstruction, and bowel lengthening is often successful, particularly in patients with quiescent disease. With type 3 intestinal failure, transplantation is the only life-saving treatment for patients with HPN failure and intractable disease. With CD being the second common indication for transplantation in adults, survival outcome continues to improve because of surgical innovation, novel immunosuppression, and better postoperative care. Despite being a rescue therapy, the procedure has achieved survival rates similar to other solid organs, and comparable to those who continue to receive HPN therapy. With similar technical, immunologic, and infectious complications, survival is similar in the CD and non-CD recipients. Full nutritional autonomy is achievable in most survivors with better quality of life and long-term cost-effectiveness. CD recurrence is rare with no impact on graft function. Further progress is anticipated with new insights into the pathogenesis of CD and mechanisms of transplant tolerance.

Computed tomography-guided endoscopic needle knife therapy for ileal pouch sinus.

Ileal pouch-anal anastomosis surgery can be complicated by anastomotic leaks, leading to the formation of abscess and chronic sinus that have been routinely managed by a surgical approach. We developed the endoscopic needle knife sinusotomy (NKSi) technique, which has become a valid alternative. The basic principle of endoscopic NKSi is dissection and drainage of the sinus through its orifice internally into the lumen of pouch body. The success of NKSi requires an access to the sinus from the pouch side. One of the most challenging situations for NKSi is a closed orifice of the sinus, which leaves an isolated chronic abscess cavity. Here we report a case of complicated presacral sinus with a closed orifice that was not amenable to NKSi, necessitating a CT-guided guide wire placement and subsequent NKSi.