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Advanced therapeutic endoscopist and inflammatory bowel disease: Dawn of a new role

World Journal of Gastroenterology 2014年第13期20卷 3485-3494页

作者： Kunjam Modha udayakumar navaneethan Digestive Disease Institute-Desk A31 The Cleveland ClinicClevelandOH 44195United States

Endoscopy plays a key role in the diagnosis and treatment of patients with inflammatory bowel disease (IBD). Colonoscopy has been traditionally used in the diagnosis of IBD and helps in determination of an important end point in patient management, “mucosal healing”. However, the involvement of an advanced endoscopist has expanded with innovations in therapeutic and newer imaging techniques. Endoscopists are increasingly being involved in the management of anastomotic and small bowel strictures in these patients. The advent of balloon enteroscopy has helped us access areas not deemed possible in the past for dilations. An advanced endoscopist also plays an integral part in managing ileal pouch-anal anastomosis complications including management of pouch strictures and sinuses. The use of rectal endoscopic ultrasound has been expanded for imaging of perianal fistulae in patients with Crohn’s disease and appears much more sensitive than magnetic resonance imaging and exam under anesthesia. Advanced endoscopists also play an integral part in detection of dysplasia by employing advanced imaging techniques. In fact the paradigm for neoplasia surveillance in IBD is rapidly evolving with advancements in endoscopic imaging technology with pancolonic chromoendoscopy becoming the main imaging modality for neoplasia surveillance in IBD patients in most institutions. Advanced endoscopists are also called upon to diagnose primary sclerosing cholangitis (PSC) and also offer options for endoscopic management of strictures through endoscopic retrograde cholangiopancreatography (ERCP). In addition, PSC patients are at increased risk of developing cholangiocarcinoma with a 20% lifetime risk. Brush cytology obtained during ERCP and use of fluorescence in situ hybridization which assesses the presence of chromosomal aneuploidy (abnormality in chromosome number) are established initial diagnostic techniques in the investigation of patients with biliary strictures

关键词： Inflammatory bowel disease Endoscopy Therapeutic endoscopy Primary sclerosing cholangitis

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Hepatobiliary manifestations of ulcerative colitis:an example of gut–liver crosstalk

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Gastroenterology Report 2014年第3期2卷 193-200页

作者： udayakumar navaneethan Department of Gastroenterology/Hepatology Digestive Disease InstituteThe Cleveland Clinic FoundationClevelandOhioUSA

The interaction between inflammatory bowel disease(IBD)and hepatobiliary manifestations represents a classic example of liver–gut *** importance of liver–gut crosstalk in IBD is demonstrated in the pathogenesis and outcome of primary sclerosing cholangitis(PSC)in IBD *** G4-associated cholangitis(IAC),which has recently been described in UC patients,may also illustrate the significance of gut–liver interaction in these *** of these hepatobiliary manifestations influences the outcome of associated IBD,in particular ulcerative colitis(UC),and vice *** pathogenesis of PSC is postulated to be related to gut inflammation in IBD that results in inflammation in the portal tracts(the‘leaky gut’).Enterohepatic circulation of lymphocytes from the gut to the liver is also of potential relevance to PSC pathogenesis and *** presence of PSC and gut inflammation in IBD influences the course and outcomes of both *** research is required,to understand the mutual effect of liver–gut crosstalk in the outcomes of UC patients,and highlights the importance of an interdisciplinary approach—involving gastroenterologists,hepatologists,advanced endoscopists and liver transplant surgeons—in the management of these patients.

关键词： primary sclerosing cholangitis restorative proctocolectomy ulcerative colitis liver transplantation

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Endoscopic management of difficult common bile duct stones

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World Journal of Gastroenterology 2013年第2期19卷 165-173页

作者： Guru Trikudanathan udayakumar navaneethan Mansour A Parsi Department of Internal Medicine University of Connecticut Medical CenterFarmingtonCT 06269United States Digestive Disease Institute Cleveland ClinicClevelandOH 44195United States

Endoscopy is widely accepted as the first treatment option in the management of bile duct *** this review we focus on the alternative endoscopic modalities for the management of difficult common bile duct *** biliary stones can be removed with an extraction balloon,extraction basket or mechanical lithotripsy after endoscopic *** papillary balloon dilation with or without endoscopic sphincterotomy or mechanical lithotripsy has been shown to be effective for management of difficult to remove bile duct stones in selected *** clearance can be safely achieved with peroral cholangioscopy guided laser or electrohydraulic lithotripsy in most cases where other endoscopic treatment modalities have *** stenting may be an alternative treatment option for frail and elderly patients or those with serious co morbidities.

关键词： Choledocholithiasis Mechanical lithotripsy Laser lithotripsy Electrohydra-ulic lithotripsy Difficult to remove biliary stones Endoscopic large balloon papillary dilation Peroral cholangioscopy

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Clostridium difficile infection and inflammatory bowel disease:Understanding the evolving relationship

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World Journal of Gastroenterology 2010年第39期16卷 4892-4904页

作者： udayakumar navaneethan Preethi GK Venkatesh Bo Shen Victor W.Fazio Center for Inflammatory Bowel Disease Department of GastroenterologyDigestive Disease Institutethe Cleveland Clinic Foundation

Clostridium difficile(***)infection(CDI)is the leading identifiable cause of antibiotic-associated *** there is an alarming trend of increasing incidence and severity of CDI in the United States and Europe,superimposed CDI in patients with inflammatory bowel disease(IBD)has drawn considerable attention in the gastrointestinal *** majority of IBD patients appear to contract CDI as *** affects disease course of IBD in several ways,including triggering disease flares,sustaining activity,and in some cases,acting as an"innocent"*** its wide spectrum of presentations,CDI has been reported to be associated with a longer duration of hospitalization and a higher mortality in IBD *** patients with restorative proctocolectomy or with diverting ileostomy are not immune to CDI of the small bowel or ileal *** immunomodulator or corticosteroid therapy for IBD should be continued in patients with superimposed CDI is *** appears that more adverse outcomes was observed among patients treated by a combination of immunomodulators and antibiotics than those treated by antibiotics *** use of biologic agents does not appear to increase the risk of acquisition of *** CDI in the setting of underlying IBD,vancomycin appears to be more efficacious than *** controlled trials are required to clearly define the appropriate management for CDI in patients with IBD.

关键词： Clostridium difficile Inflammatory bowel disease Antibiotics Colectomy

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Diagnosis and management of primary sclerosing cholangitis-perspectives from a therapeutic endoscopist

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World Journal of Hepatology 2015年第5期7卷 799-805页

作者： Kunjam Modha udayakumar navaneethan Digestive Disease Institute the Cleveland ClinicClevelandOH 44195United States Center for Interventional Endoscopy Florida HospitalOrlandoFL 32803United States

Primary sclerosing cholangitis(PSC) is a chronic,cholestatic liver condition characterized by inflammation,fibrosis,and destruction of the intra-and extrahepatic bile *** therapeutic endoscopist plays a key role in the diagnosis and management of *** patients presenting with a cholestatic profile,endoscopic retrograde cholangiopancreatography(ERCP) is warranted for a definite diagnosis of *** strictures of the bile duct occur in 36%-57% of PSC *** balloon dilatation with or without stenting have been employed in the management of dominant *** addition,PSC patients are at increased risk of developing cholangiocarcinoma with a 20% lifetime *** cytology obtained during ERCP and use of fluorescence in situ hybridization forms the initial diagnostic step in the investigation of patients with dominant biliary *** review aims to summarize the current evidence supporting the role of a therapeutic endoscopist in the management of PSC patients.

关键词： Endoscopy Therapeutic endoscopy Primary sclerosing cholangitis Bile Dominant strictures

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Non-surgical porto-mesenteric vein thrombosis is associated with worse long-term outcomes in inflammatory bowel diseases

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Gastroenterology Report 2016年第3期4卷 210-215,I0002页

作者： Zubin Arora Xianrui Wu udayakumar navaneethan Bo Shen Department of Internal Medicine The Cleveland Clinic FoundationClevelandOHUSA Department of Gastroenterology and Hepatology The Cleveland Clinic FoundationCleveland OHUSA

Objective:Our aim was to assess the risk factors for non-surgery-related portal and mesenteric vein thrombosis(PMVT)and its impact on the outcomes of inflammatory bowel diseases(IBD).Methods:All patients with a concurrent diagnosis of IBD and PMVT between January 2004 and October 2013 were identified from the electronic medical record(study group;n=20).Patients were matched for age,sex,and IBD phenotype with control IBD patients who had no PMVT,with a ratio of 1:3(control group;n=60).Risk factors for PMVT and IBD-related outcomes at one year after diagnosis of PMVT were compared between the two ***:Of the 20 patients in the Study group,6(30%)had UC,14(70%)had CD and 11(55%)were *** multivariable analysis,inpatient status(odds ratio[OR]6.88;95%confidence interval[CI]1.88-25.12)and baseline corticosteroid use(OR 4.39;95%CI 1.27-15.19)were found to be independent risk factors for the development of *** one-year follow-up,PMVT patients were more likely to have an adverse outcome of IBD,including subsequent emergency room visit(26.3%vs.1.7%;P=0.003),hospitalization for medical management(60.0%vs.20.0%;P=0.001)or IBD-related surgery(65.0%vs.26.7%;P=0.003)than the non-PMVT *** multivariable analysis,PMVT(OR 5.19;95%CI 1.07-25.28)and inpatient status(OR 8.92;95%CI 1.33-59.84)were found to be independent risk factors for poor outcome,whereas baseline immunomodulator use(OR 0.07;95%CI 0.01-0.51)was found to be a protective ***:IBD patients who were inpatients or receiving corticosteroid therapy had an increased risk of the development of *** presence of PMVT was associated with poor clinical outcomes in IBD.

关键词： inflammatory bowel diseases portal vein thrombosis outcomes risk factors

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Primary sclerosing cholangitis and the risk of colon neoplasia in patients with Crohn’s colitis

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Gastroenterology Report 2016年第3期4卷 226-231,I0002页

作者： udayakumar navaneethan Tarun Rai Preethi GK Venkatesh Ravi P Kiran Department of Gastroenterology Digestive disease InstituteThe Cleveland ClinicClevelandOHUSA Department of Colorectal Surgery Digestive disease InstituteThe Cleveland ClinicClevelandOHUSA

Background and aim:Crohn’s colitis(CC)is associated with primary sclerosing cholangitis(PSC).However the risk of colon cancer or dysplasia in CC and PSC is *** aim was to study the risk of colon neoplasia in CC in patients with and without ***:This is a nested,case-control cohort study of all patients diagnosed with concurrent CC and PSC,seen at the Cleveland Clinic between 1985 and ***-three patients with both CC and PSC were compared with a random sample of 159 CC controls without PSC during the same ***:Seven(16.3%)of 43 CC patients with PSC developed colon cancer or dysplasia,compared with 22(13.8%)of 159 controls(P=0.98).Of seven colon neoplasia cases in the PSC group,100%occurred proximal to the splenic flexure,compared with 50%(11/22)cases of colon neoplasia in controls occurring in the proximal colon(P=0.001).Based on Cox regression analysis,male gender independently increased the risk of neoplasia[hazard ratio(HR)=2.68;95%confidence interval(CI)1.30-5.54;P=0.008],as did age at CC diagnosis(HR=1.29;95%CI 1.14-1.47;P<0.001),while the use of azathioprine/6-mercaptopurine was protective(HR=0.30;95%CI 0.13-0.70;P=0.005).The presence of PSC did not increase the risk for colon neoplasia(HR=0.45;95%CI 0.18-1.13;P=0.09).Conclusions:CC patients with PSC appear not to be at increased risk of developing colon *** patients in our cohort with colon neoplasia and concurrent PSC,the neoplasia occurred in the proximal colon in all cases.

关键词： Crohn’s colitis primary sclerosing cholangitis colon neoplasia

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Pre-operative biliary drainage is associated with shortened survival time in patients with cholangiocarcinoma

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Gastroenterology Report 2019年第3期7卷 185-192,I0002页

作者： udayakumar navaneethan Xiang Zhu Mansour A.Parsi Shyam Varadarajulu Center for Interventional Endoscopy Florida Hospital601 E Rollins StOrlandoFL 32803USA Department of Gastroenterology The Cleveland Clinic9500 Euclid AveClevelandOH 44195USA

Background and objective:Although pre-operative biliary drainage(PBD)is frequently performed in patients with cholangiocarcinoma(CCA),its impact on patient survival is *** aim was to evaluate the impact of PBD on overall survival of patients with extra-hepatic ***:This was a retrospective study using the Surveillance,Epidemiology,and End Results(SEER)-Medicare *** who underwent biliary drainage within 3 months prior to and/or after diagnosis of CCA were included in the PBD *** who did not receive biliary drainage were included in the non-PBD *** proportional hazard regression was used to determine independent predictors of ***:Of 3862 patients with extra-hepatic CCA,433(11.2%)underwent curative surgical resection,with a median survival of 14 months(95%confidence interval[95%CI],10-21months)in the PBD cohort(n=126)vs 31 months(95%CI,26-39 months)in the non-PBD cohort(n=307)(P<0.001),during the median follow-up duration for the surgical cohort of 26 months(range,1-60 months).Among the 433 patients,126(29.1%)underwent PBD and had significantly higher Charlson comorbidity index and advanced SEER stage than those without PBD before *** multivariable analysis in patients who underwent curative surgical resection,after adjusting patient demographics,tumor characteristics,Charlson comorbidity index,radiotherapy and chemotherapy,PBD was significantly associated with shortened survival time(hazard ratio,2.35;95%CI,1.34-4.10;P=0.003).Conclusions:PBD appears negative impact on long-term survival in patients with potentially resectable CCA and should be avoided if possible.

关键词： Cholangiocarcinoma endoscopic retrograde cholangiopancreatography biliary drainage pre-operative mortality

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Colorectal cancer resection rates in patients with inflammatory bowel disease:a population-based study

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Gastroenterology Report 2018年第4期6卷 263-269,I0001页

作者： udayakumar navaneethan Xiang Zhu Dennisdhilak Lourdusamy Vennisvasanth Lourdusamy Bo Shen Ravi Kiran Center for Interventional Endoscopy Florida HospitalOrlandoFL 32803USA Center for Inflammatory Bowel Diseases The Cleveland ClinicClevelandOH 44195USA Division of Colorectal Surgery Columbia University Medical Center/New York Presbyterian HospitalNew YorkNY 10032USA

Background and objective:Inflammatory bowel disease(IBD)is associated with an increased risk of colorectal cancer(CRC).This study aimed to analyse the trends in rates of resection for IBD-related CRC in the ***:We used the Nationwide Inpatient Sample from 1995 to *** trends in age-adjusted rates of resection for CRC in the setting of IBD were analysed using multivariate Joinpoint regression *** primary outcome was surgical resection of CRC in the setting of ***:We included 3597168 IBD discharges in the present study,of which 275479 underwent CRC resection between 1995 and *** annual CRC resection rates among IBD population decreased significantly from 1995 to *** decrease was significant in all age groups with an annual decrease of 393(P75 years,*** annual IBD-CRC resection rate per 100000 IBD discharges for proximal CRC decreased by 149(P75 years,between 1995 and *** multivariate Poisson regression analysis,after adjustment for age and sex,CRC resections decreased by 3.9%each year from 1995 to ***:CRC resection rates among IBD patients have continued to decrease annually from 1995 to *** is a population-level decrease in resection of both proximal and distal CRC reflecting a decreasing incidence of IBD-related CRC incidence in the USA.

关键词： Colorectal cancer inflammatory bowel disease Crohn’s disease ulcerative colitis surgery

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Endoscopic ultrasound in the diagnosis of cholangiocarcinoma as the etiology of biliary strictures:a systematic review and meta-analysis

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Gastroenterology Report 2015年第3期3卷 209-215页

作者： udayakumar navaneethan Basile Njei Preethi G.K Venkatesh Vennisvasanth Lourdusamy Madhusudhan R Sanaka Digestive Disease Institute The Cleveland ClinicClevelandOHUSA Department of Internal Medicine University of Connecticut Health CenterFarmingtonCTUSA

Background and aim:Extrahepatic cholangiocarcinoma(CCA)typically presents as biliary *** ultrasound(EUS)-fine needle aspiration(FNA)may contribute to the diagnosis of CCA as the etiology of extrahepatic biliary *** aim was to study the uselfulness of EUS-FNA in diagnosing CCA as the etiology of biliary *** and methods:In this meta-analysis,PUBMED and EMBASE databases were examined to find studies published to April 2014 where diagnostic correlation of CCA was *** reporting only‘‘positive for malignancy’’were included in our *** main outcome measurements were sensitivity,specificity and likelihood ***:Six studies were included,covering 196 *** overall pooled sensitivity and negative likelihood ratio(LR-)of EUS-FNA for diagnosis of CCA were 66%[95%confidence interval(CI)57-74%]and 0.34(95%CI 0.26-0.43),*** five studies(146 patients),where a mass lesion was detected during EUS,the pooled sensitivity and LR-of EUS-FNA for diagnosis of CCA were 80%[95%CI 72-87%]and 0.20(95%CI 0.13-0.28),*** the 49 patients with a negative brush cytology,the pooled sensitivity and LR-of EUS-FNA for diagnosis of CCA were 59%[95%CI 44-73%]and 0.41(95%CI 0.27-0.56),***:Our study suggests that EUS-FNA is useful in the evaluation of CCA as the etiology of biliary ***-FNA may improve the diagnosis of CCA in patients with negative cytology and no mass on cross-sectional imaging.

关键词： endoscopic ultrasound fine-needle aspiration cholangiocarcinoma

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