Dr. Uday Nagesh Shivaji

Background Inflammatory bowel disease (IBD) is considered a risk factor for colorectal cancer (CRC). Patients with IBD are at higher risk of CRC compared with normal population and therefore undergo surveillance colonoscopy according to national guidelines which have changed over the past 10 years. Globally, the cumulative risk has generally reduced over the years and it is likely due to better management of IBD and robust surveillance practices. We aimed to study impact and outcomes of surveillance in our IBD patients with changing surveillance guidelines. Methods We reviewed all patients with IBD undergoing surveillance during a 10-year period from 2007 to 2017 in our tertiary care centre. Patients with histological reports confirming any grade of dysplasia (low grade, high grade) or CRC were included. Lesions indefinite for neoplasia were excluded. All electronic clinical records were reviewed and relevant data compiled using the endoscopy, histology, and radiology databases. Patients were also analysed as a sub-group if found to have CRC. Results Eighty-three patients (M = 58) were diagnosed with dysplasia or cancer (median age 65 years range 34–87 years) between 2007–2017. Eighty (97%) patients had ulcerative colitis (UC) and 40 (48%) had pancolitis. Seventy-five patients had identifiable lesions at endoscopy (polypoid = 35; non-polypoid = 11; other findings including pseudopolyps = 29). 76.2 % of lesions were in the left colon and rectum. Fifty-two patients underwent surgery based on surveillance findings, the majority having a panproctocolectomy. Of 28 patients (M = 20) diagnosed to have CRC in this cohort, 20 adenocarcinomas were diagnosed on histology of biopsies at colonoscopy. Of 28 CRC, 26 were associated with UC, 2 with Crohn’s disease, and 5 had primary sclerosing cholangitis. 70% of the CRC were in left colon and rectum. Only 32% of patients had surveillance within 5 years of cancer detection and majority had white light endoscopy (WLE) with random biopsies; 4 CRC patients had previous surveillance within 1 year. 29% had active disease on endoscopy. Over the 10-year period there was no change in the detection rate of dysplasia or CRC. Conclusions In our cohort of patients, male gender and UC were associated with higher risk of CRC. Our data show high interval cancer risk highlighting that WLE with random biopsies are likely to miss early dysplastic lesions. There was no change in detection rate of CRC in IBD patients over 10-year period. Unless surveillance techniques and protocols are rigorously optimised, the risk of interval CRC should be kept in mind when implementing guidelines regarding surveillance frequency.

Introduction Tuberculosis (TB) carries significant morbidity. It is most commonly pulmonary but it can also affect the gastrointestinal (GI) tract (6% of total cases in UK). Abdominal tuberculosis (A-TB) is a rare disease which can present a unique diagnostic challenge mimicking various GI diseases. We reviewed a 10 year cumulative regional TB database to report results on this unusual condition. Method A retrospective review of patients diagnosed with A-TB between 2006 & 2016 in a single tertiary centre in South Birmingham covering a multi-ethnic urban population of ~7 50 000. A central surveillance database managed by Respiratory Physicians and Public Health England was used to identify patients with A-TB. We reviewed clinical data from electronic records including radiology, chemical pathology, histopathology, endoscopy databases, surgical notes and letters. Results Of 41 patients [M=22 (54%);mean age 42y (SD ±17y)] identified with A-TB, 17 (41%) were Pakistani, 6 (15%) were other Asian and 8 (19%) were Afro-Caribbean with no data on country of origin or ethnicity recorded for the remainder. Thirty three (80%) were residents of economically deprived areas of Birmingham which were among the 10% of most deprived constituencies in UK, with an overall lowest national decile of 1#.(# Index of multiple deprivation as per local council) The most frequently reported symptoms were abdominal pain (n=23; 56%), weight loss (n=17; 41%), fever (n=10; 24%) and vomiting (n=9; 22%). Twelve (29%) patients were first seen in the surgical clinic and 9 (22%) in a medical gastroenterology clinic. A-TB was confirmed on tissue biopsy in 24 (58%) of which 2 were post-bowel resection. Seventeen (41%) patients had positive cultures with full drug sensitivity and only 5 (12%) patients had polymerase chain reaction (PCR) tests. Eight patients (20%) had concurrent pulmonary TB. Thirty seven patients (90%) received full, successful treatment for A-TB. Conclusion Asian ethnicity and low socioeconomic status appear to be risk factors for A-TB in a single tertiary centre. Histological diagnosis at endoscopic or surgical biopsy is a reliable diagnostic tool for confirming TB. Both gastroenterologists and surgeons need to consider A-TB in their differentials, as once diagnosed, most are successfully treated

Abstract Introduction Anti-TNF(tumour necrosis factor) therapy is an effective treatment for Crohn’s disease. As the usage of anti-TNF drugs increase worldwide, the proportion of reported serious side effects are expected to rise. We present a serious adverse reaction to Adalimumab. Method Case A 20 year old gentleman with background of Crohn’s disease with previous terminal ileal resection and Juvenile Idiopathic arthritis (JIA) had been on Adalimumab (Humira, Abbvie, USA), for dual indication, on a dose of 40mg per week since 2010 and was in remission. He presented to hospital in September 2014 with an erythematous maculo-papular rash distributed over his lower limbs, trunk and upper limbs. Initial blood tests showed raised inflammatory markers with no other abnormality and a vasculitis screen was negative. He had dramatic worsening of the rash while in hospital with rapid development of new lesions and bullous transformation of some of the existing lesions with necrotic areas. A skin biopsy showed severe cutaneous leucocytoclastic vasculitis. Results He was treated with high-dose intravenous Methyl-Prednisolone and was later switched to oral therapy. He improved over the next 8 weeks with reducing dose of Prednisolone. Anti-TNF drug therapy was the likely cause of the cutaneous vasculitis in absence of another specific trigger and based on existing literature, cutaneous vasculitis secondary to anti-TNF therapy is one of the side effects which may require drug withdrawal, and can be potentially serious and debilitating. There have been very few case reports worldwide of cutaneous vasculitis secondary to anti-TNF therapy, with fewer cases reported secondary to Adalimumab. According to current literature, the average duration of treatment before patients developed a major cutaneous reaction was noted to be 36 months, with all responding to drug withdrawal. Conclusion We believe this is the first reported case of bullous vasculitis of this degree of severity, secondary to Adalimumab, involving nearly 63% of body surface area (Rule of 9s) with full thickness involvement. (Picture) As the use of anti-TNF drugs increases worldwide, it is worth considering them as a possible cause of cutaneous lesions. Our experience suggests that withdrawal of the drug and high dose corticosteroids is an effective treatment strategy.