New onset of grave’s disease during anti-tnfα treatment in a case of fistulizing crohn’s disease

 New onset of grave’s disease during anti-tnfα treatment in a case of fistulizing crohn’s disease Presenting Author: NAWAF ZAKARY
Additional Authors: ALGUILI ELSHEIKH, NOOF HAMID, OMAR ABDULAAL, MOHAMMED ALGHAMDI, WALID FARAH
Corresponding Author: NAWAF ZAKARY
Affiliations: King Fahad Military Medical Complex
The association between inflammatory bowel disease in form of ulcerative colitis and autoimmune thyroid disease has been well documented. However, the association between crohn’s disease and autoimmune thyroid disease is not well established and there have only been a few reported cases in the literature.
Case presentation We present here a rare case of a 35-year-old Saudi female with simultaneous onset of Graves’ disease and fistulizing Crohn’s disease. Crohn’s disease was complicated with intra-abdominal fistulas. Despite intense medical treatment with regular Azathioprine, total parenteral nutrition, antibiotics, and corticosteroids the clinical course of the disease was suboptimal. Finally, the patient underwent laparotomy and right hemi-colectomy with ileo-transverse anastomosis, simultaneous drainage of the abdominal abscess and closure of the opening. Although the surgical approach cured the perforating complications of the disease (fistulas and abscess), the luminal disease in the colon remnant was still active. The subsequent successful treatment with infliximab, azathioprine and mesalazine resulted in the induction and maintenance of the disease remission. Later on, patient develop full blown picture of Graves’ disease after she started infliximab which was stopped later and the patient improved on antithyroid medication. Conclusion: We are not sure whether the association between Crohn’s disease and Gravés disease is infliximab dependent or independent and it needs more case studies and research.
 KeyWord(s): 1. Gravés disease; 2. Crohn’s disease; 3. ulcerative colitis; 4. infliximab; 5. azathioprine
 Poster 136 Journal of Gastroenterology and Hepatology 2014; 29 (Suppl. 3): 51–313 © 2014

Management of iatrogenic esophageal perforation with endoscopic stenting

Management of iatrogenic esophageal perforation with endoscopic stenting
Presenting Author: NAWAF ZAKARY
Additional Authors: ALGUILI ELSHEIKH, NOOF HAMID, HIND HAMID, MOHAMMED ALGHAMDI, WALID FARAH
Corresponding Author: NAWAF ZAKARY
Affiliations: King Fahad Military Medical Complex

Objective: Esophageal perforation is a challenging disease process with high morbidity and mortality. Despite the availability of diagnostic radiological tools, there is still a chance of delaying in diagnosis, because of non specific symptoms. In clinical practice 60% of cases are iatrogenic due to endoscopic procedures. The morbidity and mortality rate is directly related to the delay in diagnosis and initiation of optimum treatment. The reported mortality from treated esophageal perforation is 10% to 25%, when therapy is initiated within 24 hours of perforation, but it could rise up to 40% to 60% when the treatment is delayed beyond 48 hours.

Case Presentation: We like to present a 67 year old female patient of achalasia. She presented with weight loss and progressive dysphagia. Barium swallow and gastroscopy confirmed the diagnosis. She underwent successful first session of endoscopic pneumatic dilation but after the second session, she developed shortness of breath and abdominal pain. Gastrographin studies and computer tomography scan of the chest and abdomen confirmed the diagnosis of esophageal perforation. She was managed conservatively with endoscopic stenting, to which she recovered fully.

Conclusion: Esophageal perforation is a highly morbid condition with high mortality. More accurate diagnosis and less-invasive treatment are reducing morbidity and mortality to more acceptable levels. While surgery remains the gold standard treatment, less invasive and endoscopic methods are being explored, and their role is evolving. For optimum outcome for management of esophageal perforations, a multidisciplinary approach is needed.

Key Word(s): 1. achalasia; 2. esophageal perforation; 3. esophageal stenting

© 2014 The Authors. Journal of Gastroenterology and Hepatology

New onset of grave’s disease during anti-tnfα treatment in a case of fistulizing crohn’s disease

IBD P-254 New onset of grave’s disease during anti-tnfα treatment in a case of fistulizing crohn’s disease Presenting Author: NAWAF ZAKARY Additional Authors: ALGUILI ELSHEIKH, NOOF HAMID, OMAR ABDULAAL, MOHAMMED ALGHAMDI, WALID FARAH Corresponding Author: NAWAF ZAKARY Affiliations: King Fahad Military Medical Complex, King Fahad Military Medical Complex, King Fahad Military Medical Complex, King Fahad Military Medical Complex, King Fahad Military Medical Complex Objective: The association between inflammatory bowel disease in form of ulcerative colitis and autoimmune thyroid disease has been well documented. However, the association between crohn’s disease and autoimmune thyroid disease is not well established and there have only been a few reported cases in the literature. Case presentation We present here a rare case of a 35-year-old Saudi female with simultaneous onset of Graves’ disease and fistulizing Crohn’s disease. Crohn’s disease was complicated with intra-abdominal fistulas. Despite intense medical treatment with regular Azathioprine, total parenteral nutrition, antibiotics, and corticosteroids the clinical course of the disease was suboptimal. Finally, the patient underwent laparotomy and right hemi-colectomy with ileo-transverse anastomosis, simultaneous drainage of the abdominal abscess and closure of the opening. Although the surgical approach cured the perforating complications of the disease (fistulas and abscess), the luminal disease in the colon remnant was still active. The subsequent successful treatment with infliximab, azathioprine and mesalazine resulted in the induction and maintenance of the disease remission. Later on, patient develop full blown picture of Graves’ disease after she started infliximab which was stopped later and the patient improved on antithyroid medication. Conclusion: We are not sure whether the association between Crohn’s disease and Gravés disease is infliximab dependent or independent and it needs more case studies and research. KeyWord(s): 1. Gravés disease; 2. Crohn’s disease; 3. ulcerative colitis; 4. infliximab; 5. azathioprine Poster 136 Journal of Gastroenterology and Hepatology 2014; 29 (Suppl. 3): 51–313 © 2014

Link between early exposure to acetaminophen and childhood asthma found weak, overstated

FROM THE ARCHIVES OF DISEASE IN CHILDHOOD The reported link between early life exposure to acetaminophen and the development of asthma in children is “weak” and “overstated” based on currently available evidence, according to a report published by the Archives of Disease in Childhood. In a review of currently available data culled from Embase and PubMed databases, 1,192 relevant studies conducted between 1967 and 2013 were analyzed, of which 11 were included for analysis. Of these 11 studies, 5 found “increased odds” that exposure to acetaminophen during the first trimester of pregnancy could lead to development of asthma (pooled odds ratio, 1.39); however, there was a high degree of between-study heterogeneity among the trials (I= 64.2%, P = .03), reported Dr. M. Cheelo of the University of Melbourne, and associates. Of those five, only two studies examined the effects of acetaminophen exposure during the second trimester, but attained widely disparate results: Study one reported an OR of 1.06, while the other reported an OR of 2.15, with I= 80%. Two studies also tested acetaminophen exposure during the third trimester and found a “weak association,” with a pooled OR of 1.17. Three studies look at acetaminophen exposure through an entire pregnancy, but all had “significant heterogeneity” in their findings (OR = 1.65, 1.22, and 0.74; I= 89%). Only one study that was examined adjusted for respiratory tract infections during pregnancy, but according to the authors, “all studies that adjusted for early life respiratory tract infections found a reduction in the association between [acetaminophen] exposure and subsequent childhood asthma” (Arch. Dis. Child. 2014 [doi:10.1136/archdischild-2012-303043]). The other 6 of the 11 total studies examined acetaminophen exposure over the first 2 years of life. Three of these studies found a “weak positive association,” as did four studies directly comparing children with and without acetaminophen exposure. All but one study adjusted results for respiratory tract infections during pregnancy, which caused a “moderate attenuation of the association between frequency of [acetaminophen] intake and childhood asthma.” Consequently, investigators concluded that “evidence of an association between early life [acetaminophen] and asthma is often overstated, and there is currently insufficient evidence to support changing guidelines in the use of this medicine.”