Diagnosis and treatment of uncommon ileal endometriosis: a case report and literature review

Endometriosis is defined as the presence of endometrial tissue outside the uterine cavity. It is a common finding in premenopausal women and commonly affects the gastrointestinal tract, especially the rectosigmoid tract. Small bowel involvement is rare and usually asymptomatic making diagnosis difficult. Here we report an uncommon case of exophytic ileal endometriosis surgically treated. Detailed pre-operative counselling on the risk of ileal surgery should always be considered in all cases with endometriosis requiring surgery. We also present a review of the literature regarding the clinical presentation, diagnosis, and treatment of this challenging condition.

Rectosigmoid endometriosis: diagnostic pitfalls and management – A case report

Endometriosis constitutes a benign condition, occurring in 10-12% of menstruating women. Bowel involvement is estimated to occur in 5-12% with the rectosigmoid region involved in up to 90% of these cases. We present the case of a 45-year-old Caucasian female patient with rectosigmoid endometriosis.

Treatment preferences for medication or surgery in patients with deep endometriosis and bowel involvement -- A Discrete Choice Experiment

Objective To study the preferences and risk tolerance of women suffering from deep endometriosis (DE) with bowel involvement when they have to choose between conservative or surgical. Design Labelled Discrete Choice Experiment (DCE). Setting Dutch academic and non-academic hospitals and online recruitment. Population or Sample A total of 169 patients diagnosed with DE of the bowel. Methods Baseline characteristics and the fear for surgery were collected. Women were asked to rank attributes and choose between hypothetical conservative (medication) or surgical treatment in different choice sets (scenarios). Each choice set offered different levels of all treatment attributes. Data were analysed by using multinomial logistic regression. Main Outcome Measures The following attributes; effect/or risk on pain, fatigue, pregnancy, endometriosis lesions, mood swings, osteoporosis, temporary stoma and permanent intestinal symptoms were used in this DCE. Results In the ranking osteoporosis is the least important attribute, while in the DCE, a lower chance of osteoporosis is one of the most important drivers when choosing a conservative treatment. Women with previous surgery show less fear for surgery compared to women without surgery. The low anterior resection syndrome is almost equally important for patients as the chance of pain reduction. Pain reduction has higher importance than improving fertility chances even in women with a future child wish. Conclusions The risk of suffering from LARS as a result of treatment is almost equally important as the reduction of pain symptoms. Women with previous surgery experience less fear for surgery compared to women without a surgical history.

634 Review of Nephroureteric Surgical Service in a District Urological Center

Background New Cross hospital has been offering radical/partial nephrectomy, nephro-ureterectomy for cancer patients and simple nephrectomy for non-functioning kidney with availability of robotic system facilities since 2016. Methodology Retrospective analysis of data collected prospectively between January 2019 and September 2019. All patients underwent nephrectomy/nephroureterectomy and their demographic, comorbidities and surgical outcomes data analysed. Results 7 underwent lap robotic nephroureterectomy, 27 underwent laparoscopic radical nephrectomy, 4 underwent laparoscopic simple nephrectomy, compared to total of 13 combined cases in 2018. FtM ratio- 1:1.92(13:25). Mean cohort age 64. Mean cohort BMI is 28.3. Mean pre-op HB is 132.9. Average op time for nephroureterectomy is 247 minutes, nephrectomy is 108.2 minutes. Average blood lost is 70mls, no patient of the cohort required any blood transfusion. 1 case sustained splenic laceration had surgical repair, 1 case was abandoned due to extensive bowel involvement. No cases required conversion from laparoscopic to open procedure. Post operatively, 1 patient developed VT, 1 patient had subcut haematoma, Average increase in serum creatinine is 42, and average Hb drop is 10.7. Average admission period were 3.7 days. Conclusions Our urological centre manage to perform more laparoscopic nephroureteric procedures as compare to previous year without much decline in terms of patient surgical outcome.

P117 Patient perceptions about causes of flare in IBD: results from the baseline dataset of the PREdiCCt study

Background Patient reported outcomes are important endpoints in IBD management, but patient perceptions of the causes of disease flare are unknown and thus may reveal novel areas for future study. Methods The PREdiCCt study (https://www.predicct.co.uk) is the largest prospective study of the causes of IBD flare. 2629 patients in clinical remission were recruited from 48 UK sites and followed for 2 years with detailed assessment of environmental and dietary factors via monthly questionnaires. 1946 (74%) patients completed the baseline questionnaires. We present here the results of the baseline questionnaire analysis of patient perceptions of disease flare, derived from a list of 17 putative causes from the literature and their own experience via free text input. Results In total 1,946 IBD patients [male=852, CD=1000; UC/IBDU=946, age 45.8±15.5 (mean±SD in years)] gave their opinion about factors initiating a flare. The commonest causes reported were stress (n=1359, 69.8%), dietary changes (n=911, 46.8%), alcohol use (n=385, 19.8%), sleep disturbances (n=331, 17%) and that their medication stopped working (n=308, 15.8%) (Figure 1). CD participants were more likely to identify dietary changes (50% vs 43%, p<0.001) and menstruation (16% vs 10% of female patients, p<0.001) as flare triggers than UC/IBDU participants, while UC/IBDU participants more frequently reported loss of response to medication as a trigger for flare (9% vs 5% for CD participants, p<0.001). CD patients with small bowel involvement were more likely to name dietary changes (61% vs 42%, p<0.001), travel (14% vs 9%, p=0.016) and smoking (4% vs 1%, p=0.04) as flare triggers. When compared by gender, the ranking of causes was identical but female participants were more likely to identify stress (77% vs 65%, p<0.001) and antibiotic use (12% vs 6%, p<0.001) as reasons for disease relapse compared to male participants. Conclusion Stress, dietary changes and alcohol use were identified as the main causes of flare by patients with dietary changes more frequently reported in CD (especially those with small bowel involvement). The impact of environmental and dietary factors in the development of flare is being further investigated with ongoing longitudinal data collection in the PREdiCCt Study.

P462 Impact of teduglutide, a GLP-2 agonist, on inflammatory bowel disease-associated short bowel syndrome: a tertiary single-center study

Background Teduglutide (TED), a GLP2 agonist, have been shown to exert anti-inflammatory effects on the intestinal mucosa in murine preclinical models and evaluated with a positive trend in a phase 2a randomized controlled trial in non-short bowel syndrome (SBS) Crohn’s disease (CD) patients. TED showed efficacy in reducing parenteral nutrition and or intravenous (PN/IV) dependence in SBS with intestinal failure (SBS-IF). However, limited data exists on its specific effect on the natural history of IBD in SBS patients treated with TED. Therefore, we aimed to assess the efficacy and safety of TED in patients with IBD-associated SBS as well as the effect of TED on the course of IBD. Methods We conducted an observational retrospective study. Adult patients SBS-IF due to IBD and who were treated with TED were enrolled. Response was defined as a decrease of at least 20% in total volume of PN. Active IBD was defined based on morphologic and histologic data (CT-scan, colonoscopy and/or enteroMRI). Patients were followed until last news or TED discontinuation. Results We enrolled 14 IBD patients, including 2 patients with ulcerative colitis, with a median follow-up of 4.2 ± 4 years. Of the 12 CD patients, 11 had ileocolonic involvement and 1 had only small bowel involvement. 11 patients had type-1 SBS and 3 had type-2 SBS. 7 patients were only receiving intravenous fluid and 7 were on PN/IV. Patients were in average receiving PN/IV for 9.1 years at TED initiation. Regarding IBD, 4 patients had active disease at inclusion, 3 with a structuring behavior and 1 with a fistulizing behavior. 5 patients were on biologic treatment (antiTNF or ustekinumab) at inclusion. At month 3 (M3), 9 of 14 patients were responders. 3 were weaned from any iv supplementation. 3 of 7 patients initially on TPN were weaned from caloric input, including one still receiving iv fluids. Caloric input was in average at 7330 kcal/week at baseline versus 4615 at M3. Mean total parenteral volume went from 11849 ml/week at M0 to 8223 at M3. 2 of 4 patients with active disease at baseline showed improvement in disease activity while on TED. The latter 2 patients were totally weaned off PN/IV.Six patients withdrew TED during follow-up. 2 patients stopped after a diagnosis of cancer (1 melanoma and 1 chronic myeloid leukemia). Survival without TED discontinuation was estimated at 85.7 % IC95(69.2–100) at 1 year, 78.6% IC95(59.8–100) at 2 years and at 64.3% IC95(43.5–95) at 5 years Conclusion TED appears effective and safe in IBD-associated SBS-IF patients. In specific cases, it may impact positively the inflammatory course of the disease. Further prospective studies are warranted to specifically evaluate TED in IBD-associated SBS, including patients with active IBD.

Case of rare association of peripheral neuropathy with mixed connective tissue disorder

Chronic inflammatory demyelinating polyneuropathy (CIDP) is probably the best-recognised progressive immune-mediated peripheral neuropathy. It presents with symmetrical, motor predominant peripheral neuropathy that produces both distal and proximal weakness. Here we report a case of a 38-year-old man who presented with chronic additive large and small joint inflammatory polyarthritis, associated with morning stiffness, anasarca associated with frothy urine and progressive episodic, relapsing and remitting, sensorimotor lower motor neuron type quadriparesis without any bladder and bowel involvement. He was diagnosed as a case of CIDP, and the aetiology was found out to be mixed connective tissue disorder, which is a rare association with CIDP. The patient responded dramatically to glucocorticoid.

Deep infiltrating endometriosis with bowel involvement. Literature review

Endometriosis is a prevalent disease in females of the childbearing age. It may be accompanied by bowel involvement. In such cases, the most frequently observed lesion locations are the rectum and the rectosigmoid with the occurrence rate of 3-37 %. Treatment of severe forms of deep infiltrating endometriosis with bowel wall involvement is one of the most challenging problems of modern gynaecology. Apart from general intra- and postoperative risks (haemorrhage, infection, direct damage to the organs) or bowel and bladder dysfunction, one of the most severe complications is the development of anastomotic leaks. This article presents a review of literatures dated 2010-2020 searched for in PubMed and Google Scholar databases and devoted to operative treatment of patients with deep infi ltrating endometriosis. We made an emphasis on the effi cacy of the multidisciplinary approach to operative treatment of patients with deep infiltrating endometriosis and bowel involvement. Multidisciplinary laparoscopic treatment has become a standard of medical aid in deep infiltrating endometriosis. Depending on the size of endometrial lesion and the location of bowel involvement, complete removal of the infiltrate or bowel resection is performed in cooperation with an experienced colorectal surgeon. The operative tactics in laparoscopic endometriosis resection, including bowel resection, may provide advantages for both the patients and the healthcare system. The optimal model is to be chosen drawing on the basis of the maximum benefit for the patient.