TorontoGiFellow

 

 RCT looking at withdrawal of infliximab or immunomodulator, in patients on combination therapy and in remission for atleast 6 months - 211 patients randomized in 7 countries (Australia / Nordic countries, UK, France) to either continuing both, stopping infliximab or stopping immunomodulator  - Patients with fistulising disease, or severe reaction to infliximab were excluded. Risk of relapse at 2 years: Combination therapy: 14% Ifx stopped = 36% immunomodulator stopped = 10% Nearly all patients who relapsed on Ifx withdrawal were promptly re-captured by starting Ifx Stopping Ifx in patients with CD on combination therapy results in an excess 21% increase in risk of relapse.  No increase risk of relapse in stopping immunomodulator after stable remission has been achieved.

 Source: British society / UK-PSC guidelines -  10.1136/gutjnl-2018-317993 ERCP in PSC 1) All patients should receive broad-spectrum antibiotics for 3-5 days 2) Dominant stricture (clinically significant stricture) is defined as a stricture causing functional narrowing - either 1) biochemically (cholestatic LFT), 2) radiologically (upstream dilatation), 3) symptomatically (pruritius). The BSG guideline doesnt mention size criteria for definition of dominant stricture. 3) Obtain cytology from dominant strictures ( sensitivity 50%) every time 4) Balloon dilatation of stricture is thought to retard progression of liver disease by reducing cholestatic injury 5) Stenting is associated with high rates of cholangitis / stent occlusion, as well as pancreatitis. All guidelines recommend against routine stenting in patients with PSC. Dominant stricutre need management with periodic balloon dilatation only without stenting Other things PSC: British guidelines suggest: Annual ultrasound of GB in

10.1016/j.jhep.2023.02.023  Improved Overall survival (HR 0.6) with anticoagulation (VKA) in Cirrhotics, independent of portal vein recanalization rate Portal hypertensive bleeding - same between groups.  Non-PH bleeding:  80% of patients had main PV thrombus, with half patients had complete PVT Median duration of VKA Rx = 9 months. Overall median FU - 27 months. This was an independent patient level data Meta-analysis of 500 patients, with liver transplantation as competing event. Every study had treatment and no treatment arms. Exclusions: Tumoral PVT Limitations: Generally, patients with higher CP scores / bilirubin tended not to receive anticoagulation. This was however adjusted for, in multivariate analysis