Anti-TNF was frequently used among patients with EIM. In more than 40%, anti-TNF treatments are started to treat EIM rather than IBD. Given the good response rates, anti-TNF seems to be a valuable option in the treatment of EIM, whereas appearance of EIM under anti-TNF does not seem to be a source of considerable concern.

Background:The most common adverse event of endoscopic retrograde cholangiopancreatography is pancreatitis. Precut sphincterotomy has been regarded as a risk factor. Some authors have stated that early precut may actually reduce post-ERCP pancreatitis risk. However, early precut as a preventive measure has not been compared to other preventive measures, such as pancreatic duct stent placement.Aim: To compare the efficacy of early precut sphincterotomy versus pancreatic duct stent placement in high-risk subjects undergoing endoscopic retrograde cholangiopancreatography for the prevention of post-endoscopic cholangiopancreatography. Materials and methods:This was a single-blinded, randomized trial that took place in two tertiary referral centers in Buenos Aires, from November 2011 to December 2013. ERCP subjects presented at least one of the following risk factors: female sex, age less than 40 years, clinical suspicion of sphincter of Oddi dysfunction, previous pancreatitis, and/or common bile duct diameter of less than 8 mm. Only those who presented a difficult biliary cannulation were randomized into two groups: those who received early precut sphincterotomy and those in whom persistency of biliary cannulation was intended, with subsequent pancreatic duct stent placement after cholangiography was achieved. The incidence of post-ERCP pancreatitis, as well as other adverse events incidence, was compared.Results: Overall, 101 patients were enrolled, 51 in the pancreatic duct stent group and 50 in the early precut group. Pancreatitis rate was similar in both groups (3.92% vs. 4%, p NS). In all cases, pancreatitis was classified as mild. There were no deaths registered.Conclusion: Early precut was associated with an incidence of adverse events similar to pancreatic duct stent placement.

Extraintestinal manifestations (EIM) in inflammatory bowel disease (IBD) occur frequently and may present themselves before or after IBD diagnosis. They most commonly affect the eyes, skin, and joints, but can also involve other organs such as the liver. Some EIM are associated with intestinal disease activity and ameliorate by treatment of the underlying IBD. This is seen in patients with peripheral Type 1 arthritis, oral aphthous ulcers, episcleritis, and erythema nodosum. Other EIM are intestinal disease activity-independent such as uveitis, and ankylosing spondylitis. Finally, some EIM (e.g. pyoderma gangrenosum and primary sclerosing cholangitis) may or may not be associated with the underlying IBD. Successful therapy of EIM is important for improving quality of life of IBD patients. TNF antibody therapy is an important treatment option for EIM in IBD patients whereas no such beneficial effect was reported for alpha 4 beta 7 integrin antibodies such as vedolizumab so far. This article reviews the therapeutic experience with TNF antibodies for the treatment of EIM in IBD patients.

Early precut showed a better cost-effectiveness profile when compared to pancreatic duct stent placement.

Cholecystocolonic fistula is an unusual and late complication of cholelithiasis. The symptoms usually are nonspecific and most cases are diagnosed intraoperatively. Our patient was a female, 75 years old, smoker, with a severe aortic stenosis history. She had a 6-month evolution diarrhea associated with weight loss, coagulopathy and aerobilia in abdominal ultrasound. On behalf of the clinic manifestations, cholecystocolonic fistula was suspected so an abdominal computer tomography scan and a cholangioresonance confirmed this suspicion. Given the patient comorbidities, we decided not to perform a surgical approach. An endoscopic retrograde cholangiography with extraction of choledocolithiasis and placement of a fully covered self-expanding metallic stent was associated with a video colonoscopy and closure of the colonic fistula with a clip device. The patient had a favourable evolution and was discharged on the second day post-procedure. After 3 months of follow-up, she did not present diarrhea and has recovered her weight loss and nutritional status. Given the unusual nature of the case and the significance of the preoperative diagnosis, which allowed us to carry out a minimally invasive treatment, we believe that its report is useful. We place special emphasis on the aerobic triad, alteration of the prothrombin concentration and chronic diarrhea that allowed us to suspect the diagnosis.