bleeding, and more specifically amongst class A and Bcirrhotic patients.7 Unfortunately, issues of generalisabilityin the aforementioned trial prevent definitive conclusionsabout the impact of transfusion policy on the outcomesof patients with nonvariceal bleeding; importantly, addi-tional information will soon be available from a clusterrandomized trial in the United Kingdom.8

In the interim, based on all currently available evi-dence, clinicians should continue to follow consensusrecommendations for patients with nonvariceal bleeding.We would also like to correct Dr Lin regarding his com-ments about current recommendations. The 2010 Inter-national Consensus Group in fact suggested a restrictivetransfusion practice, with blood transfusions adminis-tered to patients with a haemoglobin level of 7 g/dL orless, pending further data.8 Furthermore, threshold hae-moglobin levels of 6–10 g/dL may warrant transfusion inpatients with underlying cardiac disease.9

ACKNOWLEDGEMENTThe authors’ declarations of personal and financial inter-ests are unchanged from those in the original article.2

REFERENCES

1. Lin H-J. Letter: is blood transfusion really a risk factor forrebleeding in nonvariceal gastrointestinal bleeding? AlimentPharmacol Ther 2013; 37: 838–9.

2. Restellini S, Kherad O, Jairath V, Martel M, Barkun AN. Redblood cell transfusion is associated with increased rebleeding inpatients with nonvariceal upper gastrointestinal bleeding. AlimentPharmacol Ther 2013; 37: 316–22.

3. Barkun A, Sabbah S, Enns R, et al. The Canadian Registry onNonvariceal Upper Gastrointestinal Bleeding and Endoscopy(RUGBE): endoscopic hemostasis and proton pump inhibition areassociated with improved outcomes in a real-life setting. Am JGastroenterol 2004; 99: 1238–46.

4. Stanley AJ, Dalton HR, Blatchford O, et al. Multicentrecomparison of the Glasgow Blatchford and Rockall Scores in theprediction of clinical end-points after upper gastrointestinalhaemorrhage. Aliment Pharmacol Ther 2011; 34: 470–5.

5. Romagnuolo J, Barkun AN, Enns R, Armstrong D, Gregor J.Simple clinical predictors may obviate urgent endoscopy inselected patients with nonvariceal upper gastrointestinal tractbleeding. Arch Intern Med 2007; 167: 265–70.

6. Hearnshaw SA, Logan RF, Palmer KR, Card TR, Travis SP,Murphy MF. Outcomes following early red blood cell transfusionin acute upper gastrointestinal bleeding. Aliment Pharmacol Ther2010; 32: 215–24.

7. Villanueva C, Colomo A, Bosch A, et al. Transfusion strategiesfor acute upper gastrointestinal bleeding. N Engl J Med 2013; 368:11–21.

8. Available at: http://www.nhsbt.nhs.uk/trigger/. Accessed January2013.

9. Barkun AN, Bardou M, Kuipers EJ, et al. International consensusrecommendations on the management of patients withnonvariceal upper gastrointestinal bleeding. Ann Intern Med2010; 152: 101–13.

Letter: infliximab therapy in inflammatorybowel disease patients after livertransplantationA. Indriolo*, S. Fagiuoli†, L. Pasulo†, G. Fiorino‡,S. Danese* & P. Ravelli*

*Gastroenterology and Digestive Unit, Ospedali Riuniti di Bergamo,Bergamo, Italy.†Gastroenterology and Hepatology of Transplantation Unit, OspedaliRiuniti di Bergamo, Bergamo, Italy.‡IBD Center, Gastroenterology Unit, Humanitas Clinic Institute,Rozzano, Italy.E-mail: amedeo.indriolo@gmail.com

doi:10.1111/apt.12256

SIRS, We read with great interest the studies by Sandhuet al.1 and Mohabbat et al.,2 which evaluated antitumournecrosis factor-alpha (TNFa) therapy for patients withrefractory inflammatory bowel disease (IBD) post ortho-

topic liver transplant (OLT). To date, there have been only18 patients treated with anti-TNF for relapsing IBD fol-lowing OLT; this number includes patients with UC, CD,indeterminate colitis and pouchitis.1–5 Such data are oftennot homogeneous in terms of administered therapy andoutcomes.

We have evaluated the efficacy and safety of inflix-imab therapy in a homogeneous series of patients withrefractory UC following OLT for advanced-stage primarysclerosing cholangitis (PSC). Four patients (all malepatients; median age 39 years, range 22–54 years) withUC (n = 3) or pouchitis (n = 1) who underwent OLTwere identified (Table 1). The median duration of inflix-imab therapy was 18 months (range: 3–30).

Three patients (75%) experienced sustained improve-ment of IBD. A significant decrease in Mayo score wasobserved after infliximab therapy, from a mean score of9.0 (range: 7–10) to a mean score of 1.0 (range: 0–3)(P < 0.0001) (Figure 1). At week 54, complete mucosal

840 Aliment Pharmacol Ther 2013; 37: 835-843

ª 2013 Blackwell Publishing Ltd

Letters to the Editors

Alimentary Pharmacology and Therapeutics

Table1|Caseserialsof

patie

ntstreatedwith

inflixim

abtherap

yforUCan

dpo

uchitis

followingorthotop

icliver

tran

splantation

Case

Age

(years)

Gen

der

Indicatio

n

forOLT

Age

atPS

C

Age

at

OLT

Anti

rejection

therap

y

Age

atUC

Durationof

IFX

therap

y

(mon

ths)

Pre-an

ti-

IFXMSS

Post-anti-

IFX

MSS

Pre-

anti-

IFX

PDAI

Post-

anti-

IFX

PDAI

Pre-an

ti-

IFX

MCES

I

Post-anti-

IFX

MCSI

Adverse

even

ts

after

IFX

Hep

atic

rejection

130

Male

PSC

1224

Tacrolim

us

1mg+

1.5mg/day;

Azathiprine

75mg/day;

Pred

nisone

5mg/day

530

100

––

30

Molluscum

contagiosum

No

248

Male

PSC

2342

Tacrolim

us

3.5mg+

3.5mg/day

2128

93

––

22

Non

eNo

322

Male

PSC

1516,2

1Ciclosporine

250mg+

200mg/

day

123

71

––

2Wait

endo

scop

y

Non

e

454

Male

PSC

42

45

Tacrolim

us

1mg+

1.5mg/day;

Sirolim

us

3mg/day

3212

––

1412

––

Non

eNo

Tot.

Med

ian

age,

rang

e

(years)

Gen

der

PSC

Med

ian

age,

rang

e

(years)

Med

ian

age,

rang

e

(years)

Med

ian

age,

rang

e

(years)

Med

ian

age,

rang

e

(mon

ths)

Med

ian

Pre-anti-

IFX MSS

,range

Med

ian

Post-anti-

IFX MSS

,

rang

e

Pre-

anti-

IFX PDAI

Post-

anti-

IFX PDAI

Med

ian

Pre-anti

IFX

MCES

I,

rang

e

Med

ian

Post-anti-

IFX

MCSI,

rang

e

Num

ber,

percen

tage

Num

ber,

percen

tage

439

(22–

54)

4/4

Male

4/4

19(12–

42)

33(24–

45)

16.5

(5–

32)

18(3–3

0)

9(7–10)

1.0*(0

–3)

1412†

2(2–3

)1(0

–2)

1/4(25%

)0/4

(0%)

*Sign

ificativ

emed

ianMMSscorede

creasedafterinflixim

abtherapyitwas

observed

,from

9(range:7

–10)to

1.0(range:0

–3)(P

<0.0001).

†Nosign

ificant

differen

cein

PDAIafterinflixim

abtherapyitwas

observed

,from

14to

12(P

=NS).

Aliment Pharmacol Ther 2013; 37: 835-843 841

ª 2013 Blackwell Publishing Ltd

Letters to the Editors

healing (defined as absence of lesions) was observed inone of three patients (33%). In the one patient withrefractory pouchitis, a nonstatistically significant decreasein pouch disease activity index was observed (from 14 to12). Subsequently, this patient presented with worseningof endoscopic lesions after interruption of infliximabtherapy, and he underwent ileostomy.

Steroid treatment was successfully withdrawn duringinfliximab therapy in all patients. Adverse eventsincluded only one infection by Molluscum contagiosum,which resolved without sequelae. No malignancies wereobserved in any patient following infliximab therapy. Nocases of hepatic rejection were documented. One patient(25%) presented with a recurrence of PSC 2 years beforeinfliximab therapy (3 years after OLT) and he underwenta second OLT 5 years after the first.

Our results are consistent with the studies of Sandhuand Mohabbat and are in line with data on IBD patientswho have not previously undergone liver transplantation.We assessed a homogenous series of refractory UC

patients, who were treated with the same anti-TNFa agent.In previous studies, some patients were treated with inflix-imab3–5 others with adalimumab5 and others patients withadalimumab for secondary loss of response to infliximab.4

Mucosal healing has been previously evaluated in onlythree studies.1, 3–5 Moreover, in contrast to previousreports, we objectively assessed clinical response, utilisinga clinical score for UC and pouchitis, and assessed muco-sal healing using an endoscopic score.

In conclusion, our small study supports previous dataon the efficacy and safety of infliximab therapy in patientswith refractory UC after OLT, and adds new data on ahomogenous population with UC and previous OLT, alltreated by infliximab. Although no cases of hepatic graftdysfunction or rejection were observed, larger studies areneed to evaluate the safety profile of biological therapycombined with anti rejection treatment in patients withrefractory IBD following liver transplantation.

ACKNOWLEDGEMENTDeclaration of personal and funding interests: None.

REFERENCES

1. Sandhu A, Alameel T, Dale CH, Levstik M, Chande N. The safetyand efficacy of antitumor necrosis factor-alpha therapy forinflammatory bowel disease in patients post liver transplantation:a case series. Aliment Pharmacol Ther 2012; 36: 159–65.

2. Mohabbat AB, Sandborn WJ, Loftus EV Jr, Wiesner RH, BruiningDH. Anti-tumor necrosis factor treatment of inflammatory boweldisease in liver transplant recipients. Aliment Pharmacol Ther 2012;36: 569–74.

3. Lal S, Steinhart AH. Infliximab for ulcerative colitis following livertransplatation. Eur J Gastroenterol Hepatol 2007; 19: 277–80.

4. El-Nachef N, Terdiman J, Mahdevan U. Anti-tumor necrosisfactor therapy for inflammatory bowel disease in the setting ofimmunosuppression for solid organ transplantation. Am JGastroenterol 2010; 105: 1210–1.

5. Indriolo A, Fagiuoli S, Pasulo L, et al. Infliximab in patients withulcerative colitis and primary sclerosing cholangitis before andafter liver transplantation. JCC 2012; 6(Suppl. 1): S117.

Letter: Coca-Cola can dissolve gastricphytobezoarsK. Uchida

Department of Anesthesiology, St. Marianna University School ofMedicine, Kawasaki, Japan.E-mail: K.U@marianna-u.ac.jp

doi:10.1111/apt.12263

SIRS, I read with interest the systematic review by Ladaset al. regarding Coca-Cola therapy for phytobezoars.1

For lack of an alternative, their outcome was based ondata from case reports and retrospective studies. In gen-eral, the selection bias included in their outcome is largerthan the bias that would have been produced using datafrom double-blinded, randomised, placebo-controlledstudies.

0

1

2

3

4

5

6

7

8

9

10

Pre-anti IFX MSS, Median, range (7–10)

Post-anti IFX MSS,Median, range (0–3)

MS

S s

core

*P < 0.0001

Figure 1 | MSS score before and after IFX therapy.Significant decrease in median Mayo score system(MMS) after infliximab therapy was observed from 9.0(range 7–10) to 1.0 (range 0–3) (P < 0.0001)*.

842 Aliment Pharmacol Ther 2013; 37: 835-843

ª 2013 Blackwell Publishing Ltd

Letters to the Editors