Quality outcome measures project in IBD: a proof-of-concept benchmarking study in three Belgian IBD units.

Introduction: Current treatment modalities in IBD allow us to render normal quality of life to most patients. Ideally, structured digital care pathways can be harmonised in order to measure (semi-) automatically key outcome quality indicators and compare between institutions. Materials and methods: Key quality criteria were selected through a consensus process and aligned with the ICHOM quality criteria in IBD, including clinical parameters, PROMs, quality of life, health care utilisation and productivity. Results: Measurements of the 11 selected key quality criteria were integrated in the structured care pathways of three IBD units. All patients received (at least) twice a year three questionnaires (PRO2 or SCCAI, ICHOM criteria and IBD Disk) through the electronic application to collect necessary information ahead of their planned outpatient clinic. In addition, interpretation of biomarkers was automated, and more difficult outcome indicators were manually added by the caregiver during the visit in anticipation of adaptations to or improvements of the electronic record. All information was collected centrally electronically in a structured way allowing benchmarking between the three centres, and stored for future retrospective research. Conclusion: A (partially) automated benchmarking for measuring quality of care is feasible. It provides an objective assessment of IBD care, enables benchmarking between centres and facilitates quality improvements projects.

Evaluation of the safety and effectiveness after switch from adalimumab originator to biosimilar SB5 in patients with inflammatory bowel disease in a real-life setting.

Background and study aims: Prospective data are lacking on evolution of trough levels, effectiveness, acceptance rate and patient satisfaction after switch from the adalimumab originator to a biosimilar in patients with inflammatory bowel disease. Patients and methods: Patients in clinical remission or stable response and treated with adalimumab originator in 2 Belgian centers were offered to participate in this phase IV, prospective trial in which patients were switched to adalimumab biosimilar SB5. The primary outcome was the description of adalimumab trough levels over time. Secondary outcomes were secondary loss of response, disease activity, patient satisfaction score and drug persistence over 12 months. Results: The study included 110 patients. Mean baseline adalimumab trough level was 9.21 µg/ml. Concentration remained within the therapeutic range over time. No changes were observed in disease activity scores nor in biochemical parameters over time. The acceptance rate of switch was 84.6%. By month 12, 74.5% was still treated with SB5. The most frequent reason for discontinuation was occurrence of adverse events. 50% of these adverse events were injection site pain. The local discomfort was only significant the first 30 minutes after injection. Satisfaction with the decision to switch to SB5 was high and remained stable over time. Conclusions: After being well informed the great majority of patients treated with the adalimumab originator is willing to switch to biosimilar SB5. In our study, there was a persistence rate of 75% over one year. The trough levels remained within the therapeutic range and no change in disease activity was seen over time.

An atypical cause of right lower abdominal pain: amoebiasis, a family cluster.

In this case report we present a family cluster of amoebiasis in a nonendemic region. A 46-year-old women, diagnosed with Crohn's disease for which she received no maintenance therapy, was evaluated for the suspicion of a flare. At colonoscopy however, atypical findings for Crohn's disease were seen. Histopathologic examination revealed micro-organisms compatible with amoebiasis. Interestingly, 4 years before this event she started a new relationship with a 38-year-old man who was diagnosed with liver-amoebiasis 3 months after the start of their relationship. On top of this, her 18-year-old daughter was diagnosed with amoebiasis 2 years after her diagnosis. The source of the infection remains unknown, but we speculate that the infection was transmitted feco-orally between the different members of this family. These cases illustrate that we should be aware of parasitological causes of colitis, especially in patients with atypical endoscopic images or when a close "relative" is diagnosed with amoebiasis.

Ischaemic necrosis of the tongue as a rare complication of cardiogenic shock.

Ischaemic necrosis of the tongue is an unusual clinical finding. In most cases it is associated with vasculitis, particularly giant cell arteritis (GCA). Other causes include profound cardiogenic shock. We report a case of tongue necrosis in an 81-year-old Caucasian woman. The patient was admitted to the intensive care unit (ICU) for cardiogenic shock. Swelling of the tongue was reported before intubation and evolved into tongue ischaemia and necrosis of the tip of the tongue. After surgical debridement the patient recovered. To our knowledge, this is the second report of a patient surviving tongue necrosis resulting from cardiogenic shock.

Intermittent adult ileocecal intussusception: a case report and review of literature.

We report the case of a 56-year-old male patient who was admitted to the emergency department with crescendo abdominal pain since 2 weeks. In the past 2 years, similar but less pronounced episodes were present, each time resolving spontaneously after spasmolytic drugs. Abdominal ultrasound revealed an ileocecal intussusception. An attempt for preoperative reduction was partially successful. A colonoscopy was performed and showed a tubulovillous adenomatous polyp with high-grade dysplasia, but subsequent right hemicolectomy revealed an underlying cecal adenocarcinoma. The combination of the low incidence and the non-specific symptoms of ileocecal intussusception in the adult makes this entity difficult to diagnose. In most cases, modern imaging techniques such as CT scan, ultrasound, or MRI make the correct preoperative diagnosis. Especially when colonic involvement is present, suspicion of a malignant lead point (i.e. culprit lesion) is primordial. The therapeutic strategy depends on several variables and asks for a patient-tailored, selective approach mostly involving surgery. Based on this case and a short review of literature, we discuss the clinical presentation, diagnostic tools, treatment, and challenges of adult ileocecal intussusception.

Acute hepatitis after treatment for hair loss with oral green tea extracts (Camellia Sinensis).

Nutritional additives based on green tea have been claiming various beneficial health effects. However, several case reports on hepatotoxicity after the intake of green tea derivatives containing Camellia Sinensis have been published. We report a patient with an acute hepatitis after intake of an oral green tea derivative claiming protection against hair loss, showing a histological image compatible with drug induced hepatitis. Other important causes of hepatitis were excluded. After cessation of this nutritional additive there was a rapid and sustained recovery. We raise concern about the safety of nutritional additives with few proven beneficial effects and want to emphasize the importance of accurate and thorough history taking, with attention for over the counter drugs and herbal products.

Quality assurance and recommendations for quality assessment of screening colonoscopy in Belgium.

As population-wide screening for colorectal cancer is adopted by many western countries for all individuals aged 50-75. The success of screening colonoscopy programs is highly dependent on the quality of the procedures. High-quality complete endoscopy with excellent patient preparation and adequate withdrawal time is necessary for effectively reducing colon cancer risk. In Belgium formal quality assurance programs and principles of credentialing do not exist. The current reimbursement system for colonoscopy does not reward a careful performed examination but rapidly performed examinations at unnecessarily short intervals. There is a clear need for evidence-based quality measures to ensure the quality of screening colonoscopy. In this guideline review we present an overview of the literature concerning criteria for best practice and important quality indicators for colonoscopy. A summary of the latest guidelines is given. Our goal of this update is to provide practical guidelines for endoscopists performing screening colonoscopy. We hope to provide a broad consensus and an increasing adherence to these recommendations.

Chronic diarrhoea in non collagenous microscopic colitis: therapeutic effect of cholestyramine.

Chronic watery diarrhoea is the main symptom of the microscopic colitis syndrome, including collagenous colitis (CC), lymphocytic colitis (LC), and not otherwise specified (NOS) colitis. The goal of this study was to evaluate the anti-diarrhoeal effect of cholestyramine in non collagenous microscopic colitis. The records of 13 patients with LC and 7 patients with NOS, who had received cholestyramine as first line therapy and who responded to a questionnaire, were reviewed. On an intention to treat basis, a good clinical effect of cholestyramine was achieved in 75 % of the patients in both LC and NOS colitis. There was no therapeutic effect in 15 % of the patients, who all had LC. In general, the anti-diarrhoeal effect appeared within one week of treatment. Cholestyramine provides a rapid and adequate symptomatic relief of the diarrhoea in non collagenous microscopic colitis.

A case of imported melioidosis presenting as prostatitis.

We report a case of melioidosis in a previously healthy Belgian man. He presented with septicemia and prostatic abscesses 1 week after a trip to Vietnam. Burkholderia pseudomallei was isolated from multiple hemocultures. He was treated successfully with intravenous ceftazidime and trimethoprim-sulfamethoxazole, followed by a per-oral maintenance therapy of amoxicillin-clavulanate with supplementary amoxicillin. There was no need for surgical drainage. This is the second reported case of melioidosis in Belgium.

Lymph loss in the bowel and severe nutritional disturbances in Crohn's disease.

A severe nutritional deficiency status is described in a 22-year-old patient with Crohn's disease. The clinical picture on admission was dominated by an episode of gastrointestinal bleeding secondary to clotting disturbances (vitamin K deficiency) and severe cachexia due to a protein energy malnutrition. The mechanisms of severe nutritional disturbances in Crohn's disease are multifactorial. In this patient, lymphatic leakage into the intestinal lumen was a major contributing factor in the pathogenesis of protein-losing enteropathy, fat malabsorption, and lymphocytopenia. The authors were able to demonstrate this intestinal lymph loss by nuclear imaging.

Occult splenic rupture: a case report.

We present a case of an atraumatic, occult rupture of the spleen. It is only in a distinct minority of cases, that the splenic capsule remains intact, thereby preventing intraperitoneal bleeding. Nevertheless, this condition can be accompanied by a severe loss of blood. A nonoperative management can be considered. Reviewing the literature on splenic rupture, the lack of uniformity in nomenclature is striking. The etiological and morphological classifications are reviewed.

Prolactin and colorectal cancer: is there a connection?

UNLABELLED: The purpose of this study was to confirm the reported incidence of hyperprolactinemia in colorectal cancer and to find further evidence for an ectopic prolactin production by the tumor. MATERIAL AND METHOD: Thirty two consecutive patients with an adenocarcinoma of the colon (n = 17) or the rectum (n = 15) were included. Preoperative serum prolactin concentrations were determined and correlated with CEA concentrations and tumor stages. To exclude an ectopic production by the colon cancer, prolactin concentrations were determined during the operation, in the peripheral blood and in the efferent venous drainage area of the tumor. After resection, immunohistochemical staining for prolactin was made in all resected tumors. RESULTS: In all except two patients with a rectal cancer, preoperative plasma prolactin concentrations were normal. Peroperative serum concentrations of prolactin were high in all patients. No significant gradient was found between the peripheral venous concentration and the local venous concentration in the drainage area of the tumor. Immunohistochemical staining for prolactin was positive in only one rectal cancer. Finally, no correlation was found between plasma prolactin concentrations and tumor stages or CEA concentrations. CONCLUSION: Our results do not support the hypothesis of an ectopic prolactin production by colon adenocarcinoma. Only in a subgroup of rectal cancers, an ectopic prolactin production remains probable. At present, prolactin cannot be recommended as a tumor marker in colorectal cancer.

Aortic pressure pain: clinical significance. Any relationship to the irritable bowel syndrome?

Pressure pain over the abdominal aorta is a clinical sign of undetermined significance. Ultrasonographic criteria were used to define and further evaluate this variety of epigastric tenderness. The incidence of aortic pressure pain, aortic characteristics, and gastrointestinal symptoms were scored in 250 consecutive patients. The incidence was approximately 7%. All the patients with aortic pressure pain had gastrointestinal symptoms, with a significantly higher mean symptom score. The occurrence of pressure pain was independent of any of the examined aortic characteristics, age, or body mass index. We further compared the incidence of aortic pressure pain between 25 patients with irritable bowel syndrome and 25 patients without apparent functional gastrointestinal disease. It was present in approximately 50% of the patients with irritable bowel syndrome. We found pressure pain over the abdominal aorta to be associated with significant gastrointestinal discomfort. A causal relationship is possible but not proven. Aortic pressure pain can be provoked in a significant subgroup of patients with the irritable bowel syndrome.

Infectious gastroenteritis: are they all the same?

Campylobacter jejuni and Salmonella spp are the most frequently cultured micro-organisms in infectious gastroenteritis among patients hospitalized at the departments of gastroenterology and geriatrics. As a whole, the hospitalized patient population with Campylobacter gastroenteritis is a younger one, compared to the Salmonella-infected group. Both pathogens can be associated with a biochemical pancreatitis, which is usually without clinical importance. However, serious complications can occur, with a predominance of visceritis for C. jejuni, and renal function impairment for Salmonella spp. Finally, an asymptomatic carrier state is well known in the Salmonella infection spectrum, whereas C. jejuni might cause a recurrent disease in some patients.

Combined Conn's and Cushing's syndrome: an unusual presentation of adrenal adenoma.

In most aldosterone-producing adenomas (APA) dedifferentiation occurs with formation of transitional cells, bearing characteristics of both glomerulosa and fasciculata cells. These cells are able to produce cortisol, and their aldosterone production follows the circadian rhythm of ACTH. Usually, no clinical signs of cortisol excess develop, since the cortisol production remains under ACTH feedback control. Only a few cases have been described with autonomous cortisol secretion, not suppressible by low dose dexamethasone. We present a patient with an APA, synthesizing enough cortisol to cause the typical clinical expression of Cushing's syndrome. Possible etiopathological mechanisms are discussed.

[Reconstruction of the anterior cruciate ligament with artificial ligament (Ligastic). Clinical results in 72 patients]. / Reconstruction du ligament croisé antérieur avec un ligament artificiel (Ligastic). Résultats cliniques de 72 patients.

INTRODUCTION: The purpose of the study was to evaluate the anatomical and functional results of Anterior Cruciate Ligament reconstruction with the synthetic ligament Ligastic. MATERIAL AND METHODS: 72 patients have been reviewed clinically and radiologically and their functional abilities have been evaluated with Lysholm and Arpege score. 46 have been operated for recent ruptures (group A) and 26 for chronic ACL tears (group B). Follow up was 2 to 4,5 years. RESULTS: The results showed in group A a Lachman test > 3 mm in 57 per cent cases, a positive pivot shift in 29 per cent and ruptures of the ligament in 22 per cent. In group B, the Lachman test was > 3 mm in 47 per cent of the cases the pivot shift was positive in 54 per cent and the rupture of the ligament occurred in 35 per cent. The functional evaluation showed that only one third was stable but painful, and one third was unstable and painful. DISCUSSION: As many authors, we found an increase of bad anatomical and functional results with time. The ligament can't be considered as a scaffold for ingrowth tissue. Two thirds of the patients had painful knees at effort. CONCLUSION: The high percentage of ruptures of the ligament, and the non satisfactory functional results led us not to recommend the ACL reconstruction with a Ligastic implant.

Results of bilio-digestive derivative surgical procedures for benign lesions.

Short and long term results of 52 derivative-surgical procedures (43 choledocho-duodenal and 9 hepatico-jejunal with 45 latero-lateral and 7 termino-lateral approaches) were examined. The procedures were performed on patients with benign bilio-digestive conditions: 46 cases of lithiasis, 2 of which were sump syndromes after latero-lateral derivations, and 6 cases of chronic pancreatitis. Several patients were in poor pre-operative condition, which may have influenced postoperative mortality rates (6%). Morbidity was 15 per cent. Four patients (8%) without anastomotic stenosis had infections of the hepatobiliary system within four years of choledochoduodenostomy. In some cases of benign bilio-digestive lesions, derivative surgery is the procedure of choice, being preferable to endoscopic sphincterotomy. In derivative surgery, a termino-lateral approach has better results than a latero-lateral approach. Furthermore, due to the risk of stasis following a choledochoduodenostomy, a hepaticojejunostomy may be preferable.

[Post-traumatic hemarthrosis of the knee and arthroscopy. Review of 161 cases]. / Hémarthroses post-traumatiques du genou et arthroscopie. Revue de 161 cas.

In a prospective study, 161 traumatic hemarthrosis of the knee had clinical, radiological and arthroscopic examination. The anatomical lesions were diagnosed clinically and radiologically in 78%, but was incomplete every other time. Arthroscopy allowed us to confirm, to complete or to do the exact diagnosis in 98%. Anatomical lesions were never benign: ligaments ruptures (65%), patella dislocations (20.5%), chondral lesions (41%), meniscal lesions (31%). The main interest of arthroscopy is to precise associated lesions and thus, to use these data for a rational treatment program. Most often, the treatment has been performed by arthroscopic techniques, avoiding arthrotomy and shortening post operative rehabilitation. No complication due to arthroscopy has been noted. This study confirms: (1) that a traumatic hemarthrosis indicates a serious knee injury, and (2) the important contribution of arthroscopy for diagnosis and treatment of these traumatic knees.