Late is too late? Surgical timing and postoperative complications after primary ileocolic resection for Crohn's disease.

BACKGROUND: Despite the recent advances in medical therapy, the majority of patients with Crohn's disease (CD) still require surgery during the course of their life. While a correlation between early primary surgery and lower recurrence rates has been shown, the impact of surgical timing on postoperative complications is unclear. The aim of this study is to assess the impact of surgical timing on 30-day postoperative morbidity. METHODS: This is a retrospective analysis of a prospectively collected database of 307 consecutive patients submitted to elective primary ileocolic resection for CD at our institution between July 1994 and July 2018. The following variables were considered: age, gender, year of treatment, smoking habits, preoperative steroid therapy, presence of fistula or abscess, type of anastomosis, and time interval between diagnosis of CD and surgery. Univariate and multivariate logistic regressions were performed to examine the association between risk factors and complications. RESULTS: Major complications occurred in 29 patients, while anastomotic leak was observed in 16 patients. Multivariate logistic regression analysis showed that surgical timing in years (OR 1.10 p = 0.002 for a unit change), along with preoperative use of steroids (OR 5.45 p < 0.001) were independent risk factors for major complications. Moreover, preoperative treatment with steroids (6.59 p = 0.003) and surgical timing (OR 1.10 p = 0.023 for a unit change) were independently associated with anastomotic leak, while handsewn anastomosis (OR 2.84 p = 0.100) showed a trend. CONCLUSIONS: Our results suggest that the longer is the time interval between diagnosis of CD and surgery, the greater is the risk of major surgical complications and of anastomotic leak.

Severe ulcerative colitis: predictors of response and algorithm proposal for rescue therapy.

BACKGROUND: There is no agreeing if rescue therapy can avoid short-term colectomy in patients treated for severe steroid-refractory ulcerative colitis. AIMS: The aim of our study was to identify predictors of response to infliximab and cyclosporine A. METHODS: In this cross-sectional study, 49 patients with severe ulcerative colitis were included. Response to therapy was defined as three or more point reductions in Mayo score after 6 months of treatment and avoidance of colectomy after 1 year. The predictors analysed were gender, age, time from ulcerative colitis diagnosis, months of steroid or/and azathioprine therapy before onset of the severe phase, smoking habits, extension of the disease, laboratory analyses and Mayo score. RESULTS: Patients treated with infliximab showed a statistically significant higher response rate in case of moderate Mayo score (P = 0.04). Ex-smokers had very low chance of response to infliximab (P = 0.03). In the group treated with cyclosporine A, patients with C-reactive protein >3 mg/L had a response rate significantly higher than those with C-reactive protein <3 mg/L (P = 0.03); those with negative C-reactive protein and moderate Mayo score did not responded to therapy, while in the ones with elevated C-reactive protein and/or severe Mayo score, 15 versus 4 responded (P = 0.008). CONCLUSIONS: Our data suggest that cyclosporine A is advisable in ex-smokers. In never smokers or active smokers, infliximab can be prescribed in case of Mayo score ≤10 and/or negative CRP, while cyclosporine A is indicated in case of Mayo score >10 and positive CRP.

Benefit of supplements in functional dyspepsia after treatment of Helicobacter pylori.

AIM: Functional dyspepsia, though benign, leads to deterioration of the quality of life and high costs for healthcare systems. The optimal therapy for functional dyspepsia is still to be defined because of its multifactorial pathogenesis. In an open multicentric study of patients with functional dyspepsia, we prospectively evaluated the benefit of treatment with a food supplement composed of sodium alginate, carbonate calcium, pineapple, papaya, ginger, α-galactosidase and fennel (Perdiges, Bioten Snc, Turin, Italy). METHODS: Ninety-one consecutive patients were included, suffering from functional dyspepsia, who had been previously submitted to therapy to eradicate the infection from Helicobacter pylori (H. pylori) and were waiting to perform the Urea Breath Test (UBT). The primary goal was to establish the percentage of patients who continued to abstain from proton pump inhibitors (PPI) as they waited to carry out the UBT, differentiating between patients who were treated (N.=55) with Perdiges and those who were not (N.=36). Our secondary goal was to document the differences within the 2 groups in terms of symptoms perceived between the start and end of the observation period. The wellness reported, during or in absence of treatment with Perdiges, was evaluated by the use of the VAS scale (Visual Analogical Scale) completed before the start of the treatment and after 30 days. RESULTS: All the patients treated with Perdiges (55/55, 100%) and 31/36 (86.1%) patients who were not (P=0.008) continued to abstain from PPI in the period awaiting the UBT. The VAS scale of those who took Perdiges improved on average by 1.78 points versus a worsening of 0.08 points of those who did not take it (P<0.0001). Furthermore, while among those who took Perdiges there was a statistically significant improvement (P<0.0001) in the VAS scale, between the baseline and the end of treatment, a worsening of 0.08 points (P=0.78) was noticed among the patients who did not take it. CONCLUSION: Perdiges is significantly effective in the period following treatment to eradicate the infection from H. pylori in patients with functional dyspepsia. This allows to reduce the need to use antisecretive drugs. Further randomised studies, with wide ranging case histories, must assess its long-term efficacy.

Osteopenia and osteoporosis in patients with new diagnosis of inflammatory bowel disease.

AIM: The decrease in bone density may occur as a result of inflammatory bowel disease (IBD). Studies conducted on this issue generally focused on treated IBD patients. It is thus difficult to discriminate the role of disease from the effect of therapy on bone density reduction. We evaluated the prevalence of osteopenia/osteoporosis and abnormalities in indices of bone metabolism in patients with newly diagnosed IBD. METHODS: Evaluation of dual-energy X-ray absorptiometry (DXA) at the lumbar spine and intact parathormone (PTH), 25-hydroxy vitamin D and urinary cross-links, on 37 (26 females, median age 35.6±14.5 years) consecutive patients. RESULTS: Sixteen of 37 patients (43%) had normal DXA, 17 (46%) were osteopenic and 4 (11%) osteoporotics. Most male patients >30 years (63%) old as well as young women (62%) had osteopenia/osteoporosis. Mean value of intact-PTH was significantly higher in women >50 years (55.0±18.1 pg/mL) compared with those aged 16-20 years (30.0±14.6 pg/mL) (P=0.042). Furthermore, there was a significant difference between mean value of 25-hydroxy vitamin D in women >50 years old (16.2±4.7 ng/mL) compared to those aged 21-30 years (26.6±7.9 ng/mL) (P=0.041). Intact-PTH was significantly higher in osteoporotic patients (55.7±12.7 pg/mL) compared to normal subjects (28.3±13.0 pg/mL) (P=0.0014). CONCLUSION: High prevalence of osteopenia/osteoporosis was observed in this population. On the basis of these data, we propose to perform DXA in male patients aged >30 years and in all women with new diagnosis of IBD.

Inflammatory bowel diseases and primary sclerosing cholangitis: hepatic and pancreatic side effects due to azathioprine.

BACKGROUND AND OBJECTIVES: In up to 80% of cases primary sclerosing cholangitis (PSC) is associated with inflammatory bowel diseases (IBD). The efficacy of azathioprine (AZA), in the maintenance of remission of IBD has been suggested by several studies. However, AZA tends to exter varied well-known toxicity. Since the rate of hepato-pancreatic side-effects in patients with IBD and PSC is still unclear, we investigated this issue. MATERIALS AND METHODS: Consecutive subjects who underwent Outpatient Clinic admission for both IBD and PSC were included. Both conditions were diagnosed according to International Guidelines. RESULTS: Data of 43 patients were elaborated. Twelve of them underwent therapy with AZA. Five (41.7%) presented hepatic (n=4) or pancreatic toxicity. Eighty percent of the patients with hepato-pancreatic reactions versus 28.6% of those without (p < 0.001) were males, with 60% affected by ulcerative colitis and 40% by Crohn's disease versus 57% and 43%, respectively. Forty percent of patients with reactions versus 43% of those without needed an operation for IBD, and the same percentage underwent orthotopic liver transplantation, with a 100% versus 66.7% (p < 0.001) need of second transplantation. Colonic neoplasia (20%) was detected only in the former group while cholangiocarcinoma (28.6%) only in the latter. CONCLUSIONS: The occurrence of hepato-pancreatic reactions from AZA in our caseload is higher (41.7%) compared to that reported in literature (4%). Therefore, the presence of PSC, in association to IBD, may strongly affect AZA tolerability compared to presence of IBD only.  

Epilepsy and celiac disease: review of literature.

Celiac disease (CD) is a chronic, immune-mediated disorder, characterized by small intestinal malabsorption of nutrients after the ingestion of gluten by genetically susceptible individuals. The discovery of the wide variations in the nature and intensity of clinical presentation of CD has transformed its status, long considered a rare disease, to that of a common health problem. As patients with CD get older, they tend to present with complaints not directly referable to the gastrointestinal tract. Neurologic symptoms, caused by lesions of the central or peripheral nervous system occasionally occur in patients with CD and are poorly understood. This review focalizes on the present knowledge of the potential relationship between CD and epilepsy. The prevalence of CD among patients with epilepsy is not homogeneously distributed, probably because epilepsy encompasses a heterogeneous group of disorders. In fact, the clinical spectrum of epilepsy related to CD ranges from benign syndromes to intractable epilepsy. The precise mechanism of the potential association between CD and epilepsy is also still under discussion.

Polyphenol supplementation as a complementary medicinal approach to treating inflammatory bowel disease.

Inflammatory bowel disease (IBD) comprises a group of idiopathic chronic intestinal inflammation syndromes that are very common in developed countries. It is characterized by intermittent episodes of clinical remission and relapse, with recurrent inflammatory injury that can lead to structural damage of the intestine. The uncontrolled intestinal immune response to bacterial antigens leads to the production of abundant cytokines and chemokines, by activated leukocytes and epithelial cells, which trigger inflammatory and oxidative reactions. The current treatment of IBD consists in long-term anti-inflammatory therapy that, however, does not exclude relapses and side effects, frequently resulting in surgical intervention. Polyphenols have been acknowledged to be anti-oxidant and anti-inflammatory and therefore, have been proposed as an alternative natural approach to prevent or treat chronic inflammatory diseases. Most studies have been in animal models of colitis, using chemical inducers or mice defective in anti-inflammatory mediators and in intestinal cell lines treated with pro-inflammatory cytokines or lipid oxidation products. These studies provide evidence that polyphenols can effectively modulate intestinal inflammation. They exert their effects by modulating cell signaling pathways, mainly activated in response to oxidative and inflammatory stimuli, and NF-kB is the principal downstream effector. Polyphenols may thus be considered able to prevent or delay the progression of IBD, especially because they reach higher concentrations in the gut than in other tissues. However, knowledge of the use of polyphenols in managing human IBD is still scanty, and further clinical studies should afford more solid evidence of their beneficial effects.

A retrospective study on a cohort of patients with lymphocytic colitis.

OBJECTIVE: The term "microscopic colitis" includes lymphocytic colitis (LC) and collagenous colitis, bearing common clinical presentation distinguishable only by histopathological examination of colonic biopsies. This study reports on demographic and clinical characteristics, and outcome of a cohort of patients with LC. METHODS: Demographic, clinical and histopathological data were reviewed. Every patient underwent total colonoscopy with multiple biopsies examined by an expert pathologist. Diagnosis of LC was confirmed if histopathological criteria were present. Routine laboratory tests were collected to rule out other diagnosis. RESULTS: We included 80 patients (28 males; mean age: 46.4 years). At diagnosis, 71 patients (88%) reported diarrhea, 46 (58%) abdominal pain, 21 (36%) weight loss, 10 (13%) nausea. Regarding autoimmune or inflammatory diseases accompanying LC, thyroid disorders and celiac disease (CD) ranked first. Moreover, in over 10% of patients who underwent esophagogastroduodenoscopy, duodenal biopsies showed villi alterations classified as Marsh I damage, without clinical and serological data for diagnosis of CD. Mesalazine and oral topical steroids (budesonide or beclomethasone) were used to treat LC in 34 (43%) and 32 (39%) of patients, respectively, with similar percentages of clinical response (approximately 80%). CONCLUSIONS: The need for total colonoscopy with multiple biopsies in all patients with chronic watery diarrhea was confirmed. Since the association between CD and LC exists, additional tests should be performed in patients not responding to gluten-free diet or to LC specific therapy to exclude the other condition. Mesalazine obtained a similar outcome than oral steroids in this cohort.