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.  

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.

Benefit of dietary integrators for treating functional dyspepsia: a prospective pilot study.

AIM: Because of the multifactorial pathogenesis of functional dyspepsia, strategies alternative to antacid therapy are being sought for treating the disorder. This prospective study evaluated the benefit of treatment with a dietary integrator composed of sodium alginate, sodium bicarbonate, bromelin and essential oils. METHODS: The study population included 53 consecutive patients (22 males, 31 females; mean age, 54+/-2.5 years) with functional dyspepsia and negative for Helicobacter pylori infection. The patients were categorized into four subgroups according to predominant symptom: ulcer-like dyspepsia, motility-like dyspepsia, reflux-like dyspepsia, and nonspecific dyspepsia. All received TUBES gastro (0.80 g oral tablets bid) for a minimum of 3 months (range, 3-11). Treatment efficacy was measured by means of a Visual Analogue Scale (VAS). RESULTS: Two patients were lost to follow-up; of the remaining 51 patients who completed the study, 35 (68%) showed an improvement in VAS score. The difference in scores between the initial and the final visit was -1.9+/-2.1 cm (range, -6 to +3), or 23.8+/-40.8% (range, -150% to 100%) compared to the scores at the baseline visit (P=0.0001). CONCLUSIONS: The study results indicate that in the short term TUBES gastro can significantly improve dyspeptic symptoms in dyspeptic patients negative for H. pylori infection through the synergistic action of its components: alginate buffers gastric acid; bicarbonate helps to eliminate gas and rebalance pH; essential oils regulate motility; and bromelin stimulates enzymatic activity.

2008 Clinical approach to irritable bowel syndrome.

Irritable bowel syndrome (IBS), as defined by Rome III diagnostic criteria, affects 10-20% of the general population, with women 20-40 years old accounting for the majority of patients. Although variable and intermittent, IBS symptoms may persist for many years. Repeated referrals for medical consultation and diagnostic studies generate huge healthcare costs. Since there is no evidence that IBS leads to more severe gastrointestinal disorders, in absence of alarm symptoms or signs, an invasive diagnostic algorithm is not indicated. Optimal treatment for IBS still needs to be defined. The clinical approach is based on treatment of the prevalent symptom. When pain predominates, antispasmodics are the first choice. In case of diarrhea, loperamide is useful for reducing bowel frequency. Soluble fiber represents the first option in subjects with IBS and constipation or mixed IBS. Dietary integrators composed of probiotics and serotonin precursors are a promising therapeutic option.

A 2008 panorama on osteoporosis and inflammatory bowel disease.

The availability of osteodensitometry has contributed significantly to increase the awareness of inflammatory bowel disease (IBD)-associated bone disease. Reported osteoporosis prevalence in patients with IBD range from 2% to 30%. The fractures risk varies between studies, influenced by demographic, clinical and genetic factors. The main pathogenetic factors involved are malabsorption, treatment with glucocorticoids, inflammation (increased cytokine production) and hypogonadism. A screening should be considered for all patients with small bowel Crohn's disease and especially for those with extensive disease, multiple resections, and malnutrition. Supplementation with both calcium and vitamin D is frequently the first step taken, but is insufficient to inhibit bone loss in many patients requiring use of glucocorticoids. Among available therapies, only biphosphonates are effective for treatment of glucocorticoid-induced osteoporosis.

[Massive hemobilia caused by necrotic hemorrhagic cholecystitis. Report of a case]. / Emobilia massiva da colecistite necrotico-emorragica. Segnalazione di un caso.

The authors report a case of massive hematobilia due to hemorrhagic cholecystitis. Hematobilia is a rare pathology which affects the biliary tract and gallbladder. The first authors to describe hematobilia defined it as a hemorrhage of the gastroenteric tract due to the communication of blood vessels with the intra and extra-hepatic biliary tract and in some rare cases to the communication of the branches of the cystic artery within the gallbladder wall. Sandblom, in particular, specified that bleeding must be within the biliary tract and not secondary to an enterobiliary fistula. In 55% of cases the pathogenesis of hematobilia is traumatic, whereas in the remaining 45% the cause may be attributed to a variety of pathologies. Trauma include both non-surgical and surgical traumas; in the first group the most frequent cause is hepatic trauma, although it is worth taking into account the presence of post-traumatic arteriobiliary fistulas, lesions of arterial vessel walls with subsequent necrosis and rupture within the biliary vessels. Surgical traumas comprise lesions caused by therapeutic or diagnostic transparenchymal manoeuvres (PTC, biopsy). Non-traumatic causes include pathologies of vascular, cholecystic, inflammatory-infective and neoplastic origin. Symptoms are varied and take the form of anemia, massive bleeding with the onset of jaundice and pain in the hypochondrium and sometimes the epigastrium, whereas enterorrhagia is manifested by melena and more rarely hematemesis. The diagnosis must be made as quickly as possible; mortality increases with the delay in controlling hemorrhage. Differential diagnosis must take into account other causes of enterorrhagia, obstructive jaundice and anemia.(ABSTRACT TRUNCATED AT 250 WORDS)

[Sarcomatous degeneration of a giant scrotal lipoma. Presentation of a clinical case]. / Degenerazione sarcomatosa di lipoma gigante dello scroto. Presentazione di un caso clinico.

This paper presents a case of giant scrotal lipoma with areas of sarcomatous degeneration which were evident on anatomico-pathological examination; the authors considered it worth-while reporting this case given that giant lipomas with sarcomatous degenerations are rare. It is important to underline that in comparison to other malignant tumours of the scrotum the frequency of liposarcomas is very low. In addition to the liposarcoma reported here, at the level of the scrotum it is worth recalling neurofibrosarcoma and fibrosarcoma and some rare sarcomas of the spermatic cord among the malignant sarcomas of sarcomatous origin reported in the literature. Difficulties may arise from a diagnostic point of view due to the scarcity of symptoms. Among the most frequent symptoms is the presence of a hard mass on palpation of the scrotum; the volume of this mass may increase very rapidly. It is important to note that this tumour may sometimes originate as malignant and then degenerate in toto or in some isolated areas. Instrumental tests include abdominal radiography without the use of contrast medium in order to exclude the presence of herniated abdominal viscera at the level of the scrotum. Ultrasonography may also be extremely useful since it is capable of providing information regarding the presence, inside the scrotal sack, of liquid retention or solid forms. At all events histological diagnosis is carried out in the majority of cases following the removal of the operated part. The exeresis of the tumour therefore becomes both diagnostic and therapeutic. Surgery consists in the simple exeresis of the neoplasia; in some cases orchiectomy is required in addition to exeresis. Some authors also recommend the dissection of inguinal lymph nodes following extemporary anatomo-pathological tests. In other cases when histological tests confirm the malignant degeneration with a high degree of biological aggressiveness, the patient has to undergo postoperative radiotherapy and/or chemotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Squamous papillomas of the esophagus]. / I papillomi squamosi dell'esofago.

The paper reports 14 cases of squamous papilloma of the esophagus which were removed using an endoscopic method: this is a comparatively rare benign pathology of which an increasing number of cases have been recently observed. Endoscopic controls were carried out in all cases and the results of the follow-up are reported.

[Nephrobronchial fistula]. / La fistola nefrobronchiale.

Nephrobronchial fistula is a rare pathology both in absolute terms and in relation to the complications of renal inflammatory processes. Clinical symptoms may be varied but pulmonary complications, which may mask renal symptoms, are generally predominant; cough, hemoptysis and the expectoration of calculi are rarely found. Occasionally, as in the case reported here, the most evident sign is an infective process due to the contemporaneous fistulization of subcutaneous tissues. Instrumental diagnosis is based on chest and abdomen X-ray, fistulography, retrograde pyelography and abdominal CT. CAT may be useful above all in the study of pararenal abscesses.

[Primary torsion of the omentum]. / La torsione primitiva dell'omento.

The paper reports a case of spontaneous torsion of the omentum. Following a review of the international literature on the topic, the Authors discuss the pathogenesis, clinical symptoms and surgical therapy of this pathology.

[Malignant schwannoma of the mesentery. Presentation of a clinical case and clinical and histopathological considerations]. / Schwannoma maligno del mesentere. Presentazione di un caso clinico e considerazioni cliniche ed istopatologiche.

A case of malignant schwannoma of the mesentery is described which was treated with radical surgery. The natural history, diagnosis and therapy of neoplasias of the mesentery are discussed.