Role of Probiotics in Crohn's Disease and in Pouchitis.

The alterations in the gut microbiota observed in patients with inflammatory bowel disease and in particular in Crohn's disease and in ulcerative colitis patients with pouchitis, provide the rationale for administering probiotic agents in the medical treatment of those conditions. In the maintenance treatment of inactive Crohn's disease probiotics, when administered alone, were found ineffective in preventing clinical and/or endoscopic recurrence. By contrast, a combination of a probiotic agent (eg, Saccharomyces boulardii) with standard pharmacological therapy can promote clinical benefit. In patients with pouchitis, so far only the probiotic mixture VSL #3 proved to effectively prevent relapses after successful antibiotic treatment of active inflammation. Further controlled studies, enrolling higher numbers of patients, are needed to better identify the exact role of probiotics in this area.

Recommendations for Probiotic Use--2015 Update: Proceedings and Consensus Opinion.

This paper describes the consensus opinion of the participants in the 4th Triennial Yale/Harvard Workshop on Probiotic Recommendations. The recommendations update those of the first 3 meetings that were published in 2006, 2008, and 2011. Recommendations for the use of probiotics in necrotizing enterocolitis, childhood diarrhea, inflammatory bowel disease, irritable bowel syndrome and Clostridium difficile diarrhea are reviewed. In addition, we have added recommendations for liver disease for the first time. As in previous publications, the recommendations are given as A, B, or C ratings.

Remifentanil vs. meperidine for patient-controlled analgesia during colonoscopy: a randomized double-blind trial.

OBJECTIVES: The aim was to compare patients' and endoscopists' satisfaction in terms of efficacy and safety of remifentanil patient-controlled analgesia (PCA) during colonoscopy with that of a combination of midazolam and meperidine. METHODS: Sixty patients undergoing colonoscopy were randomly assigned to two groups. All of the patients received midazolam 0.03 mg/kg intravenously for premedication. In the remifentanil group, a bolus dose of remifentanil was given, and a patient-controlled sedation analgesia (PCSA) pump was set to inject further bolus doses with no "lockout" time. Patients in the meperidine group received a bolus of meperidine and sham PCSA. Non-invasive arterial blood pressure, electrocardiography, and pulse oximetry were monitored throughout the study. The Observer's Assessment of Alertness and Sedation Scale (OAA/S) was performed at baseline, every 5 min during, and after colonoscopy. Assessment of pain and satisfaction with sedoanalgesia was scheduled after colonoscopy and 24-72 h later by a 100 mm visual analog scale (VAS). The technical difficulty of the examination and the gastroenterologist's satisfaction were assessed similarly. RESULTS: The degree of pain, the level of satisfaction with sedoanalgesia by patients and gastroenterologists, and the degree of difficulty experienced by the endoscopist were not different in the two groups. The time to reach an Aldrete score > or = 9 was significantly shorter in the remifentanil group (P < 0.0001); discharge times did not differ between the groups (P = 0.36). There was no difference between the groups regarding the duration of colonoscopy (P = 0.82) and the stability of vital signs. At the end of the procedure, OAA/S was significantly higher in the remifentanil group (P = 0.03). CONCLUSIONS: Remifentanil PCA is safe and effective to induce sedoanalgesia during colonoscopy. Further studies should address the optimization of dosing and lock out setting.

Meta-analysis of the impact of SPINK1 p.N34S gene variation in Caucasic patients with chronic pancreatitis. An update.

BACKGROUND: SPINK1 p.N34S gene variation is one of the endogenous factors which seem to be associated with chronic pancreatitis (CP). However, in literature there is no clear agreement regarding its contribution in different ethnicity and CP etiologies. AIM: To investigate the role of SPINK1 p.N34S gene variation in CP patients with European origin by means of meta-analysis. METHODS: Literature search was conducted and case-control studies evaluating Caucasian population, published between May 2007 and May 2015, were included. We also included Caucasian selected studies analyzed in previous meta-analysis. We carried out meta-analysis including all selected studies. After that, we performed two additional meta-analyses considering the incidence of SPINK1 p.N34S gene variation in alcoholic or in idiopathic CP patients vs control group. RESULTS: Twenty-five studies were included and the total number of subjects was 8800 (2981 cases and 5819 controls). The presence of p.N34S variation increased nine times the overall CP risk in population of European origin [OR 9.695 (CI 95% 7.931-11.851)]. Also, the contribution of SPINK1 in idiopathic pancreatitis [OR 13.640 (CI 95% 8.858-21.002)] was found to be higher than in alcoholic CP [5.283 (CI 95% 3.449-8.092)]. CONCLUSION: The association between SPINK1 p.N34S gene variation and CP is confirmed. Also, we confirmed that the idiopathic etiology needs a better definition by means of genetic analysis.

Low Alcohol and Cigarette Use Is Associated to the Risk of Developing Chronic Pancreatitis.

OBJECTIVES: The aim of this study was to investigate the contribution of smoking and alcohol intake and pancreas divisum on the risk of developing chronic pancreatitis (CP). METHODS: Consecutive patients with CP who underwent secretin-enhanced magnetic resonance cholangiopancreatography were compared with consecutive patients without pancreatic disease who underwent secretin-enhanced magnetic resonance cholangiopancreatography for irritable bowel syndrome. RESULTS: We enrolled 145 consecutive CP patients and 103 irritable bowel syndrome patients from 2010 to 2014. In a univariate analysis, statistically significant differences in sex, mean age, and the duration and amount of cigarette and alcohol use were found. Per a receiver operating characteristic curve analysis, thresholds for cigarette and alcohol consumption were, respectively, 5.5 cigarettes and 13.5 g daily. In a multivariate analysis, independent risk factors for CP were male sex (odds ratio [OR], 2.05), smoking more than 5.5 cigarettes per day (OR, 2.72), and drinking more than 13.5 g/d (OR, 6.35). CONCLUSIONS: In an Italian population, we confirmed smoking and alcohol as cofactors in the development of CP. This study shows that alcohol intake and smoking habits are 2 of the most important risk factors for the development of CP.

Exacerbation of inflammatory bowel disease by nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors: fact or fiction?

The existence of a possible link between inflammatory bowel disease (IBD) and nonsteroidal anti-inflammatory drugs (NSAIDs) has been repeatedly suggested. Recently, a few studies have addressed the issue of a possible, similar effect by selective cyclooxygenase-2 inhibitors (COXIBs). The present article reviews the available scientific evidence for this controversial subject.

Antibiotics for inflammatory bowel disease: do they work?

A growing amount of evidence indicates that the intestinal flora plays a pathogenic role in inflammatory bowel disease (IBD): hence, the use of anti-bacterial agents as ancillary treatment in patients with ulcerative colitis, or Crohn's disease. While the results with anti-tubercular agents remain inconclusive, antibiotic treatment in IBD is usually carried out with either metronidazole or ciprofloxacin, or both. Controlled trials are scarce and, although both antibiotics appear to provide clinical benefit, definitive conclusions cannot be drawn and precise therapeutic guidelines cannot be suggested. The best results are achieved in the long-term treatment of Crohn's disease and in the management of pouchitis, or of perianal Crohn's disease. Long-term tolerability of antibiotic treatment may be poor due to the appearance of systemic side-effects. The use of non-absorbable anti-bacterial agents such as rifaximin deserves further investigation.

Segmental colitis: so what?

The existence of chronic mucosal inflammation, confined to sigmoid colons that bear diverticula, is termed 'segmental colitis'. This condition often mimicks inflammatory bowel disease at histological examination. The observed rectal sparing suggests a possible form of Crohn's disease, but no other similarities between segmental colitis and Crohn's colitis are detectable. Medical treatment for segmental colitis, empirically carried out with drugs such as sulfasalazine and mesalazine, is mostly successful and, when surgery is required, post-operative recurrences are infrequent. Although the existence of segmental colitis as a true clinical entity remains questionable, it appears unlikely that this condition represents an atypical form of inflammatory bowel disease.

A pilot trial of Saccharomyces boulardii in ulcerative colitis.

OBJECTIVES: Probiotics can be useful in the treatment of inflammatory bowel disease. In a previous report, the non-pathogenic yeast Saccharomyces boulardii was found to be beneficial in the maintenance treatment of Crohn's disease. The aim of this study was to assess the efficacy of S. boulardii in ulcerative colitis patients. METHODS: A group of 25 patients with a mild to moderate clinical flare-up of ulcerative colitis received additional treatment with S. boulardii 250 mg three times a day for 4 weeks during maintenance treatment with mesalazine. These patients were unsuitable for steroid therapy. Before and after treatment, Rachmilewitz's clinical activity index was calculated. The probiotic treatment was considered a therapeutic success only when the final score was lower than 6. RESULTS: Of the 24 patients who completed the study, 17 attained clinical remission; this was confirmed endoscopically. CONCLUSIONS: Our preliminary results suggest that S. boulardii can be effective in the treatment of ulcerative colitis. Controlled studies with this probiotic agent are warranted.

Distal ulcerative colitis refractory to rectal mesalamine: role of transdermal nicotine versus oral mesalamine.

BACKGROUND: Distal ulcerative colitis usually responds to treatment with rectal mesalamine, but the management of refractory cases is poorly defined. AIM: To evaluate the possible therapeutic benefit of transdermal nicotine versus oral mesalamine. PATIENTS AND METHODS: Thirty patients with left-sided ulcerative colitis unresponsive to treatment with a mesalamine 4 g enema at bedtime were randomly allocated to additional therapy with either transdermal nicotine 15 mg daily or oral mesalamine 800 mg tid for four weeks. Clinical remission was evaluated by Rachmilewitz's activity index and confirmed by sigmoidoscopy. RESULTS: Remission was observed in 12 of 15 patients receiving additional treatment with nicotine and in five of 15 patients receiving additional treatment with oral mesalamine (P=0.027). CONCLUSIONS: The addition of transdermal nicotine to treatment with mesalamine enemas is significantly superior to combined therapy with oral and rectal mesalamine in patients with distal ulcerative colitis refractory to rectal mesalamine alone.

Corticosteroid-sparing effect of rifaximin, a nonabsorbable oral antibiotic, in active ulcerative colitis: Preliminary clinical experience.

BACKGROUND: The role of enteric flora in the pathogenesis of inflammatory bowel disease constitutes the rationale for the use of antibiotics as adjuvant agents in the treatment of ulcerative colitis (UC) and Crohn's disease. OBJECTIVE: The aim of this study was to assess, in a preliminary fashion, the efficacy of the nonabsorbable antibiotic rifaximin in the treatment of exacerbation of UC in patients with a history of poor corticosteroid tolerance. METHODS: This open label pilot study was conducted in the Gastroenterology Unit, S. Raffaele University Hospital (Milan, Italy). Male and female patients aged 18 to 65 years with an established diagnosis of left-sided UC who were experiencing a clinical relapse during maintenance treatment with mesalamine and with a history of poor tolerance to corticosteroid therapy were included in the study. They received rifaximin 400 mg BID for 4 weeks while continuing to receive mesalamine 2.4 g/d. Disease activity before and after treatment was assessed using Rachmilewitz's Activity Index (RAI). A final RAI score <6 was considered clinical remission. RESULTS: Ten patients (9 men, 1 woman; mean [sd]age, 48.1 [12.3] years [range, 23-64 years]) participated in the study. The RAI decreased in all patients. Rifaximin treatment induced clinical remission in 7 patients (70%). No adverse effects were reported. CONCLUSIONS: Due to our study design, no definitive Conclusions can be drawn. However, our preliminary data suggest that rifaximin may be beneficial in the treatment of active UC, obviating corticosteroid therapy in most cases.