Are colonoscopy and bowel ultrasound useful for assessing response to short-term therapy and predicting disease outcome of moderate-to-severe forms of ulcerative colitis?: a prospective study.

OBJECTIVES: Mucosal healing has been proposed as an important sign of the efficacy of medical treatment of inflammatory bowel disease; however, direct evidence in ulcerative colitis (UC) is scarce. We evaluated the usefulness of colonoscopy and bowel ultrasound (US) as indexes of response to short-term therapy and as predictors of subsequent outcome in UC. METHODS: A total of 83 patients with moderate-to-severe UC were recruited; endoscopic and US severity was graded 0-3 at entry according to validated scores. Of the recruited patients, 74, who were clinically responsive to steroids, were followed up with repeated colonoscopy and bowel US at 3, 9, and 15 months from recruitment. Concordance between clinical, endoscopic, and US scores at various visits was determined by kappa statistics. Multiple unconditional logistic regression models were used to assess the predictivity of clinical, endoscopic, and US scores measured at 3 and 9 months on the development of endoscopic UC relapse within 15 months. RESULTS: A variable concordance was found over time between endoscopic and clinical score (weighted kappa between 0.38 and 0.95), with high and consistent concordance between endoscopic and US scores (weighted kappa between 0.76 and 0.90). On logistic regression analysis, moderate-to-severe endoscopic and US scores at 3 months were associated with a high risk of endoscopic activity at 15 months (odds ratio (OR): 5.2; 95% confidence interval (CI): 1.6-17.6 and OR: 9.1; 95% CI: 2.5-33.5, respectively). CONCLUSIONS: Bowel US may be used as a surrogate of colonoscopy in assessing the short-term response of severe forms of UC to therapy. Both US score and endoscopic score after 3 months of steroid therapy predict outcome of disease at 15 months.

Imaging inflammatory bowel disease using bowel ultrasound.

During the last two decades the general availability of high resolution ultrasound has greatly improved the diagnostic potential of ultrasound in the assessment of inflammatory bowel disease (IBD). This technique has proved to be useful as a screening imaging modality in patients with symptoms or clinical signs that strongly indicate an inflammatory bowel disorder as well as for assessing the anatomical extension of Crohn's disease (CD) lesions at primary diagnosis. Another important indication is the follow-up of patients who are already known to have CD. Here, the technique may play a key role in the detection of luminal and mesentery complications or for the evaluation of disease extension during a clinical flare-up of both CD and ulcerative colitis. By contrast, the role of bowel ultrasound in the assessment of disease activity is limited so far, even though colour Doppler flow imaging may, perhaps, help to differentiate inflammatory from fibrotic intestinal strictures. New ultrasound technologies, such as those using oral and intravenous contrast agents, will probably further increase the diagnostic capability of ultrasound in this context, thus radically changing the diagnostic approach to IBD in the near future.

Modern imaging of Crohn's disease using bowel ultrasound.

Technological advancement of ultrasound (US) equipments and understanding of bowel appearances with high resolution US during the last decade has led to consideration of this imaging procedure as an important tool for inflammatory bowel diseases assessment. In particular, Crohn's disease (CD) for its pathologic characteristics (that is, inflammatory infiltration of the entire bowel wall with possible extension to the surrounding mesentery) is the disease entity which has mainly taken advantage from this non-invasive, radiation-free technique. Beside correctly defining anatomic location and extension of CD lesions within the bowel in the majority of cases, US also shows perigut abnormalities and may demonstrate complications such as fistulas and abscesses. With the help of Power Doppler function, some additional information may be obtained about the local activity of the disease which is particularly useful in the presence of strictures. New US technologies (such as those using intravenous bolus contrast agents or oral nonabsorbable anechoic solutions) may further improve diagnostic capability of US in this context, thus probably revolutioning the diagnostic approach to this disease in the near future, particularly during follow-up in CD of the small bowel.

Predictors of long-term outcome of functional dyspepsia and duodenal ulcer after successful Helicobacter pylori eradication--a 7-year follow-up study.

AIMS: To investigate the course of dyspeptic symptoms, predictors of symptom relief and use of antidyspeptic drugs in patients with duodenal ulcer disease and functional dyspepsia 6-7 years after successful Helicobacter pylori eradication. PATIENTS AND METHODS: Patients with H. pylori-positive duodenal ulcer or functional dyspepsia, included in a prospective, randomized study from January 1996 to June 1997, and successfully treated with standard triple therapy, were eligible. After 6-7 years, case histories of 142 patients were retrieved and patients were interviewed by telephone. They were asked about the presence of dyspeptic symptoms and health care needs during the last week and over the last 6-7 years. Predictive factors of complete long-term relief of symptoms have been evaluated. RESULTS: Of the 114 eligible patients, 104 (49 with duodenal ulcer and 55 with functional dyspepsia) were included in the study. The mean duration of follow up was 6.6+/-0.5 years. Complete relief of dyspeptic symptoms was reported, in this period, by 49.0% of duodenal ulcer patients and 36.4% of patients with functional dyspepsia (P=0.271). Persistence of symptoms within 3 months of H. pylori eradication and female sex were predictive of persistence of symptoms in the following 6-7 years, in patients with functional dyspepsia. In turn, approximately 50% of the patients with complete symptom remission, within 6 months of H. pylori eradication, later became symptomatic. Since the end of the H. pylori eradication trial, 26.9% of patients were still using or had used antidyspeptic drugs; patients with functional dyspepsia having used them more frequently than duodenal ulcer patients (36.4 vs. 16.3%; P=0.037). CONCLUSION: In clinical practice, long-term symptomatic benefit, in duodenal ulcer patients, after H. pylori eradication, is similar to that in patients with functional dyspepsia. Early evaluation of symptoms after successful H. pylori eradication may be predictive of outcome in dyspeptic patients. Most symptomatic patients did not seek antidyspeptic drugs. Use of antisecretory medications was, however, greater in patients with functional dyspepsia than in duodenal ulcer patients.

Prevalence of pancreatic insufficiency in inflammatory bowel diseases. Assessment by fecal elastase-1.

Pancreatic insufficiency (PI) may be an extraintestinal manifestation of inflammatory bowel diseases (IBD). We report the results of a cross-sectional study that was carried out to investigate both the prevalence of PI in IBD patients and its clinical course over a 6-month follow-up period. In total, 100 Crohn's disease (CD) patients, 100 ulcerative colitis (UC) patients, and 100 controls were screened for PI by the fecal elastase-1 (FE-1) test. The decision limits employed were: < or =200 microg/g stool for PI and < or =100 microg/g for severe PI. Patients with abnormal FE-1 values were re-tested after 6 months. Odds ratios (OR) for PI were estimated by unconditional logistic regression analysis. PI was found in 22 UC and 14 CD patients. The OR for the FE-1 test < or =200 microg/g was 10.5 [95% confidence interval (CI): 2.5-44.8] for IBD patients compared to the controls. The risk of PI was related to three or more bowel movements per day (OR = 25.0), the passage of loose stools (OR = 7.7), and previous surgery (OR = 3.7). At the 6-month follow-up, FE-1 values became normal in 24 patients and showed persistently low concentrations in 12. These patients had a larger number of bowel movements per day (OR = 5.4), previous surgery (OR = 5.7), and a longer duration of the disease (OR = 4.2). PI is frequently found in IBD patients, particularly in those with loose stools, a larger number of bowel movements/day and previous surgery. PI is reversible in most patients, and persistent PI is not associated with clinically active disease.

Incidence and risk factors for gallstones in patients with inflammatory bowel disease: a large case-control study.

UNLABELLED: The risk for gallstones (GD) in inflammatory bowel diseases and the factors responsible for this complication have not been well established. We studied the incidence of GD in a cohort of Crohn's disease (CD) and ulcerative colitis (UC) patients and investigated the related risk factors. A case-controlled study was carried out. The study population included 634 inflammatory bowel disease (IBD) patients (429 CD, 205 UC) and 634 age-matched, sex-matched, and body mass index (BMI)-matched controls free of GD at enrollment, who were followed for a mean of 7.2 years (range, 5-11 years). The incidence of GD was calculated by dividing the number of events per person-years of follow-up. Multivariate analysis was used to discriminate among the impact of different variables on the risk of developing GD. The incidence rates of GD were 14.35/1,000 persons/year in CD as compared with 7.75 in matched controls (P=0.012) and 7.48/1000 persons/year in UC patients as compared with 6.06 in matched-controls (P=0.38). Ileo-colonic CD location (OR, 2.14), disease duration>15 years (OR, 4.26), >3 clinical recurrences (OR, 8.07), ileal resection>30 cm (OR, 7.03), >3 hospitalizations (OR, 20.7), multiple TPN treatments (OR, 8.07), and long hospital stay (OR, 24.8) were significantly related to GD in CD patients. CONCLUSION: Only CD patients have a significantly higher risk of developing GD than well-matched hospital controls. Site of disease at diagnosis, lifetime surgery, extent of ileal resections, number of clinical recurrences, TPN, and the frequency and duration of hospitalizations are independently associated with GD.

Azathioprine and mesalamine for prevention of relapse after conservative surgery for Crohn's disease.

BACKGROUND & AIMS: Because the reoperation rate for Crohn's disease is high after resective surgery, use of conservative surgery has increased. Mesalamine was investigated for the prevention of postoperative relapse, with disappointing results. The role of azathioprine in the postoperative setting is unknown. We aimed to compare the efficacy and safety of azathioprine and mesalamine in the prevention of clinical and surgical relapse in patients who have undergone conservative surgery for Crohn's disease. METHODS: In a prospective, open-label, randomized study, 142 patients received azathioprine (2 mg. kg -1. day -1 ) or mesalamine (3 g/day) for 24 months. Clinical relapse was defined as the presence of symptoms with a Crohn's Disease Activity Index score >200 and surgical relapse as the presence of symptoms refractory to medical treatment or complications requiring surgery. RESULTS: After 24 months, the risk of clinical relapse was comparable in the azathioprine and mesalamine groups, both on intention-to-treat (odds ratio [OR], 2.04; 95% confidence interval [CI], 0.89-4.67) and per-protocol analyses (OR, 1.79; 95% CI, 0.80-3.97). No difference was observed with respect to surgical relapse at 24 months between the 2 groups. In a subgroup analysis, azathioprine was more effective than mesalamine in preventing clinical relapse in patients with previous intestinal resections (OR, 4.83; 95% CI, 1.47-15.8). More patients receiving azathioprine withdrew from treatment due to adverse events than those receiving mesalamine (22% vs. 8%; P = 0.04). CONCLUSIONS: While no difference was observed in the efficacy of azathioprine and mesalamine in preventing clinical and surgical relapses after conservative surgery, azathioprine is more effective in those patients who have undergone previous intestinal resection.