Pouchitis: diagnosis and management.

PURPOSE OF REVIEW: Pouchitis is the most common complication in patients who undergo ileal pouch-anal anastomosis (IPAA), occurring more frequently in patients with ulcerative colitis. Pouchitis - the inflammation of the pouch - can be due to idiopathic or secondary causes. Chronic antibiotic-dependent pouchitis (CADP) and chronic antibiotic-resistant pouchitis (CARP) are the most difficult forms of chronic idiopathic pouchitis to treat. Crohn's disease of the pouch may develop de novo in ulcerative colitis patients following colectomy with IPAA. It carries a high risk for pouch failure, and its diagnosis and management are challenging. The purpose of this review is to illustrate the present trends in the diagnosis and treatment of idiopathic pouchitis and Crohn's disease of the pouch. RECENT FINDINGS: The use of the newer biologic agents, vedolizumab and ustekinumab, has shown promising results in patients with CADP, CARP, and Crohn's disease of the pouch. Fecal microbiota transplantation has also been reported to have encouraging preliminary results in small studies and case series for the treatment of chronic pouchitis. SUMMARY: Promising new treatments are emerging for difficult-to-treat forms of pouchitis. Larger prospective and head-to-head comparative studies among the various treatments are needed to evaluate the efficacy and safety of these agents across the pouchitis subgroups, and to identify predictors of response.

Associations between quantitative evaluation of bowel wall microvascular flow by contrast-enhanced ultrasound and indices of disease activity in Crohn's disease patients using both bolus and infusion techniques.

PURPOSE: The aim is to investigate whether baseline contrast-enhanced ultrasound (CEUS) correlates with indices of activity in Crohn's disease (CD) and can predict response to medical treatment. METHODS: In this prospective study, symptomatic CD patients underwent baseline CEUS performed with Definity using both bolus and infusion methods. Time-intensity curves (TIC), peak intensity (PI), and area under curve (AUC) from a region of interest over the diseased bowel were calculated for both bolus and infusion acquisitions. We used Mann-Whitney U test for continuous and chi-square/two-tailed Fisher's exact test for categorical variable comparison and Spearman's correlation coefficient to correlate clinical score and CEUS kinetic parameters. RESULTS: Twenty-one patients (9 men, 12 women, median age 32 years) were accrued. Fifteen patients had clinically active disease defined as Harvey-Bradshaw Index (HBI) score ≥5. Median values of baseline CEUS parameters PI (bolus: 26 vs 8.86; P = .023 and perfusion: 7.6 vs 3.2; P = .009) and AUC (bolus: 769 vs 248.8; P = .036 and perfusion: 188.9 vs 73.9; P = .012) differed significantly in patients with active vs inactive disease. Nine patients with active disease underwent escalated or new treatment. Five were nonresponders. Responders had higher median values of baseline parameters (PI, bolus: 35 vs 18.8; P = .556, and perfusion: 7.6 vs 3.9; P = 190), (AUC, bolus: 1473.9 vs 314; P = .111, and perfusion: 154.7 vs 74.4, P = .286). CONCLUSIONS: CEUS kinetic parameters correlate with clinical and laboratory indices and are significantly higher in patients with active disease. The responders had higher CEUS kinetic parameters than nonresponders that did not reach statistical significance in our small cohort.

Coagulation and fibrinolysis activation after single-incision versus standard laparoscopic cholecystectomy: a single-center prospective case-controlled pilot study.

Laparoscopic cholecystectomy is associated with attenuated acute-phase response and hypercoagulable state compared with the open procedure. Single-incision laparoscopic cholecystectomy is a new technique aiming to minimize the invasiveness of the procedure. By comparing the degree of coagulation and fibrinolysis activation after conventional multiport (CLC) and single-incision (SILC) laparoscopic cholecystectomy, we aimed to determine whether the reduced incision size induces a lower thrombophilic tendency. Thirty-two adult patients with noncomplicated symptomatic cholelithiasis were nonrandomly assigned to CLC or SILC. Prothrombin fragment 1 + 2 (F1 + 2), thrombin-antithrombin complexes (TAT), D-dimers, fibrinogen, and von Willebrand factor levels were measured at baseline, at 1st, and 24th hour, postoperatively. Twenty-six patients were finally included in the study. Fifteen patients underwent CLC (male/female: 5/10) and 11 underwent SILC (male/female: 1/10). There were no perioperative complications. An almost similar postoperative pattern and degree of activation of coagulation and fibrinolysis pathways was noted in both groups. No statistically significant differences were found between SILC and CLC for F1 + 2, TAT, D-dimers, fibrinogen, and von Willebrand factor levels, duration of surgery, length of hospital stay, and postoperative morbidity. A similar pattern and extent of coagulation and fibrinolysis activation is present in SILC and CLC, and therefore there is no difference in tendency for thrombosis. Thromboembolic prophylaxis should be considered in SILC as recommended for CLC, pharmacologic or mechanical, considering the hemorrhagic risk and the presence of additional thromboembolism risk factors. SILC appears to be a safe, feasible technique that can be recommended for its potential advantages in cosmesis and reduced incisional pain.

CT-Enteroclysis in the preoperative assessment of the small-bowel involvement in patients with peritoneal carcinomatosis, candidates for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

PURPOSE: To assess the performance of CT-Enteroclysis (CTE) in the preoperative evaluation of the small bowel (SB) involvement in patients with peritoneal carcinomatosis (PC), candidates for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). MATERIAL AND METHODS: In this prospective study, 48 consecutive patients (37 women, 11 men, mean age: 57.02 years) with PC of different primaries, eligible for cytoreductive surgery and HIPEC underwent CTE before surgery. Lesions were gathered according to their location (SB wall or mesentery), distribution (jejunum/ileum, proximal/distal) and lesion size (LS, where LS0 is the absence of disease, LS1 < 1 cm, LS < 1-5 cm, and LS3 > 5 cm in maximal diameter). The preoperative CTE classification was correlated with surgical scoring of PC in the SB. RESULTS: CTE was found to have sensitivity 92%, specificity 96%, PPV 97%, NPV 91%, in assessing PC in the SB/mesentery. CTE exhibited "excellent" agreement with surgical classification of disease extent (overall kappa-weighted coefficient of agreement (κ (w)) was 0.962). Patients (n = 6) found inoperable at surgery manifested extensive plaque-like cover of the SB wall/mesentery on CTE. CONCLUSIONS: CTE may be considered a reliable imaging technique for the preoperative evaluation of the extent and distribution of PC in the SB/mesentery in order to assist surgical planning or to prevent unnecessary surgery.

Basal ganglia hyperintensity on T1-weighted MRI in Rendu-Osler-Weber disease.

The purpose of this study was to evaluate possible central nervous system (CNS) involvement in Rendu-Osler-Weber (ROW) disease in magnetic resonance imaging (MRI). Three patients with symptomatic ROW disease underwent brain MRI. Brain MRI depicted in all three of them increased signal intensity on T1-weighted images involving the globus pallidus and cerebral crura bilaterally. Laboratory studies of the two men showed iron deficiency anemia, while all three of them had normal liver function tests and increased manganese blood concentration. Gastroscopy and colonoscopy revealed a gastric and a cecal arteriovenous malformation (AVM) in the first one, while pulmonary and hepatic computed tomography (CT) angiography did not detect any intrahepatic shunts. Liver ultrasound in the second one revealed dilatation of intrahepatic artery branches consistent with intrahepatic shunts, while it was normal in the third patient. Chest radiographs were normal in all three patients. Pallidal T1 hyperintensity on T1-weighted imaging may be a biomarker of manganese overload in ROW disease.

Ulcerative Colitis Patients Continue to Improve Over the First Six Months of Vedolizumab Treatment: 12-Month Clinical and Mucosal Healing Effectiveness.

BACKGROUND: Vedolizumab (VDZ) is a humanized monoclonal IgG1 antibody which inhibits leukocyte vascular adhesion and migration into the gastrointestinal tract through α4ß7 integrin blockade. AIMS: We retrospectively assessed the 12-month, real-world efficacy and safety of VDZ as induction and maintenance therapy in adult patients with ulcerative colitis (UC). METHODS: The rates of clinical remission (CR, partial Mayo score < 2), steroid-free clinical remission (SFCR), and mucosal healing were assessed with nonresponder imputation analysis. Baseline independent predictors of clinical remission were investigated, and adverse events were recorded. RESULTS: We analyzed outcomes in 74 patients; 32% were anti-TNF naïve, 68% had pancolitis, and 46% were on systemic steroids at baseline. At week six, week 14, six months and one year, the CR rates were 26%, 34%, 39% and 39% respectively, and the SFCR rates were 24%, 31%, 38% and 39%, respectively. Among patients not in CR after induction, the probability of remission at six months was 20%. Sustained SFCR between weeks 14 and 52 and between weeks 22 and 52 was found in 69% and 86% of the patients, respectively. Steroid-free clinical remission at 12 months was significantly associated with remission after the induction phase (OR = 30.4; 95% CI, 6 to 150; P < 0.001). Mucosal healing rate at one year was 39%. The most common side effect was headache (7%). CONCLUSIONS: Increasing remission rates were observed over the first six months of VDZ treatment. One-fifth of patients not in remission post-induction achieved remission by six months of continued therapy. Mucosal healing was associated with higher rates of one-year steroid-free remission and VDZ treatment continuation.

Peroral transgastric endoscopic procedures in pigs: feasibility, survival, questionings, and pitfalls.

BACKGROUND: Multiple studies have demonstrated the feasibility of peroral transgastric endoscopic procedures in porcine models. We present our experience with these procedures in a porcine survival model and expose the technical difficulties and worries about their application in humans. METHODS: We performed the following transgastric procedures in nine small pigs (20-30 kg) under general anesthesia using a double-channel therapeutic endoscope: peritoneoscopy (nine pigs), cholecystectomy (six pigs), gastrojejunal anastomosis (two pigs), and fallopian tube excision (one pig). Postsurgical complications and survival of the pigs were recorded during a 3-week follow-up. RESULTS: In six pigs, the gallbladder was successfully resected. The time of the procedure ranged from 2.5 to 3.5 hours. In one case, severe bleeding occurred from the cystic artery during dissection and was successfully managed by placement of endoscopic clips. Five pigs survived for 3 weeks after cholecystectomy. In one pig, severe peritonitis developed because of gastric contents leakage due to failure of gastric closure and the animal was euthanized 3 days after the procedure. Endoscopic transgastric gastrojejunostomy was successfully performed in two pigs without major complications. The time required for the procedure averaged about 50 min. Fallopian tube excision was also successful in one pig without any complications. The entire procedure was performed within 60 min. CONCLUSIONS: This study reports the feasibility of natural orifice transluminal endoscopic surgery (NOTES) procedures in a porcine survival model and impresses the efficacy, the safety, the complications, and some technical difficulties of transgastric NOTES procedures, which merit further evaluation in future studies.

The significance of histological evidence of bile reflux gastropathy in patients with gastro-esophageal reflux disease.

BACKGROUND: Synergetic activity between acid and bile has been associated with extensive esophageal mucosal damage in patients with gastro-esophageal reflux disease (GERD). Reflux of bile causes injury to gastric mucosa evaluated with an established histological index (bile reflux index, BRI). The aim of the study was to investigate the role of bile reflux in patients with GERD using the BRI. MATERIAL/METHODS: Fifteen asymptomatic subjects and 53 patients with GERD underwent upper gastrointestinal endoscopy with biopsies taken from the gastric antrum, body, cardia, and lower esophagus. The updated Sidney system was used for histological examination and BRI was calculated according to the findings in the antrum. RESULTS: BRI was elevated in 25/53 GERD patients (47%) and in 2/15 15 controls (13%) (OR: 5.8, 95%CI: 1.2-28.3). Elevated BRI was noted in 72% (13/18) of the patients with severe esophagitis (grade B or C) or Barrett's esophagus, whereas it was present in 34% (12/35) of those with mild or no lesions (OR: 5, 95%CI: 1.4-17.3). Additionally, 5 of the 6 patients detected with intestinal metaplasia (IM) at the cardia (83%) and 9 of the 12 patients with IM of the antrum (75%) had elevated BRI. CONCLUSIONS: Bile reflux gastropathy is present in a significant proportion of patients with GERD and associated with disease severity. The elevated BRI in such patients highlights the role of duodeno-gastro-esophageal reflux as an additional factor in the pathogenesis of GERD.

Elevated markers of thrombin generation and fibrinolysis in patients with active and quiescent ulcerative colitis.

BACKGROUND: Prothrombotic abnormalities within the coagulation system, the presence of microvascular thrombi in intestinal mucosa, and the increased risk of thromboembolic complications in patients with Inflammatory bowel disease, suggest that a hypercoagulable state may be an important contributing factor in disease pathogenesis. The activation of the coagulation system in a cohort of ulcerative colitis patients was investigated. MATERIAL/METHODS: Markers of coagulation activation in blood (thrombin-antithrombin complex, TAT; prothrombin fragments 1 and 2, F1+2; and D-dimers) and markers of inflammation (erythrocyte sedimentation rate, ESR; C-reactive protein, CRP; and fibrinogen) were measured in 38 patients with active and 13 patients with long-standing quiescent ulcerative colitis. Disease activity was assessed by clinical, endoscopic, and histological criteria. The markers of coagulation activation were also measured in 28 healthy volunteers. RESULTS: There were no differences in TAT, F1+2, and D-dimer plasma levels between active and inactive ulcerative colitis. D-dimer and F1+2 levels were significantly higher in the active ulcerative colitis patients than in the healthy controls. Plasma levels of TAT, F1+2, and D-dimers did not differ between inactive ulcerative colitis patients and healthy controls. However, both active and inactive ulcerative colitis patients had significantly higher proportions of elevated (above-normal) values of coagulation markers than the healthy controls. Correlation analyses revealed strong correlation between ESR, fibrinogen, and D-dimers, which also correlated with the severity and extent of ulcerative colitis. CONCLUSIONS: A chronic low-grade activation of coagulation exists in ulcerative colitis, regardless of disease activity, and it might be implicated in disease pathogenesis.

The clinical significance of indeterminate pulmonary nodules in melanoma patients at baseline and during follow-up chest CT.

OBJECTIVE: This study aims to determine an appropriate timeline to monitor indeterminate pulmonary nodules (IPN) in melanoma patients to confirm metastatic origin. MATERIALS AND METHODS: 588 clinically non-metastatic melanoma patients underwent curative intent surgery during 3 years. Patients with baseline chest CT and at least one follow-up (FU) CT were retrospectively analyzed to assess for IPN. Patients with definitely benign nodules, metastases and non-melanoma malignancies were excluded. Change in volume from first to FU CT, initial diameter (D1) and volume (V1), distance from pleura, peripheral and perifissural location, density and clinical stage were evaluated. Nodules were volumetrically measured on CTs and were considered metastases if they increased in size between two CTs or if increase was accompanied by multiple new nodules or extrapulmonary metastases. RESULTS: 148 patients were included. Two out of 243 baseline IPN detected in 70 patients, increased significantly in volume in 3 and 5 months and were proven metastases. During FU, 86% of 40 interval IPN detected in 28 patients, were proven metastases. Interval nodule (p < 0.0001, HR:243,CI:[57.32,1033.74]), 3-month volume change (OR:1.023,CI:[1.014,1.033]), V1 (OR:1.006,CI:[1.003,1.009]), D1 (OR:1.424,CI:[1.23,1.648]), distance from pleura (OR:1.03,CI:[1.003,1.059]), and combined stage IIC + III (OR:11.29,CI:[1.514,84.174]), were associated with increased risk for metastasis. 43%, 72% and 94% of patients with IPN were confirmed with metastases in the first FU CT at 3, 6 and 12 months respectively. CONCLUSION: Baseline IPN are most likely benign, while interval IPN are high risk for metastasis. Absence of volume increase of IPN within 6 months excluded metastasis in most patients.

Web-based learning in inflammatory bowel diseases: General truths and current specifics.

In a field rapidly evolving over the past few years, the management of inflammatory bowel diseases (IBD), Crohn's disease and ulcerative colitis, is becoming increasingly complex, demanding and challenging. In the recent years, IBD quality measures aiming to improve patients' care have been developed, multiple new medical therapies have been approved, new treatment goals have been set with the "treat-to-target" concept and drug monitoring has been implemented into IBD clinical management. Moreover, patients are increasingly using Internet resources to obtain information about their health conditions. The healthcare professional with an interest in treating IBD patients should deal with all these challenges in everyday practice by establishing, enhancing and maintaining a strong core of knowledge and skills related to IBD. This is an ongoing process and traditionally these needs are covered with additional reading of textbook or journal articles, attendance at meetings or conferences, or at local rounds. Web-based learning resources expand the options for knowledge acquisition and save time and costs as well. In the new era of communications technology, web-based resources can cover the educational needs of both patients and healthcare professionals and can contribute to improvement of disease management and patient care. Healthcare professionals can individually visit and navigate regularly relevant websites and tailor choices for educational activities according to their existing needs. They can also provide their patients with a few certified suitable internet resources. In this review, we explored the Internet using PubMed and Startpage (Google), for web-based IBD-related educational resources aiming to provide a guide for those interested in obtaining certified knowledge in this subject.

Thrombophilic abnormalities of natural anticoagulants in patients with ulcerative colitis.

BACKGROUND/AIMS: Ulcerative colitis patients have increased risk for thromboembolic events. Factors predisposing to thrombosis in ulcerative colitis are poorly defined. The aim of this study was to evaluate possible thrombophilic abnormalities in patients with ulcerative colitis. METHODOLOGY: Fifty-one patients with ulcerative colitis and 51 healthy controls were studied. Disease activity, clinical and endoscopic, was assessed by standard criteria. Plasma levels of antithrombin, protein C, free protein S and activated protein C resistance were determined in both study groups. Genetic test for factor V Leiden was performed in cases with abnormal activated protein C resistance. Parameters of inflammation and fibrinogen were additionally measured in ulcerative colitis patients. RESULTS: Mean values of free protein S were significantly lower in ulcerative colitis patients (84.01 +/- 21.57) compared to healthy controls (100.17 +/- 24.7) (p < 0.001). Mean values of protein C were higher in ulcerative colitis patients (124.6 +/- 39.03) than healthy controls (100.19 +/- 19.86) (p < 0.001). No other significant differences were observed, but there was a trend towards higher prevalence of low values for antithrombin (9.8% vs. 0%, p = 0.056) and free protein S (19.6% vs. 5.9%, p = 0.072) in ulcerative colitis patients. Three ulcerative colitis patients and three healthy controls had low activated protein C resistance ratio. All these subjects were heterozygous for factor V Leiden. No correlation was observed between abnormalities in thrombophilic parameters and clinical, endoscopic or inflammatory parameters in ulcerative colitis group. CONCLUSIONS: Abnormalities in natural anticoagulants are more common in ulcerative colitis patients compared to healthy controls, irrespective of disease activity. Low activated protein C resistance ratio due to factor V Leiden is not more common in ulcerative colitis patients than in healthy controls.

Use of Complementary and Alternative Medicine in Inflammatory Bowel Disease Around the World.

Use of complementary sand alternative medicine (CAM) is common among patients with inflammatory bowel disease (IBD). CAM can be broadly categorized as whole medical systems, mind-body interventions, biologically based therapies, manipulative and body-based methods, and energy therapies. Most do not use it to treat IBD specifically, and most take it as an adjunct to conventional therapy not in place of it. However, patients are frequently uncomfortable initiating a discussion of CAM with their physicians, which may impact adherence to conventional therapy. A greater emphasis on CAM in medical education may facilitate patient-physician discussions regarding CAM.

Cloxacillin: A New Cause of Pill-Induced Esophagitis.

A large variety of medications can cause pill-induced esophagitis. Herein we present a case of cloxacillin-induced esophagitis. A 66-year-old male presented with an acute onset of epigastric and retrosternal pain on the 5th day of a course of oral cloxacillin prescribed for erysipelas. Initial clinical and imaging assessment was negative and he was sent home. A few days later, he returned with persistent severe retrosternal pain; endoscopy at the same day revealed a normal upper esophagus, several small stellate erosions in the midesophagus, and a normal squamocolumnar junction with a small hiatus hernia. Treatment with esomeprazole 40 mg bid and Mucaine(R) suspension resulted in complete resolution of his symptoms. Pill-induced esophagitis may be underreported by patients, when symptoms are mild and unrecognized and/or underdiagnosed by the clinicians as a cause of retrosternal pain, odynophagia, or dysphagia. Failure of early recognition may result in unnecessary diagnostic investigations and prolongation of the patient's discomfort. This case signifies the importance of enhancing clinician awareness for drug-associated esophageal injury when assessing patients with retrosternal pain, as well as the value of prophylaxis against this unpleasant condition by universally recommending drinking enough water in an upright position during ingestion of any oral medication.

Endoscopically Assisted Transumbilical Single-Incision Laparoscopic Gastric Resection for GIST Treatment.

PURPOSE: Complete surgical resection with negative margins without lymphadenectomy is the treatment of choice for nonmetastatic Gastrointestinal Stromal Tumors (GISTs). Laparoscopic resection of gastric GISTs <5 cm is an acceptable and oncologically feasible, safe, and effective treatment. We present our experience of an endoscopically assisted minimally invasive transumbilical single-incision laparoscopic (SILS) technique for gastric GISTs resection. METHODS: Four patients with small gastric GISTs ≤5 cm located on the greater curvature or the anterior wall were resected with SILS by using a lesion-lifting technique under the guidance of flexible gastroscopy. RESULTS: The technique was feasible and safe and offered significant advantages in locating the tumor and controlling the resection margins. There were no major intraoperative or postoperative complications, conversions, or tumor ruptures. Pathology showed low-risk GISTs resected with disease-free margins without tumor rupture. No recurrences have been observed. CONCLUSION: The endoscopically assisted SILS wedge gastrectomy is a feasible, safe, and advantageous technique for the treatment of the greater curvature or anterior wall gastric GISTs.

Hyperhomocysteinemia in ulcerative colitis is related to folate levels.

AIM: To study the prevalence and clinical significance of hyperhomocysteinemia (hHcys), an independent factor for arterial and venous thrombosis, in a group of patients with ulcerative colitis (UC). METHODS: Fasting homocysteine (Hcys), folate, and vitamin B(12) serum levels were measured in 40 UC patients and 50 healthy controls. Clinical data regarding UC were gathered. RESULTS: Median serum Hcys levels in UC patients were similar to controls (12.26 micromol/L vs 12.32 micromol/L), but the prevalence of hHcys was higher in UC patients than in controls (30% vs 10%, P = 0.028). UC significantly increased the risk of hHcys (adjusted odds ratio: 4.125; 95%CI: 1.26-13.44). Multivariate regression analysis showed that male sex, folate and vitamin B(12) deficiency or lower serum values were significant independent predictors of higher Hcys levels in UC patients (r(2) = 0.4; P<0.001). CONCLUSION: HHcys is common in UC patients and it is related to folate and vitamin B(12) deficiency or lower serum values. It would be reasonable for patients with UC to receive folate and vitamin B complex supplements as a prophylactic measure.

Elevated plasma von Willebrand factor levels in patients with active ulcerative colitis reflect endothelial perturbation due to systemic inflammation.

AIM: To evaluate the plasma von Willebrand factor (vWF) levels in patients with ulcerative colitis (UC) and to investigate their relationship with disease activity, systemic inflammation and coagulation activation. METHODS: In 46 patients with ulcerative colitis (active in 34 patients), clinical data were gathered and plasma vWF levels, markers of inflammation (ESR, CRP, and fibrinogen) and thrombin generation (TAT, F1+2, and D-dimers) were measured at baseline and after 12 wk of treatment. Plasma vWF levels were also determined in 52 healthy controls (HC). The relationship of plasma vWF levels with disease activity, disease extent, response to therapy, acute-phase reactants (APRs) and coagulation markers (COAGs) was assessed. RESULTS: The mean plasma vWF concentrations were significantly higher in active UC patients (143.38+/-63.73%) than in HC (100.75+/-29.65%, P = 0.001) and inactive UC patients (98.92+/-43.6%, P = 0.031). ESR, CRP and fibrinogen mean levels were significantly higher in active UC patients than in inactive UC patients, whereas there were no significant differences in plasma levels of D-dimers, F1+2, and TAT. UC patients with raised APRs had significantly higher mean plasma vWF levels than those with normal APRs (144.3% vs 96.2%, P = 0.019), regardless of disease activity. Although the mean plasma vWF levels were higher in UC patients with raised COAGs than in those with normal COAGs, irrespective of disease activity, the difference was not significant (141.3% vs 118.2%, P = 0.216). No correlation was noted between plasma vWF levels and disease extent. After 12 wk of treatment, significant decreases of fibrinogen, ESR, F1+2, D-dimers and vWF levels were noted only in UC patients with clinical and endoscopic improvement. CONCLUSION: Our data indicate that increased plasma vWF levels correlate with active ulcerative colitis and increased acute-phase proteins. Elevated plasma vWF levels in ulcerative colitis possibly reflect an acute-phase response of the perturbed endothelium due to inflammation. In UC patients, plasma vWF levels may be another useful marker of disease activity or response to therapy.

Inflammatory pouch disease: The spectrum of pouchitis.

Restorative proctocolectomy with ileal-pouch anal anastomosis (IPAA) is the operation of choice for medically refractory ulcerative colitis (UC), for UC with dysplasia, and for familial adenomatous polyposis (FAP). IPAA can be a treatment option for selected patients with Crohn's colitis without perianal and/or small bowel disease. The term "pouchitis" refers to nonspecific inflammation of the pouch and is a common complication in patients with IPAA; it occurs more often in UC patients than in FAP patients. This suggests that the pathogenetic background of UC may contribute significantly to the development of pouchitis. The symptoms of pouchitis are many, and can include increased bowel frequency, urgency, tenesmus, incontinence, nocturnal seepage, rectal bleeding, abdominal cramps, and pelvic discomfort. The diagnosis of pouchitis is based on the presence of symptoms together with endoscopic and histological evidence of inflammation of the pouch. However, "pouchitis" is a general term representing a wide spectrum of diseases and conditions, which can emerge in the pouch. Based on the etiology we can sub-divide pouchitis into 2 groups: idiopathic and secondary. In idiopathic pouchitis the etiology and pathogenesis are still unclear, while in secondary pouchitis there is an association with a specific causative or pathogenetic factor. Secondary pouchitis can occur in up to 30% of cases and can be classified as infectious, ischemic, non-steroidal anti-inflammatory drugs-induced, collagenous, autoimmune-associated, or Crohn's disease. Sometimes, cuffitis or irritable pouch syndrome can be misdiagnosed as pouchitis. Furthermore, idiopathic pouchitis itself can be sub-classified into types based on the clinical pattern, presentation, and responsiveness to antibiotic treatment. Treatment differs among the various forms of pouchitis. Therefore, it is important to establish the correct diagnosis in order to select the appropriate treatment and further management. In this editorial, we present the spectrum of pouchitis and the specific features related to the diagnosis and treatment of the various forms.

Pulmonary fibrosis and emphysema: Is the emphysema type associated with the pattern of fibrosis?

AIM: To investigate whether the predominant emphysema type is associated with the high resolution computed tomography (HRCT) pattern of fibrosis in combined pulmonary fibrosis and emphysema (CPFE). METHODS: Fifty-three smokers with upper lobe emphysema and lower lobe pulmonary fibrosis on - HRCT - were retrospectively evaluated. Patients were stratified into 3 groups according to the predominant type of emphysema: Centrilobular (CLE), paraseptal (PSE), CLE = PSE. Patients were also stratified into 3 other groups according to the predominant type of fibrosis on HRCT: Typical usual interstitial pneumonia (UIP), probable UIP and nonspecific interstitial pneumonia (NSIP). HRCTs were scored at 5 predetermined levels for the coarseness of fibrosis (Coarseness), extent of emphysema (emphysema), extent of interstitial lung disease (TotExtILD), extent of reticular pattern not otherwise specified (RetNOS), extent of ground glass opacity with traction bronchiectasis (extGGOBx), extent of pure ground glass opacity and extent of honeycombing. HRCT mean scores, pulmonary function tests, diffusion capacity (DLCO) and systolic pulmonary arterial pressure were compared among the groups. RESULTS: The predominant type of emphysema was strongly correlated with the predominant type of fibrosis. The centrilobular emphysema group exhibited a significantly higher extent of emphysema (P < 0.001) and a lower extent of interstitial lung disease (P < 0.002), reticular pattern not otherwise specified (P < 0.023), extent of ground glass opacity with traction bronchiectasis (P < 0.002), extent of honeycombing (P < 0.001) and coarseness of fibrosis (P < 0.001) than the paraseptal group. The NSIP group exhibited a significantly higher extent of emphysema (P < 0.05), total lung capacity (P < 0.01) and diffusion capacity (DLCO) (P < 0.05) than the typical UIP group. The typical UIP group exhibited a significantly higher extent of interstitial lung disease, extent of reticular pattern not otherwise specified, extent of ground glass opacity with traction bronchiectasis, extent of honeycombing and coarseness of fibrosis (0.039 > P > 0.000). Although the pulmonary arterial pressure was higher in typical UIP group relative to the NSIP group, the difference was not statistically significant. CONCLUSION: In CPFE patients, paraseptal emphysema is associated more with UIP-HRCT pattern and higher extent of fibrosis than centrilobular emphysema.

Single-incision assisted laparoscopic surgery (SILS) in the treatment of an intussusception induced by a solitary hamartomatous polyp: a case report and review of the literature.

INTRODUCTION: In this case report, we describe the successful treatment of a small-bowel intussusception, which was caused by a 3 cm solitary hamartomatous polyp, with single-incision laparoscopic surgery. Single-incision laparoscopic surgery is a minimally invasive surgical procedure with important advantages that allows the reduction of the intussusception and the resection of the polyp. This case report contributes to the medical literature by describing the advantages of this surgical technique that warrant its consideration as a treatment of choice in similar cases. CASE PRESENTATION: We report a case of a 19-year-old Greek woman who complained about intermittent, non-specific abdominal pain in her left lateral abdomen. She had been admitted to the hospital because of incomplete obstructive ileus. Ultrasound and computed tomography were carried out, which revealed an intussusception of the small bowel. This pathogenic situation was treated by single-incision laparoscopic surgery. Her pathology report revealed a benign, hamartomatous excised polyp of the Peutz-Jeghers type. The patient had a quick recovery without any post-operative complications. CONCLUSION: We recommend single-incision laparoscopic surgery for the safe excision of solitary hamartomatous polyps and the management of their complications, as it represents a potential advance in minimally invasive approaches.