Low-dose oral methotrexate in refractory inflammatory bowel disease.

The purpose of this study was to evaluate the efficacy and safety of low-dose weekly, oral methotrexate in patients with steroid-dependent or steroid-refractory inflammatory bowel disease (IBD). Oral methotrexate was given weekly at 15 mg/week. The primary criterion of response was based on steroid withdrawal. Of the 10 patients with Crohn's disease, daily prednisone dosage dropped from a mean of 37 +/- 9.6 mg to 8.3 +/- 2.1 mg/day (P < 0.02); two had a complete withdrawal and four a partial response (< 7.5 mg/day). In the eight patients with ulcerative colitis, daily prednisone dose dropped from a mean of 26.3 +/- 3.2 mg/day to 12.7 +/- 2.0 mg/day (P < 0.001); three had a partial response. Adverse effects due to methotrexate were mild in both groups. We conclude that oral methotrexate may be useful and reasonably safe as a steroid-sparing agent in patients with refractory IBD.

Endoscopy, gastric ulcer, and gastric cancer. Follow-up endoscopy for all gastric ulcers?

The practice of following benign-appearing gastric ulcers until healing was critically evaluated in a retrospective manner by reviewing all gastric ulcers that were followed with serial endoscopy and all gastric cancers diagnosed at the University of Alabama at Birmingham. The stated purpose of following ulcers to healing is to detect those gastric cancers that may be masquerading as benign ulcer and were not correctly diagnosed at initial endoscopy. Over a five-year period, 148 gastric ulcers were followed with serial endoscopy and in no case was an unsuspected carcinoma found at follow-up endoscopy. In addition, of 67 gastric cancers diagnosed between 1979 and 1986, 62 were suspected of being malignant by the endoscopist at initial examination for an accuracy of 92%. The accuracy rate based solely on biopsy and/or brush cytology was 94%. When endoscopic and biopsy and/or cytology impressions were combined, only one case of gastric carcinoma was not suspected. The overall accuracy was 99%. These results suggest that if either the endoscopic impression or the biopsy and cytology is suspicious for malignancy, then follow-up endoscopy until healing should be done. On the other hand, if, at the initial examination, the ulcer appears benign and biopsy plus cytology are negative, then serial endoscopy has a low benefit relative to its cost.

Gastrointestinal bleeding in patients receiving long-term anticoagulant therapy.

When gastrointestinal (Gl) bleeding occurs in patients receiving anticoagulation, an underlying pathologic lesion is usually suspected and a thorough diagnostic evaluation is undertaken. Over a 15-year period, 50 patients were identified as having Gl bleeding while receiving warfarin. Approximately half of all bleeding episodes occurred from the upper Gl tract, with a lesion identified 81 percent of the time, usually peptic ulcer disease. Lower Gl bleeding occurred in one-third of bleeding episodes, with a diagnosis made in only 52 percent. Only three neoplasms were found and all were diagnosed by barium studies. No diagnosis was established in 47 percent of all bleeding episodes despite appropriate evaluation; in these patients, a mean follow-up of 39.6 months disclosed no premalignant or malignant lesions. Mortality associated with bleeding was less than 2 percent. These data suggest that a diagnosis is usually established in patients receiving anticoagulation who experience upper Gl bleeding, whereas the cause of lower Gl bleeding may remain occult even after a thorough evaluation; however, the absence of a definitive diagnosis carries a good prognosis.

CT appearance of sclerosing cholangitis.

Ten cases of sclerosing cholangitis, both primary and secondary forms, were found to have similar abnormalities within the liver on CT examinations. These changes are different from those seen in cases of biliary obstruction due to tumor, stone, inflammatory mass, or other focal process. The finding of focal, discontinuous areas of minimal intrahepatic biliary dilatation without associated mass lesion seems to be highly suggestive of sclerosing cholangitis. Only the rare, diffuse form of cholangiocarcinoma would be likely to produce a similar CT appearance.