SECOND BRAZILIAN CONSENSUS ON THE MANAGEMENT OF ULCERATIVE COLITIS IN ADULTS: A CONSENSUS OF THE BRAZILIAN ORGANIZATION FOR CROHN'S DISEASE AND COLITIS (GEDIIB).

BACKGROUND: Inflammatory bowel diseases are immune-mediated disorders that include Crohn's disease (CD) and ulcerative colitis (UC). UC is a progressive disease that affects the colorectal mucosa causing debilitating symptoms leading to high morbidity and work disability. As a consequence of chronic colonic inflammation, UC is also associated with an increased risk of colorectal cancer. OBJECTIVE: This consensus aims to provide guidance on the most effective medical management of adult patients with UC. METHODS: A consensus statement was developed by stakeholders representing Brazilian gastroenterologists and colorectal surgeons (Brazilian Organization for Crohn's Disease and Colitis [GEDIIB]). A systematic review including the most recent evidence was conducted to support the recommendations and statements. All recommendations/statements were endorsed using a modified Delphi Panel by the stakeholders/experts in inflammatory bowel disease with at least 80% or greater consensus. RESULTS AND CONCLUSION: The medical recommendations (pharmacological and non-pharmacological) were mapped according to the stage of treatment and severity of the disease onto three domains: management and treatment (drug and surgical interventions), criteria for evaluating the effectiveness of medical treatment, and follow-up/patient monitoring after initial treatment. The consensus targeted general practitioners, gastroenterologists and surgeons who manage patients with UC, and supports decision-making processes by health insurance companies, regulatory agencies, health institutional leaders, and administrators.

SECOND BRAZILIAN CONSENSUS ON THE MANAGEMENT OF CROHN'S DISEASE IN ADULTS: A CONSENSUS OF THE BRAZILIAN ORGANIZATION FOR CROHN'S DISEASE AND COLITIS (GEDIIB).

BACKGROUND: Inflammatory bowel disease (IBD) is an immune-mediated disorder that includes Crohn's disease (CD) and ulcerative colitis. CD is characterized by a transmural intestinal involvement from the mouth to the anus with recurrent and remitting symptoms that can lead to progressive bowel damage and disability over time. OBJECTIVE: To guide the safest and effective medical treatments of adults with CD. METHODS: This consensus was developed by stakeholders representing Brazilian gastroenterologists and colorectal surgeons (Brazilian Organization for Crohn's disease and Colitis (GEDIIB)). A systematic review of the most recent evidence was conducted to support the recommendations/statements. All included recommendations and statements were endorsed in a modified Delphi panel by the stakeholders and experts in IBD with an agreement of at least 80% or greater consensus rate. RESULTS AND CONCLUSION: The medical recommendations (pharmacological and non-pharmacological interventions) were mapped according to the stage of treatment and severity of the disease in three domains: management and treatment (drug and surgical interventions), criteria for evaluating the effectiveness of medical treatment, and follow-up/patient monitoring after initial treatment. The consensus is targeted towards general practitioners, gastroenterologists, and surgeons interested in treating and managing adults with CD and supports the decision-making of health insurance companies, regulatory agencies, and health institutional leaders or administrators.

Effects of kefir fermented milk beverage on sodium dextran sulfate (DSS)-induced colitis in rats.

Background and aim: The etiopathogenesis of inflammatory bowel disease (IBD) is associated with different factors such as genetic, infectious, immunological, and environmental, including modification of the gut microbiota. IBD's conventional pharmacological therapeutic approaches have become a challenge due to side effects, complications from prolonged use, and higher costs. Kefir fermented milk beverage is a functional food that has demonstrated multiple beneficial effects including anti-inflammatory and antioxidant activity. Alternative therapeutic strategies have been used for IBD as more natural products with low-cost and easy acquisition. The aim of this study is to evaluate the anti-inflammatory effects of kefir fermented milk beverage on sodium dextran sulfate (DSS)-induced colitis in rats. Methods: We used 4 groups to perform this study: baseline control (BC), kefir control (KC), 5% untreated DSS-induced colitis (DSS), and 5% DSS-induced colitis treated with kefir (DSSK). The animals received fermented kefir milk beverage ad libitum for six days and the disease activity index was recorded daily. Colon samples were processed for Transmission Electron Microscopy and histopathological evaluation. We analyzed short fatty chain acids through the fecal sample using gas chromatography. Results: Kefir supplementation was able to reduce the clinical activity index and inflammatory process evidenced by decreased neutrophil accumulation, decreased reticulum edema, and increased autophagosomes. Also, showed a trend to increase the levels of acetate and propionate. Conclusions: Our results suggest that kefir fermented milk beverage may have an anti-inflammatory effect minimizing the intestinal damage of DSS-induced colitis.

Long-term effectiveness and safety of ustekinumab in bio-naïve and bio-experienced anti-tumor necrosis factor patients with Crohn's disease: a real-world multicenter Brazilian study.

BACKGROUND: The effectiveness of ustekinumab (UST) in the treatment of Crohn's disease (CD) has been demonstrated in the pivotal Phase 3 UNITI 1 and 2 and IM-UNITI studies in both anti-TNF-naïve and anti-TNF-exposed patients. Given the selective nature of pivotal trial designs, real-world effectiveness and safety studies are warranted. We report our experience with UST treatment in a large, real-world multicenter cohort of Brazilian patients with CD. METHODS: We performed a retrospective multicenter study including patients with CD, predominantly biologically refractory CD, who received UST. The primary endpoint was the proportion of patients in clinical remission at weeks 8, 24 and 56. Possible predictors of clinical and biological response/remission and safety outcomes were also assessed. RESULTS: Overall, 245 CD (mean age 39.9 [15-87]) patients were enrolled. Most patients (86.5%) had been previously exposed to biologics. According to nonresponder imputation analysis, the proportions of patients in clinical remission at weeks 8, 24 and 56 were 41.0% (n = 98/239), 64.0% (n = 153/239) and 39.3% (n = 94/239), respectively. A biological response was achieved in 55.4% of patients at week 8, and 59.3% were in steroid-free remission at the end of follow-up. No significant differences in either clinical or biological remission were noted between bio-naïve and bio-experienced patients. Forty-eight patients (19.6%) presented 60 adverse events during the follow-up, of which 8 (13.3%) were considered serious adverse events (3.2% of 245 patients). Overall, a proximal disease location, younger age, perianal involvement, and smoking were associated with lower rates of clinical remission over time. CONCLUSIONS: UST therapy was effective and safe in the long term in this large real-life cohort of Brazilian patients with refractory CD, regardless of previous exposure to other biological agents.

Segundo Consenso Brasileiro de Manejo da Doença de Crohn em adultos: um consenso da Organização Brasileira de Doença de Crohn e Colite (GEDIIB) / Second brazilian consensus on the management of crohn's disease in adults: a consensus of the brazilian organization for crohn's disease and colitis (gediib)

ABSTRACT Background: Inflammatory bowel disease (IBD) is an immune-mediated disorder that includes Crohn's disease (CD) and ulcerative colitis. CD is characterized by a transmural intestinal involvement from the mouth to the anus with recurrent and remitting symptoms that can lead to progressive bowel damage and disability over time. Objective: To guide the safest and effective medical treatments of adults with CD. Methods: This consensus was developed by stakeholders representing Brazilian gastroenterologists and colorectal surgeons (Brazilian Organization for Crohn's disease and Colitis (GEDIIB)). A systematic review of the most recent evidence was conducted to support the recommendations/statements. All included recommendations and statements were endorsed in a modified Delphi panel by the stakeholders and experts in IBD with an agreement of at least 80% or greater consensus rate. Results and conclusion: The medical recommendations (pharmacological and non-pharmacological interventions) were mapped according to the stage of treatment and severity of the disease in three domains: management and treatment (drug and surgical interventions), criteria for evaluating the effectiveness of medical treatment, and follow-up/patient monitoring after initial treatment. The consensus is targeted towards general practitioners, gastroenterologists, and surgeons interested in treating and managing adults with CD and supports the decision-making of health insurance companies, regulatory agencies, and health institutional leaders or administrators.

RESUMO Contexto: A doença inflamatória intestinal (DII) é uma doença imunomediada que inclui a doença de Crohn (DC) e a retocolite ulcerativa. A DC é caracterizada por um envolvimento intestinal transmural da boca ao ânus com sintomas recorrentes e remitentes que podem levar a danos intestinais progressivos e incapacidade ao longo do tempo. Objetivo: Orientar os tratamentos médicos mais seguros e eficazes de adultos com DC. Métodos: Este consenso foi desenvolvido por autores que representam gastroenterologistas e cirurgiões brasileiros especialistas em doenças colorretais (GEDIIB, Organização Brasileira de Doença de Crohn e Colite). Uma revisão sistemática das evidências mais recentes foi realizada para apoiar as recomendações/declarações. Todas as recomendações e declarações incluídas foram endossadas em um painel Delphi modificado pelas partes interessadas e especialistas em DII com uma concordância de pelo menos 80% ou mais. Resultados e conclusão: As recomendações médicas (intervenções farmacológicas e não farmacológicas) foram mapeadas de acordo com o estágio de tratamento e gravidade da doença em três domínios: manejo e tratamento (intervenções medicamentosas e cirúrgicas), critérios para avaliar a eficácia do tratamento médico, e acompanhamento/monitoramento do paciente após o tratamento inicial. O consenso é direcionado a clínicos gerais, gastroenterologistas e cirurgiões interessados em tratar e gerenciar adultos com DC e apoia a tomada de decisões de companhias de seguro de saúde, agências reguladoras e líderes ou administradores de instituições de saúde.

Segundo Consenso Brasileiro no manejo da retocolite ulcerativa em adultos: um consenso da Organização Brasileira para Doença de Crohn e Colite (GEDIIB) / Second brazilian consensus on the management of ulcerative colitis in adults: a consensus of the brazilian organization for crohn's disease and colitis (gediib)

ABSTRACT Background: Inflammatory bowel diseases are immune-mediated disorders that include Crohn's disease (CD) and ulcerative colitis (UC). UC is a progressive disease that affects the colorectal mucosa causing debilitating symptoms leading to high morbidity and work disability. As a consequence of chronic colonic inflammation, UC is also associated with an increased risk of colorectal cancer. Objective: This consensus aims to provide guidance on the most effective medical management of adult patients with UC. Methods: A consensus statement was developed by stakeholders representing Brazilian gastroenterologists and colorectal surgeons (Brazilian Organization for Crohn's Disease and Colitis [GEDIIB]). A systematic review including the most recent evidence was conducted to support the recommendations and statements. All recommendations/statements were endorsed using a modified Delphi Panel by the stakeholders/experts in inflammatory bowel disease with at least 80% or greater consensus. Results and conclusion: The medical recommendations (pharmacological and non-pharmacological) were mapped according to the stage of treatment and severity of the disease onto three domains: management and treatment (drug and surgical interventions), criteria for evaluating the effectiveness of medical treatment, and follow-up/patient monitoring after initial treatment. The consensus targeted general practitioners, gastroenterologists and surgeons who manage patients with UC, and supports decision-making processes by health insurance companies, regulatory agencies, health institutional leaders, and administrators.

RESUMO Contexto: As doenças inflamatórias intestinais são doenças imunomediadas que incluem a doença de Crohn (DC) e a retocolite ulcerativa (RCU). A RCU é uma doença progressiva que acomete a mucosa colorretal causando sintomas debilitantes levando a alta morbidade e incapacidade laboral. Como consequência da inflamação crônica do cólon, a RCU também está associada a um risco aumentado de câncer colorretal. Objetivo: Este consenso visa fornecer orientações sobre o manejo médico mais eficaz de pacientes adultos com RCU. Métodos: As recomendações do consenso foram desenvolvidas por gastroenterologistas e cirurgiões colorretais referências no Brasil (membros da Organização Brasileira para Doença de Crohn e Colite [GEDIIB]). Uma revisão sistemática, incluindo as evidências mais recentes, foi conduzida para apoiar as recomendações. Todas as recomendações foram endossadas pelas partes interessadas/especialistas em doença inflamatória intestinal usando um Painel Delphi modificado. O nível de concordância para alcançar consenso foi de 80% ou mais. Resultados e conclus ão: As recomendações médicas (farmacológicas e não farmacológicas) foram mapeadas de acordo com o estágio de tratamento e gravidade da doença em três domínios: manejo e tratamento (intervenções medicamentosas e cirúrgicas), critérios para avaliar a eficácia do tratamento médico, e acompanhamento/monitoramento do paciente após o tratamento inicial. O consenso foi direcionado a clínicos gerais, gastroenterologistas e cirurgiões que tratam pacientes com RCU e apoia os processos de tomada de decisão por companhias de seguro de saúde, agências reguladoras, líderes institucionais de saúde e administradores.

The relationship between the commensal microbiota levels and Crohn's disease activity.

BACKGROUND AND AIM: Human gut microbiota play an important role in metabolism and host physiology. Perturbations of the gut microbial communities lead to the development of various diseases such as inflammatory bowel disease, celiac disease, allergic diseases, and metabolic diseases. Crohn's disease is a chronic inflammatory bowel disease characterized by periods of remission and relapse. Several studies suggest that intestinal inflammation arises due to an abnormal response of the intestinal immune system to the fecal microbiota. The goal of the study was to evaluate the relative amount of four bacterial groups in fecal samples of Crohn's disease patients and their relation to the inflammatory activity. METHODS: We studied stool samples of 105 individuals, 54 with Crohn's disease and 51 as a control group. The DNA extracted from the stool samples was subjected to real-time polymerase chain reaction (qPCR) for quantification of the Bacteroidetes phylum, class Bacilli, and Bifidobacteriaceae and Enterobacteriaceae families. RESULTS: We found a significant increase in Bacteroidetes in Crohn's disease samples when compared to the control group (14 650 and 2060 CFU/ng DNA, respectively) (P = 0.014). On the other hand, we observed a significant reduction in Bacilli and Bifidobacteriaceae (13 and 58 CFU/ng DNA, respectively) (P < 0.0001). In contrast, patients without any drug treatment presented an increase of Bacilli and Bifidobacteriaceae (102 521 and 6235 CFU/ng DNA, respectively) (P < 0.0001). CONCLUSION: The commensal bacteria were decreased in fecal samples of participants with Crohn's disease when compared to the control group. There was no relation between the disease location and/or disease activity with the microbiota.

Ulcerative colitis - treatment with biologicals.

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

Ulcerative colitis - treatment with biologicals

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

Evaluation of Home Polysomnography Findings, Quality of Sleep, and Fatigue in Inflammatory Bowel Disease: A Case Series.

STUDY OBJECTIVES: The pathogenesis of inflammatory bowel disease (IBD) is not well understood, and sleep disorders may be potential triggers for IBD. Thus, an evaluation of the sleep characteristics, fatigue symptoms, and cytokine levels was performed in patients with IBD during periods of active disease and remission. METHODS: A total of 20 participants presenting with Crohn's disease or ulcerative colitis, with active disease (n = 7) or in remission (n = 13), underwent home polysomnography (H-PSG). Pittsburgh Sleep Quality Index (PSQI) and Modified Fatigue Impact Scale (MFIS) were applied, in addition to the evaluation of interleukin (IL)-6, IL-10, and tumor necrosis factor alpha (TNF-α) serum levels. Exploratory analysis, t test and Mann-Whitney U test were used. RESULTS: The mean sleep latency in patients with active disease was 133.07 minutes and 106.79 minutes in those in remission. The sleep efficiency and sleep fragmentation in patients with active disease and those in remission were 80.90% and 84.20% (median), and 76.36/min and 69.82/min (mean), respectively, although the H-PSG parameters did not differ between the groups. The PSQI scores indicated poor sleep quality (global score above 5) in all participants with IBD, and the participants with active disease presented more symptoms of fatigue (P = .032). IL-6 and TNF-α average levels were higher in the participants with disease remission, although with a larger dispersion of the data. CONCLUSIONS: No significant difference in the H-PSG characteristics was observed between the patients with IBD with active disease and those in remission; however, the perception of the participants with IBD showed significant effect on the sleep quality and fatigue symptoms.

Using computed tomography enterography to evaluate patients with Crohn's disease: what impact does examiner experience have on the reproducibility of the method?

OBJECTIVE: To assess the impact that examiner experience has on the reproducibility and accuracy of computed tomography (CT) enterography in the detection of radiological signs in patients with Crohn's disease. MATERIALS AND METHODS: This was a retrospective, cross-sectional observational study involving the analysis of CT enterography scans of 20 patients with Crohn's disease. The exams were analyzed independently by two radiologists in their last year of residence (duo I) and by two abdominal imaging specialists (duo II). The interobserver agreement of each pair of examiners in identifying the main radiological signs was calculated with the kappa test. The accuracy of the examiners with less experience was quantified by using the consensus among three experienced examiners as a reference. RESULTS: Duo I and duo II obtained a similar interobserver agreement, with a moderate to good correlation, for mural hyperenhancement, parietal thickening, mural stratification, fat densification, and comb sign (kappa: 0.45-0.64). The less experienced examiners showed an accuracy > 80% for all signs, except for lymph nodes and fistula, for which it ranged from 60% to 75%. CONCLUSION: Less experienced examiners have a tendency to present a level of interobserver agreement similar to that of experienced examiners in evaluating Crohn's disease through CT enterography, as well as showing satisfactory accuracy in identifying most radiological signs of the disease.

OBJETIVO: Avaliar o impacto da experiência do examinador na reprodutibilidade e na acurácia de detecção de sinais radiológicos em exames de enterografia por tomografia computadorizada (entero-TC) de pacientes portadores da doença de Crohn. MATERIAIS E MÉTODOS: Análise retrospectiva de exames de entero-TC de 20 pacientes com doença de Crohn. Os exames foram analisados, independentemente, por dois radiologistas do último ano de residência (dupla I) e dois especialistas em imagem abdominal (dupla II). A concordância interobservador de cada dupla de examinadores para a identificação dos principais sinais tomográficos foi calculada pelo teste kappa. A acurácia da dupla I foi medida usando-se como referência um consenso entre três examinadores experientes. RESULTADOS: Ambas as duplas obtiveram concordância interobservador semelhante e com correlação moderada a boa para os sinais de estratificação mural, espessamento da parede, realce mucoso, densificação da gordura e sinal do pente (kappa: 0,45-0,64). Os examinadores menos experientes apresentaram acurácia superior a 80% para os sinais, exceto para linfonodos e fístula (entre 60% e 75%). CONCLUSÃO: Examinadores menos experientes têm tendência a apresentar grau de concordância entre si semelhante à de examinadores experientes na avaliação dos principais sinais tomográficos da doença de Crohn, com acurácia considerada satisfatória, para a maioria dos sinais.

Using computed tomography enterography to evaluate patients with Crohn's disease: what impact does examiner experience have on the reproducibility of the method? / Avaliação da doença de Crohn por meio da enterografia por tomografia computadorizada: qual o impacto da experiência dos examinadores na reprodutibilidade do método?

Abstract Objective: To assess the impact that examiner experience has on the reproducibility and accuracy of computed tomography (CT) enterography in the detection of radiological signs in patients with Crohn's disease. Materials and Methods: This was a retrospective, cross-sectional observational study involving the analysis of CT enterography scans of 20 patients with Crohn's disease. The exams were analyzed independently by two radiologists in their last year of residence (duo I) and by two abdominal imaging specialists (duo II). The interobserver agreement of each pair of examiners in identifying the main radiological signs was calculated with the kappa test. The accuracy of the examiners with less experience was quantified by using the consensus among three experienced examiners as a reference. Results: Duo I and duo II obtained a similar interobserver agreement, with a moderate to good correlation, for mural hyperenhancement, parietal thickening, mural stratification, fat densification, and comb sign (kappa: 0.45-0.64). The less experienced examiners showed an accuracy > 80% for all signs, except for lymph nodes and fistula, for which it ranged from 60% to 75%. Conclusion: Less experienced examiners have a tendency to present a level of interobserver agreement similar to that of experienced examiners in evaluating Crohn's disease through CT enterography, as well as showing satisfactory accuracy in identifying most radiological signs of the disease.

Resumo Objetivo: Avaliar o impacto da experiência do examinador na reprodutibilidade e na acurácia de detecção de sinais radiológicos em exames de enterografia por tomografia computadorizada (entero-TC) de pacientes portadores da doença de Crohn. Materiais e Métodos: Análise retrospectiva de exames de entero-TC de 20 pacientes com doença de Crohn. Os exames foram analisados, independentemente, por dois radiologistas do último ano de residência (dupla I) e dois especialistas em imagem abdominal (dupla II). A concordância interobservador de cada dupla de examinadores para a identificação dos principais sinais tomográficos foi calculada pelo teste kappa. A acurácia da dupla I foi medida usando-se como referência um consenso entre três examinadores experientes. Resultados: Ambas as duplas obtiveram concordância interobservador semelhante e com correlação moderada a boa para os sinais de estratificação mural, espessamento da parede, realce mucoso, densificação da gordura e sinal do pente (kappa: 0,45-0,64). Os examinadores menos experientes apresentaram acurácia superior a 80% para os sinais, exceto para linfonodos e fístula (entre 60% e 75%). Conclusão: Examinadores menos experientes têm tendência a apresentar grau de concordância entre si semelhante à de examinadores experientes na avaliação dos principais sinais tomográficos da doença de Crohn, com acurácia considerada satisfatória, para a maioria dos sinais.

A guide to prepare patients with inflammatory bowel diseases for anti-TNF-α therapy.

Current therapy of moderate-to-severe inflammatory bowel disease (IBD) often involves the use of anti-tumor necrosis factor alpha (TNF-α) agents. Although very effective, theses biologics place the patient at increased risk for developing infections and lymphomas, the latter especially when in combination with thiopurines. Appropriate patient selection, counseling, and education are all important features for the successful use of anti-TNF-α therapy. A thorough history to rule-out contraindications of this therapy and emphasis on monitoring guidelines are important steps preceding administration of anti-TNF-α agents. This therapy should only be considered if a recent evaluation has established that the patient has active IBD. In addition, it is important to exclude disease mimickers. Anti-TNF-α agents have been considered to present a globally favorable benefit/risk ratio. However, it is important that in routine practice, initiation of anti-TNF-α therapy be carefully discussed with the patient, extensively explaining the potential benefits and risks of such treatment. Prior to starting anti-TNF-α therapy, the patients need to be screened for latent tuberculosis, hepatitis B virus infection, and (usually) hepatitis C virus and HIV infection. Vaccination schedules of IBD patients should be evaluated and updated prior to the commencement of anti-TNF-α therapy. Ordinarily, immunization in adult patients with IBD should not deviate from recommended guidelines for the general population. With the exception of live vaccines, immunizations can be safely administered in patients with IBD, even those on immunosuppressants or biologics. The purpose of this review is providing an overview of appropriate steps to prepare patients with IBD for anti-TNF-α therapy.

Anti-tissue transglutaminase antibodies (IgA and IgG) in both Crohn´s disease and autoimmune diabetes.

OBJECTIVE: a strong association has been observed between celiac disease, generally its silent clinical form, and autoimmune disorders. A potential correlation with inflammatory bowel disease has also been suggested. Anti-tissue transglutaminase antibodies have been detected in Crohn´s disease. We investigated the prevalence of celiac disease in patients with autoimmune diabetes and in Crohn´s disease patients and also evaluated the correlation between anti-transglutaminase antibody positivity and the clinical status of these diseases. METHODS: anti-tissue transglutaminase and anti-endomysium antibodies were assessed by enzyme-linked immunosorbent assay and indirect immunofluorescence, respectively. Upper digestive endoscopy and duodenal biopsy were indicated for cases with positive serology. RESULTS: anti-transglutaminase antibodies were detected in five diabetic patients (prevalence of 11.1%), only one serum sample was positive for IgG isotypes. Nine of thirty-three patients with Crohn´s disease had low positive levels for IgA anti-transglutaminase. Antiendomysium antibodies were detected only in celiac patients. Celiac disease was confirmed in all diabetic patients submitted to duodenal biopsies who presented both anti-transglutaminase and anti-endomisyum antibodies positivity. In Crohn´s disease, its clinical status and the diagnosis of celiac disease were not associated with positiveanti-transglutaminase result. CONCLUSIONS: the prevalence of celiac disease was high in diabetic patients. Anti-tissue transglutaminase antibodies were sensitive and specific markers of celiac disease in this diabetic group, while these antibodies were of limited value for celiac disease screening in patients with Crohn´s disease.

Nutritional follow-up of patients with ulcerative colitis during periods of intestinal inflammatory activity and remission

CONTEXT: Ulcerative colitis is an inflammatory bowel disease involving superficial inflammation of the mucosa of the colon, rectum, and anus, sometimes including the terminal ileum. When in clinical activity, the disease is characterized by various daily evacuations containing blood, mucus and/or pus alternating periods of remission. OBJECTIVE: To compare nutritional parameters (dietary, biochemical and anthropometric) among patients with ulcerative colitis followed up on an outpatient basis over a period of 1 year and during periods of intestinal inflammatory activity and remission. METHODS: Sixty-five patients were studied over a period of 1 year and divided into two groups: group 1 with inflammatory disease activity (n = 24), and group 2 without disease activity (n = 41). Anthropometric measures, biochemical parameters, quantitative food intake, and qualitative food frequency were analyzed. RESULTS: A significant reduction in body mass index and weight and in the intake of energy, proteins, lipids, calcium, iron and phosphorus was observed in the group with inflammatory activity (group 1) when compared to the period of clinical remission. The most affected food groups were cereals, legumes, oils, and fats. In contrast, in group 2 significant differences in triceps and sub scapular skin fold thickness, total protein, hemoglobin and hematocrit were observed between the first and final visit. Calcium and vitamin B6 intake, as well as the consumption of legumes, meat and eggs, and sugar and sweets, was significantly higher than on the first visit. CONCLUSION: Patients with ulcerative colitis followed up on an outpatient basis tend to be well nourished. However, the nutritional aspects studied tend to worsen during the period of inflammatory disease activity.

CONTEXTO: A retocolite ulcerativa inespecífica compreende uma das doenças inflamatórias intestinais, com características de inflamação superficial da mucosa do cólon, reto, ânus, podendo incluir o íleo terminal. Caracteriza-se por várias exonerações diárias, com a presença de sangue e/ou pus, cursando em períodos de atividade e remissão inflamatória intestinal. OBJETIVO: Comparar os parâmetros nutricionais (alimentares, bioquímicos e antropométricos) em pacientes com retocolite ulcerativa inespecífica acompanhados em ambulatório, durante a atividade e remissão da doença inflamatória, no período de 1 ano. MÉTODOS: Foram estudados 65 pacientes durante 1 ano e divididos em dois grupos: grupo 1 com atividade inflamatória da doença (n = 24) e grupo 2 sem atividade da doença (n = 41), e analisadas as medidas antropométricas, os exames bioquímicos, o consumo alimentar quantitativo e a frequência alimentar qualitativa. RESULTADOS: O grupo com atividade inflamatória (grupo 1) apresentou redução estatisticamente significante no índice de massa corpórea, peso, no consumo de energia, proteínas, lipídios, cálcio, ferro e fósforo, em relação ao período de remissão clínica. Os grupos alimentares com significado prejuízo foram os cereais, as leguminosas, os óleos e as gorduras. Já no grupo 2, foram observadas alterações com significância estatística na dobra cutânea tricipital e subescapular, nos valores de proteínas totais, hemoglobina e hematócrito da consulta inicial para a final. Encontrou-se consumo de cálcio e vitamina B6, assim como na ingestão do grupo das leguminosas, carnes e ovos, açúcares e doces maiores significativamente do que na consulta inicial. CONCLUSÃO: Pacientes com retocolite ulcerativa inespecífica, acompanhados em ambulatório, tendem a ser bem nutridos, mas na fase de atividade inflamatória da doença, há tendência na piora dos aspectos nutricionais estudados.

Estudo multicêntrico aberto com lactulose em cristais no tratamento da constipação intestinal funcional / Crystalline lactulose in the treatment of functional bowel constipation. An open, multicentric study

Introdução: Constipação funcional é uma das mais freqüêntes causas de consulta médica em gastroenterologiae apenas 60por cento dos casos respondem ao aumento de fibras na dieta. A lactulose é um açucar semi-sintético, cuja formulação líquida contém outros açucares, aos quais muitos de seus efeitos adversos são atribuídos. Lactulose em cristais, uma forma altamente purificada deste dissacarídeo, poderia diminuir a incidência de tais reações adversas. Objetivos: Avaliar a eficácia, segurança e tolerabilidade da lactulose em cristais como medicamento auxiliar à dieta no tratamento da constipação intestinal funcional. Casuística e métodos: Pacientes com idade de 20 a 60 anos portadores de constipação intestinal funcional foram inicialmente submetidos a dieta laxativa por três dias. Aqueles sem resposta ao tratamento dietético receberam lactulose em cristais 20g/dia por quatro semanas, além de preencher um diário sobre hábito intestinal, sintomas gastrointestinais e a freqüência do uso de suporsitórios e clisteres como tratamento alternativo. Resultados: Oitenta pacientes completaram o tratamento. Houve melhora da constipação intestinal em 74 e, destes, 77por cento referiram normalização do hábito intestinal. A média de tempo necessário para ação da droga foi de 1,5 dia, embora para cinco pacientes esse tempo tenha ultrapassado quatro dias. Reações adversas relacionaram-se ao trato gastrointestinal: 67,8por cento referiram cólicas abdominais; 63,3por cento flatulência; e 89,0por cento, náuseas, que regridiram com o decorrer do tratameno (p<0,001), o qual foi interrompido apenas em dois casos. A aceitação da medicação foi referida com muito boa ou boa por 97,5por cento dos pacientes. Conclusão: lactulose em cristais é eficaz e segura como droga auxiliar à dieta no tratamento da constipação intestinal funcional

Avaliação ultra-sonográfica da resposta motora da vesícula biliar em adultos assintomáticos após medicação fitoterápica / ultrasound evaluation of the gallbladder motor response in asymptomatic adults after phytotherapic medication

A motilidade da vesícula biliar é controlada por uma complexa rede de interações neuroumorais. A associação de substâncias fitoterápicas tais como alcachofra (Cynara scolymus) e boldo (Peumus boldus) tem sido utilizada há vários anos por sua ação colerética reconhecida. A contração da vesícula biliar está descrita entre 35 e 85por cento, dependendo do agente utilizado. O objetivo deste trabalho foi avaliar a eficácia colecinética de produto contendo alcachofra, boldo e outras substâncias fitoterápicas (Solvobil, (Farmasa), sua aceitação e tolerabilidade. Foram estudados, prospectivamente, 30 indivíduos adultos saudáveis. Na primeira fase avaliou-se a a vesícula biliar, em jejum, antes de qualquer estímulo, através do método ultrasonográfico. Sua contração foi monitorizada aos 30 e 60 minutos após ingestão de água e em seguida à medicação. Do total dos 30 indivíduos estudados, 53,3por cento apresentaram redução máxima do volume vesicular aos 30 minutos e, cerca de 40por cento deles, aos 60 minutos, a partir da ingestão do medicamento. O volume cúbico médio da vesícula, em condição basal, foi estatisticamente superior ao da média dos volumes observados aos 30 e 60 minutos, após o estímulo pela droga. Houve diferença estatisticamente significante quando se comparou o volume vesicular médio nos tempos de 30 e 60 minutos, após a ingestão de água, e o encontrado, nos mesmos tempos, após ingestão do medicamento. Os autores concluem que o composto farmacêutico avaliado nas condições metodológicas deste estudo foi capaz de provocar contração vesicular efetiva em voluntários hígidos após jejum alimentar

Obstipação intestinal crônica / constipation

Além de diagnosticar a obstipação intestinal, o autor orienta a classificação, através de critérios definidos pelo consenso chamado Roma 11 e também por meios utilizados na prática diária, estabelece os passos do processo de avaliação clínica, laboratoríai e radiológica, que diferenciam os quadros funcionais dos orgânicos e a partir desta classificação, destaca as várias opções de tratamento, que passam por orientações dietáticas, mudanças nos hábitos de vida e introdução de medicamentos. Acrescenta uma subclassificação de obstipação resistente ao tratamento, levando à necessidade de avaliação do tempo de trânsito intestinal e da anatomia e funcionamento da musculatura do assoalho pálvico, o que implica em formas terapêuticas alternativas.

Avaliação da função pancreática exócrina em portadores da doença de Crohn / Pancreatic exocrin function avaliation in Crohn's disease

Apesar de nao integrarem as manifestaçoes extra-intestinais da doença de Crohn (DC), algumas alteraçoes pancreáticas foram inicialmente notadas na prática clínica, sobretudo pancreatites agudas, e posteriormente diminuiçao de sua funçao exócrina. Em nossa pesquisa, estudamos a secreçao exócrina pancreática nos doentes portadores de DC, correlacionado-a com algumas características da doença inflamatória, como tempo de existência, atividade, localizaçao da doença, complicaçoes, presença de desnutriçao e esteatorréia. Selecionamos 15 doentes, sem antecedente de alcoolismo, diabete ou outra doença crônica, que nao estivessem fazendo o uso de imunossupressores, nem fossem desnutridos moderados ou graves, com propedêutica de imagem normal para a glândula pancreática. Quatro indivíduos, nao portadores de doença pancreática ou intestinal, compuseram o grupo controle. Utilizou-se para obtençao do suco pancreático puro (SPP) a cateterizaçao endoscópica do ducto pancreático principal e sua colheita, em dois tempos de 5 minutos, após estímulo com injeçao de secretina endovenosa, processado para as medidas de volume e dosagens de amilase, lipase, bicarbonato e proteína total. Nossos resultados mostraram nao haver diferença estatística entre os grupos, mas algumas observaçoes individualizadas puderam ser feitas. Demonstramos aumento da secreçao de bicarbonato quanto maior o tempo de doença. O valores de lipase no tempo 2 e volumes secretados estavam diminuídos, quando relacionados com o índice de atividade CDAI e ao índice Simples, respectivamente. Também foi notado que os menores valores de secreçao de amilase e lipase se correlacionaram ao paciente que possuia a maior extensao da doença. Nao foi encontrada relaçao dos resultados aferidos no SPP com aspectos nutricionais, complicaçoes da doença ou com a perda da gordura fecal. Chegamos à conclusao de que em determinadas situaçoes como doença extensa, atividade inflamatória elevada, quando medida pelo CDAI e índice Simples e tempo de sua existência, há alteraçoes da funçao exócrina pancreática, porém sutis e, na nossa casuística, nao acarretaram mudanças clínicas e laboratoriais mensuráveis, em relaçao à perda de gordura fecal e desnutriçao, que seriam alvo de tratamento enzimático suplementar nos casos em que a diarréia do paciente com DC fosse irresponsiva ao tratamento exclusivo da inflamaçao

Avaliaçäo clínico-laboratorial do fígado em alcoólatras: resultados preliminares / Clinico-laboratory evaluation of the liver in alcohol addicts: preliminary results

Estudando-se 45 alcoólatras sem hepatopatia clínica evidente, pode-se classificá-los em três grupos: 27% dos alcoólatras näo apresentaram nenhuma anormalidade clínica ou laboratorial; 38% apresentaram apenas alteraçöes laboratoriais (sendo que em 59% destes o único exame alterado foi a gamaglutamiltransferase); e 35% apresentaram hepatomegalia. O grupo com hepatomegalia teve média de ingesta etílica total significativamente superior em relaçäo à dos outros dois grupos. Destaca-se a importância, para avaliaçäo do fígado em alcoólatras, do uso dos seguintes parâmetros: ingesta etílica total, hepatomegalia e gamaglutamiltransferase