Severe ischemic cytomegalovirus proctocolitis with multiple perforation.

Cytomegalovirus (CMV) typically causes gastrointestinal infections in immunocompetent patients. Colonic perforations secondary to CMV are exceeding rare. We describe a 88-year-old male presenting with a week-long history of intractable abdominal discomfort, bloating, nausea and diarrhea. Flexible sigmoidoscopy revealed significant ulceration with yellowish slough. Emergency surgery was performed subsequently in view of multiple perforations in the rectosigmoid junction. CMV gastrointestinal infections demonstrated an ischemic process secondary to vasculitis, which accelerated the pathway to colonic perforation. CMV gastrointestinal infection should be considered as a differential diagnosis in patients with colonoscopy findings similar to ischemic colitis and Clostridium difficile infections.

Quantitative MRI in murine radiation-induced rectocolitis: comparison with histopathological inflammation score.

Murine radiation-induced rectocolitis is considered to be a relevant animal model of gastrointestinal inflammation. The purpose of our study was to compare quantitative MRI and histopathological features in this gastrointestinal inflammation model. Radiation rectocolitis was induced by localized single-dose radiation (27 Gy) in Sprague-Dawley rats. T2 -weighted, T1 -weighted and diffusion-weighted MRI was performed at 7 T in 16 rats between 2 and 4 weeks after irradiation and in 10 control rats. Rats were sacrificed and the histopathological inflammation score of the colorectal samples was assessed. The irradiated rats showed significant increase in colorectal wall thickness (2.1 ± 0.3 mm versus 0.8 ± 0.3 mm in control rats, P < 0.0001), normalized T2 signal intensity (4 ± 0.8 versus 2 ± 0.4 AU, P < 0.0001), normalized T1 signal intensity (1.4 ± 0.1 versus 1.1 ± 0.2 AU, P = 0.0009) and apparent and pure diffusion coefficients (ADC and D) (2.06 × 10-3 ± 0.34 versus 1.51 × 10-3 ± 0.23 mm2 /s, P = 0.0004, and 1.97 × 10-3 ± 0.43 mm2 /s versus 1.48 × 10-3 ± 0.29 mm2 /s, P = 0.008, respectively). Colorectal wall thickness (r = 0.84, P < 0.0001), normalized T2 signal intensity (r = 0.85, P < 0.0001) and ADC (r = 0.80, P < 0.0001) were strongly correlated with the histopathological inflammation score, whereas normalized T1 signal intensity and D were moderately correlated (r = 0.64, P = 0.0006, and r = 0.65, P = 0.0003, respectively). High-field MRI features of single-dose radiation-induced rectocolitis in rats differ significantly from those of control rats. Quantitative MRI characteristics, especially wall thickness, normalized T2 signal intensity, ADC and D, are potential markers of the histopathological inflammation score.

Clinical pattern and progression of ulcerative proctitis in the Japanese population: a retrospective study of incidence and risk factors influencing progression.

AIM: The rate of extension of proctitis in Western countries has been reported, but no data regarding long-term follow-up have been described for the Japanese population. Additionally, patients with long-standing or extensive ulcerative colitis have an increased risk for developing colorectal cancer. This study evaluated both the rate of extension of the disease and the development of neoplasia among patients with an initial diagnosis of ulcerative proctitis. METHOD: We retrospectively investigated the medical charts of patients with proctitis from 1979 to 2014. The primary focus of this research was the extension of the inflammatory area. The secondary focus included risk factors for disease extension and the development of neoplasia. RESULTS: Sixty-six patients satisfied the inclusion criteria. Proximal extension of the disease occurred in 34 patients: 19 patients had left-sided colitis and 15 had pancolitis. According to a multivariate analysis, disease extension was significantly higher in patients with disease onset before 25 years of age (P-value = 0.043). The cumulative rates of disease extension at 10 and 20 years were 33.8% and 52.2%, respectively. Three patients were diagnosed with dysplasia during follow-up, all of whom experienced disease extension before the development of dysplasia. CONCLUSION: The rate of extension of ulcerative colitis in the Japanese population was comparable to that in Western countries. A younger age of disease onset was associated with disease extension. Extension of proctitis may be associated with an increased risk of colorectal cancer.

Diversion proctocolitis and response to treatment with short-chain fatty acids--a clinicopathological study in children.

OBJECTIVE: Diversion proctocolitis (DPC) frequently develops in the colorectum after diversion of the fecal stream characterized by bleeding from the inflamed mucosa. Short-chain fatty acids (SCFA) are responsible for growth and differentiation of enterocytes. Adult series have reported variable response of DPC to luminal SCFA. There is dearth of studies in children. We aimed to study incidence, clinical, endoscopic, and histopathological characteristics of DPC and effect of SCFA in children. METHODS: Prospectively clinical, endoscopic, and histopathological evaluation was done for DPC in children undergoing fecal diversion. Patient characteristics, type and duration of stoma, symptoms, endoscopy and biopsy findings, duration of treatment and response to SCFA, time of closure of stoma, and any associated gut anomaly were recorded. RESULTS: Fifteen children completed the study. Anorectal malformation was the commonest indication for stoma. Sixty percent were symptomatic within 2-9 months, excessive mucous discharge being the commonest symptom. All had at least one positive endoscopic finding; erythema, edema, and exudates being the commonest findings. All DPCs improved clinically and endoscopically following SCFA. Histological resolution was seen in 78 %, while 22 % had persistent disease. Closure of stoma showed complete resolution of DPC. CONCLUSION: DPC was common (87 %) following stoma formation in children with strong male preponderance (6.5:1). The commonest indication for stoma was anorectal malformation (67 %). Clinical, endoscopic, and histopathological changes appeared within 2-9 months with symptomatic DPC in 60 %. All patients (100 %) had at least one positive endoscopic finding, histopathological examination confirmed the diagnosis. SCFA led to symptomatic, endoscopic, and histopathological resolution of DPCs. Closure of stoma cured all the persistent DPCs.

International cooperation for science and technology development: a way forward for equity in health / Cooperação internacional para o desenvolvimento científico e tecnológico: um caminho para equidade em saúde

Since 1990, international organizations have been increasingly involved in building an international sub-regime for research, development and innovation in health. This article analyzes the priorities of developing countries in health since the 1990s. It is a descriptive and analytical study that investigates the literature and contributions of key informants. Calling for the end of global inequities in the support for science and technology in health, international organizations recommend that developing countries focus their efforts on neglected diseases and operational research, an insufficient agenda for science and technology cooperation to effectively overcome the vulnerabilities between countries.

Desde 1990, intensificou-se o movimento das organizações internacionais na construção do sub-regime internacional de pesquisa, desenvolvimento e inovação em saúde. Este artigo analisa as prioridades dos países em desenvolvimento para essa área desde a década de 1990. Estudo descritivo-analítico, estabelece um diálogo entre a literatura e as contribuições de informantes-chave. Defendendo a superação da iniquidade mundial no fomento científico-tecnológico em saúde, as organizações internacionais recomendam aos países em desenvolvimento focalizar suas ações em doenças negligenciadas e pesquisa operacional - agenda insuficiente para a cooperação científico-tecnológica ser fator de superação de vulnerabilidades entre países.

[Clinical characteristics of infants with allergic proctocolitis: a retrospective study of 96 cases].

OBJECTIVE: To study the clinical characteristics of hospitalized infants with allergic proctocolitis, and to provide a scientific basis for early diagnosis and effective treatment of allergic proctocolitis. METHODS: The clinical data of 96 infants with allergic proctocolitis between September 2011 and March 2013 were reviewed retrospectively. Descriptive analysis was performed to assess the clinical characteristics of allergic proctocolitis. RESULTS: The most common clinical manifestation was diarrhea in the 96 infants. The electronic colonoscopy results indicated that 40% of the infants had multiple small nodules, 26% showed focal erythema and brittle mucous membranes, 25% showed multiple superficial erosion, and 9% showed ulcers with surface exudates. The affected areas included the sigmoid colon (87%), rectum (24%), descending colon (13%), and transverse colon ascending colon and ileocecal junction (8%). Histopathologic examination showed eosinophilic infiltration of mucosal layers, the condition of which was mild to moderate in 89% and severe and extremely severe in 12% of the infants. To treat the allergic proctocolitis, mothers and infants were suggested to avoid allergenic foods; 43% of them continued breastfeeding, 45% switched to highly hydrolyzed protein formula, and 13% were prescribed amino acid-based elemental formula. All infants were in complete remission at discharge. CONCLUSIONS: As the clinical manifestations of allergic proctocolitis in infants lack specificity, the electronic colonoscopy and mucosal histopathologic examination are helpful for early and differential diagnosis. The best treatment is to avoid allergenic foods. Formula-feeding infants should be prescribed highly hydrolyzed protein formula or amino acid-based elemental formula.

Padronização e quantificação de critérios histopatológicos melhoram o diagnóstico da doença intestinal inflamatória? / Do standardization and quantification of histopathological criteria improve the diagnosis of inflammatory bowel disease?

Introduction: Inflammatory bowel disease comprises two major categories: Crohn's disease and ulcerative rectocolitis, both with different clinical and histological aspects, causing sometimes significant morbidity. Objectives: Choose and apply standardized and quantified histopathological diagnosis method, and compare the results and quality index with the original diagnosis. Materials and methods: 43 histological colonoscopic biopsies of 37 patients were re-evaluated by standardized system. Results and discussion: The original diagnoses were more inconclusive (23.3%) than those standardized (2.3%). The agreement with gold standard (clinical, colonoscopical, and radiological diagnosis) was higher on standardized diagnoses (95.3%) than in original (74.4%), especially in relation to Crohn's disease, which percentages were 92.3% and 46.1%, respectively. The quality index was calculated in conclusive diagnosis of each method. For ulcerative rectocolitis, both methods showed sensitivity and negative predictive value of 100%; otherwise the original diagnosis demonstrated specificity of 85.7%, positive predictive value of 96.3% and accuracy of 97.0%, and the standardized diagnosis 92.3%, 96.7% and 97.6%, respectively. For Crohn's disease, there is specificity and positive predictive value of 100% in both methods; the original diagnosis showed sensitivity of 85.7%, negative predictive value of 96.3% and accuracy of 97%, while for the standardized diagnoses 92.3%, 96.7%, and 97.6%, respectively. Conclusion: The standardized diagnosis presented a higher percentage of correct and conclusive diagnoses than those presented in the original diagnosis, especially for Crohn's disease, as well as equal or slightly higher values in some quality index...

Introdução: Duas são as formas de manifestação da doença intestinal inflamatória: doença de Crohn e retocolite ulcerativa, ambas com evolução clínica, tratamento e aspectos histopatológicos diferentes, causando, por vezes, significativa morbidade. Objetivos: Escolher e aplicar método padronizado e quantificado de diagnóstico histopatológico e comparar os resultados e os índices de qualidade, com os dos diagnósticos originais. Materiais e métodos: Foram reavaliadas histologicamente 43 biópsias colonoscópicas seriadas de 37 pacientes por sistema padronizado. Resultado e discussão: Os diagnósticos originais foram mais inconclusivos (23,3%) do que os padronizados (2,3%). A concordância com o padrão-ouro (diagnóstico clínico, colonoscópico e radiológico) foi maior nos diagnósticos padronizados (95,3%) do que nos originais (74,4%), principalmente em relação à doença de Crohn, cujos percentuais foram de 92,3% e 46,1%, respectivamente. Para retocolite ulcerativa, ambos os métodos apresentaram sensibilidade e valor preditivo negativo de 100%; já nos diagnósticos originais, foram verificados especificidade de 85,7%, valor preditivo positivo de 96,3% e acurácia de 97%, e nos diagnósticos padronizados, 92,3%, 96,7% e 97,6%, respectivamente. Para doença de Crohn, verificaram-se especificidade e valor preditivo positivo de 100% nos dois métodos; nos diagnósticos originais, sensibilidade de 85,7%, valor preditivo negativo de 96,3% e acurácia de 97%, e nos diagnósticos padronizados, 92,3%, 96,7% e 97,6%, respectivamente. Conclusão: O diagnóstico padronizado apresentou maior percentual de diagnósticos corretos e conclusivos do que os apresentados no diagnóstico original, principalmente para doença...

Sex, lies, and gastrointestinal tract biopsies: a review of selected sexually transmitted proctocolitides.

There are many insults that result in gastrointestinal tract inflammation. Infections can be particularly challenging because (1) only a limited number of organisms provoke a specific endoscopic and/or histologic appearance; and (2) although some organisms may be present on biopsies, the findings may be so subtle or organisms so few that they are easily missed if the reviewer is not performing a specific search for the offender. Sexually transmitted infections (STI) are rarely a consideration at the time of GI biopsy examination and clinicians rarely inquire about sexual behavior at the time of initial patient interview. Although establishing a definitive STI diagnosis is not possible on histology alone, these infections are associated with inflammatory patterns that may help raise this diagnostic possibility. Becoming familiar with these patterns is necessary as worldwide outbreaks of these infections are being reported. This review aims to provide the pathologist with histologic clues associated with the most frequently encountered bacterial pathogens in the setting of STI proctitis, namely, Chlamydia trachomatis, Neisseria gonorrhoeae, and Treponema pallidum.

Proximal disease extension and related predicting factors in ulcerative proctitis.

OBJECTIVE: Ulcerative colitis usually involves the rectum, may extend in a proximal and continuous fashion to involve varying portions of the bowel. However, the risk factors predictive of proximal extension have yet to be determined. The aim of this study was to evaluate both the natural course of disease and the risk factors influencing the proximal disease extension in ulcerative proctitis. MATERIAL AND METHODS: We retrospectively analyzed 98 patients with ulcerative proctitis at the time of diagnosis who were regularly followed and underwent sigmoidoscopy or colonoscopy between January 2000 and December 2007. RESULTS: The mean duration of follow-up was 109.2 ± 49.5 months. A total of 27 (27.6%) patients experienced proximal disease extension. Mayo scores were significantly higher in the extension group compared with patients whose ulcerative proctitis did not extend proximally (p < 0.001). Corticosteroid use at initial diagnosis was also more frequent in the extension group (p = 0.026). In addition, chronic, continuous disease activation within 6 months of the initial diagnosis was significantly higher in the extension group (p < 0.001), as was disease relapse and the number of hospitalizations over the entire follow-up period (p < 0.001 and p = 0.002). According to multivariate analysis, disease extension after the initial diagnosis was associated with chronic disease activation, disease relapse and hospitalization (p = 0.030, p = 0.042 and p = 0.044, respectively). CONCLUSION: Increased severity of disease upon diagnosis of ulcerative proctitis was associated with a higher probability of proximal disease extension during the follow-up period. Moreover, those with disease extension were more likely to experience relapse and to be hospitalized, indicating poor prognosis.

[Natural history of intestinal lesions in inflammatory bowel disease]. / Histoire naturelle de l'atteinte intestinale des maladies inflammatoires chroniques de l'intestin.

Crohn's disease may involve any part of the digestive tract from mouth to anus, but affects mainly the distal ileum and the,colon. At diagnosis, perianal lesions are observed in 20% of the cases. During the disease course, strictures develop in the majority of patients with ileal disease, while penetrating lesions (fistulas and abscesses) develop in half of the patients. Only one third of patients with colonic involvement will develop structuring or penetrating lesions. Intestinal lesions of ulcerative colitis involve constantly the rectum and may extend continuously throughout the colon. At diagnosis, lesions involve the rectum, the left colon and most of the colon in similar proportions. Subsequent extension of the lesions over 20 years is observed in half of the patients. In Crohn's disease, 40%-50% of the patients require intestinal resection at 10 years. The risk of colectomy in ulcerative colitis is about 1% per year Dysplasia and cancer may complicate longstanding extensive colonic lesions in Crohn's disease and ulcerative colitis. Malignant transformation of chronic inflammatory lesions may also occur in patients with longstanding lesions of the small bowel in Crohn's disease.

[New therapeutic goals in inflammatory bowel diseases]. / Nouveaux objectifs thérapeutiques dans les maladies inflammatoires chroniques de l'intestin.

Crohn's disease and ulcerative colitis are chronic, progressive, destructive and disabling conditions. So far therapeutic strategies based only on the relief of symptoms did not change the natural history of inflammatory bowel diseases (BD). In Crohn's disease the concept of deep remission, which includes clinical and inflammatory (endoscopic and biologic) remission, is emerging. In ulcerative colitis, evidence accumulates to recommend achieving and maintaining mucosal healing as assessed by proctosigmoidoscopy. Whether histologic remission is the ultimate therapeutic goal in ulcerative colitis will require further investigation. These new therapeutic targets may be the best way to change disease course (hospitalizations, surgery) and to prevent disability in IBD.

[Management of intestinal complications in inflammatory bowel diseases]. / Traitement des complications digestives des maladies inflammatoires chroniques de l'intestin.

The evolution of inflammatory bowel disease (IBD) is characterized by the occurrence of gastrointestinal complications. For Crohn's disease (CD), it is mainly strictures, fistulas and abdominal or pelvic abscess in luminal forms and perianal lesions (ulcers, fissures, fistula/abscess) in the perineal forms. For ulcerative colitis (UC), main complications are severe flare up and dysplasia/cancer. In Crohn's disease, stenosis can be treated medically in first line (steroid-immunosupppresseurs or antiTNF) especially when the inflammatory component is predominant or in extensive lesions. In case of limited lesions (< 4 cm) and low inflammatory component, endoscopic dilatation can be propose before surgery, especially in patients previously operated on. Abdomino-pelvic abscess should be drained if the size is greater than 4-5 cm and treated with antibiotics. If obstructive signs are present after the resolution of the abscess, surgery is usually required. In some cases, an antiTNF therapy can be discussed (ongoing trial with the GETAID). Surgery during the MC should be performed laparoscopically, particularly in uncomplicated forms (first ileocecal resection) but also whenever possible for complicated diseases. Anoperineal abscess must be drained by non-tight setons. Medical treatment also involves antibiotics and antiTNF, usually in combotherapy. Biological glue is especially interesting in simple fistulas. Collagen plugs have not demonstrated efficacy in simple or complex perianal Crohn's disease fistulas and may have a deleterious effect. They are therefore not recommended. Severe UC flare up are still conventionally treated with corticosteroids IV for 3-5 days, followed in case of failure of a 2nd line treatment with infliximab or ciclosporin. The place of emergency colectomy had regressed due to the effectiveness of medical treatments.

[Value of dual-time-point (18)F-fluorodeoxyglucose integrated positron emission and computed tomography in differentiation of malignant from benign gastrointestinal diseases].

OBJECTIVE: To explore the value of dual-time-point (18)F-fluorodeoxyglucose integrated positron emission and computed tomography ((18)F-FDG PET-CT) in differentiation of malignant from benign gastrointestinal diseases. METHODS: Sixty five patients with suspected gastrointestinal lesions underwent dual-time-point (18)F-FDG PET-CT imaging. Standardized uptake value (SUV) was calculated for semi-quantitative assessment. The SUV of the two acquisitions were signed SUV(early) and SUV(delayed), respectively. Then the change of SUVmax (ΔSUVmax) was calculated. The ROC curves of the SUV(early), SUV(delayed) and ΔSUV were drawn to find the best cut-off point value for differential diagnosis, and then the sensitivity, specificity, positive predictive value, negative predictive value and accuracy were calculated, respectively. RESULTS: Of the malignant lesions, the SUVmax in delayed imaging were significantly higher than those in early imaging, while there were no significant differences of SUVmax between the two images of the benign lesions. The ΔSUVmax of the malignant lesions were significantly higher than that of the benign ones. Taking the SUVmax higher than 9.2 in early imaging as positive diagnostic criteria, the sensitivity was 72.7%, the specificity was 85.7%, the positive predictive value was 91.4%, the negative predictive value was 60.0%, and the accuracy was 76.9%. Taking the SUVmax higher than 10.9 in delayed imaging as positive diagnostic criteria, the sensitivity was 75.0%, the specificity was 90.5%, the positive predictive value was 94.3%, the negative predictive value was 63.3%, and the accuracy was 80.0%. Taking the ΔSUVmax higher than 5.1% as positive diagnostic criteria, the sensitivity was 95.5%, the specificity was 85.7%, the positive predictive value was 93.3%, the negative predictive value was 90.0%, and the accuracy was 92.3%. The accuracy of dual-time-point (18)F-FDG PET-CT imaging was significantly higher than that of single-time point (18)F-FDG PET-CT imaging. CONCLUSION: Dual-time-point (18)F-FDG PET-CT imaging is a useful method for differentiating malignant from benign gastrointestinal diseases, and it is superior to the single-time point (18)F-FDG PET-CT imaging.

Glutaraldehyde-induced colitis: case reports and literature review.

Glutaraldehyde-induced colitis is an uncommon colitis in clinical practice. Because the involvement of colonic segment is determined by the endoscopic part where glutaraldehyde remains, a recent history of endoscopy and a demarcated involvement of colonic segment are the most characteristic signs of glutaraldehyde-induced colitis. The typical clinical scenario is acute onset of lower abdominal pain, fever, and bloody stool. Laboratory data usually show leukocytosis and elevated C-reactive protein. The endoscopic pictures of involved segments are compatible with acute colitis, including hyperemic, edematous, with or without multiple erosions. Acute ischemic colitis and infectious colitis should be differentiated at the outset of the disease. Stool pathogen tests are usually negative. Parenteral empiric antibiotic may be considered if severe transmural edema of the involved segment is observed in computed tomography. Conservative treatment, including bowel rest and parenteral hydration, is able to stabilize the condition in a week. Herein, we present two cases of acute proctocolitis caused by glutaraldehyde after uneventful colonoscopy.

[Appendiceal orifice inflammation in distal ulcerative colitis. Report of a case and review of the literature]. / Inflamación del Orificio Apendicular en Colitis Ulcerativa Distal.

We report the case of a 45-year-old female patient with an 18 month diagnosis of distal ulcerative colitis (proctosigmoiditis) of 18 months, who presented initially with allergy to salicylates, for which the disease was managed with corticosteroids and azathioprine and subsequently with Infliximab infusions, entering in remission. When she was about to receive her fifth Infliximab infusion she presented an exacerbation of her underlying disease with frequent stools with mucus, blood and tenesmus. Given that her initial diagnosis was made with a sigmoidoscopy we scheduled a total colonoscopy showing marked inflammation, erythema and friability limited to the recto-sigmoid mucosa, like at the disease onset, and when we reached the cecum an erythematous area circumscribed to the appendiceal orifice was observed, with a mucosal aspect identical to the described for the recto-sigmoid mucosa. The biopsies taken from that area were compatible with ulcerative colitis. We herein describe the details of the case and review the literature.

Dietary protein-induced proctocolitis in childhood.

Cow's milk protein-induced proctocolitis presents with overt rectal bleeding in otherwise healthy infants and is characterized by an eosinophilic infiltrate of the left colonic mucosa. Although it is the most common cause of proctocolitis in infancy, dietary protein-induced proctocolitis had hardly ever been reported in childhood so far. We hereby report 16 otherwise healthy children aged 2-14 yr, who presented over a 6-yr period with persistent or recurrent rectal bleeding related to a mild form of left-sided colitis characterized by a prominent eosinophilic infiltration, focal lymphoid follicle hyperplasia, and a prompt clinical and histological response to a cow's milk-free diet. No patient had a history of food-induced proctocolitis during infancy, and most patients did not show an IgE-mediated response to cow's milk protein. Half of the patients did have other gastrointestinal symptoms, but no systemic symptoms were present and other causes of colitis were excluded by appropriate investigation. Tolerance to cow's milk protein developed in half of the patients within a year. Dietary protein-induced proctocolitis is a relatively common cause of overt rectal bleeding in childhood, and its features are remarkably similar to those of dietary protein-induced proctocolitis of infancy.

An unusual case of hematochezia: acute ischemic proctosigmoiditis.

Acute ischemia of the rectum is uncommon and usually occurs after aorto-iliac surgery. In this report, we present a case of acute ischemic proctosigmoiditis that developed from a brief episode of hypotension. An 85-year-old male presented to the emergency room with hypotension, mental confusion, and passage of maroon-colored stool. He was resuscitated and treated for presumed sepsis. Computerized tomography of the abdomen and pelvis displayed signs of acute inflammation of the distal colon and rectum. Endoscopic findings and microscopic examination of the rectal biopsy revealed changes consistent with acute ischemic proctosigmoiditis. An evaluation for infectious etiologies was negative. The patient's clinical condition improved over the next 24 h with supportive care. Involvement of the rectum is rare in ischemic colitis because of its abundant collateral blood supply. Acute ischemic proctosigmoiditis should be considered in the differential diagnosis of elderly patients with multiple co-morbidities presenting with hematochezia.