Relato de caso: herpes-zoster após o uso de infliximabe / Case report: herpes zoster after infliximab infusion

O uso de drogas biológicas como o anti-TNF (infliximabe) no tratamento das doenças inflamatórias intestinais trouxe nova perspectiva terapêutica na busca da cura e controle dessas doenças. O TNF-alfa é um mediador inflamatório e modula a resposta imunológica celular. Portanto, existe a possibilidade de que o infliximabe possa afetar a resposta imunológica normal e predispor o paciente a infecções oportunistas com maior freqüência do que o habitual. O objetivo deste relato é descrever a ocorrência de herpes-zoster após a segunda aplicação do infliximabe em paciente com doença inflamatória intestinal. A doente com 49 anos de idade e diagnóstico de retocolite ulcerativa distal não responsiva ao tratamento com sulfassalazina, derivados e corticóide recebeu a primeira aplicação de infliximabe na dose de Smg/kg de peso, com melhora importante da sintomatologia - sangramento intestinal, diarréia e artralgia - logo nos primeiros dias. Após dois meses, foi administrada a segunda aplicação da medicação, após a qual a doente evoluiu com prurido e aparecimento de lesões pustulosas em região genital compatível com herpes-zoster. A doente foi medicada com aciclovir oral por sete dias, com regressão total do quadro. Apesar do aparecimento da infecção oportunista, o tratamento adequado e em curto intervalo de tempo não impossibilitou o tratamento continuado com infliximabe, desde que sob vigilância permanente do médico assistente.

Short- and long-term outcomes of ileal pouch-anal anastomosis for ulcerative colitis

Ileal pouch-anal anastomosis was an important advancement in the treatment of ulcerative colitis. The aim of this study was to determine whether early complications of ileal pouch-anal anastomosis in patients with ulcerative colitis are associated with poor late functional results. PATIENTS AND METHODS: Eighty patients were operated on from 1986 to 2000, 62 patients with ileostomy and 18 without. The early and late complications were recorded. Specific emphasis has been placed on the incidence of pouchitis with prolonged follow-up. RESULTS: The ileostomy was closed an average of 9.2 months after the first operation. Fourteen patients were excluded from the long-term evaluation; 6 patients were lost to regular follow-up, 4 died, and 4 patients still have the ileostomy. Of the 4 patients that died, 1 died from surgical complications. Early complications after operation (41) occurred in 34 patients (42.5 percent). Late complications (29) occurred in 25 patients as follows: 16 had pouchitis, 3 associated with stenosis and 1 with sexual dysfunction; 5 had stenosis; and there was 1 case each of incisional hernia, ileoanal fistula, hepatic cancer, and endometriosis. Pouchitis occurred in 6 patients (9.8 percent) 1 year after ileal pouch-anal anastomosis, 9 (14.8 percent) after 3 years, 13 (21.3 percent) after 5 years, and 16 (26.2 percent) after more than 6 years. The mean daily stool frequency was 12 before and 5.8 after operation. One pouch was removed because of fistulas that appeared 2 years later. CONCLUSIONS: Ileal pouch-anal anastomosis is associated with a considerable number of early complications. There was no correlation between pouchitis and severe disease, operation with or without ileostomy, or early postoperative complications. The incidence of pouchitis was directly proportional to duration of time of follow-up

Inflammatory bowel diseases: principles of nutritional therapy

Inflammatory Bowel Diseases - ulcerative colitis and Crohn's disease- are chronic gastrointestinal inflammatory diseases of unknown etiology. Decreased oral intake, malabsorption, accelerated nutrient losses, increased requirements, and drug-nutrient interactions cause nutritional and functional deficiencies that require proper correction by nutritional therapy. The goals of the different forms of nutritional therapy are to correct nutritional disturbances and to modulate inflammatory response, thus influencing disease activity. Total parenteral nutrition has been used to correct and to prevent nutritional disturbances and to promote bowel rest during active disease, mainly in cases of digestive fistulae with high output. Its use should be reserved for patients who cannot tolerate enteral nutrition. Enteral nutrition is effective in inducing clinical remission in adults and promoting growth in children. Due to its low complication rate and lower costs, enteral nutrition should be preferred over total parenteral nutrition whenever possible. Both present equal effectiveness in primary therapy for remission of active Crohn's disease. Nutritional intervention may improve outcome in certain individuals; however, because of the costs and complications of such therapy, careful selection is warranted, especially in patients presumed to need total parenteral nutrition. Recent research has focused on the use of nutrients as primary treatment agents. Immunonutrition is an important therapeutic alternative in the management of inflammatory bowel diseases, modulating the inflammation and changing the eicosanoid synthesis profile. However, beneficial reported effects have yet to be translated into the clinical practice. The real efficacy of these and other nutrients (glutamine, short-chain fatty acids, antioxidants) still need further evaluation through prospective and randomized trials