Anemia following Roux-en-Y gastric bypass for morbid obesity; a 5-year follow-up study.

OBJECTIVES: Patients are at risk of anemia post Roux-en-Y gastric bypass (RYGB). We sought to determine the prevalence of anemia and related nutritional deficiencies 5 years after RYGB and to evaluate adherence to nutritional supplements with iron, vitamin B12, and folate. MATERIAL AND METHODS: Patients operated with RYGB 2004-2006 were eligible for evaluation. Blood samples were collected and use of nutritional supplements was recorded preoperatively, and at outpatients' consultations 1, 2, and 5 years postoperatively. Of 203 patients operated, 184 (91%) completed the 5 year follow-up and were included in the study. Of these, 97% had valid measurements of hemoglobin both at baseline and after 5 years. RESULTS: During the 5 years after RYGB, the prevalence of anemia increased from 4% preoperatively to 24% in females, and from 0% to 7% in males. Ferritin levels decreased gradually in both genders. Iron deficiency increased from 6% preoperatively to 42% at 5 years in females, and from 0% to 9% in males. Vitamin B12 deficiency was not altered while folate deficiency decreased from 10% preoperatively to 1% at 5 years. Five years after surgery 25% reported the use of supplements with iron, while 83% used vitamin B12 and 65% used multivitamins with folate. CONCLUSIONS: We observed a long-term increase in anemia and iron deficiency after RYGB in both genders, but most pronounced in women. Our postoperative protocol for prevention of vitamin B12 and folate deficiencies appear acceptable. Iron status and iron supplementation seems to need stronger emphasis during follow-up after RYGB.

The management of iron deficiency in inflammatory bowel disease--an online tool developed by the RAND/UCLA appropriateness method.

BACKGROUND: Iron deficiency is a common and undertreated problem in inflammatory bowel disease (IBD). AIM: To develop an online tool to support treatment choice at the patient-specific level. METHODS: Using the RAND/UCLA Appropriateness Method (RUAM), a European expert panel assessed the appropriateness of treatment regimens for a variety of clinical scenarios in patients with non-anaemic iron deficiency (NAID) and iron deficiency anaemia (IDA). Treatment options included adjustment of IBD medication only, oral iron supplementation, high-/low-dose intravenous (IV) regimens, IV iron plus erythropoietin-stimulating agent (ESA), and blood transfusion. The panel process consisted of two individual rating rounds (1148 treatment indications; 9-point scale) and three plenary discussion meetings. RESULTS: The panel reached agreement on 71% of treatment indications. 'No treatment' was never considered appropriate, and repeat treatment after previous failure was generally discouraged. For 98% of scenarios, at least one treatment was appropriate. Adjustment of IBD medication was deemed appropriate in all patients with active disease. Use of oral iron was mainly considered an option in NAID and mildly anaemic patients without disease activity. IV regimens were often judged appropriate, with high-dose IV iron being the preferred option in 77% of IDA scenarios. Blood transfusion and IV+ESA were indicated in exceptional cases only. CONCLUSIONS: The RUAM revealed high agreement amongst experts on the management of iron deficiency in patients with IBD. High-dose IV iron was more often considered appropriate than other options. To facilitate dissemination of the recommendations, panel outcomes were embedded in an online tool, accessible via http://ferroscope.com/.

Medical treatment: does it influence the natural course of inflammatory bowel disease?

It is difficult to predict the clinical course of inflammatory bowel disease (IBD). Moderately sick Crohn's disease (CD) patients and patients with distal ulcerative colitis (UC) may get better even without medical or surgical treatment. Once better, they may continue in remission even without treatment. If they are not treated, there are several factors that predict whether they will maintain remission. Most patients will probably alternate between remission and relapse, with 10% having a relapse-free course after 10 years, and only 1% having a continuously active course. Frequent relapses initially are associated with active disease later on, but the disease activity course is independent of the response to the initial medical treatment. There is a cumulative frequency of operation of 50-80% and of reoperation of 33% in CD, which suggests that CD has a more serious course than UC. In UC, the overall probability of surgery is 33% for pancolitis and 10% for proctitis within 5 years of diagnosis, and the majority of patients are operated on within the first few years. Maintenance treatment with sulphasalazine (SASP) and 5-aminosalicylic acid (5-ASA) in UC has reduced relapse rates to about half over a 1-year follow-up period. The use of 5-ASA for maintenance of CD has been shown to result in only a modest therapeutic gain, while azathioprine and 6-mercaptopurine (6-MP) improve the relapse frequency for at least 3 years whilst on treatment. Changes in disease distribution in UC are part of the natural course of the disease, which should have implications for medical treatment strategies, and affects the risk of colectomy and colonic cancer. Certain enviromental factors are thought to determine disease activity and disease outcome in UC and CD. Patient compliance with prescribed medication and clinical check-ups must be considered another non-specific variable affecting the clinical outcome. IBD frequently requires potent medication with side effects that limit patients' acceptance. Such patients often resort to medicinal herbs, acupuncture, and homeopathy, which may alter the expected course.

Change in the extent of colonoscopic and histological involvement in ulcerative colitis over time.

OBJECTIVE: Colonoscopy has replaced barium enema as the method for determining the extent of disease in patients with ulcerative colitis (UC). Normally, the extent of disease is determined by direct visualization of the mucosa, but biopsies are also used with increasing frequency. Very little is known about the extent to which these two ways of assessing the extent of disease are correlated and whether the correlation differs over time. The aim of this study was to determine the changes in extent of disease assessed by direct visualization and by histological examination of the mucosa at the time of diagnosis and after 1 yr of follow-up in a cohort of incident cases of UC patients. METHODS: All new cases of UC in a defined population were identified during a 4-yr period (496 patients). Of these, 384 patients (78%) were available for follow-up and were subjected to a second colonoscopy with representative biopsies taken from both normal and affected mucosa. RESULTS: After 1 yr there were macroscopical signs of progression in 14%; 22% showed regression, and 30% had a normal colonoscopy. The histological changes from diagnosis until follow-up showed progression in 20%, 24% showed regression, and 24% had normal histological findings. Histological examination showed more extensive disease than did direct visualization in 4% of patients at diagnosis and in 28% at follow-up, whereas direct visualization showed more extensive disease than did histological examination in 18% of patients at diagnosis and 12% at follow-up. The best correlation at both diagnosis and follow-up was seen in pancolitis (99% and 88%, respectively). CONCLUSIONS: With regard to the extent of colonic involvement in the UC patients, we found less agreement between endoscopic and histological evaluation at the follow-up examination than at the start of the study. This could indicate that biopsies represent a better indicator than endoscopical examination for long term prognosis. Further studies are needed to confirm this finding.

Highly effective second-line anti-Helicobacter pylori therapy in patients with previously failed metronidazole-based therapy.

BACKGROUND: In this study we compared the cure rates of two clarithromycin-based regimens in patients in whom anti-Helicobacter pylori therapy had previously failed. METHODS: Thirty-three patients were randomized to receive either regimen OAC (20 mg omeprazole, 750 mg amoxicillin, and 250 mg clarithromycin) or BTC (240 mg bismuth subcitrate, 750 mg oxytetracycline, and 250 mg clarithromycin), all twice daily for 10 days. A further 28 patients were all treated with OAC. Previously failed therapy included combinations of bismuth (B), omeprazole (O), tetracycline (T), metronidazole (M), amoxicillin (A), or clarithromycin (C) in BTM (n = 48), OAM (n = 13), OA (n = 7), OCM (n = 2), or BCM (n = 1). H. pylori infection was confirmed by culture of biopsy specimens, and antimicrobial susceptibility testing was performed with the E test. RESULTS: H. pylori infection was cured in all patients (n = 18) with OAC and in 8 patients (53%) with BTC (P = 0.001) in the randomized group and in 27 patients (96%) receiving OAC in the open-label group. CONCLUSIONS: Ten-day OAC is highly effective and superior to BTC in patients in whom metronidazole-based treatment has previously failed.

[Natural products can be hazardous to health]. / Naturmidler kan forårsake helseskader.

Side effects of herbal and health food products have been infrequently reported such as hepatic damage after use of such products. Four such patients were treated in our department in the course of two years. In all four patients, the use of herbal remedies was the probable cause of serious hepatic damage, but both etiology and pathogenesis were difficult to establish. Two major areas of concern are inaccurate formulation and contaminated preparations. As long as no therapeutic effect can be demonstrated from this type of medicine, serious side effects are unacceptable. A critical attitude should be adopted towards these medicines and the use of them.