Evolution After Anti-TNF Discontinuation in Patients With Inflammatory Bowel Disease: A Multicenter Long-Term Follow-Up Study.

OBJECTIVES: The aims of this study were to assess the risk of relapse after discontinuation of anti-tumor necrosis factor (anti-TNF) drugs in patients with inflammatory bowel disease (IBD), to identify the factors associated with relapse, and to evaluate the overcome after retreatment with the same anti-TNF in those who relapsed. METHODS: This was a retrospective, observational, multicenter study. IBD patients who had been treated with anti-TNFs and in whom these drugs were discontinued after clinical remission was achieved were included. RESULTS: A total of 1,055 patients were included. The incidence rate of relapse was 19% and 17% per patient-year in Crohn's disease and ulcerative colitis patients, respectively. In both Crohn's disease and ulcerative colitis patients in deep remission, the incidence rate of relapse was 19% per patient-year. The treatment with adalimumab vs. infliximab (hazard ratio (HR)=1.29; 95% confidence interval (CI)=1.01-1.66), elective discontinuation of anti-TNFs (HR=1.90; 95% CI=1.07-3.37) or discontinuation because of adverse events (HR=2.33; 95% CI=1.27-2.02) vs. a top-down strategy, colonic localization (HR=1.51; 95% CI=1.13-2.02) vs. ileal, and stricturing behavior (HR=1.5; 95% CI=1.09-2.05) vs. inflammatory were associated with a higher risk of relapse in Crohn's disease patients, whereas treatment with immunomodulators after discontinuation (HR=0.67; 95% CI=0.51-0.87) and age (HR=0.98; 95% CI=0.97-0.99) were protective factors. None of the factors were predictive in ulcerative colitis patients. Retreatment of relapse with the same anti-TNF was effective (80% responded) and safe. CONCLUSIONS: The incidence rate of inflammatory bowel disease relapse after anti-TNF discontinuation is relevant. Some predictive factors of relapse after anti-TNF withdrawal have been identified. Retreatment with the same anti-TNF drug was effective and safe.

[Predictive factors of eosinophilic esophagitis in esophageal food bolus impaction]. / Factores predictores de esofagitis eosinofílica en impactación esofágica por bolo alimenticio.

BACKGROUND: Food bolus esophageal impaction is often the first symptom in patients diagnosed with eosinophilic esophagitis, representing a change in the epidemiology and management of this urgency. AIM: To detect eosinophilic esophagitis predictive factors in patients with esophageal impaction due to food bolus. METHODS: Patients seen for foreign body impaction were retrospectively analyzed. Epidemiologic characteristics, endoscopic findings, and impaction history were studied. The statistical analysis was carried out using the Student's t test and the chi square test and a logistic regression model. RESULTS: Of the 131 patients, 65% were men and the mean age was 56 years. The endoscopic suspicion of eosinophilic esophagitis was the most frequent finding in patients with food bolus impaction (n=89); those patients that did not have histologic confirmation were excluded (n=7). The remaining patients (n=82) were divided into two groups: confirmed eosinophilic esophagitis (Group A) (n=18) and other endoscopic findings (Group B) (n=64). Group A presented with a lower mean age (36.47 vs. 64.45, P=.001) and a more frequent past history of impaction (38% vs. 6%, OR=15.70, 95% CI (3.60-62.50), P=.001) than Group B. Age and impaction history acted as predictors for eosinophilic esophagitis with 82% sensitivity, 80% specificity, and 84% diagnostic accuracy (P<.001). CONCLUSIONS: Age and a history of impaction predict the presence of eosinophilic esophagitis in patients with food bolus impaction.

[Usefulness of self-expanding biodegradable prosthesis in the treatment of refractory benign stenosis: a case series study]. / Utilidad de las prótesis autoexpandibles biodegradables en el tratamiento de estenosis benignas refractarias. Estudio de una serie de casos.

BACKGROUND: The use of self-expanding biodegradable prosthesis treatment of refractory benign stenosis is still undefined. OBJECTIVE: To determine the utility and safety of biodegradable polydioxanone prostheses as treatment of gastrointestinal tract refractory benign strictures. METHODS: Consecutive patients diagnosed with refractory benign stricture of gastrointestinal tract following Kochman's criteria were included. The type of stenosis were anastomotic (n = 5), peptic (n = 1), post-radiotherapy (n = 1) and they were located in proximal esophagus-hypofarynge (n = 2), esophagus medium (n = 1), distal esophagus (n = 2) and rectum (n = 2). The prosthesis was placed under endoscopic and fluoroscopic control under conscious sedation with propofol. RESULTS: Seven patients (8 prosthesis) were included. Mean patient age was 49 years-old (range: 37-70). Insertion prosthesis was successful in all cases. Distal migration of prosthesis was observed in both rectal stenosis and was the indication of a second prosthesis placement in one case. At the end of follow-up (median follow-up 30 weeks for esophageal stricture, 33 weeks for rectal stricture) 5 patients remained asymptomatic. Eighty per cent of patients with esophageal stenosis showed partial and transient re-stenosis due to hyperplastic reaction during the degradation of the prosthesis, with transient dysphagia in two patients resolved medically. Complete prosthesis degradation was confirmed by endoscopy in all cases. CONCLUSIONS: The use of self-expanding biodegradable polydioxanone prosthesis is a safe and utile therapeutic option for refractory benign gastrointestinal stenosis.

[Eosinophilic enteritis as a rare cause of ascites]. / Enteritis eosinofílica como causa infrecuente de ascitis.

Eosinophilic gastroenteritis is an infrequent entity characterized by tissular eosinophilia that can affect different layers of the intestinal wall. This entity can affect any area of the digestive apparatus from the esophagus to the rectum. Clinical manifestations depend on the affected layers and range from barely perceptible symptoms to intestinal obstruction or ascites. We present the case of an 18-year-old woman who showed abdominal ascites as a rare form of presentation with difficult differential diagnosis with peritoneal carcinomatosis.

[Rectosigmoid endometriosis with lymph node involvement]. / Endometriosis de rectosigma con afección de los ganglios linfáticos.

Endometriosis mainly affects women of a fertile age and is usually located in the pelvis. Extrapelvic involvement is less frequent. We present the case of a female patient with endometriosis of the rectosigmoid and mesenteric lymph nodes, which is an extremely rare finding. Although the most widely accepted theory of the pathogenesis of this disease postulates retrograde menstruation through the Fallopian tubes with subsequent implantation in the peritoneum, these findings support lymphatic dissemination of endometrial cells as a theory of pathogenesis in cases of extrapelvic involvement.

Tratamiento con infliximab en la enfermedad de Crohn fistulizante y active: nuestra experiencia / Our experience in treatment of with anti-tumor necrosis factor antibody (infliximab) in Crohn's disease

Introducción. El infliximab es un anticuerpo sintético IgG1, compuesto por una región constante humana y una región variable murina dirigido contra el factor de necrosis tumoral, de tipo quimérico, indicado en la enfermedad de Crohn (EC) refractaria al tratamiento convencional. Objetivo. Valorar la tasa de respuesta y remisión clínica en la enfermedad de Crohn activa refractaria y en la fistulosa tratados con infliximab, y conocer el número de dosis necesarias para remisión clínica (RC/RP). Pacientes y métodos. 14 pacientes con EC (5 varones) edad media 33.3±10 años. Se indicó tratamiento por enfermedad fistulosa (13 casos) y por broto agudo de corticorresistente (1 caso). Administramos 5mg/kg. De infliximab en perfusión durante 2 horas a las 0, 2 y 6 semanas. Tres de los pacientes con fístula perianal se les administró una cuarta dosis. El paciente con brote grave recibió una sola dosis. Definimos como remisión clínica la del CDAI <150 puntos y como respuesta clínica la reducción de 70 puntos del CDAI desde la medición basal. En el paciente fistuloso definimos como respuesta completa (RC) el cierre total de las fístulas, con ausencia de drenaje y por respuesta parcial (RP) el cierre al menos el 50% de todas las fístulas. Resultados. Siete pacientes (60%) con fístulas obtuvieron RC tras la segunda dosis, tres (29%) con RP tras cuatro dosis de infliximab y tres (20%) no mejoraron y tuvieron que ser intervenidos quirúrgicamente. El paciente con brote grave obtuvo una mejoría total y se suspendió la 2º dosis por presentar como efectos secundarios taquicardia, disnea y calor, siendo el único que presentó efectos adversos. Todos habían recibido tratamiento con inmunosupresores. Conclusiones. El infliximab ha demostrado ser eficaz en el tratamiento de la enfermedad de Crohn fistulizada y en el manejo de la enfermedad aguda moderada a grave. Los efectos secundarios fueron generalmente leves y transitorios. En nuestro caso la respuesta al infliximab tuvo lugar con la segunda dosis en el 60%, con ganancial parcial del 20% con cuatro dosis

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