RESUMEN
BACKGROUND AND STUDY AIM: The traditional endoscopic therapy of anastomotic strictures (AS) after orthotopic liver transplantation (OLT) is multiple ERCPs with the insertion of an increasing number of plastic stents side-by-side. Fully covered self-expanding metal stents (cSEMS) could be a valuable option to decrease the number of procedures needed or non-responders to plastic stents. This study aims to retrospectively analyse the results of AS endoscopic treatment by cSEMS and to identify any factors associated with its success. PATIENTS AND METHODS: Ninety-one patients (mean age 55.9 ± 7.6 SD; 73 males) from nine Italian transplantation centres, had a cSEMS positioned for post-OLT-AS between 2007 and 2017. Forty-nine (54%) patients were treated with cSEMS as a second-line treatment. RESULTS: All the procedures were successfully performed without immediate complications. After ERCP, adverse events occurred in 11% of cases (2 moderate pancreatitis and 8 cholangitis). In 49 patients (54%), cSEMSs migrated. After cSEMS removal, 46 patients (51%) needed further endoscopic (45 patients) or radiological (1 patient) treatments to solve the AS. Lastly, seven patients underwent surgery. Multivariable stepwise logistic regression showed that cSEMS migration was the only factor associated with further treatments (OR 2.6, 95% CI 1.0-6.6; p value 0.03); cSEMS implantation before 12 months from OLT was associated with stent migration (OR 5.2, 95% CI 1.7-16.0; p value 0.004). CONCLUSIONS: cSEMS appears to be a safe tool to treat AS. cSEMS migration is the main limitation to its routinary implantation and needs to be prevented, probably with the use of new generation anti-migration stents.
Asunto(s)
Colestasis , Trasplante de Hígado , Colangiopancreatografia Retrógrada Endoscópica/efectos adversos , Colestasis/etiología , Colestasis/cirugía , Constricción Patológica/cirugía , Humanos , Trasplante de Hígado/efectos adversos , Masculino , Persona de Mediana Edad , Plásticos , Estudios Retrospectivos , Silicatos , Stents/efectos adversos , Resultado del TratamientoRESUMEN
BACKGROUND: Intestinal ischemia has been described in case reports of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (coronavirus disease 19, COVID-19). AIM: To define the clinical and histological, characteristics, as well as the outcome of ischemic gastrointestinal manifestations of SARS-CoV-2 infection. METHODS: A structured retrospective collection was promoted among three tertiary referral centres during the first wave of the pandemic in northern Italy. Clinical, radiological, endoscopic and histological data of patients hospitalized for COVID-19 between March 1st and May 30th were reviewed. The diagnosis was established by consecutive analysis of all abdominal computed tomography (CT) scans performed. RESULTS: Among 2929 patients, 21 (0.7%) showed gastrointestinal ischemic manifestations either as presenting symptom or during hospitalization. Abdominal CT showed bowel distention in 6 patients while signs of colitis/enteritis in 12. Three patients presented thrombosis of main abdominal veins. Endoscopy, when feasible, confirmed the diagnosis (6 patients). Surgical resection was necessary in 4/21 patients. Histological tissue examination showed distinctive features of endothelial inflammation in the small bowel and colon. Median hospital stay was 9 d with a mortality rate of 39%. CONCLUSION: Gastrointestinal ischemia represents a rare manifestation of COVID-19. A high index of suspicion should lead to investigate this complication by CT scan, in the attempt to reduce its high mortality rate. Histology shows atypical feature of ischemia with important endotheliitis, probably linked to thrombotic microangiopathies.
Asunto(s)
COVID-19 , Enfermedades Gastrointestinales , Humanos , Pandemias , Estudios Retrospectivos , SARS-CoV-2RESUMEN
BACKGROUND AND AIM: Since the outbreak of COVID-19, concerns have been raised as to whether inflammatory bowel disease (IBD) patients under biologic therapy may be more susceptible to the disease. This study aimed to determine the incidence and outcomes of COVID-19 in a large cohort of IBD patients on biologic therapy. METHODS: This observational retrospective multicenter study collected data about COVID-19 in IBD patients on biologic therapy in Italy, between February and May 2020. The main end-points were (i) to assess both the cumulative incidence and clinical outcome of COVID-19, according to different biologic agents and (ii) to compare them with the general population and a cohort IBD patients undergoing non-biologic therapies. RESULTS: Among 1816 IBD patients, the cumulative incidence of COVID-19 was 3.9 per 1000 (7/1816) with a 57% hospitalization rate and a 29% case-fatality rate. The class of biologic agents was the only risk factor of developing COVID-19 (P = 0.01). Non-gut selective agents were associated with a lower incidence of COVID-19 cases, related symptoms, and hospitalization (P < 0.05). Compared with the general population of Lombardy, an overall lower incidence of COVID-19 was observed (3.9 vs 8.5 per 1000, P = 0.03). Compared with 565 IBD patients on non-biologic therapies, a lower rate of COVID-19 symptoms was observed in our cohort (7.5% vs 18%, P < 0.001). CONCLUSIONS: Compared with the general population, IBD patients on biologic therapy are not exposed to a higher risk of COVID-19. Non-gut selective agents are associated with a lower incidence of symptomatic disease, supporting the decision of maintaining the ongoing treatment.
Asunto(s)
Factores Biológicos/administración & dosificación , Terapia Biológica/efectos adversos , COVID-19/epidemiología , Enfermedades Inflamatorias del Intestino/tratamiento farmacológico , Adolescente , Adulto , Anciano , Niño , Preescolar , Colitis , Femenino , Humanos , Incidencia , Lactante , Recién Nacido , Enfermedades Inflamatorias del Intestino/epidemiología , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , SARS-CoV-2 , Adulto JovenRESUMEN
BACKGROUND: Treatment of esophageal perforations and postoperative anastomotic leaks of the upper gastrointestinal tract remains a challenge. Endoluminal vacuum-assisted closure (E-Vac) therapy has positively contributed, in recent years, to the management of upper gastrointestinal tract perforations by using the same principle of vacuum-assisted closure therapy of external wounds. The aim is to provide continuous wound drainage and to promote tissue granulation, decreasing the needed time to heal with a high rate of leakage closure. CASES PRESENTATION: A series of two different cases with clinical and radiological diagnosis of esophageal fistulas, recorded from 2018 to 2019 period at our institution, is presented. The first one is a case of anastomotic leak after esophagectomy for cancer complicated by pleuro-mediastinal abscess, while the second one is a leak of an esophageal suture, few days after resection of a bronchogenic cyst perforated into the esophageal lumen. Both cases were successfully treated with E-Vac therapy. CONCLUSION: Our experience shows the usefulness of E-Vac therapy in the management of anastomotic and non-anastomotic esophageal fistulas. Further research is needed to better define its indications, to compare it to traditional treatments and to evaluate its long-term efficacy.
Asunto(s)
Fístula Esofágica , Terapia de Presión Negativa para Heridas , Fuga Anastomótica/etiología , Fuga Anastomótica/cirugía , Fístula Esofágica/etiología , Fístula Esofágica/cirugía , Humanos , PronósticoAsunto(s)
Infecciones Asintomáticas/epidemiología , Productos Biológicos/efectos adversos , COVID-19/epidemiología , Enfermedades Inflamatorias del Intestino/tratamiento farmacológico , SARS-CoV-2/aislamiento & purificación , Adulto , COVID-19/sangre , COVID-19/inmunología , COVID-19/virología , Prueba Serológica para COVID-19/estadística & datos numéricos , Estudios de Cohortes , Femenino , Humanos , Enfermedades Inflamatorias del Intestino/sangre , Enfermedades Inflamatorias del Intestino/inmunología , Italia/epidemiología , Masculino , Persona de Mediana Edad , Factores de Riesgo , SARS-CoV-2/inmunología , Estudios SeroepidemiológicosAsunto(s)
Infecciones por Coronavirus/complicaciones , Intestinos/irrigación sanguínea , Isquemia/virología , Neumonía Viral/complicaciones , Anciano , Anciano de 80 o más Años , Betacoronavirus , COVID-19 , Infecciones por Coronavirus/sangre , Femenino , Productos de Degradación de Fibrina-Fibrinógeno/metabolismo , Humanos , Isquemia/sangre , Masculino , Persona de Mediana Edad , Pandemias , Neumonía Viral/sangre , Pronóstico , Estudios Retrospectivos , SARS-CoV-2 , Tromboembolia/virología , Trombofilia/sangre , Trombofilia/virologíaAsunto(s)
Betacoronavirus/genética , Infecciones por Coronavirus/diagnóstico , Infarto/diagnóstico , Mucosa Intestinal/metabolismo , Intestino Delgado/irrigación sanguínea , Isquemia Mesentérica/diagnóstico , Neumonía Viral/diagnóstico , Betacoronavirus/metabolismo , COVID-19 , Prueba de COVID-19 , Técnicas de Laboratorio Clínico , Infecciones por Coronavirus/complicaciones , Infecciones por Coronavirus/patología , Endarteritis/etiología , Endarteritis/patología , Resultado Fatal , Humanos , Infarto/etiología , Infarto/patología , Infarto/cirugía , Mucosa Intestinal/virología , Intestino Delgado/metabolismo , Intestino Delgado/cirugía , Masculino , Isquemia Mesentérica/etiología , Isquemia Mesentérica/patología , Isquemia Mesentérica/cirugía , Persona de Mediana Edad , Pandemias , Neumonía Viral/complicaciones , Neumonía Viral/patología , ARN Mensajero/metabolismo , SARS-CoV-2 , Choque Séptico/etiología , Glicoproteína de la Espiga del Coronavirus/genética , Trombosis/etiología , Trombosis/patología , Tomografía Computarizada por Rayos XAsunto(s)
Betacoronavirus/inmunología , Infecciones por Coronavirus/epidemiología , Inmunosupresores/administración & dosificación , Enfermedades Inflamatorias del Intestino/inmunología , Neumonía Viral/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Betacoronavirus/aislamiento & purificación , COVID-19 , Prueba de COVID-19 , Niño , Técnicas de Laboratorio Clínico/estadística & datos numéricos , Infecciones por Coronavirus/diagnóstico , Infecciones por Coronavirus/inmunología , Infecciones por Coronavirus/virología , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Humanos , Inmunosupresores/efectos adversos , Enfermedades Inflamatorias del Intestino/complicaciones , Enfermedades Inflamatorias del Intestino/tratamiento farmacológico , Italia/epidemiología , Masculino , Persona de Mediana Edad , Pandemias , Neumonía Viral/diagnóstico , Neumonía Viral/inmunología , Neumonía Viral/virología , Prevalencia , Factores de Riesgo , SARS-CoV-2 , Centros de Atención Terciaria/estadística & datos numéricos , Adulto JovenAsunto(s)
Antineoplásicos Inmunológicos/efectos adversos , Ipilimumab/efectos adversos , Enfermedades de Inicio Tardío/inducido químicamente , Enfermedades Pulmonares Intersticiales/inducido químicamente , Melanoma/tratamiento farmacológico , Neoplasias Cutáneas/tratamiento farmacológico , Enfermedad Aguda , Lesión Pulmonar Aguda/inducido químicamente , Lesión Pulmonar Aguda/complicaciones , Puntos de Control del Ciclo Celular/efectos de los fármacos , Quimioterapia Adyuvante , Femenino , Humanos , Ipilimumab/administración & dosificación , Enfermedades Pulmonares Intersticiales/complicaciones , Melanoma/patología , Persona de Mediana Edad , Estadificación de Neoplasias , Inhibidores de Proteínas Quinasas/efectos adversos , Ensayos Clínicos Controlados Aleatorios como Asunto , Neoplasias Cutáneas/patología , Síndrome , Factores de Tiempo , Neoplasias de la Vulva/tratamiento farmacológico , Neoplasias de la Vulva/patologíaRESUMEN
There was estimated a higher incidence of de novo inflammatory bowel disease (IBD) after solid organ transplantation than in the general population. The onset of IBD in the organ transplant recipient population is an important clinical situation which is associated to higher morbidity and difficulty in the medical therapeutic management because of possible interaction between anti-reject therapy and IBD therapy. IBD course after liver transplantation (LT) is variable, but about one third of patients may worsen, needing an increase in medical therapy or a colectomy. Active IBD at the time of LT, discontinuation of 5-aminosalicylic acid or azathioprine at the time of LT and use of tacrolimus-based immunosuppression may be associated with an unfavorable outcome of IBD after LT. Anti-tumor necrosis factor alpha (TNFα) therapy for refractory IBD may be an effective and safe therapeutic option after LT. The little experience of the use of biological therapy in transplanted patients, with concomitant anti-rejection therapy, suggests there be a higher more careful surveillance regarding the risk of infectious diseases, autoimmune diseases, and neoplasms. An increased risk of colorectal cancer (CRC) is present also after LT in IBD patients with primary sclerosing cholangitis (PSC). An annual program of endoscopic surveillance with serial biopsies for CRC is recommended. A prophylactic colectomy in selected IBD/PSC patients with CRC risk factors could be a good management strategy in the CRC prevention, but it is used infrequently in the majority of LT centers. About 30% of patients develop multiple IBD recurrence and 20% of patients require a colectomy after renal transplantation. Like in the liver transplantation, anti-TNFα therapy could be an effective treatment in IBD patients with conventional refractory therapy after renal or heart transplantation. A large number of patients are needed to confirm the preliminary observations. Regarding the higher clinical complexity of this subgroup of IBD patients, a close multidisciplinary approach between an IBD dedicated gastroenterologist and surgeon and an organ transplantation specialist is necessary in order to have the best clinical management of IBD after transplantation.
Asunto(s)
Enfermedad Hepática en Estado Terminal/complicaciones , Enfermedad Hepática en Estado Terminal/terapia , Trasplante de Corazón/efectos adversos , Enfermedades Inflamatorias del Intestino/terapia , Trasplante de Hígado/efectos adversos , Azatioprina/uso terapéutico , Colangitis Esclerosante/complicaciones , Colangitis Esclerosante/terapia , Colectomía/efectos adversos , Neoplasias Colorrectales/complicaciones , Neoplasias Colorrectales/terapia , Rechazo de Injerto/prevención & control , Humanos , Enfermedades Inflamatorias del Intestino/complicaciones , Trasplante de Riñón/efectos adversos , Mesalamina/uso terapéutico , Factores de Riesgo , Tacrolimus/uso terapéutico , Resultado del Tratamiento , Factor de Necrosis Tumoral alfa/antagonistas & inhibidoresRESUMEN
BACKGROUND: The management of extrahepatic portal vein obstruction (EHPVO) in children is controversial. We report our experience with a prospective evaluation of a stepwise protocol based on severity of portal hypertension and feasibility of mesoportal bypass (MPB). METHODS: After diagnosis, children with EHPVO underwent surveillance endoscopies and received nonselective ß-blockers (NSBBs) or endoscopic variceal obliteration (EVO) when large varices were detected. In patients who failed NSBBs and EVO, we considered MPB as first-line and shunts or transjugular intrahepatic portosystemic shunt (TIPS) as second-line options. RESULTS: Sixty-five children, median age 12.5 (range 1.6-25.8), whose age at diagnosis was 3.5 (0.2-17.5) years, were referred to our unit. Forty-three (66%) had a neonatal illness, 36 (55%) an umbilical vein catheterisation. Thirty-two (49%) presented with bleeding at a median age of 3.8 years (0.5-15.5); during an 8.4-year follow-up period (1-16), 43 (66%) had a bleeding episode, 52 (80%) were started on NSBBs, 55 (85%) required EVO, and 33 (51%) required surgery or TIPS. The Rex recessus was patent in 24 of 54 (44%), negatively affected by a history of umbilical catheterisation (P = 0.01). Thirty-four (53%) patients underwent a major procedure: MPB (13), proximal splenorenal (13), distal splenorenal (2), mesocaval shunt (3), TIPS (2), and OLT (1). At the last follow-up, 2 patients died, 53 of 57 (93%) are alive with bleeding control, 27 of 33 (82%) have a patent conduit. CONCLUSIONS: Children with EHPVO have a high rate of bleeding episodes early in life. A stepwise approach comprising of medical, endoscopic, and surgical options provided excellent survival and bleeding control in this population.
Asunto(s)
Enfermedad Veno-Oclusiva Hepática/cirugía , Vena Porta/cirugía , Derivación Portosistémica Quirúrgica , Técnicas de Ablación , Adolescente , Antagonistas Adrenérgicos beta/uso terapéutico , Adulto , Niño , Preescolar , Estudios de Cohortes , Terapia Combinada , Árboles de Decisión , Endoscopía , Estudios de Seguimiento , Enfermedad Veno-Oclusiva Hepática/tratamiento farmacológico , Enfermedad Veno-Oclusiva Hepática/fisiopatología , Humanos , Hipertensión Portal/etiología , Hipertensión Portal/prevención & control , Lactante , Italia , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Várices/etiología , Adulto JovenRESUMEN
Ulcerative colitis (UC) is an inflammatory bowel disease (IBD) characterized by chronic inflammation affecting the colonic mucosa, that can extend to the whole large bowel. The severity of mucosal lesions directly reflects the disease activity and severity and may be prognostic for an aggressive behavior of the pathology. Remission, is usually defined as resolution of symptoms. Recently, mucosal healing (MH) has emerged as an important end point of any short-term medical therapy for IBD. It may predict long-term remission and may impact on the natural history of the disease in Crohn's disease (CD), while data in UC patients are still limited. This review of the literature is focused on the recent evidence on the impact of medications on MH in UC and on the impact of MH on the natural course of UC.
Asunto(s)
Colitis Ulcerosa/patología , Colitis Ulcerosa/terapia , Mucosa Intestinal/patología , Humanos , Cicatrización de HeridasRESUMEN
OBJECTIVES: The aim of this review was to evaluate possible common pathogenic pathways and risk factors in inflammatory bowel disease (IBD) and periodontitis. MATERIALS AND METHODS: A MEDLINE-PubMed research was conducted. RESULTS: The pathogenesis of both diseases is multi-factorial leading to a substantial defect of the mucosal barrier, deregulation of the immune response and chronic inflammation of the mucosa. Environmental factors, particularly bacteria, are key factors in the pathogenesis of both diseases. Genetic predisposition is a key factor in the IBD pathogenesis, while a clear role of genetics in the pathogenesis of periodontitis is still unclear. The immune response in IBD is mediated by T lymphocytes as a consequence of a genetic trait associated with T-cell deregulation. On the other hand, in periodontitis plasma cells and lymphocytes are the predominant cells in the chronic inflammatory lesion, with the presence of B cells being proportionally larger than T cells. CONCLUSION: IBD and periodontitis share several factors in their aetiology and pathogenesis, although they also have distinct characteristics.