International consensus on the prevention of venous and arterial thrombotic events in patients with inflammatory bowel disease.

Patients with inflammatory bowel disease (IBD) are at increased risk of thrombotic events. Therapies for IBD have the potential to modulate this risk. The aims of this Evidence-Based Guideline were to summarize available evidence and to provide practical recommendations regarding epidemiological aspects, prevention and drug-related risks of venous and arterial thrombotic events in patients with IBD. A virtual meeting took place in May 2020 involving 14 international IBD experts and 3 thrombosis experts from 12 countries. Proposed statements were voted upon in an anonymous manner. Agreement was defined as at least 75% of participants voting as 'fully agree' or 'mostly agree' with each statement. For each statement, the level of evidence was graded according to the Scottish Intercollegiate Guidelines Network (SIGN) grading system. Consensus was reached for 19 statements. Patients with IBD harbour an increased risk of venous and arterial thrombotic events. Thromboprophylaxis is indicated during hospitalization of any cause in patients with IBD. Disease activity is a modifiable risk factor in patients with IBD, and physicians should aim to achieve deep remission to reduce the risk. Exposure to steroids should be limited. Antitumour necrosis factor agents might be associated with a reduced risk of thrombotic events.

Mirtazapine (Remeron) as treatment for non-mechanical vomiting after gastric bypass.

Two morbidly obese patients are reported who underwent gastric bypass and suffered nausea and vomiting 1 month after the operation. Endoscopy and upper GI series showed no evidence of stomal stenosis or other mechanical cause for a GI obstruction. Control of vomiting by current antiemetic drugs such as bromopride and ondansetrone was unsuccessful. The patients were then given Remeron Soltab (mirtazapine, Organon, Brazil) 30 mg once per day orally for 2 to 8 months. Nausea and vomiting disappeared within days after beginning the medication. Stomal stenosis is the main cause of vomiting after gastric bypass. After ruling out mechanical causes, other reasons for postoperative vomiting must be considered. Mirtazapine is a noradrenergic and specific serotonergic antidepressant, which blocks the 5HT3 receptor, leading to an antiemetic effect. It has successfully been used as an antiemetic drug in patients undergoing chemotherapy. We concluded that mirtazapine may be a successful option to treat non-mechanical postoperative vomiting in morbidly obese patients after gastric bypass.

Morphology of ileal and jejunal pouches used as rectal substitutes.

PURPOSE: Our aim was to determine whether the mucosa of a canine jejunal pouch used as a rectal substitute after proctocolectomy retains its morphologic features better than the mucosa of a canine ileal pouch so used. METHODS: Among ten dogs that underwent proctocolectomy, five had a jejunal pouch-distal rectal anastomosis and five an ileal pouch-distal rectal anastomosis. After six months, the animals were killed, the intestinal pouches and portions of unaltered distal ileum were removed, and a blinded, mucosal morphometric analysis was performed. RESULTS: The mucosa of the jejunal pouches had an overall thickness (mean +/- standard deviation, anterior and posterior walls, 1,300 +/- 140 microm), villous height (286 +/- 46 microm), and crypt depth (790 +/- 77 microm) greater than that of the ileal pouches (920 +/- 170, 208 +/- 47, and 530 +/- 130 microm, respectively; P < 0.05). Moreover, the mucosal thickness of the jejunal pouches was similar to that of the distal ileum proximal to the pouch (1,200 +/- 200 microm; P > 0.05), whereas the mucosal thickness of the ileal pouch was thinner (P < 0.05). CONCLUSIONS: The jejunal mucosa retains its major morphometric features when the jejunum is used as a rectal substitute after proctocolectomy. In contrast, the ileal mucosa atrophies when the ileum is so used.

Use of a colonic pouch as a rectal substitute after rectal excision

Mid or distal rectal resection with straight coloanal anastomosis effectively treats distal rectal cancer and avoids a permanent stoma. However, the straight colonic segment is a poor reservoir for stools, and patients usually experience varying degrees of impaired rectal function after operation, including frequent bowel movements, incontinence, tenesmus, and soiling. In contrast a J-shaped colonic pouch provides an adequate neorectal reservoir after operation. Patients with a colonic pouch-anal canal anastomosis have bowell movements per day than patients with straight colorectal or coloanal anastomosis. Furthermore, the morbility of the colonic pouch is not greater than that of the straight coloanal anastomosis. An important technical aspect of the colonic pouch procedure is that the limbs used to form the pouch must be no longer than 5 to 6 cm. Patients with larger pouches experience emptying difficulties. Also, the level of the anastomosis between the pouch and the anal canal must be no more than 4 cm from the anal verge, again to avoid problems with defecation. With these caveats, the operation should be considered in patients who require excision of the mid and distal rectum for cancer.