Combined evaluation of fecal calprotectin and C-reactive protein as a therapeutic target in the management of patients with Crohn's disease / Evaluación combinada de Calprotectina Fecal y Proteína C-reactiva como objetivo terapéutico en el tratamiento de pacientes con Enfermedad de Crohn

Objectives: Proper management of the inflammatory process in Crohn's disease (CD) results in lower rates of complications. The objective of this study was to investigate the performance of isolated and combined use of fecal calprotectin (FC) and serum levels of C-reactive protein (CRP) as markers of inflammatory activity in CD and the possibility of their use as a therapeutic target. Patients and methods: Patients with CD and indication for colonoscopy were prospectively enrolled in the study and allocated according to the presence or absence of endoscopic inflammatory activity. The correlation between FC and CRP levels and the Simplified Endoscopic Score of Crohn's Disease (SES-CD) was performed, and the accuracy of these markers was evaluated for the diagnosis of inflammatory activity, when used alone or in series. Results: Eighty colonoscopies were performed in patients with CD. The FC cut-off value of 155μg/g showed high sensitivity (96%) and accuracy (78%) for the diagnosis of endoscopic activity. For CRP, the value of 6.7mg/L demonstrated sensitivity of 75% and specificity of 67%. The sequential usage of these markers (FC+CRP) showed greater specificity (82%) when compared to the use of these markers alone. Depending on the probability of inflammatory activity, different scenarios were used to evaluate the performance of these markers and an algorithm is proposed. Discussion: Combined analysis of FC and CRP, when performed consecutively, allows decisions to be made with a high degree of certainty and even eliminates the need for colonoscopy in many situations.(AU)

Introducción: Un adecuado control del proceso inflamatorio en la enfermedad de Crohn (EC) supone menores tasas de complicaciones. El objetivo de este estudio es evaluar la utilidad de la calprotectina fecal (CF) y los niveles séricos de la proteína C-reactiva (PCR), aisladamente o en combinación, como marcadores de actividad inflamatoria en la EC, así como la posibilidad de ser utilizados como objetivo terapéutico. Pacientes y métodos: Se incluyeron prospectivamente en el estudio pacientes con EC e indicación para colonoscopia siendo distribuidos de acuerdo a la presencia o no de actividad inflamatoria endoscópica. Se determinó la correlación entre CF y niveles de PCR con el índice SES-CD, y se evaluó la precisión de estos marcadores en el diagnóstico de la actividad inflamatoria, utilizados individualmente o en combinación. Resultados: Se realizaron un total de 80 colonoscopias en pacientes con EC. Para la CF, el punto de corte de 155μg/g mostró una elevada sensibilidad del 96% y una especificidad del 78% en el diagnóstico de actividad endoscópica. En cuanto a la PCR, el valor de 6,7mg/l proporcionó una sensibilidad del 75% y una especificidad del 67%. El uso combinado de estos marcadores (CF+PCR) obtuvo mayor especificidad (82%) cuando se comparó con su utilización individual. De acuerdo al riesgo de actividad inflamatoria, se manejaron diferentes escenarios para evaluar la eficacia de estos marcadores y se propuso un algoritmo de uso. Discusión: La monitorización conjunta de CF y PCR, cuando se realiza de forma consecutiva, permite tomar decisiones con un mayor grado de certeza, eliminando, incluso, la necesidad de colonoscopia en muchas situaciones.(AU)

Combined evaluation of fecal calprotectin and C-reactive protein as a therapeutic target in the management of patients with Crohn's disease.

OBJECTIVES: Proper management of the inflammatory process in Crohn's disease (CD) results in lower rates of complications. The objective of this study was to investigate the performance of isolated and combined use of fecal calprotectin (FC) and serum levels of C-reactive protein (CRP) as markers of inflammatory activity in CD and the possibility of their use as a therapeutic target. PATIENTS AND METHODS: Patients with CD and indication for colonoscopy were prospectively enrolled in the study and allocated according to the presence or absence of endoscopic inflammatory activity. The correlation between FC and CRP levels and the Simplified Endoscopic Score of Crohn's Disease (SES-CD) was performed, and the accuracy of these markers was evaluated for the diagnosis of inflammatory activity, when used alone or in series. RESULTS: Eighty colonoscopies were performed in patients with CD. The FC cut-off value of 155µg/g showed high sensitivity (96%) and accuracy (78%) for the diagnosis of endoscopic activity. For CRP, the value of 6.7mg/L demonstrated sensitivity of 75% and specificity of 67%. The sequential usage of these markers (FC+CRP) showed greater specificity (82%) when compared to the use of these markers alone. Depending on the probability of inflammatory activity, different scenarios were used to evaluate the performance of these markers and an algorithm is proposed. DISCUSSION: Combined analysis of FC and CRP, when performed consecutively, allows decisions to be made with a high degree of certainty and even eliminates the need for colonoscopy in many situations.

Faecal calprotectin is the biomarker that best distinguishes remission from different degrees of endoscopic activity in Crohn's disease.

BACKGROUND: Effective control of the inflammatory process in Crohn's disease (CD) is reflected in intestinal mucosal healing. The performances of faecal calprotectin (fcal), clinical and serologic parameters in the inflammatory activity evaluation and their correlation to the simple endoscopic score (SES-CD) are the goals of this study. METHODS: Patients with CD referred for ileocolonoscopy were prospectively included and distributed according to the degree of endoscopic inflammatory activity into remission, mild activity, and moderate to severe activity groups. The different degrees of endoscopic activity were correlated with the following indexes: Crohn's disease activity index (CDAI), fCal, serum C-reactive protein (CRP), and haemogram. The control group comprised individuals without known intestinal disease who were referred for colorectal cancer screening. RESULTS: Eighty colonoscopies were performed in patients with CD and 21 in the control group. The control group had a lower median fCal (59.7 mcg/g) than patients with CD (683 mcg/g, p < 0.001). A moderate Spearman correlation occurred between SES-CD and CRP (r = 0.525), fCal (r = 0.450), and CDAI (r = 0.407), while a weak correlation was found with the platelet count (r = 0.257). Only fCal distinguished patients in remission from those with mild activity (236.6 mcg/g × 654.9 mcg/g, p = 0.014) or moderate to severe activity (236.6 mcg/g × 1128 mcg/g, p < 0.001). An fCal cut-off of 155 mcg/g was sensitive (96%) and accurate (78%) for the diagnosis of endoscopic activity. CONCLUSIONS: fCal provides greater diagnostic accuracy than the other activity markers for endoscopic activity of patients with CD, moderate correlation to SES-CD, and a capacity to discriminate patients in remission from those with mild or moderate to severe activity.

Correlation of nndoscopic and histological featres in adults with suspected ceeliac disease in a referral center of minas gerais, Brazil / Correlação entre os aspectos endoscópicos e histológicos de pacientes adultos com suspeita de doença celíaca em um centro de referência de Minas Gerais, Brasil

Context Clinical presentation of celiac disease is extremely variable and the diagnosis relies on serologic tests, mucosal intestinal biopsy and clinic and serologic response to a gluten-free diet. Objectives To correlate the endoscopic and histological aspects of adult patients with suspicion of celiac disease and to evaluate the interobserver histological agreement. Methods Endoscopic aspects of 80 adult patients were evaluated and correlated with the histological features according the Marsh-Oberhuber classification system. The interobserver histological agreement was based on kappa values. Results The symptoms of the patients varied largely, with prominence for chronic diarrhea, present in 48 (60%) patients. The endoscopic aspects related with the duodenal villous atrophy had been observed in 32 (40%) patients. There were confirmed 46 cases of celiac disease, with prevalence of 57.5%. The sensitivity, specificity, positive predictive value and negative predictive value of the endoscopic markers for celiac disease diagnosis were of 60.9%, 88.2%, 87.5% and 62.5%. There was moderate interobserver histological agreement (kappa = 0.46). Conclusions The endoscopic markers of villous atrophy, although not diagnostic, had assisted in the suspicion and indication of the duodenal biopsies for diagnosis proposal. Histology is sometimes contradictory and new biopsies or opinion of another professional can provide greater diagnostic agreement. .

Contexto A apresentação clínica da doença celíaca é extremamente variável e o diagnóstico se baseia em testes sorológicos, histologia intestinal e respostas clínica e sorológica à dieta sem glúten. Objetivos Correlacionar os aspectos endoscópicos e histológicos de pacientes adultos com suspeita de doença celíaca e avaliar a concordância histológica interobservadores. Métodos Os aspectos endoscópicos de 80 pacientes adultos foram avaliados e correlacionados com os achados histológicos de acordo com a classificação de Marsh-Oberhuber. A concordância histológica foi baseada nos valores kappa. Resultados A sintomatologia clínica foi muito variável com destaque para a diarréia crônica, presente em 48 (60%) pacientes. Os aspectos endoscópicos relacionados à atrofia vilositária duodenal foram observados em 32 (40%) pacientes. Foram confirmados 46 casos de doença celíaca, prevalência de 57.5%. A sensibilidade, a especificidade, o valor preditivo positivo e o valor preditivo negativo dos aspectos endoscópicos para o diagnóstico da doença celíaca foram, respectivamente, 60,9%, 88,2%, 87,5% e 62,5%. A concordância histológica interobservadores foi moderada (kappa = 0,46). Conclusões Os aspectos endoscópicos de atrofia vilositária contribuíram para a suspeita e a indicação das biópsias duodenais com objetivo diagnóstico. A histologia pode ser contraditória e novas biópsias ou a opinião de outro profissional podem propiciar maior concordância diagnóstica. .

Correlation of endoscopic and histological features in adults with suspected celiac disease in a referral center of Minas Gerais, Brazil.

CONTEXT: Clinical presentation of celiac disease is extremely variable and the diagnosis relies on serologic tests, mucosal intestinal biopsy and clinic and serologic response to a gluten-free diet. OBJECTIVES: To correlate the endoscopic and histological aspects of adult patients with suspicion of celiac disease and to evaluate the interobserver histological agreement. METHODS: Endoscopic aspects of 80 adult patients were evaluated and correlated with the histological features according the Marsh-Oberhuber classification system. The interobserver histological agreement was based on kappa values. RESULTS: The symptoms of the patients varied largely, with prominence for chronic diarrhea, present in 48 (60%) patients. The endoscopic aspects related with the duodenal villous atrophy had been observed in 32 (40%) patients. There were confirmed 46 cases of celiac disease, with prevalence of 57.5%. The sensitivity, specificity, positive predictive value and negative predictive value of the endoscopic markers for celiac disease diagnosis were of 60.9%, 88.2%, 87.5% and 62.5%. There was moderate interobserver histological agreement (kappa = 0.46). CONCLUSIONS: The endoscopic markers of villous atrophy, although not diagnostic, had assisted in the suspicion and indication of the duodenal biopsies for diagnosis proposal. Histology is sometimes contradictory and new biopsies or opinion of another professional can provide greater diagnostic agreement.

Bilateral paracoccidioidomycotic iliopsoas abscess associated with ileo-colonic lesion.

This case report shows the clinical development of a patient with systemic paracoccidioidomycosis presenting with lymphatic-intestinalmanifestation. The patient initially had a substantial clinical improvement but had a recrudescence after six months of sulfamethoxazoletrimethoprim oral treatment, with the emergence of feverish syndrome, lumbar pain, and intermittent claudication, characterizing a bilateral iliopsoas muscle abscess, necessitating clinicosurgical therapeutics.

Bilateral paracoccidioidomycotic iliopsoas abscess associated with ileo-colonic lesion / Abscesso paracoccidioidomicótico bilateral do iliopsoas associado ao acometimento íleo-colônico

This case report shows the clinical development of a patient with systemic paracoccidioidomycosis presenting with lymphatic-intestinalmanifestation. The patient initially had a substantial clinical improvement but had a recrudescence after six months of sulfamethoxazoletrimethoprim oral treatment, with the emergence of feverish syndrome, lumbar pain, and intermittent claudication, characterizing a bilateral iliopsoas muscle abscess, necessitating clinicosurgical therapeutics.

Este relato de caso descreve a evolução clínica de paciente comparacoccidioi-domicose sistêmica com manifestação linfática-intestinal.O paciente evoluiu inicialmente com melhora clínica acentuada erecrudescência após seis meses de uso de SMX-TMP pela via oral, com o surgimento de síndrome febril, dor lombar, e claudicação intermitente,caracterizando um abscesso bilateral do músculo íleopsoas, comnecessidade de terapêutica clínico-cirúrgica.