Ileal or Anastomotic Location of Lesions Does Not Impact Rate of Postoperative Recurrence in Crohn's Disease Patients Classified i2 on the Rutgeerts Score.

BACKGROUND: The Rutgeerts score with 5 grades of severity (i0-i4) is a suitable endoscopic model to predict clinical recurrence following ileocolonic resection in Crohn's disease (CD). Definition of grade i2 includes lesions confined to the ileocolonic anastomosis (i2a) or moderate lesions on the neo-terminal ileum (i2b). The aim of the present study was to evaluate the probability of clinical recurrence in i2a and i2b patients. METHODS: This multicenter retrospective study included all CD patients classified i2 at the first postoperative ileocolonoscopy. The primary outcome was to evaluate the probability of clinical recurrence in patients classified i2a and i2b. The secondary outcome was to compare the rate of global recurrence of CD. RESULTS: Fifty patients were included: 23 were classified i2a and 27 were classified i2b. The median duration of follow-up was 40 (18.0-80.4) months in the i2a group and 53.5 (25.0-69.0) months in the i2b group (p = 0.9). The probability of clinical recurrence was not significantly different between patients classified i2a and i2b (p = 0.64). Median time to clinical recurrence after the first ileocolonoscopy and probability of global CD recurrence were not different between the two groups (p ≥ 0.19). CONCLUSIONS: The rate of clinical postoperative recurrence is not different in i2a and i2b patients. These results suggest that the same therapeutic strategy should be used in all patients classified i2 on the Rutgeerts score whatever the location of postoperative CD recurrence.

[Cholesterol embolism: unusual cause of small intestine occlusion]. / Embolie de cholestérol: une cause rare d'occlusion de l'intestin grêle.

We describe a case of small bowel obstruction secondary to cholesterol crystal embolism in a 83-year-old man. Clinical symptoms were dominated by weight loss and vomiting. Small bowel barrium X-ray displayed a short and unique stricture of the jejunum. Atheromatous embolism was suspected in the presence of an aortic aneurysm. At laparotomy, a 2 cm stricture of jejunum was identified and a 6 cm length segment of small bowel was resected. Pathological features were consistent with cholesterol crystal embolism. The patient did well 3 months after surgery. This observation points out the nonspecific clinical presentation of gastrointestinal cholesterol embolism.

Frequency and risk factors of recurrent pain during refeeding in patients with acute pancreatitis: a multivariate multicentre prospective study of 116 patients.

BACKGROUND/AIMS: The period of refeeding in patients with acute pancreatitis is critical because they may have pain relapse. A multicentre, multidimensional, prospective study was performed to assess the frequency and the risk factors of pain relapse in these patients. METHODS: Patients were included if they had acute pancreatitis severe enough to stop oral feeding for more than 48 hours. Clinical, biochemical, radiological, and therapeutic data were prospectively recorded and analysed by unidimensional and multidimensional analysis. The moment to refeed patients was chosen by the clinician but the diet was the same in all centres. RESULTS: A total of 116 patients were included with a Ranson's bioclinical score > or = 3 in 35% and a Balthazar's CT score > or = D in 42%. The cause of acute pancreatitis was biliary in 47% and alcohol misuse in 31%. During the oral refeeding period, 21% of the patients had pain relapse. This occurred on days 1 and 2 in 50% of patients. The duration of the painful period was longer in patients who relapsed than in others (p < 0.002). Pain relapse occurred in 39% of patients with a serum lipase concentration > 3x the upper limit of the normal range the day before refeeding and in 16% of other patients (p < 0.03). Patients with higher Balthazar's CT scores had pain relapse more often than the others (p < 0.002). None of the therapeutic procedures significantly modified the frequency of pain relapse. Using multidimensional analysis, Balathazar's CT score, period of pain, and serum lipase concentration the day before refeeding were independently associated with an increased risk of pain relapse. At a threshold of 0.5, a logistic score had a 37% sensitivity, 95% specificity, and 83% accuracy to predict pain relapse. Pain relapse nearly doubled total hospital stay and hospital stay after the first attempt at oral refeeding. CONCLUSION: Pain relapse occurred in one fifth of the patients with acute pancreatitis during oral refeeding and was more common in patients with necrotic pancreatitis and with longer periods of pain. The results of this study can be used to predict high risk patients and are a first step in the prevention of pain relapse.

[Chronic pancreatitis: an extraintestinal manifestation of hemorrhagic rectocolitis?]. / La pancréatite chronique: une manifestation extra-intestinale de la rectocolite hémorragique?

We reported here a case of unexplained chronic pancreatitis diagnosed 4 years before the onset of ulcerative colitis. The diagnosis of chronic pancreatitis was confirmed by recurrent pancreatitis and irregularities of the main pancreatic duct on retrograde pancreatography. None of the classical etiologies for chronic pancreatitis was found. Chronic pancreatitis associated with ulcerative colitis has already been reported in 5 cases. Our case reinforces the hypothesis of a non fortuitous association between both diseases.

Colonic xanthelasma due to glyceride accumulation associated with an adenoma.

The case is reported of a 66-year-old woman who presented with endoscopic and histological features of multiple lipid deposits in the mucosa of the sigmoid colon associated with an adenoma. Associated clinical features were abdominal pain and diarrhea. Colectomy led to the complete resolution of symptoms. Biochemical analysis disclosed the presence of glycerides in the mucosa. The pathogenesis of lipid deposits and the possible link with the formation of an adenoma is discussed.

[Pseudotumor nodular lymphoid hyperplasia of the ileum]. / Hyperplasie nodulaire lymphoïde pseudo-tumorale de l'iléon.

We report a case of pseudotumoral nodular lymphoid hyperplasia of the ileum in an immunocompetent 62-year-old woman. Ileoscopy showed multiple voluminous, soft, pliable, polypoid ileal lesions. Perendoscopic biopsies revealed a florid inflammation of the mucosa, characterised by numerous enlarged follicles with well-developed reactive germinal centres separated by a mixed infiltrate of lymphocytes, plasma cells and eosinophils. Immunohistochemistry showed a polytypic staining for kappa and lambda light-chains in the follicles and between and confirmed the reactive nature of the infiltrate. CT scan of the abdomen disclosed large periileal lymph nodes and a right ileocolectomy was performed. Twelve cases of pseudotumoral nodular lymphoid hyperplasia of the ileum have been reported in the literature in patients older than 25. In all cases, the diagnosis was performed after laparotomy. As shown in our case report, the diagnosis is possible on multiple perendoscopic biopsies.

Intravenous cyclosporine in attacks of ulcerative colitis: short-term and long-term responses.

The present study reports the results of intravenous cyclosporine in 32 patients with refractory and/or severe attacks of ulcerative colitis (UC). Twenty of 32 patients responded to intravenous cyclosporine; cyclosporine was clinically effective and improved colonic lesions. However, one colonic perforation and one postoperative death were observed in two patients with severe endoscopic colitis who had failed to reach clinical remission with high-dose corticosteroids and cyclosporine. Moreover, after a median follow-up of 190 days, only one-third of the patients avoided colectomy. No predictive factor of response to cyclosporine was identified. This study confirms that cyclosporine is effective in severe UC but suggests that its use could be associated with serious complications in patients with severe lesions who had failed to settle with corticosteroids and cyclosporine.

Chronic pancreatitis: a complication of sarcoidosis?

Gastrointestinal localizations of sarcoidosis are rare. A total of 14 cases of pancreatic involvement in sarcoidosis has been reported previously. We report here a case of late onset idiopathic chronic pancreatitis diagnosed at the same time as sarcoidosis with liver, colonic, renal, mediastinal and neurologic involvement in a 56-year-old man. This case further suggests a possible relationship between idiopathic chronic pancreatitis and multisystem diseases.