Correlation between incidental FDG PET/CT colorectal observations and endoscopic and histopathological results.

Fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) is used in the imaging workup of various malignancies. Incidental gastrointestinal observations on FDG PET/CT may be of clinical significance. The aim of the present study was to evaluate endoscopic and histopathological observations in patients referred for colonoscopy due to incidental FDG colonic uptake on a PET/CT study. Fifty-six patients with incidental colonic findings on FDG PET/CT underwent colonoscopy. Normal colonoscopies were observed in 63% of the patients. In 37% of the colonoscopies, we identified an endoscopic observation, including 67% with benign adenomatous polyps, 3% with hyperplastic polyps, 20% with advanced histological lesions and 10% with a malignancy.

Lifestyle modification parallels to sleeve success.

BACKGROUND: The role of laparoscopic sleeve gastrectomy (LSG) has increased over the past 10 years. We present our results of patients who were 5 years out from surgery with regard to safety and long-term efficacy. METHODS: Retrospective analysis was carried out from prospectively collected data of patients who underwent LSG for morbid obesity. Bariatric Analysis and Reporting Outcome System (BAROS) and Food Tolerance Scores (FTS) were assessed. At 5 years, two lifestyle modification questions (regarding nutrition habits and physical fitness) were separately assessed. RESULTS: One hundred fourteen patients underwent LSG and were available for postoperative visits. Mean excess weight loss (EWL) was >65% during the initial 3 years and declined to 45.3% in 5 years. Of the patients, 71.92% did not reach 50% EWL at 60 months and were considered objective failures. BAROS and FTS scores were 7.15 and 4.32, and 23.5 and 22.5 at 30 and 60 months, respectively. Analyzing the 32 patients with EWL >50% in the 5-year group, 26 (81.25%) of them had scored ≥0.5 on the two lifestyle modification questions compared with 6 (18.75%) that scored <0.5 (P < 0.001). CONCLUSION: LSG is an effective bariatric surgical procedure with significant long-term (5 year) weight loss, resolution of comorbid medical conditions and significant improvement in the quality of life. The basis for this success, which must be always emphasized preoperatively by the bariatric team, is knowledge and implementation of better nutritional habits and increasing physical fitness or, in other words, in significant lifestyle modification.

Increased Toll-like receptor 9 expression by B cells from inflammatory bowel disease patients.

BACKGROUND: Toll-like receptors (TLRs) are important mediators of the innate immune response. Our aim was to evaluate TLR9 expression in peripheral B cells, taken from inflammatory bowel disease (IBD) patients before and after anti-inflammatory treatment. Nineteen patients with IBD (12-crohn's disease, 7-ulcerative colitis) and 18 healthy controls were included in the study. Disease severity was assessed using the Pediatric/Adults crohn's disease activity index and the ulcerative colitis activity index as needed. Accordingly, patients were classified as mild, moderate or severe disease. Peripheral B cells isolated from IBD patients, before and after anti-inflammatory treatment, and from the control group, were cultured for 24 h with and without CpG oligodeoxynucleotides (ODN-CpG) 0.5 µM. TLR9 expression by memory B cells (CD19+CD27+) was assessed by flow cytometry. RESULTS: We found that TLR9 expression by peripheral B cells was significantly higher in IBD patients than that in healthy controls (12.42 ± 9.5 MFI vs. 6.0 ± 2.6 MFI p = 0.02). The addition of ODN-CpG to B cells resulted in a significantly increase of TLR9 expression in B cells from healthy controls (6.5 ± 3.2 MFI vs. 8.8 ± 4.2 MFI p = 0.007). On the contrary, B cells from IBD patients only partly respond to the addition of ODN-CpG after anti-inflammatory treatment (6.3 ± 3.8 vs. 7.3 ± 3.7, p = 0.1). TLR9 expression was positively correlated with IBD disease severity (r = 0.681, p < 0.0001). CONCLUSIONS: TLR9 expression in memory B from IBD patients is elevated and associated with disease severity.

Dietary glutamine supplementation prevents mucosal injury and modulates intestinal epithelial restitution following acetic acid induced intestinal injury in rats.

Beneficial effects of glutamine (GLN) have been described in many gastrointestinal disorders. The aim of the present study was to evaluate the preventative effect of oral GLN supplementation against acetic acid (AA) induced intestinal injury in a rat. Male Sprague-Dawley rats were divided into four experimental groups: control (CONTR) rats underwent laparotomy, control-glutamine (CONTR-GLN) rats were treated with enteral glutamine given in drinking water (2%) 48 hours before and five days following laparotomy, AA rats underwent laparotomy and injection of AA into an isolated jejunal loop, and acetic acid-glutamine (AA-GLN) rats underwent AA-induced injury and were treated with enteral GLN 48 hours before and 5 days following laparotomy. Intestinal mucosal damage (Park's injury score), mucosal structural changes, enterocyte proliferation and enterocyte apoptosis were determined five days following intestinal injury. Western blotting was used to determine p-ERK and bax protein levels. AA-induced intestinal injury resulted in a significantly increased intestinal injury score with concomitant inhibition of cell turnover (reduced proliferation and enhanced apoptosis). Treatment with dietary GLN supplementation resulted in a decreased intestinal injury score with concomitant stimulation of cell turnover (enhanced proliferation and reduced apoptosis). In conclusion, pre-treatment with oral GLN prevents mucosal injury and improves intestinal recovery following AA-induced intestinal injury in rats.

Getting the most from the sleeve: the importance of post-operative follow-up.

BACKGROUND: Bariatric approach to obesity provides substantial weight loss and comorbidity resolution. Our unique service includes pre- and postoperative visits to the Health and Nutrition Clinic headed by a specialist in gastroenterology and nutrition. We compared patients attending regular clinic routine with those who were lost to follow-up with regard to anthropometry, comorbidity, quality of life, and food tolerance and determined who benefited most from the operation. METHODS: A retrospective review was performed on patients 30 months after undergoing sleeve gastrectomy. Body mass index was used to report weight loss. Bariatric Analysis and Reporting Outcome System (BAROS) and Food Tolerance Score were (FTS) completed by all patients at the 30-month follow-up visit and compared between two groups (group I-30 months of active postoperative follow-up; group II-without). RESULTS: A total of 119 patients participated in the study. For groups I and II, the mean percentage of excess BMI loss at 30 months was 82.08 ± 9.83 and 74.88 ± 8.75, respectively, with better comorbidity improvement in group I. BAROS scores were 7.62 ± 0.72 and 6.92 ± 0.92. FTS was 24.30 ± 2.09 and 22.55 ± 2.27, respectively. CONCLUSIONS: From our experience, getting the most from the sleeve is attributed to two main factors: surgery and nutrition. Surgery results in optimal restriction and improved satiety, whereas nutrition relies on a professional medical team providing constant, ongoing patient support throughout all the bariatric process stages. These teams of surgeons and gastroenterologists specializing in nutrition, working side by side, each in their area of specialty, are the main pillars leading to the success of the sleeve.

Adenosine deaminase activity in patients with Crohn's disease: distinction between active and nonactive disease.

BACKGROUND: Crohn's disease (CD) is a common chronic inflammatory bowel disease. During the disease a cascade of immunologic events occur including mucosal influx of inflammatory cells like neutrophils. Adenosine deaminase (ADA) is important in inflammatory responses and serves as a marker of activated leukocytes. MATERIALS AND METHODS: In this study, we investigated the activity of total ADA (tADA) and its isoenzymes, ADA1 and ADA2, in serum and neutrophils derived from 20 active patients with CD, 20 patients in remission, as well as in 15 healthy controls. RESULTS: Patients with active disease had significantly (P<0.001) higher levels of tADA in serum (22.9±4.9 U/l) than patients in remission or healthy controls (14.0±3.4 U/l and 13.2±2.4 U/l respectively). ADA2, the main isoenzyme in the serum was higher in active patients by 60% as compared with patients in remission and healthy controls (19.7±1.9 U/l, 12.3±1.2 U/l, and 12.2±0.9 U/l respectively). We did not find a significant difference in these parameters between healthy controls and stable patients. There was a positive correlation (R=0.516) between tADA activity and C-reactive protein levels in patients with CD. Enhanced activity in tADA was also detected in neutrophils that were obtained from all patients with CD as compared with healthy controls (15.3±2.9 U/g, 14.1±2.3 U/g, and 9.4±2.9 U/g protein, respectively). This is mainly due to a significant increment (up to 51%) in ADA1 activity, the main isoenzyme in the neutrophils (84% out of the tADA). The cause of this increment remains to be elucidated. CONCLUSION: The results obtained in this study demonstrated elevated levels of tADA and ADA2 in patients with active disease. As the patient improves and becomes clinically stable these levels decrease, approaching normal values. tADA and ADA2 can be used as markers of inflammation, and provide a supportive indicator of CD activity.

A nine-year audit of open-access upper gastrointestinal endoscopic procedures: results and experience of a single centre.

BACKGROUND: The appropriateness and safety of open-access endoscopy are very important issues as its use continues to increase. OBJECTIVE: To present a review of a nine-year experience with open-access upper gastrointestinal endoscopy with respect to indications, diagnostic efficacy, safety and diseases diagnosed. METHODS: A retrospective, observational case series of all patients who underwent open-access endoscopy between January 2000 and December 2008 was conducted. Indications were classified as appropriate or not appropriate according to American Society of Gastrointestinal Endoscopy (ASGE) guidelines. Endoscopic diagnoses were based on widely accepted criteria. Major complication rates were assessed. RESULTS: A total of 20,620 patients with a mean age of 58 years were assessed, of whom 11,589 (56.2%) were women and 9031 (43.8%) were men. Adherence to ASGE indications led to statistically significant, clinically relevant findings. The most common indications in patients older than age 45 years of age were dyspepsia (28.5%) and anemia (19.7%) in the ASGE-appropriate group, and dyspepsia in patients younger than 45 years of age without therapy trial (6.6%) in the nonappropriate group. Of the examinations, 38.57% were normal. Hiatal hernia and nonerosive gastritis were the most common findings. Important diagnoses such as malignancies and duodenal ulcers would have been missed if endoscopies were performed only according to appropriateness. There were only two major complications and no mortalities. CONCLUSIONS: Open-access upper gastrointestinal endoscopy is a safe and effective system. More relevant findings were found when adhering to the ASGE guidelines. However, using these guidelines as the sole determining factor in whether to perform an endoscopy is not advisable because many clinically relevant diagnoses may be overlooked.

Colorectal cancer among Arab-Israeli women--possible reasons for increased incidence and mortality.

BACKGROUND: Colorectal cancer (CRC) screening is effective in reducing its incidence by discovering precancerous polyps and detecting early cancer. Evidence indicates lower participation in screening programs among minority ethnic groups. In addition, the Israel Cancer Registry published an increase in the incidence of CRC among Israeli-Arab women. It is important to attempt to understand attitudes toward screening among Israeli-Arab women, assuming it has to do to lack of knowledge and compliance. METHODS: During the study period, a female team gave lectures in Arabic regarding CRC to women in 16 Arab villages. Prior to the lecture, the participants were asked to complete a questionnaire, obtaining information regarding CRC knowledge and screening. Following the lecture, FOBT kits were distributed. Two weeks later, a telephone survey was performed, regarding whether the FOBT was performed, the result of the test, and, if FOBT was not performed, the reasons for not completing the test. RESULTS: FOBT was performed by 17.8% prior to the lecture; 61% performed the FOBT following our lecture. Reasons cited for avoiding FOBT: 37% was "afraid of a positive result," 32% avoided performing the test as they were concerned they would be further examined by a male physician; 47.8% concluded that Arab women lack knowledge regarding screening interventions; 23.9% neglect themselves from a health point of view; 11.6% advised that Arab women have no free time to perform tests. CONCLUSIONS: Israeli-Arab women may be less knowledgeable concerning CRC. Educational efforts must be made to increase awareness and promote benefits of CRC screening, by targeting ethnic minorities and women in Israel.

Sleeve gastrectomy leads to Helicobacter pylori eradication.

BACKGROUND: The role of Helicobacter pylori (HP) in patients scheduled and undergoing laparoscopic sleeve gastrectomy (LSG) has not been previously evaluated. METHODS: Included were obese patients presenting to our institution for LSG over 24 months. All patients had presurgical HP breath test, and the symptomatic ones received triple therapy with symptom follow-up. Post surgery, all excluded stomachs were evaluated for HP, and those that were positive performed a second 13C-urea breath test (UBT) 3 months later. RESULTS: Forty patients underwent LSG. Male to female sex ratio was 1:3; mean age-42 years; mean weight-122 kg; and mean BMI of 43.4 kg/m2. Presurgical HP was positive in 15 (37.5%) patients (11 symptomatic and four asymptomatic). Only these 11 patients were given HP eradication therapy and all experienced complete subsequent symptom resolution. HP was detected in 17 out of the 40 (42.5%) cases of excluded stomachs. All performed a 13C-UBT 3 months post operation and only three (17.6%) tested positive. CONCLUSIONS: HP infection is frequent in biopsies from patients with previous LSG and the majority of follow-up 13C-UBT were negative. In our small initial sample, we treated only symptomatic patients preoperatively. Routine screening for HP for all LSG patients and/or treatment for all positive ones would subject patients to expensive and unnecessary investigations. We propose that this stomach-reducing, pylorus-preserving surgery might even lead to HP eradication. The clinical implications of HP and this gastrectomy for a non-neoplastic, non-peptic indication deserve further study.

Incidental colorectal computed tomography abnormalities: would you send every patient for a colonoscopy?

BACKGROUND: The clinical significance of colorectal wall thickening (CRWT) in patients undergoing abdominal computed tomography (CT) has not yet been definitively established. OBJECTIVES: To compare alleged findings on abdominal CT with those of a follow-up colonoscopy. METHODS: Ninety-four consecutive patients found to have large-bowel abnormalities on abdominal CT were referred for colonoscopy. Of these patients, 48 were referred for a suspected colorectal tumour and 46 for CRWT. Colonoscopy was performed and findings were compared. RESULTS: Of the 48 suspected colorectal tumours, 34 were determined to be neoplastic lesions on colonoscopy. Of these, 26 were malignant and eight were benign. Colonoscopy revealed no abnormality in 30 of 46 patients with CRWT as a solitary finding, and revealed some abnormality in 16 patients (12 had diverticular disease, four had benign neoplastic lesions). CONCLUSIONS: CRWT as an incidental and solitary finding on CT should not be regarded as a pathology prompting a colonoscopy. Approximately two-thirds of the patients had a normal colonoscopy and the remaining patients had benign lesions (12 had diverticular disease and four had benign neoplastic lesions). However, many of these patients seem to warrant colonoscopy regardless of CT findings, particularly patients who have a family history of colorectal cancer, have positive fecal occult blood test results or who are older than 50 years of age.

Significant colonic neoplasia prevalence and ASGE recommendations: is it time for a change?

GOALS AND BACKGROUND: To Evaluate the indications versus diagnostic yield of significant colonic neoplasia (SCN) in the open-access era and screening colonoscopy. STUDY: During 6-year period, all procedural data were obtained from all consecutive patients who underwent colonoscopies. Indications were compared with American Society for Gastrointestinal Endoscopy guidelines. RESULTS: In all 22,341 procedures were included in the study. Indications were divided into 3 groups: Screening (21.89% of the procedures), surveillance (17.60%) and symptoms/signs (60.51%). A total of 2867 patients (12.83%) had SCNs. Of these, 278 (7.00%) SCNs were found in the group less than 50 years of age and 2589 in the group over the age of 50 years (14.10%). SCN as per indication frequency was 12.69% in the symptom/sign group (subdivided to 7.24% and 14.01% in the under 50 and over 50, age groups, respectively); screening 13.37% (5.48% and 15.09%, respectively); surveillance 12.64% (8.48% and 13.19%, respectively). The indications leading to the highest SCN rate (over 25%) were: abnormal imaging, elevated carcinoembryonic antigen, and rectal pain. CONCLUSIONS: Colonoscopy is a unique screening tool that can detect neoplastic lesions. SCN prevalence in our study was between 13% and 15% for all indications in patients above 50 years of age. This emphasizes performing a screening colonoscopy for the entire population over the age of 50 years, regardless of the indication. We feel that American Society for Gastrointestinal Endoscopy guidelines should be reassessed. The revised criteria should state that the primary indication, are all people over the age of 50 years, who should have a colonoscopy performed, unless otherwise contraindicated.

Oxidative stress, inflammation and neutrophil superoxide release in patients with Crohn's disease: distinction between active and non-active disease.

Increased oxidative stress has been previously demonstrated in patients with Crohn's disease (CD). However, to date, this parameter has not been assessed in a comparative study of patients in prolonged remission and those with the active disease. We report here our study of lipid peroxidation, antioxidant and inflammation status in serum derived from 16 active CD patients, 27 clinically stable patients, and 15 healthy controls. Results The extent of lipid peroxidation was higher in CD patients than in the healthy controls, while the levels of lipid peroxides (PD) and of thiobarbituric acid-reactive substances (TBARS) were significantly (P < 0.01) higher in serum obtained from patients with active CD (22 and 30%, respectively) than in that obtained from patients in remission. An analysis of the antioxidant status revealed that the beta-carotene levels in sera derived from all CD patients - patients with active or stable CD (49.4 +/- 15 and 95.6 +/- 25 mg% beta-carotene, respectively) - were higher than that in the controls (145 +/- 40 mg%). Serum activity of glutathione peroxidase (GSH-Px) was significantly (P < 0.001) higher (by 31%) in the patients with active CD than in the control group. There was no significant difference in GSH-Px activity between patients in remission and the controls. In terms of the inflammatory status, we found significantly (P < 0.01) higher levels of C-reactive proteins (CRP) and of tumor necrosis factor alpha (TNFalpha) in patients with active CD than in CD patients in remission. There was a significant correlation between those parameters and the extent of lipid oxidation. Neutrophils, which are a potential source of oxygen-free radicals, were activated by incubation with phorbol myristate acetate (PMA). Superoxide and lysozyme release were significantly reduced in neutrophils derived from patients with active CD (by 25 and 28%, respectively) in comparison to the control group. However, stimulated neutrophils from stable patients demonstrated only a minimally non-significant lower release of superoxide and lysozyme compared to the controls. Conclusion The results obtained in this study demonstrate an enhanced inflammatory and oxidative stress and a decreased antioxidant status in patients with active CD. As the patients improved and became clinically stable, the oxidative parameters decreased, approaching normal values. As neutrophil activation was also lower in patients with active disease, neutrophil activation may represent a possible defense mechanism of the body against tissue injury.

Primary duodenal mucosa-associated lymphoid tissue (MALT) lymphoma--a rare presentation of gastric outlet obstruction.

Malignant lymphoma of mucosa-associated lymphoid tissue (MALT) can arise in a variety of anatomical sites. The majority of these tumors arise in the stomach, with fewer than 30% arising in the small intestine. Primary duodenal MALT lymphoma is a very rare neoplasm. There are very few cases of duodenal MALT lymphoma reported in the literature. This is the third published case presenting clinically as a gastric outlet obstruction. The patient was successfully treated with a combination of chemotherapy and rituximab.

Diagnostic yield and safety of colonoscopy in Israeli patients in an open access referral system.

BACKGROUND: Open access endoscopy allows reference of patients for endoscopic procedures without prior gastrointestinal consultation, allowing the procedure to be more accessible. This practice is becoming increasingly widespread in the United States and other countries and has become commonplace in clinical practice in Israel. The objective of our study is to bring forward our experience with an open access referral system for colonoscopy and to measure the yield and safety of colonoscopy in this system. METHODS: Between January 2001 and September 2003, 10,866 colonoscopies were performed. Patient's charts were reviewed for the following data: demographics, indication for endoscopy, endoscopic and histopathologic findings, and complications. The practice guidelines of the American Society for Gastrointestinal Endoscopy were used to assess appropriateness of colonoscopy. RESULTS: 3533 pathologic findings were found, in 2978 colonoscopies. 2336 polyps were removed, including 18% hyperplastic, 26% tubular adenomata, 13% villous adenomata, 11% tubulovillous adenomata. Advanced disease was found in 41% of pathologic findings, 11% were invasive cancer. Rate of colonoscopies "generally indicated" according to American Society for Gastrointestinal Endoscopy guidelines was 78% with a rate of colonoscopies "generally not indicated" of 22%. Colonoscopy was completed successfully to the cecum in 93% of patients. 0.08% had serious complications during or immediately after colonoscopy. CONCLUSIONS: Our results suggest that open access colonoscopy is a reliable and safe method for screening average risk population. As colonoscopy is becoming the recommended screening model for colorectal cancer this attitude of performing screening in an open access system could both cut costs in the future and improve availability, in an aim to become common practice.

Enhanced oxidative stress and leucocyte activation in neoplastic tissues of the colon.

Excess of intracellular reactive oxygen species results in an environment that may modulate gene expression, or damage cellular molecules. These events are assumed to contribute to the process of carcinogenesis. In the present study, we measured the extent of lipid peroxidation and antioxidative status in colonic tumors and normal colonic mucosa obtained from 25 patients with colorectal carcinoma. Levels of lipid peroxides (PD) and of thiobarbituric acid reactive substances (TBARS) were significantly increased, by 54 and 59%, respectively, in tissue specimens obtained from the colonic tumor as compared with normal colonic mucosa (PD, 2.78+/-0.31 versus 1.81+/-0.29 nmol/mg tissue, TBARS, 0.86+/-0.1 versus 0.54+/-0.08 nmol/mg tissue). Activities of the antioxidant enzymes catalase and glutathione peroxidase (GPx) were also higher (by 67 and 29%, respectively) than in normal mucosa, probably in response to the increased free radical stress occurring in cancerous tissues. Myeloperoxidase (MPO) and adenosine deaminase (ADA) are markers of activated leukocytes and are related to the production of oxygen free radicals by these cells. Their activities were significantly elevated in the neoplastic tissue as compared to the normal tissue (MPO, 7.4+/-1.5 versus 4.1+/-0.95 U/mg tissue, ADA, 4.17+/-0.65 versus 2.99+/-0.80 U/g tissue), suggesting a possible involvement of activated leukocytes in the enhanced oxidative stress in the cancerous tissue. Our results demonstrate an enhanced oxidative stress in the neoplastic tissue. Leukocyte activation was also higher in the carcinogenic tissue, indicating a possible contribution of these cells to a further oxidative stress-derived tissue injury. These observations add to previous studies and may encourage therapeutic trials with antioxidants as a means of preventing colorectal cancer and preventing further tissue injury in the neoplastic tissue and its surroundings.

[Open access colonoscopy: do primary care physicians use it properly?].

BACKGROUND: Open access endoscopy facilitates the performance of colonoscopy on a physician's request, without a prior consultation with a gastroenterologist. OBJECTIVES: To investigate: (1) the rates of relevant endoscopic findings in patients referred by family physicians compared to other specialists; (2) whether there is overuse of open-access colonoscopy in our country where the examination is free of charge for the patient; (3) whether a high rate of pre-malignant and malignant incidental findings might justify a more liberal approach to the indications of colonoscopy. METHODS: Prospective study including all consecutive ambulatory patients referred for open access colonoscopy. The indication for the examination was tabulated according to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines. Endoscopic findings were classified into relevant or normal; each relevant finding was correlated with the indication for which the examination was performed. RESULTS: A total of 34.2% of patients had a colonoscopy performed for an inappropriate indication; family physicians had a slightly higher rate of appropriate indications compared with the other specialists. However, a relevant endoscopic finding was diagnosed only in 14.0% of their referred cases, compared with 22.8% of the other specialists (p = 0.032). Polyps larger than 5 mm or a malignant tumor were diagnosed in 20.7% of the colonoscopies; 19 out of the 83 cases (23%) were diagnosed in examinations performed for inappropriate indications. CONCLUSION: It was found that 34% of the colonoscopies were performed for inappropriate indications. A higher proportion of relevant endoscopic findings was diagnosed among patients referred by surgeons, oncologists and internists as compared with those referred by family physicians. Considering that as much as 23% of polyps and malignant tumors were found in cases performed for inappropriate indications, we suggest that a liberal approach to the indications for colonoscopy--probably age over 50 years--may benefit the patients.

[Infliximab in inflammatory bowel diseases--conference summary and suggested guidelines].

Infliximab, the monoclonal anti-tumor necrosis factor-alpha (TNF-alpha) antibodies preparation, is efficacious in the treatment of inflammatory bowel diseases. However, the optimal therapeutic approach is still under investigation. Reports on side effects and potential complications of infliximab therapy, as well as of other anti-TNF-alpha blocking agents are accumulating. Hence, the Israeli Gastroenterological Association had initiated a conference in order to discuss the frequent clinical issues that have arisen following the use of infliximab for the treatment of inflammatory bowel diseases. The aim was to report on the published clinical experience and problems regarding several practical aspects of the use of Infliximab, to suggest guidelines that are evidence-based and to discuss them with experienced IBD-oriented gastroenterologists. The subjects that were discussed include: (1) treatment protocols; (2) maintenance therapy in Crohn's disease; (3) prevention of infections and (4) therapeutic potential in ulcerative colitis. These topics reflect everyday issues that gastroenterologists deal with while treating inflammatory bowel disease patients. The manuscript summarizes the literature and evidence that were presented in the conference, the points raised at the discussions as well as guidelines suggested by work groups that were established for each subject. These guidelines may assist and direct the gastroenterologist treating inflammatory bowel disease patients with infliximab.

Acute pancreatitis and upper gastrointestinal bleeding as presenting symptoms of duodenal Brunner's gland hamartoma.

Brunner's gland hamartomas are rare, benign small bowel tumours. There were fewer than 150 cases reported in the English literature until the end of the last century. These hamartomas may be discovered incidentally during an upper gastrointestinal tract endoscopy. Otherwise, they may be diagnosed in patients presenting with acute upper gastrointestinal bleeding, anemia or symptoms of intestinal obstruction. The case of a young woman admitted for acute upper gastrointestinal bleeding along with acute pancreatitis is presented. The investigation revealed a giant Brunner's gland hamartoma in the second part of the duodenum. After total endoscopic resection of the tumour, the patient has remained completely asymptomatic for a follow-up period of seven months.

Is traveler's diarrhea a significant risk factor for the development of irritable bowel syndrome? A prospective study.

A total of 564 travelers were enrolled in a study aimed at investigating the influence of traveler's diarrhea in the development of irritable bowel syndrome. At 6-7 months after repatriation, we found that an episode of traveler's diarrhea was associated with a quintuple risk of developing irritable bowel syndrome.

Increasing the infliximab dose is beneficial in Crohn's disease patients who responded to a lower dose and relapsed.

BACKGROUND: Relapse after an initial response to infliximab therapy poses a problem for maintenance treatment. AIM: To assess the effects of increasing the infliximab dosage in Crohn's disease (CD) patients who initially responded but flared during maintenance therapy. METHODS: This was an observational study. Twelve CD patients with both inflammatory and fistulizing manifestations were included. All patients initially responded to 5 mg/kg of infliximab, relapsed during maintenance therapy, and were treated with 10 mg/kg. The Harvey-Bradshaw index, the fistula activity, and steroid use were assessed before and after treatment with the increased dose of infliximab. RESULTS: The mean Harvey-Bradshaw index score after flare-up during treatment with 5 mg/kg of infliximab was 13.5+/-3.7. Treatment with 10 mg/kg, in a mean of 3.3 infusions, decreased the activity score to a mean of 8.8+/-2.5. Two patients were weaned off prednisone, and a reduced dose was possible in the other steroid-treated patients. CONCLUSIONS: Increasing the infliximab dose may be beneficial in CD patients who initially responded to therapy, but relapsed during maintenance with the lower dosage.