[Changes in the treatment of Crohn's disease: fewer hospitalizations, less surgery, and reduced glucocorticoid use]. / Veranderingen in de behandeling van ziekte van Crohn.

OBJECTIVE: To study changes in treatment and disease course in patients with Crohn's disease (CD) in the South Limburg region of the Netherlands between 1991 and 2014. DESIGN: Population-based cohort study. METHODS: All 1162 CD patients in the 'IBD South Limburg cohort' were divided across three subcohorts on the basis of year of diagnosis: 1991-1998 (N = 316), 1999-2005 (N = 387) and 2006-2011 (N = 459). We compared the risk of hospitalization, bowel resection and the development of strictures and/or fistulas across the subcohorts. We also compared cumulative corticosteroid use and the relationship between the outcome measures and maintenance medication. RESULTS: In the period 1991-2014 there was an increase in the number of patients treated within 5 years with immunomodulators from 30.6% to 70.8%. For treatment with biologicals there was an increase from 3.1% to 41.2%. In parallel, the risk of hospitalization decreased from 65.9% to 44.2% and the risk of bowel resection decreased from 42.9% to 17.4%. The risk of developing strictures or fistulas remained stable (21.2%). There was no significant association between the outcome measures and the use of immunomodulators or biologicals. Furthermore, corticosteroid use decreased over time; this was linked to use of immunomodulators and biologicals. CONCLUSION: Treatment of Crohn's disease has changed over the past two decades, and the disease course has improved. We found no association between changes in maintenance medication and disease course.

Intragastric acidification inhibits motilin-induced phase III activity in humans.

In a randomized, placebo-controlled crossover design we studied the effect of gastric acidification on motilin-induced interdigestive antropyloroduodenal motility. Ten healthy volunteers participated in the study consisting of four experiments. Each experiment started after a spontaneous occurring phase III and consisted of intragastric infusion of either saline or acid (0.08 mol L(-1) HCl) for 90 min and intravenous infusion of either saline or motilin (4 pmol kg(-1) min(-1)) for 30 min. Antropyloroduodenal motility and pH were recorded continuously for 240 min. Reoccurrence of phase III was significantly (P < 0.05) earlier during intragastric saline-intravenous motilin infusion compared with control (intragastric saline-intravenous saline), 52 min (range 25-79) and 113 min (84-141) respectively. This effect was completely abolished during intragastric acid-intravenous motilin infusion, 112 min (82-142). The percentage of phase III of antral origin was significantly (P < 0.05) higher during intragastric saline-intravenous motilin infusion (90%) compared with control (30%). The mean area under the contraction (AUC) for phase II was significantly (P < 0.05) lower during intragastric saline-intravenous motilin infusion and intragastric acid-intravenous saline infusion compared with control. It is concluded that in humans intragastric acidification inhibits the effect of motilin on antroduodenal motility, decreases the AUC of antral phase II contractions and delays the occurrence of phase III of the migrating motor complex.

Review article: The diagnosis and management of gastroparesis.

BACKGROUND: Gastroparesis is a disorder characterized by a delay in gastric emptying of a meal in the absence of a mechanical gastric outlet obstruction. AIM: To provide an evidence based overview on diagnosis and management of gastroparesis. METHODS: A PubMed search was performed using search terms including gastroparesis, gastric retention, gastric emptying, accommodation, manometry, prokinetics, antiemetics, metoclopramide, domperidone, erythromycin, botulinum toxin, gastric pacing. Relevant studies were identified and original articles and reviews were collected. References in these articles were examined for relevance and included where appropriate. RESULTS: Diagnosis of gastroparesis is based on the presence of symptoms such as nausea, vomiting and postprandial abdominal fullness and on an objectively determined delay in gastric emptying. The true prevalence of gastroparesis is unknown. Gastric emptying can be assessed by scintigraphy and stable isotope breath tests. Management of gastroparesis consists of dietary and lifestyle measures and/or pharmacological interventions (prokinetics, antiemetics, intrapyloric botulinum toxin injection) or other interventions that focus on adequate nutrient intake either through a nasoduodenal tube, percutaneous gastrostomy or jejunostomy. CONCLUSIONS: Accurate diagnosis of gastroparesis requires an adequate protocol to measure gastric emptying. Treatment options in gastroparesis remain limited despite the disabling nature of the disorder.