NONINVASIVE BREATH TESTS FOR DIAGNOSIS OF SIBO AND LACTOSE INTOLERANCE IN PATIENTS ON CHEMOTHERAPY TREATMENT FOR COLORECTAL AND GASTRIC CÂNCER.

BACKGROUND: Worldwide, colorectal cancer (CRC) and gastric cancer (GC) are the third and the fifth most prevalent, respectively. Diarrhea is a common symptom in patients on chemotherapy or radiotherapy treatment and can reduce treatment tolerance. Surgical resections and chemotherapy change the intestinal microbiota that can lead to lactose intolerance, small intestinal bacterial overgrowth (SIBO). OBJECTIVE: The aim of the study was to evaluate the frequency of diarrhea in patients with CRC and GC on chemotherapy with SIBO or intolerance of lactose. METHODS: This is a descriptive and observational study with patients of both sexes, over 18 years old, in treatment in the Gastro-Oncology outpatient clinic of the Federal University of São Paulo. Patients with a confirmed diagnosis of CRC or GC during chemotherapy treatment were included. To detect bacterial overgrowth and lactose intolerance, breath hydrogen test with lactulose and lactose was done. Number and aspects of the evacuations and toxicity degree were collected. For the nutritional assessment, weight and height were performed to calculate the BMI. and the Patient Generated Subjective Global Assessment (PG-SGA). RESULTS: A total of 33 patients were included, 29 with CRC and 3 with GC. Most of them were male (57.57%), mean age of 60.03±10.01 years and in chemotherapy with fluoropyrimidine and oxaliplatin (54.5%). Diarrhea was present in 57.6% and 30.3% had toxicity grade 2. According to the BMI, 78.9% were eutrophics, obese or overweight, but according to PG-SGA, 84.9% had moderate or severe nutritional risk grade. Between patients, 45% had lactose intolerance and 9% SIBO. Diarrhea grade 2-3 was observed in 66.6% of patients with SIBO and 66.7% of that with lactose intolerance. No statistical difference was observed between patients with SIBO or lactose intolerance and grade of diarrhea. CONCLUSION: Diarrhea was a frequent symptom in chemotherapy patients with gastric or colorectal cancer independent of the presence of SIBO or lactose intolerance. Surgery and chemotherapy treatment impacted in the intestinal habit of patients. Diagnosis of other causes of diarrhea may contribute to a better tolerance to treatment and quality of life.

Clinical and Demographic Profile of Inflammatory Bowel Disease Patients in a Reference Center of São Paulo, Brazil.

BACKGROUND: Crohn's disease (CD) and ulcerative colitis (UC) are chronic inflammatory diseases of the gastrointestinal tract with an increasing incidence in developing countries. PURPOSE: To report clinical and demographic data of CD and UC at a referral center for inflammatory bowel disease (IBD) in São Paulo. PATIENTS AND METHODS: We conducted a retrospective cross-sectional study on adult patients with established IBD. Demographic and clinical data were obtained by medical records analysis from the IBD Outpatient Clinic of EPM-UNIFESP, from October 1997 to October 2017. RESULTS: Of 658 patients included, 355 had UC (54%) and 303 had CD (46%). UC was more prevalent in women than CD (219 [61.7%] vs 152 [50.2%], p=0.003). The median time between the onset of symptoms and diagnosis was 13 (5-38) months, with a longer duration for CD patients. CD mostly affected the ileocolonic location (47.9%). CD patients with stricture, fistula and/or perianal disease (213/303, 70.3%) were younger at diagnosis, had a longer disease duration, higher rates of corticosteroid, immunomodulatory, and biological therapy, hospitalization, and referral to surgery, compared to patients without complication. Extensive colitis was the most common extension of UC (50.6%), which was more frequently associated with younger age at diagnosis, hepatobiliary disease, increased need for hospitalization, higher use of immunomodulatory, and biologic therapy, compared to patients with less extensive disease. In the last 5 years, CD patients were more frequently on biologic and/or immunomodulatory (70.9%) therapy, and UC patients often received salicylates (78.1%) and immunomodulatory (28.1%) treatments. There was a consistent reduction in salicylate usage for CD in the last 5 years compared to the total period of follow-up. CONCLUSION: Despite the increasing incidence, we highlight the diagnostic delay and a more complicated CD and extensive UC in this cohort, reflecting a high need for immunomodulatory and biological treatment, hospitalization, and surgery.

EVALUATION OF CARBOHYDRATE AND FIBER CONSUMPTION IN PATIENTS WITH IRRITABLE BOWEL SYNDROME IN OUTPATIENT TREATMENT.

BACKGROUND: Irritable bowel syndrome (IBS) is a chronic functional condition, which main symptoms of pain, discomfort and abdominal distension, constipation, diarrhea, altered fecal consistency and sensation of incomplete evacuation can be influenced by the presence of dietary fiber and fermentable carbohydrates (FODMAPs). This study aimed to assess the relationship between the quantity of fermentable carbohydrates (FODMAP) and fiber consumed by individuals diagnosed with IBS, and their classification according to the Rome III criteria. METHODS: A transversal study was carried out in the Intestinal Outpatient Clinic of the Gastroenterology Discipline of UNIFESP. The nutrients of interest for the study were: fiber, general carbohydrates and FODMAPs, with intake quantity measured in grams, analyzed through portions consumed. A nutrition log was used, along with a semi-quantitative questionnaire of consumption frequency. RESULTS: The sample included 63 adult patients; 21 with constipated IBS, 21 with diarrhea IBS, and 21 with mixed IBS. Carbohydrate intake was suboptimal in 55.6% of patients in all groups; excessive consumption was identified in 38.1% of the diarrhea group, 14.3% of the mixed group and 38.1% of the constipated group. Low consumption of carbohydrates was found in 28.6% of diarrhea patients and 47.6% of the mixed group. A mean intake of 23 g of fiber per day was identified, lower than recommended. CONCLUSION: The study identified a number of inadequacies in the consumption of different nutrients, excessive carbohydrate intake, especially FODMAPs, identified by the respondents as responsible for a worsening of their conditions. By contrast, other food groups such as meat, eggs and dairy were consumed by the sample population in insufficient quantities.

The retinal foveal avascular zone as a systemic biomarker to evaluate inflammatory bowel disease control.

BACKGROUND: Inflammatory bowel disease (IBD) is a systemic inflammatory disease and is classified as Crohn's disease (CD) or ulcerative colitis (UC) depending on the extent of gastrointestinal tract involvement. IBD can be associated with extraintestinal findings, such as fever, weight loss, arthralgia, and mucocutaneous lesions, as well as hepatic, renal and ophthalmological involvement. Clinical parameters and colonoscopy are used to establish the criteria for controlled or non-controlled disease and subsequent definition of treatment. Our objective in the present study was to compare the area of the foveal avascular zone (FAZ) in patients with a diagnosis of IBD during remission and active disease. METHODS: 144 eyes of 72 patients with IBD were evaluated via a complete ophthalmological exam. Fundus photography and optical coherence tomography/angiography (OCT/OCTA) were performed with a Topcon Triton. The macula and posterior pole were evaluated by binocular indirect ophthalmoscopy and fundus biomicroscopy. The area of the FAZ was determined via manual delimitation of superficial retinal vascular layers from OCTA with image6.net software. To establish disease activity, we considered the Mayo Score, fecal calprotectin levels, colonoscopy results and clinical parameters. All retinal parameters were evaluated in a blinded manner. Means were compared between groups using the Mann-Whitney test. RESULTS: The participants had a mean age of 42.26 years and included 28 males (38.88%) and 44 females (61.11%). Among the participants, 37 had a diagnosis of CD (51.38%), and 35 had a diagnosis of UC (48.61%). Twenty-five patients (34.72%) had active disease, and 47 (65.27%) were in remission. The area of the FAZ did not differ significantly between the CD and UC groups (p = 0.91 for the right eye and p = 0.76 for the left eye) but did differ significantly between the remission and active disease groups (p = 0.01 for the right eye and p = 0.02 for the left eye). DISCUSSION: Our study is the first to evaluate the area of the FAZ in patients with IBD via swept-source OCTA. The area of the FAZ did not differ significantly in either eye between the CD and UC groups. However, patients classified as having active disease according to clinical parameters and colonoscopy presented a significant decrease in the area of the FAZ compared with patients in remission. The area of the FAZ is an ophthalmological parameter that can be obtained non-invasively and is increased in ischemic diseases such as diabetic retinopathy. The FAZ may decrease due to vascular engorgement or increased systemic inflammation. This parameter can be used to help determine whether a patient is in remission or active IBD, thus potentially reducing the need for invasive exams during disease follow-up.

FREQUENCY OF OPHTHALMOLOGICAL POSTERIOR SEGMENT FINDINGS IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE.

BACKGROUND: Inflammatory bowel disease is a systemic inflammatory disease classified as Crohn disease or ulcerative colitis. It could present extra intestinal findings, such as fever, weight loss, arthralgia, mucocutaneous lesions, hepatic, renal and ophthalmological involvement. Among ophthalmological findings, posterior segment findings are present in less than 1% of patients with inflammatory bowel disease, however, these findings could bring definitive visual impairment. OBJECTIVE: Our study objective was to evaluate ocular posterior segment findings is patients with inflammatory bowel disease, through retinal mapping, color fundus retinography, optical coherence tomography (OCT) and OCT angiography, and compare our results to literature. METHODS: We evaluated eighty patients with inflammatory bowel disease through complete ophthalmological examination and posterior segment assessment. Color fundus retinography, OCT and OCT angiography was performed with Topcon Triton (Topcon ® , Tokyo, Japan). Macula and posterior pole were evaluated with binocular indirect ophthalmoscopy and fundus biomicroscopy. RESULTS: Participants mean age was 44.16 years (18.08-68.58), 28 (35%) male patients and 52 (65%) female patients. Thirty-five (44%) with diagnosis of Crohn disease, 41 (52%) patients with diagnosis of ulcerative colitis and 3 (4%) had non-conclusive Crohn disease or ulcerative colitis classification. We found abnormal exams in 21 (26.25%) patients. CONCLUSION: Our study found similar prevalence of ophthalmological posterior segment commitment compared to previous literature prevalence. The findings were predominantly unrelated to inflammatory bowel disease, rather than primarily related to it. The most prevalent, and non-previous reported, finding was increased arteriolar tortuosity, probably occurs due to systemic vascular impairment in inflammatory bowel disease.

Assessment of the response of patients with Crohn's disease to biological therapy using new non-invasive markers: lactoferrin and calprotectin.

CONTEXT: The use of fecal markers to monitor Crohn's disease is crucial for assessing the response to treatment. OBJECTIVE: To assess the inflammatory activity of Crohn's disease by comparing fecal markers (calprotectin and lactoferrin), colonoscopy combined with biopsy, and the Crohn's disease activity index (CDAI), as well as serum markers, before treatment with infliximab, after the end of induction, and after the end of maintenance. METHODS: Seventeen patients were included who had been previously diagnosed with Crohn's disease and were using conventional treatment but required the introduction of biological therapy with infliximab. Each patient underwent a colonoscopy with biopsy, serum, and fecal (calprotectin and lactoferrin) tests to assess inflammatory activity, and CDAI assessments before treatment with infliximab, after induction (week 8), and after maintenance (week 32). RESULTS: The calprotectin levels exhibited significant reductions (P=0.04) between the assessment before treatment with infliximab and the end of induction, which did not occur after the end of the maintenance phase. Lactoferrin remained positive throughout the three phases of the study. Regarding the histological assessment, a significant difference was found only between the assessment before treatment and after the end of maintenance (P=0.036), and 60% of the patients exhibited histological improvements after the completion of the follow-up period. The CDAI exhibited a significant difference between the assessment before treatment with infliximab and after induction, as well as before treatment and after maintenance (P<0.01). CONCLUSION: Calprotectin and lactoferrin are not useful for monitoring inflammatory activity in Crohn's disease patients who are subjected to biological therapy.

Nutritional follow-up of patients with ulcerative colitis during periods of intestinal inflammatory activity and remission.

CONTEXT: Ulcerative colitis is an inflammatory bowel disease involving superficial inflammation of the mucosa of the colon, rectum, and anus, sometimes including the terminal ileum. When in clinical activity, the disease is characterized by various daily evacuations containing blood, mucus and/or pus alternating periods of remission. OBJECTIVE: To compare nutritional parameters (dietary, biochemical and anthropometric) among patients with ulcerative colitis followed up on an outpatient basis over a period of 1 year and during periods of intestinal inflammatory activity and remission. METHODS: Sixty-five patients were studied over a period of 1 year and divided into two groups: group 1 with inflammatory disease activity (n = 24), and group 2 without disease activity (n = 41). Anthropometric measures, biochemical parameters, quantitative food intake, and qualitative food frequency were analyzed. RESULTS: A significant reduction in body mass index and weight and in the intake of energy, proteins, lipids, calcium, iron and phosphorus was observed in the group with inflammatory activity (group 1) when compared to the period of clinical remission. The most affected food groups were cereals, legumes, oils, and fats. In contrast, in group 2 significant differences in triceps and sub scapular skin fold thickness, total protein, hemoglobin and hematocrit were observed between the first and final visit. Calcium and vitamin B6 intake, as well as the consumption of legumes, meat and eggs, and sugar and sweets, was significantly higher than on the first visit. CONCLUSION: Patients with ulcerative colitis followed up on an outpatient basis tend to be well nourished. However, the nutritional aspects studied tend to worsen during the period of inflammatory disease activity.

Treatment of inflammatory bowel disease and pregnancy: a review of the literature.

CONTEXT: The inflammatory bowel disease is diagnosed frequently among woman of childbearing capacity. The management must be carefully because there are potential risks for the mother and fetus. RESULTS AND CONCLUSIONS: We review literature about the management of inflammatory bowel disease in pregnancy. Some studies are needed to ensure the best approach to inflammatory bowel disease in pregnant women.

Inflammatory bowel disease and pregnancy: report of two cases treated with infliximab and a review of the literature.

Inflammatory bowel disease is relatively frequent in women of childbearing age. Disease management requires greater attention during this clinical condition because of potential risk of maternal-fetal complications. Infliximab has been shown to be safe during pregnancy and lactation, but reports in the literature are scarce. We report two cases of refractory Crohn's disease treated with infliximab with good results, in women. Both patients became pregnant during maintenance regimen and treatment was continued. The literature regarding pregnant patients with inflammatory bowel disease was reviewed.

Doença inflamatória intestinal e gravidez: relatos de dois casos de uso de infliximab e revisão da literatura / Inflammatory bowel disease and pregnancy use of infliximab: a report of two cases and literature review

A doença inflamatória intestinal acomete mulheres em idade fértil com relativa frequência. A conduta exige maior atenção durante esta condição clínica em virtude dos riscos potenciais de complicações materno-fetais. O uso de infliximab tem se mostrado seguro durante a gravidez e lactação, todavia ainda são poucos os relatos existentes na literatura. Relatamos dois casos de gestação durante o uso de infliximab e realizamos revisão dos dados existentes na literatura acerca da conduta em pacientes com doença inflamatória intestinal nessa condição.

The inflammatory bowel disease is diagnosed frequently among woman of childbearing capacity. The management must be carefully because there are potential risks for the mother and fetus. Infliximab seems to be safe in pregnancy and nursing, however there are few studies about this issue. We report two cases and review literature about the management of inflammatory bowel disease in pregnancy.

Treatment of inflammatory bowel disease and pregnancy: a review of the literature / Tratamento da doença inflamatória intestinal durante a gravidez: revisão da literatura

CONTEXT: The inflammatory bowel disease is diagnosed frequently among woman of childbearing capacity. The management must be carefully because there are potential risks for the mother and fetus. RESULTS AND CONCLUSIONS: We review literature about the management of inflammatory bowel disease in pregnancy. Some studies are needed to ensure the best approach to inflammatory bowel disease in pregnant women.

CONTEXTO: A doença inflamatória intestinal acomete mulheres em idade fértil com relativa frequência. A conduta exige maior atenção durante esta condição clínica em virtude dos riscos potenciais de complicações materno-fetais. RESULTADOS E CONCLUSÕES: Esta é uma revisão sobre as manifestações clínicas das doenças inflamatórias intestinais durante a gravidez e seu tratamento durante este período. Ainda são necessários estudos sobre o tema para melhor abordagem das doenças inflamatórias intestinais em gestantes.