A. Casà

Prevalence of Cytomegalovirus Infection in Severe Refractory Ulcerative and Crohn's Colitis

Abstract OBJECTIVES Cytomegalovirus infection has been reported as a cause of refractory inflammatory bowel disease, but no data are available on its prevalence in severe colitis. The aim of this study was to evaluate the prevalence and outcome of cytomegalovirus infection in a consecutive series of patients with severe steroid refractory colitis admitted to our department from 1997 to 1999. METHODS: Among 62 patients with severe colitis, 55 with ulcerative colitis and seven with Crohn’s disease, 19 (30%) were resistant to intravenous steroids and bowel rest. In all of them, rectal biopsies were examined for cytomegalovirus (the flexible proctoscopy being performed without air insufflation and limited to the first 10 cm). Buffy coat preparation on leukocytes was also performed to detect systemic infection. If cytomegalovirus was not detected, cyclosporine was started. RESULTS: In seven (five with ulcerative colitis and two with Crohn’s disease) out of 19 (36%) patients with refractory disease, cytomegalovirus was diagnosed in the rectal specimens as well as by buffy coat preparation. Five patients went into remission after antiviral treatment (three with ganciclovir and two with foscarnet). One patient did not respond and was operated on. In one patient, cytomegalovirus was found in the surgical specimen. CONCLUSIONS: Cytomegalovirus infection is a frequent cause of severe refractory colitis. Rectal biopsy should always be performed in severe steroid-resistant colitis.

Familial occurrence of inflammatory bowel disease in celiac disease

BACKGROUND The authors have previously reported a possible increased risk of the familial occurrence of Crohns disease in patients with celiac disease. AIM The aim of the current study was to evaluate in a case-control study the familial occurrence of inflammatory bowel disease (IBD) in first-degree relatives of patients with celiac disease. METHODS One hundred eleven consecutive patients with biopsy-proven celiac disease were interviewed to ascertain whether IBD was present in first-degree relatives. The number of relatives, their ages, and possible IBD status were collected in a questionnaire. When a diagnosis of familial IBD was reported, the diagnosis was checked in the hospital records. Two hundred twenty-two controls matched for age and sex (111 from the general population and 111 from orthopedic wards) were also interviewed regarding the possible occurrence of IBD in first-degree relatives. The chi2 test was used to evaluate the difference in proportion of familial occurrence of IBD among individuals with celiac disease and controls. RESULTS Among 600 first-degree relatives of patients with celiac disease, 10 cases of IBD were identified among first-degree relatives (7 cases of ulcerative colitis and 3 cases of Crohns disease), whereas only 1 case of IBD was identified among the 1,196 first-degree relatives of control patients (p < 0.01). When ulcerative colitis and Crohns disease were analyzed separately, only the prevalence of ulcerative colitis was statistically significant (p </= 0.02). CONCLUSIONS This case-control study shows that there is a significantly increased prevalence of familial ulcerative colitis in patients with celiac disease. There was no significant increase in the prevalence of Crohns disease in patients with celiac disease. The possible role of this association is discussed.

Prevention of postsurgical relapse and recurrence in Crohn's disease

After first resection in Crohns disease at 1 year 60–80% of patients have endoscopic recurrence, 10–20% have clinical relapse, and 5% have surgical recurrence. 1,  2 This review focuses on the actual evidence on the prevention of recurrence and relapse dealing with risk factors and with drugs. Smoking is the only risk factor for Crohns disease, that has been shown to be related to both endoscopic and surgical recurrence and relapse. Among the different drugs evaluated, some (Mesalamine and Metronidazole) have been shown to be effective, whereas others (immunosuppressive) need to be evaluated in further, new trials.

Incidence of Crohn’s disease and CARD15 mutation in a small township in Sicily

Background: The incidence of Crohn’s disease (CD) has been shown to be lower in Southern than in Northern Europe. Data on the frequency of the NOD2/CARD15 mutations for Mediterranean area are very scant.Aim: To determine the incidence of CD from 1979 to 2002 in a township in Sicily together with the allele frequency of NOD2/CARD15 mutations in patients, family members and controls, and to determine the allele frequency of these mutations in sporadic CD from other areas of Sicily in comparison with a control population.Methods: Casteltermini is a small town close to Agrigento (Sicily) with a population of 9,130 inhabitants. All the diagnoses of inflammatory bowel disease (IBD) made from 1979 to 2002 were obtained through the local health authority. NOD2/CARD15 mutations were studied in 23 out of the 29 patients with CD in Casteltermini, in 60 family members and in 64 controls. NOD2/CARD15 was also studied in 80 sporadic cases of CD disease among Sicilians outside Casteltermini and 118 healthy controls.Results: From 1979 to 2002, 29 patients with CD and 13 patients with ulcerative colitis (UC) were registered. The 6-year mean incidence of CD ranged from 8.0 to 17 new cases for every 100,000 inhabitants, whereas the mean incidence of UC ranged from five new cases to 7.8 for every 100,000 inhabitants. The allele frequencies of NOD2/CARD15 mutations (L1007finsC, G908R, R702W) were 8.7, 4.3 and 8.7%, respectively, in CD cases; 5.0, 4.2 and 3.1% in family members; 1.6, 2.3 and 3.1% in controls. In sporadic Sicilian CD patients outside Casteltermini the allele frequency was 7.5, 8.1, 6.2% whereas in control population it was 3.3, 1.6, 1.6%.Conclusions: A high incidence of CD compared with UC was observed in this small town in Southern Italy. The frequency of NOD2/CARD15 mutations in CD is similar to other Caucasian population studied so far.

Beclomethasone dipropionate in Crohn's ileitis: a randomised, double-blind trial.

BACKGROUND Steroids, the mainstay of Crohns disease treatment, have been associated with systemic side effects. AIM To evaluate the efficacy and tolerability of beclomethasone dipropionate for maintaining remission induced by a short course of systemic steroids in patients with Crohns ileitis with or without right colonic involvement. METHODS Patients (n=84) with active Crohns disease who achieved remission during a 2-week prednisone run-in period were randomised to receive beclomethasone dipropionate for 24 weeks or continue prednisone for a further 2 weeks followed by placebo for 22 weeks. The primary outcome was relapse rate (Crohns Disease Activity Index score>150 and an increase of ≥60 points from baseline) or withdrawal due to disease deterioration. RESULTS The relapse rate was 23.3% and 53.8% in beclomethasone dipropionate and placebo groups, respectively (p=0.027). According to Kaplan-Meier analysis, the cumulative relapse rate was 38.0% in the beclomethasone dipropionate group and 56.0% in the placebo group (p=0.025). Six percent and 1.7% of all adverse events in the beclomethasone dipropionate and placebo groups, respectively, were endocrine-related. CONCLUSION These results demonstrate that beclomethasone dipropionate significantly reduces the relapse rate in post-active Crohns ileitis patients compared with placebo after induction of remission with a short course of systemic steroids, and is well tolerated.

P.05.9 RISK ANALYSIS OF PNEUMONIA IN TWO DIFFERENT COHORTS OF PATIENTS WITH INFLAMMATORY BOWEL DISEASES

dipropionate in inducing remission and improving quality of life in patients with chronic refractory pouchitis. Material and methods: Ten consecutive patients with active pouchitis, not responding after 1 month of antibiotic treatment were treated with beclomethasone dipropionate 10 mg/day for 8 weeks. Symptomatic, endoscopic and histological evaluations were undertaken before and after treatment according to Pouchitis Disease Activity Index. Remission was defined as a combination of Pouchitis Disease Activity Index clinical score of =2, endoscopic score of =1 and total Pouchitis Disease Activity Index score of =4. Results: Eigth of 10 patients (80%) achieved remission. The median total Pouchitis Disease Activity Index scores before and after therapy were, respectively, 12 (range 8–14) and 3 (range 2–9) (P<0.001). Conclusions: Eight-week treatment with oral beclometasone dipropionate appears effective in inducing remission in patients with active pouchitis refractory to antibiotic treatment in this open-label study.

7 P Familial occurrence of inflammatory bowel disease in celiac disease

BackgroundThe authors have previously reported a possible increased risk of the familial occurrence of Crohns disease in patients with celiac disease. AimThe aim of the current study was to evaluate in a case–control study the familial occurrence of inflammatory bowel disease (IBD) in first-degree relatives of patients with celiac disease. MethodsOne hundred eleven consecutive patients with biopsy-proven celiac disease were interviewed to ascertain whether IBD was present in first-degree relatives. The number of relatives, their ages, and possible IBD status were collected in a questionnaire. When a diagnosis of familial IBD was reported, the diagnosis was checked in the hospital records. Two hundred twenty-two controls matched for age and sex (111 from the general population and 111 from orthopedic wards) were also interviewed regarding the possible occurrence of IBD in first-degree relatives. The &khgr;2 test was used to evaluate the difference in proportion of familial occurrence of IBD among individuals with celiac disease and controls. ResultsAmong 600 first-degree relatives of patients with celiac disease, 10 cases of IBD were identified among first-degree relatives (7 cases of ulcerative colitis and 3 cases of Crohns disease), whereas only 1 case of IBD was identified among the 1,196 first-degree relatives of control patients (p < 0.01). When ulcerative colitis and Crohns disease were analyzed separately, only the prevalence of ulcerative colitis was statistically significant (p ≤ 0.02). ConclusionsThis case–control study shows that there is a significantly increased prevalence of familial ulcerative colitis in patients with celiac disease. There was no significant increase in the prevalence of Crohns disease in patients with celiac disease. The possible role of this association is discussed.