A. Pera

Development and validation of a new, simplified endoscopic activity score for Crohn's disease: the SES-CD.

BACKGROUNDnHealing of mucosal lesions appears to offer significant benefit and is an important end point in clinical trials of treatment for Crohns disease. The only validated endoscopic activity score at present is the Crohns Disease Endoscopic Index of Severity, which is complicated and time consuming and, hence, is unsuitable for routine use. The aim of this study was to develop and to prospectively validate a simpler endoscopic score of disease activity, the Simple Endoscopic Score for Crohns Disease.nnnMETHODSnSelected endoscopic parameters (ulcer size, ulcerated and affected surfaces, stenosis) were scored from 0 to 3. Reproducibility for scoring of these parameters was evaluated through 71 examinations in which the endoscopist was paired with an observer. The simplest score (Simple Endoscopic Score for Crohns Disease) that was highly correlated with both the Crohns Disease Endoscopic Index of Severity and Crohns Disease Activity Index was derived for 70 patients and then was prospectively validated in 121 different patients with Crohns disease.nnnRESULTSnThe interobserver agreement for all selected endoscopic variables was excellent (kappa coefficient 0.791-1.000). Based on multiple linear regression, the Simple Endoscopic Score for Crohns Disease resulted in the sum of the scores for ulcer size, ulcerated surface, affected surface, and luminal narrowing. In the validation phase of the study, a strong correlation was demonstrated for the Simple Endoscopic Score for Crohns Disease with Crohns Disease Endoscopic Index of Severity (r = 0.920). In addition, the Simple Endoscopic Score for Crohns Disease was correlated to clinical parameters and serum C-reactive protein level.nnnCONCLUSIONSnSimple Endoscopic Score for Crohns Disease is a simple, reproducible, and easy-to-use endoscopic scoring system for Crohns disease.

Crohn's disease: monitoring disease activity

A global measurement of Crohns disease activity, comprising clinical, endoscopic, biochemical and pathological features is not available yet and perhaps is unobtainable. In this review we analyse the most used and validated clinical indices (Crohns Disease Activity Index [CDAI], Perianal Disease Activity Index [PDAI], fistula drainage assessment), quality of life scores (Inflammatory Bowel Disease Questionnaire [IBDQ]), sub‐clinical markers (C‐reactive protein, faecal calprotectin, intestinal permeability) and endoscopic indices (Crohns Disease Endoscopic Index of Severity [CDEIS]/Simple Endoscopic Score for Crohns Disease [SES‐CD], Rutgeeerts score for postsurgical recurrence). We also review the main advantages and disadvantages of each of these scoring systems. All these indices are rather complex and time‐consuming, therefore their use is limited to clinical trials. In everyday clinical practice most gastroenterologists rely on their global clinical judgement, which is less reproducible, but simpler for decision‐making.

Effectiveness of Helicobacter pylori eradication treatments in a primary care setting in Italy

To evaluate the choice and relative effectiveness of Helicobacter pylori eradication regimens in a primary care setting.

Alcohol abstinence does not offset the strong negative effect of lifetime alcohol consumption on the outcome of interferon therapy

summary.u2002Heavy alcohol consumption has been reported to negatively affect the outcome of interferon therapy. We studied the impact of lifetime alcohol consumption in patients with chronic hepatitis C treated with interferon after 6u2003months of alcohol withdrawal. Alcohol intake was measured when patients with chronic hepatitis C were referred to us for the first time, and from that moment complete abstinence was recommended. After 6u2003months of abstinence, 150 patients with persistent elevated serum alanine aminotransferase (ALT) have been treated with interferon (IFN)‐α, 3 or 6u2003summaryU three times per week for 12u2003months. Univariate and multivariate analysis were performed to identify the predictors of treatment response. Carbohydrate‐deficient transferrin was employed to assess alcoholic abstinence. The sustained response rate felt from 33% in nondrinkers to 20% of mild‐drinkers and to only 9% in heavy drinkers. Drinker patients showed a relapse rate twice as high as that of nondrinkers. According to the multivariate analysis, the strongest independent predictors of nonresponse were genotype 1b infection, age of the patients and their lifetime alcohol intake. Carbohydrate‐deficient transferrin detected at baseline, at 3 months of therapy and at the end of follow‐up gave a positive result only in eight determinations (1.77%), confirming the compliance of patients to our recommendation of alcohol abstinence. Lifetime alcohol consumption has a strong negative effect on the outcome of interferon treatment, mainly in heavy drinkers. A 6‐month period of abstinence may not be sufficient to offset this negative effect on treatment outcome.

The ASGE guidelines for the appropriate use of upper gastrointestinal endoscopy in an open access system.

AIMSnThis multicenter and prospective study was aimed at examining the appropriate use of upper gastrointestinal endoscopy in an open access system (primary endoscopy) using the American Society for Gastrointestinal Endoscopy (ASGE) guidelines. We also wished to see whether these guidelines can be easily used in clinical practice.nnnMATERIALS AND METHODSnThree thousand four hundred fourteen upper gastrointestinal endoscopies performed in seven endoscopy units of different size were studied prospectively. The real indication, to be with the guidelines, was determined by the endoscopist before performing the examination, based on a patients history.nnnRESULTSnSeven hundred eighty-one (23%) endoscopies were generally not indicated, according to ASGE guidelines, and were distributed as follows: follow-up of duodenal ulcer healing (33%), follow-up of other healed benign diseases (24%), surveillance of gastric atrophy, pernicious anemia, metaplasia, treated achalasia, and prior gastric intervention (14%), diagnosis of dyspepsia considered functional in origin (13%), and uncomplicated heartburn responding to medical therapy (7%). Endoscopies generally not indicated accounted for 23% in the bigger endoscopy units, 24% in the average sized units, and 22% in the smaller ones. They accounted for 32% when the examination was prescribed by family doctors, 17% when prescribed by internists, 19% by surgeons, and 14% by gastroenterologists (p < 0.001). Eighty-six (2.5%) endoscopies were done for indications not provided in the guidelines.nnnCONCLUSIONSnThis study shows that ASGE guidelines are complete and easy to use and that the rate of inappropriate indications in an open access system can be considerable. They occurred mainly in the follow-up of healed benign disease and were more frequent when the examination was prescribed by the family doctor.

Analysis of the CARD15 variants R702W, G908R and L1007fs in Italian IBD patients

CARD15 on chromosome 16 is the only IBD susceptibility gene identified among several mapped loci. Its recurrent variants R702W, G908R and L1007fs have shown significant association with Crohns disease (CD), but not with ulcerative colitis (UC), in different Caucasian populations. We analysed these three variants in 184 CD and 92 UC Italian patients and in 177 healthy controls. L1007fs and G908R were independently associated with CD, while R702W showed a nonsignificant increase. After combining the three variants together, 32.6% of CD patients were positive vs 18.6% of the controls. The association was stronger for homozygotes and compound heterozygotes, OR 13.9 (1.8–108), and weaker but still significant for simple heterozygotes, OR 1.7 (1.0–2.9). An excess of homozygotes/compound heterozygotes also resulted from the comparison with Hardy–Weinberg expectations. Phenotype–genotype correlations were analysed first by univariate logistic regression and then by multivariate analysis, the effect of CARD15 positivity being adjusted according to the status of smoking, familiarity and sex, so as to focus on the predictivity of genetic and environmental risk factors on the clinical phenotype. Significant risk estimates of the CARD15 genotype were obtained for stricturing vs inflammatory behaviour, OR 2.76 (1.2–6.3), and for penetrating behaviour, 2.59 (1.0–6.6), and marginally significant for ileal vs colic location, OR 3.0 (0.9–9.8). Our findings indicate that the association of the CARD15 genotype with behaviour and location of disease holds also for the Italian population.

Medical treatment of severe ulcerative colitis

Approximately 15% of patients with ulcerative colitis have a severe attack requiring hospitalization at some time during their illness. This treatment leads to a remission in 60–80% of patients and non‐responders may require a total colectomy. Mortality in severe episodes of ulcerative colitis decreased from 31–61% in the 1950s to 5–9% in the 1960s thanks to the introduction of steroids and to a policy of early colectomy. Recently, some new drugs have been shown to be effective in the treatment of severe steroid‐refractory ulcerative colitis. This review concentrates on the clinical evaluation, prognostic factors and new developments in medical therapy in severe ulcerative colitis. A retrospective evaluation of a consecutive series of patients with severe ulcerative colitis admitted to a Gastroenterology Department in Torino, Italy, is also reported.

Discrepancy between Helicobacter pylori stool antigen assay and urea breath test in the detection of Helicobacter pylori infection

BACKGROUNDnThe reference diagnostic methods available for detection of Helicobacter pylori infection are either invasive (histology) or expensive and highly sophisticated (Urea Breath Test). A new enzyme immunoassay, which can be easily performed in any laboratory, has been developed to detect Helicobacter pylori in stool specimens (HpSA-Meridian Diagnostics, Cincinnati, USA). Aim of the study was to compare HpSA to Urea Breath Test.nnnPATIENTS AND METHODSnA total of 125 patients (52 never treated for Helicobacter pylori infection and 73 after Helicobacter pylori eradication therapy) referring to our Department, underwent both tests within two weeks.nnnRESULTSnContrasting results between the two tests were found in 30% of cases: in 19% of the untreated patients and in 37% of the treated patients (p<0.001). The main discrepancy consisted in positive HpSA associated with negative Urea Breath Test. Mean HpSA value in such conditions was 0.273 optical density, while in patients with both positive tests, it was 1.192 optical density. In untreated, but not in treated patients, raising the HpSA cut off value significantly decreased the percentage of conflicting results.nnnCONCLUSIONSnSome disagreement was detected between HpSA and Urea Breath Test results, especially in treated patients. Possible explanations for our findings are a low HpSA cut off value together with the identification of Helicobacter pylori coccoid forms by the immunoassay but not by the urease based Urea Breath Test. The higher percentage of discrepancy detected in treated patients might support this hypothesis.

Detection of anti-Saccharomyces cerevisiae antibodies in Crohn's disease: is it reliable diagnostic and prognostic marker?

BACKGROUNDnIn the past few years, serologic markers have been proposed in inflammatory bowel disease. Anti-Saccharomyces cerevisiae antibodies showed high specificity for Crohns disease. A prognostic role for serology has also been hypothesised.nnnAIMSnTo evaluate anti-Saccharomyces cerevisiae antibody distribution in an unselected Italian inflammatory bowel disease population. To analyse whether anti-Saccharomyces cerevisiae antibody status (positive/negative) and/or anti-Saccharomyces cerevisiae antibody titres are associated with clinical variables and outcome measures in Crohns disease patients.nnnPATIENTS AND METHODSnA series of 299 inflammatory bowel disease patients were evaluated; serum samples were taken and a short clinical history was recorded. anti-Saccharomyces cerevisiae antibodies IgG enzyme-linked immunosorbent assay Medilab (Milan, Italy) kit was used in order to determine anti-Saccharomyces cerevisiae antibody status.nnnRESULTSnSensitivity, specificity and likelihood ratio for positive test in the differential diagnosis of inflammatory bowel disease was 59%, 89%, 8.1, respectively. Clinical variables significantly associated with anti-Saccharomyces cerevisiae antibody status in logistic regression were found to be ileal location (p=0.01) and earlier age at diagnosis (p<0.01). Among ileal Crohns disease patients, there was a trend in concordance between anti-Saccharomyces cerevisiae antibody titres and higher number of surgical procedures which was not statistically significant applying more complex statistics.nnnCONCLUSIONSnIn an Italian inflammatory bowel disease population, anti-Saccharomyces cerevisiae antibodies status showed characteristics similar to those previously reported. Anti-Saccharomyces cerevisiae antibody positivity is associated with ileal involvement and with earlier onset of Crohns disease.

IgM antibody against measles virus in patients with inflammatory bowel disease: a marker of virus-related disease?

Objective: Viral infections of the mesenteric microvascular endothelium have been hypothesized as pathogenetic factors in inflammatory bowel diseases. The aim of this study was to determine whether immunoglobulin M (IgM) antibody against measles virus is associated with disease. Patients and methods: The IgM antibody was detected by indirect antibody test in 36 patients with evidence of Crohns disease (23 males and 13 females, median age 40 years, range 20‐66), 22 patients with ulcerative colitis (14 males and 8 females, median age 42 years, range 19‐65), 59 patients with a chronic active hepatitis (35 males and 24 females, median age 56 years, range 38‐77) and 30 blood donors (20 males and 10 females, median age 45 years, range 29‐62). Results: Twenty‐eight of 36 patients (78%) with Crohns disease and 13 of 22 patients (59%) with ulcerative colitis tested positive as compared to only 3 of 89 (3.3%) controls (P≤0.001). Conclusion: The detection of IgM anti‐measles virus in the majority of patients with Crohns disease and in about half of ulcerative colitis patients as compared to a very low prevalence in patients with other chronic inflammatory disease is consistent with the hypothesis that the measles virus has pathogenetic implications in inflammatory bowel diseases.