Andrea Cocco

European evidence based consensus on the diagnosis and management of Crohn’s disease: special situations

This third section of the European Crohn’s and Colitis Organisation (ECCO) Consensus on the management of Crohn’s disease concerns postoperative recurrence, fistulating disease, paediatrics, pregnancy, psychosomatics, extraintestinal manifestations, and alternative therapy. The first section on definitions and diagnosis reports on the aims and methods of the consensus, as well as sections on diagnosis, pathology, and classification of Crohn’s disease. The second section on current management addresses treatment of active disease, maintenance of medically induced remission, and surgery of Crohn’s disease.

GI distension in severe ulcerative colitis.

OBJECTIVES:In previous retrospective studies in patients with severe ulcerative colitis (UC), small bowel distension was found to characterize a subgroup of patients at higher risk for both toxic megacolon (TMC) and multiple organ dysfunction syndrome (MODS). In this study we prospectively evaluated the prevalence of GI distension and its relationship to clinical outcome in patients with severe UC.METHODS:Of 109 consecutive inpatients with acute UC (admitted to the GI Unit of the University of Rome during the period 1995–2000), 45 had severe colitis. Routine blood tests and acid-base balance and plain abdominal film evaluations were performed upon admission and repeated every 1–3 days. The gas content of the stomach and small and large intestines was evaluated on plain abdominal films. All patients were submitted to the standard Oxford intensive medical regimen; clinical improvement, occurrence of major complications, need for surgery, and mortality were evaluated. Statistical analysis was carried out using Students t, χ2, Fishers exact, Mann-Whitney, and Wilcoxon rank sum tests, when appropriate.RESULTS:Of 45 patients with severe UC, 24 (53%) had GI distension. Three of these 24 patients had TMC on admission (all underwent surgery and survived), 21 showed increased GI gas content (four developed TMC 1–4 days after the detection of GI distension and were operated on, two developed MODS and died, and eight did not improve but were submitted to surgery and survived). None of the 21 patients with normal GI gas content had complications; all survived (five did not improve and required surgery).CONCLUSIONS:In severe UC, persistent GI distension characterized a subgroup of patients with poor response to medical therapy and at higher risk for TMC and of need for surgery. The development of MODS was the most important predicting factor for fatal outcome.

Clinical course of Crohn’s disease first diagnosed at surgery for acute abdomen

BACKGROUND The severity of clinical activity of Crohns disease is high during the first year after diagnosis and decreases thereafter. Approximately 50% of patients require steroids and immunosuppressants and 75% need surgery during their lifetime. The clinical course of patients with Crohns disease first diagnosed at surgery has never been investigated. AIM To assess the clinical course of Crohns disease first diagnosed at surgery for acute abdomen and to evaluate the need for medical and surgical treatment in this subset of patients. PATIENTS AND METHODS Hospital clinical records of 490 consecutive Crohns disease patients were reviewed. Patients were classified according to the Vienna criteria. Sex, extraintestinal manifestations, family history of inflammatory bowel diseases, appendectomy, smoking habit and medical/surgical treatments performed during the follow-up period were assessed. STATISTICAL ANALYSIS Kaplan-Meier survival method and Cox proportional hazards regression model. RESULTS Of the 490 Crohns disease patients, 115 had diagnosis of Crohns disease at surgery for acute abdomen (Group A) and 375 by conventional clinical, radiological, endoscopic and histologic criteria (Group B). Patients in Group A showed a low risk of further surgery (Log Rank test p<0.001) and a longer time interval between diagnosis and first operation compared to Group B (10.8 years vs. 5.8 years, p<0.01, respectively). Furthermore, patients in Group A used less steroids and immunosuppressants (OR 0.3, p<0.0001; OR 0.6, p<0.004, respectively). CONCLUSIONS Crohns disease patients first diagnosed at surgery for acute abdomen showed a low risk for reintervention and less use of steroids and immunosuppressants during follow-up than those not operated upon at diagnosis. Early surgery may represent a valid approach in the initial management of patients with Crohns disease, at least in the subset of patients with ileal and complicated disease.

Monthly and Seasonal Birth Patterns and the Occurrence of Crohn's Disease

The American Journal of GASTROENTEROLOGY VOLUME 104 | JUNE 2009 www.amjgastro.com oral use of FPS as a bowel preparation agent for endoscopy, surgery, and radiologic procedures (3 – 5) . It is mentioned that even in patients with normal serum creatinine levels, signi3 cant changes in serum electrolytes can occur (6) . Under normal conditions, 60 – 65 % of dietary phosphorus is absorbed from the intestinal lumen; therea er, it is transferred intracellularly or excreted in the urine. In elderly patients, especially, electrolyte disorders occur more o en and are severe because of inadequate renal potassium conservation, a more sedentary lifestyle, altered gut motility, and the use of some medications, such as diuretics (7) . However, in our case, none of these problems were present. Moreover, serum electrolyte values of our patient were proved to be within normal limits before the administration of oral FPS. 0 erefore, the hypocalcemia in our patient cannot be attributed to her malabsorption syndrome. To the best of our knowledge, this paper is the 3 rst presentation of symptomatic hypocalcemia secondary to the oral administration of FPS in a patient with celiac disease.

A randomized trial comparing 4.8 vs. 2.4 g/day of oral mesalazine for maintenance of remission in ulcerative colitis

BACKGROUND Mesalazine is used as maintenance therapy in ulcerative colitis but the optimal dosage is still controversial. AIM To compare the remission-maintenance efficacy and tolerability of two daily doses of oral mesalazine (4.8 g and 2.4 g) in patients with ulcerative colitis with frequent relapses in a randomized controlled trial. METHODS 112 ulcerative colitis patients in remission were enrolled and randomly allocated to treatment for 1 year with oral mesalazine at a daily dose of 4.8 g (n=56, Group A) or 2.4 g (n=56, Group B). RESULTS At the end of the 12 months, intention to treat analysis revealed persistent remission in 42 (75%) in Group A and 36 (64.2%) in Group B (p=0.3). The higher daily dose (4.8 g) proved to be significantly more effective for maintaining remission in patients under 40 years of age (90.5% Group A vs. 50% Group B; Fishers exact test, p=0.0095) and in those with extensive disease (90.9% Group A vs. 46.7% Group B; Fishers exact test, p=0.0064). CONCLUSIONS In ulcerative colitis patients younger than 40 years and/or with extensive disease, a daily dose of 4.8 g oral mesalazine results in increased rates and duration of remission compared to 2.4 g.

Morphologically and immunohistochemically undifferentiated gastric neoplasia in a patient with multiple metastatic malignant melanomas: a case report.

IntroductionMalignant melanoma is a neoplasia which frequently involves the gastrointestinal tract (GIT). GIT metastases are difficult to diagnose because they often recur many years after treatment of the primary cutaneous lesion and also manifest clinically at an advanced stage of the neoplasia. Furthermore, GIT metastases can appear in various morphological forms, and therefore immunohistochemistry is often useful in distinguishing between a malignant melanoma and other malignancies.Case presentationWe report the case of a 60-year-old man with a multiple metastatic melanoma who underwent an upper endoscopy to clarify the possible involvement of the gastric wall with a mass localized in the upper abdomen involving the pancreas and various lymph nodes, which was previously described with computed tomography. Clinically, the patient reported a progressive loss of appetite, nausea and vomiting. The upper endoscopy and histological examination revealed a gastric location of an undifferentiated neoplasm with an absence of immunohistochemical characteristics referable to the skin malignant melanoma that was removed previously.ConclusionThe present case report shows the difficulty in diagnosing a metastatic melanoma in the GIT and therefore, it seems worthwhile to consider metastatic malignant melanoma in the differential diagnosis of undifferentiated neoplasia.

P.06.15 SAFETY OF ANTI-TNFA THERAPY IN IBD: AN ITALIAN EXPERIENCE

Material and methods: All pts receiving biologics were included in the study. Cause and length of delay/anticipation respect to scheduled administration were considered. Adherence to ADA was assessed using patient diaries. The mean duration of biological therapy was 16.5 months (1-61). Pts: 136, 60M/76F, 110CD/26UC, mean age at diagnosis 32.4 (20-73) and at 1st administration 40.5 (16-78). IFX was administered to 93/136 pts (68.4%) and ADA to 43/136 (31.6%). Indications to biologicals were: steroiddependence/resistance in 91/136 (66.9%), fistulae in 35/136 (25.8%), AZA failure in 6/136 (4.4%) others in 4/136 (2.9%). The overall number of administrations was 1763 (mean 12.9/pt, range1-73). Results: A total of 187/1763 administrations (10.6%) in 45 pts (33%) was delayed [29 IFX (32.6%), 16 ADA (43.2%) (p=0.3)]. The mean number of delayed administrations was 2.2 and the delay 13.7 days (1-35). Forgetfulness, summer holidays, pharmaceutical supply and intentional non adherence were responsible for 294 days delay (28 pts). Adverse events were responsible for 198 days delay (18 pts). A total of 82/1763 administrations (4.65%) were anticipated in 14 pts, (13 on IFX -92.8%and 1 on ADA -7.2%p<0.01), with a mean of 2.05 events/pt and an anticipation vs scheduled timing of 7.8 days (1-28). The reason for anticipation was related to practical issues in 19 (23.2%), occurrence of articular pain in 1 (1.2%) and lost response/active disease in 62 (75.6%) administrations. A clinical need and not a lack of adherence justify anticipation in these last 62 patients. Conclusions: About 30% of patients failed to adhere strictly to scheduled treatment with biologics, in 10.6% of administrations. Possible consequences of reduced compliance remain to be assessed. Interestingly, in this study lack of adherence has been found also with agents which do not require daily and/or multiple administrations. No difference has been found between IFX and ADA in terms of decreased adherence.