Antonio Magnano

The role of capsule endoscopy in the work-up of obscure gastrointestinal bleeding.

Objective To evaluate the role of capsule endoscopy in the detection of causes of obscure gastrointestinal bleeding. Methods Fifteen patients, nine males and six females, mean age 46 years (range 20–75 years), were investigated. All patients had undergone upper and lower gastrointestinal endoscopy with no evidence of causes of bleeding. Indication for capsule endoscopy was overt bleeding in 10 patients (eight with melaena and two with rectal bleeding) and anaemia in five patients. Results Diagnosis was made in four out of 10 patients with overt bleeding (40%) and in four out of five (80%) in the group with anaemia. The overall detection rate was 53%. Of the eight patients with melaena, two had angiodysplasia, one showed a diffuse inflammation of the jejunum and ileum probably related to associated portal hypertension, and five had a normal examination. Of the two patients with rectal bleeding, one had a polyp in the terminal ileum and the other a normal examination. Of the five patients with anaemia, one had jejunal carcinoma, three had Crohns disease and one had a normal endoscopy. Conclusion Wireless capsule endoscopy is safe, effective, non-invasive, and provides definitive diagnosis in about one-half of patients presenting with obscure gastrointestinal bleeding and previous negative endoscopic examinations.

Endoscopic Esophageal Sclerotherapy: Long-Term Results of the Elective Procedure

Chronic endoscopic esophageal sclerotherapy represents a primary technique for the prevention of recurrent bleeding in cirrhotic patients who have already experienced one variceal bleeding episode. 131 patients with portal hypertension and a history of esophageal variceal bleeding underwent endoscopic sclerotherapy. 74 of these patients constituted a subgroup which was singled out for special analysis. In these patients, treatment had been started after conservative management of an acute bleeding episode had stopped the bleeding and follow-up data for at least 6 months were available. 90.5% of these patients had nonalcoholic etiology for their portal hypertension. 60.8% of patients developed recurrent varices and 11.1% had recurrent bleeding from esophageal varices. The bleeding risk index, calculated as the number of hemorrhages/patient/months of follow-up, correlated strongly with the number of previous hemorrhages and inversely with hepatic reserve (Childs class). The bleeding risk index decreased tenfold after sclerotherapeutic obliteration of varices. These data suggest that chronic elective endoscopic sclerotherapy may play a primary role in the management of patients who have bled from esophageal varices.

Early and late complications of endoscopic oesophageal varices sclerotherapy

SummaryWe report the complications of perendoscopic sclerotherapy observed during treatment of oesophageal varices in 104 patients and 409 sclerotherapy sessions. Complications were related to each individual session and to the aim of the treatment (therapeutic or prophylactic). Major complications occurred in 17.3% of the patients treated: 13 cases of severe bleeding and 5 of oesophageal stricture. Conservative therapy stopped haemorrhage in all but 4 patients, who died of uncontrolled bleeding (3.8%). Three oesophageal strictures recovered spontaneously, while the remaining two required endoscopic dilations. Minor complications occurred after 102/409 sessions (24.9%). Epigastric and/or retrosternal pain developed after 17.6% of the sessions, oesophageal ulcerations after 12.5%, fever after 11.7% and transient dysphagia after 3.7%. Bleeding was observed only in Childs category C patients who underwent therapeutic treatment. The risk of bleeding remained unchanged until complete eradication of varices was achieved. The incidence of minor complications did not correlate with the progression or the aim of the treatment.

Complications de la polypectomie endoscopique gastrique et duodénale expérience italienne

RÉsumÉĽexérèse endoscopique des polypes gastriques et duodénaux a été reconnue comme une alternative valable par rapport au traitement chirurgical.Les auteurs rapportent les résultats ďune enquête italienne concernant les complications de la polypectomie endoscopique gastroduodénale.Le nombre total de polypectomies effectuées est de 2 547 : 89,5 % ďentre elles concernent les polypes gastriques et 10,5 % des polypes duodénaux.Le taux total de morbidité est de 3,5 % (88/2 547), alors que la mortalité est nulle.Ľhémorragie est la complication la plus commune et a été présente chez 86/88 cas (97,8 %). Le traitement a été conservateur, médical ou endoscopique, dans 87,2 % des cas.La perforation n’est survenue que dans 1 cas sur 88 (1,1 %) : un traitement conservateur s’est révélé efficace.Actuellement la chirurgie n’est nécessaire que si la taille ou la morphologie des polypes contre-indique la résection endoscopique.SummaryGastric and duodenal endoscopic polypectomy has been recognized as a valid alternative to the surgical treatment.The A A. reports the results of an italian survey concerning the complications of gastric and duodenal endoscopic polypectomy.Total number of polypectomies carried out was 2 547 : 89.5 % of them for gastric polyps, and 10.5 % for duodenal polyps.Total morbidity was 3.5 % (88/2 547), whereas mortality was nil.Bleeding was the most common complication and was present in 86/88 cases (97.8 %). The treatment was conservative, medical or endoscopic, in 87.2 % of the cases.Perforation occurred only in 1 out of 88 cases (1.1 %) : a conservative therapy was successful.Today surgery is only required when the size and morphology of the polyps prevent endoscopic resection.

LncRNA UCA1, Upregulated in CRC Biopsies and Downregulated in Serum Exosomes, Controls mRNA Expression by RNA-RNA Interactions

Long non-coding RNAs (lncRNAs) and circular RNAs (circRNAs) contribute to the onset of many neoplasias through RNA-RNA competitive interactions; in addition, they could be secreted by cancer cells into biological fluids, suggesting their potential diagnostic application. By analyzing the expression of 17 lncRNAs and 31 circRNAs in biopsies and serum exosomes from colorectal cancer (CRC) patients through qRT-PCR, we detected CCAT1, CCAT2, HOTAIR, and UCA1 upregulation and CDR1AS, MALAT1, and TUG1 downregulation in biopsies. In serum exosomes, UCA1 was downregulated, while circHIPK3 and TUG1 were upregulated. Combined receiver operating characteristic (ROC) curves of TUG1:UCA1 and circHIPK3:UCA1 showed high values of sensitivity and specificity. Through in vitro (i.e., RNA silencing and mitogen-activated protein kinase [MAPK] inhibition) and in silico analyses (i.e., expression correlation and RNA-RNA-binding prediction), we found that UCA1 could (1) be controlled by MAPKs through CEBPB; (2) sequester miR-135a, miR-143, miR-214, and miR-1271, protecting ANLN, BIRC5, IPO7, KIF2A, and KIF23 from microRNA (miRNA)-induced degradation; and (3) interact with mRNA 3′-UTRs, preventing miRNA binding. UCA1 and its co-regulated antisense LINC01764 could interact and reciprocally mask their own miRNA-binding sites. Functional enrichment analysis of the RNA-RNA network controlled by UCA1 suggested its potential involvement in cellular migration. The UCA1 regulatory axis would represent a promising target to develop innovative RNA-based therapeutics against CRC.

A propensity score-matched comparison of infliximab and adalimumab in TNF-α inhibitors naïve and non-naïve patients with Crohn’s disease: real-life data from the Sicilian Network for Inflammatory Bowel Disease (SN-IBD)

Background and Aims There is an unmet need to better understand the effectiveness of different biologics in inflammatory bowel diseases. We aimed at performing a multicentre, real-life comparison of the effectiveness of infliximab [IFX] and adalimumab [ADA] in Crohns disease [CD]. Methods Data of consecutive patients with CD treated with IFX and ADA from January 2013 to May 2017 were extracted from the cohort of the Sicilian Network for Inflammatory Bowel Disease. We used propensity score-matching accounting for the main baseline characteristics in TNF-α inhibitor-naïve and non-naïve patients. Results A total of 632 patients [735 total treatments] were included. Among naïve patients, a clinical benefit [the sum of steroid-free remission plus clinical response] was achieved in 81.8% patients treated with ADA and in 77.6% patients treated with IFX (adjusted odds ratio [OR]: 1.23, 95% CI 0.63-2-44, p = 0.547] at 12 weeks; after 1 year, a clinical benefit was achieved in 69.2% of patients treated with ADA and in 64.5% patients treated with IFX [adjusted OR: 1.10, 95% CI 0.61-1.96, p = 0.766]. Among non-naïve patients, a clinical benefit was achieved in 61.7% of patients treated with ADA and in 68.1% of patients treated with IFX [adjusted OR: 0.72, 95% CI 0.21-2.44, p = 0.600] at 12 weeks; after 1 year, a clinical benefit was achieved in 48.9% of patients treated with ADA and in 40.4% patients treated with IFX [adjusted OR: 1.23, 95% CI 0.54-2.86, p = 0.620]. Conclusions In this propensity score-matched comparison of ADA and IFX in CD, both drugs showed high rates of clinical benefit, without significant differences between them.

A real life comparison of the effectiveness of adalimumab and golimumab in moderate-to-severe ulcerative colitis, supported by propensity score analysis

BACKGROUND Adalimumab and golimumab are effective in the treatment of moderate to severe ulcerative colitis. AIMS We reported the comparative effectiveness of adalimumab and golimumab in ulcerative colitis. METHODS 118 patients treated with adalimumab and 79 treated with golimumab were included and evaluated at 8 weeks and at the end of follow up. RESULTS Overall clinical benefit was 72.6% at 8 weeks and 58.9% at the end of follow up. Patients with longer disease duration and those treated with adalimumab had a better outcome. Clinical benefit was 78.8% in adalimumab patients and 63.3% in golimumab patients (p = 0.026) after 8 weeks; it was 66.9% in adalimumab patients and 46.8% in golimumab patients (p = 0.008) at the end of follow up. These data were confirmed by propensity score analysis. A further analysis considering adalimumab optimization as treatment failure showed that the difference between adalimumab and golimumab was not significant. CONCLUSION Adalimumab and golimumab are effective in the treatment of ulcerative colitis. Adalimumab seems to be more effective than golimumab. This difference is probably affected by the impossibility of golimumab to be optimized in Italy while adalimumab is.

The role of endoscopy in the diagnosis of infectious colitis

The clinical onset of idiopathic inflammatory bowel diseases (IBD) and acute infectious colitis (AIC) is characterized by bloody mucoid diarrhea (1 ) . It is crucial to differentiate between the first and second types of colitis because only an early and correct ethiologic diagnosis allow us to perform a specific medical treatment« The differentiation between the two groups of colitis must be supported by: clinical pictures, stool cultures, endoscopic and hystological findings, §?ool Cu?ture remains the most important diagnostic tool in defining the specific cause of infectious diarrhea (2).However, diagnostically, it has two main limitations: in appropriately equipped laboratories an ethiologic diagnosis can be established for only 42-60% of patients seeking treatment (2,3,4); occasional patients with well defined chronic ulcerative colitis (CUC) have potential pathogens in their stools (3). EOaQscgpic differentj,atign between specific and nonspecific inflammatory bowel diseases may be difficult because the intestinal lining can respond in a limited number of ways to any process that disrupts its integrity (5). Any inflammatory condition that affects the colon may alter the smoothness of the surface lining, may change its colour or may affect the delicate branching vascular pattern; any or all of which may be observed endoscopically. In addition there may be bleeding or ulceration of the mucosa as well as pus or purulent exudate on the surface, or any combination of these (5). Moreover some infections of the colon are primarily mucosal inflammatory processes and thereby produce an endoscopic picture

Le rôle de l’endoscopie dans le diagnostic et la surveillance de I’ulcère duodénal

RésuméLes auteurs évaluent la contribution de l’endoscopie au diagnostic et à la surveillance de l’ulcère duodénal. Trois aspects sont examinés en détail:— la place de la première endoscopic chez les patients dont les symptômes sont évocateurs d’un ulcère duodénal;— l’influence de la morphologie endoscopique de l’ulcère sur l’évolution à court et à long terme de la lésion, en rapport avec le traitement médical;— l’utilité des contrôles endoscopiques pendant et après le processus de cicatrisation de l’ulcère.SummaryThe authors review the contribution of endoscopy to the diagnosis and management of duodenal ulcer. Three points are examined in detail:— the place of primary panendoscopy in patients whose symptoms call out for duodenal ulcer;— the contribution of endoscopic ulcer morphology in short and long-term outcome of the lesion in relationship with medical therapy;— the usefulness of endoscopic controls during and after ulcer healing process.ResumenLos autores evalúan la contribución de la endoscopia al diagnóstico y al seguimiento de la úlcera duodenal. Se examinan en detalle tres aspectos de la cuestión:— el papel de la primera endoscopia en los pacientes con síntomas sugestivos de ulcus duodenal;— la influencia de la morfología endoscópica de la úlcera en su evolución a corto y largo plazo y en función del tratamiento médico;— la utilidad de los controles endoscópicos durante y después del proceso de cicatrización de la úlcera.

Suivi endoscopique après sclérothérapie élective pour varices œsophagiennes: résultats de deux schémas de surveillance différents

RésuméLes auteurs ont pratiqué une étude rétrospective de la surveillance de patients soumis à une sclérothérapie endoscopique (S.E.).Entre mars 1983 et mai 1989, 61 patients ont été traités pour un ou plusieurs épisodes hémorragiques sur varices œsophagiennes, et suivis pendant au moins douze mois.Ils ont été répartis en deux groupes selon deux schémas différents de surveillance.Le groupe A comporte 33 malades soumis à une S.E. jusqu’en mai 1986; après éradication des varices, ils ont subi des contrôles endoscopiques trimestriels au cours de la première année et ensuite semestriels. La durée moyenne du suivi était de 34,2 mois.Le groupe B comporte 28 malades, soumis après éradication des varices, à un contrôle endoscopique précoce (un mois) et ensuite assujettis au même schéma de contrôle que les malades du groupe A. La durée moyenne de la surveillance était de 19,8 mois.Dans le groupe A, la récidive des varices a été observée dans 87,9 % des cas (60,9 % grade 1; 39,1 % grade 2) et les récidives hémorragiques ont été observées chez 18,2 % des patients; la mortalité par hémorragie était de 6,1 %.Dans le groupe B, la récidive des varices s’observait dans 46,4 % des cas; 55 % des cas de récidive variqueuse ont été identifiés au grade 1 lors du premier contrôle; seules deux récidives hémorragiques sont survenues (7,1 %); aucun cas de décès en rapport avec une hémorragie.Dans les deux groupes, la récidive des varices et les accidents hémorragiques se sont produits au cours des six premiers mois.Bien que cette différence ne soit pas significative, elle suggère l’utilité d’un contrôle endoscopique précoce au cours de la surveillance postsclérothérapie des malades chez lesquels l’éradication des varices a été obtenue.SummaryThe Authors rewieved retrospectively their experience in the endoscopic surveillance of patients submitted to elective sclerotherapy (E.S.).Between March 1983 and May 1988, 61 patients with one or more previous episodes of variceal bleeding were treated and followed-up for at least 12 months.According to the different surveillance schedule, they were divided into two groups. In group A there were 33 patients submitted to E.S. until May 1986; after eradication of varices they underwent endoscopic controls every three months during the first year and every six months thereafter. Their mean follow-up was 34.2 months.In group B there were 28 patients submitted, after variceal eradication, to an early endoscopic control (1 month) and then followed-up like group A patients. Their mean follow-up was 19.8 months.In group A, recurrent varices occurred in 87.9 % (60.9 % grade 1: 39.1 % grade 2) and variceal rebleeding in 18.2 % of patients; bleeding-related mortality rate was 6.1 %.In group B, varices recurred in 46.4 % of patients; in 55 % of cases recurrent varices were detected as grade 1 at the early control; only two variceal rebleedings occurred (7.1 %); no bleeding-related death occurred. In both groups, recurrences of varices and bleeding have been observed mainly within the first six months.Although not significant, these differences suggest that an early endoscopic control may be helpful in post-sclerotherapy surveillance of patients with eradicated varices.ResumenLos autores practicaron un estudio retrospectivo de seguimiento de pacientes sometidos a escleroterapia endoscópica (EE).Entre marzo 1983 y mayo 1989, se trataron 61 pacientes que habian sufrido episodios hemorrágicos por varices esofágicas, pacientes que fueron controlados posteriormente por un periodo minimo de doce meses.Los pacientes se repartieron en 2 grupos segun dos esquemas distintos de seguimiento.El grupo A consta de 33 pacientes que fueron sometidos a EE hasta mayo 1986; después de la erradicación de las varices siguieron controles endoscópicos trimestrales en el primer año y posteriormente semestrales. La duración media de seguimiento fué de 34.2 meses.El grupo B consta de 28 pacientes, sometidos, después de la erradicación de las varices a un control endoscópico precoz (1 mes) y sujetos posteriormente al mismo esquema de control que los pacientes del grupo A. La duración media de éste control fué de 19.8 meses.En el grupo A se observó récidiva de las varices en un 87,9 % de los casos (60,9 % de grado I; 39,1 % de grado 2) y hubo recidiva hemorrágica en 18,2 % de enfermos. La mortalidad por hemorragia fué del 6,1 %.En el grupo B se observó récidiva de varices en un 46,4 % de casos; se identificaron 55 % de récidiva varicosa grado 1 en el primer control; sólo se observaron 2 recidivas hemorrágicas (7,1 %) y ningun caso de fallecimiento de origen hemorrágico.En ambos grupos, tanto la récidivas varicosas como los accidentes hemorrágicos tuvieron lugar en el curso de los 6 primeros meses.Si bien la diferencia no es significativa, sugiere la utilidad de un control endoscópico precoz en el curso del seguimiento postescleroterapia de los pacientes en los que se ha logrado una erradicación de las varices esofágicas.