Ariadne Desjeux

Clinical usefulness of a treatment algorithm for pancreatic pseudocysts

BACKGROUND Endoscopic procedures have become a first-line approach to the treatment of pancreatic pseudocysts. OBJECTIVE Our purpose was to determine the results of a therapeutic algorithm including EUS-assisted drainage, transpapillary drainage, and conventional endoscopic drainage in terms of (1) feasibility and efficacy of the endoscopic procedure and (2) morbidity. DESIGN Prospective study with a treatment algorithm drawn up before the endoscopic procedure, including either conventional endoscopic transmural drainage (CTMD), conventional transpapillary drainage (CTPD), or EUS-guided transmural drainage (EUS-GTD). PATIENTS A total of 50 patients, including 15 women and 35 men with a mean age of 51 years, were included in this prospective study. RESULTS The mean size of the pseudocysts was 8.2 cm (range 3-12 cm). A total of 29 pseudocysts did not bulge into the digestive wall (58%); 24 (48%) neither bulged nor communicated with the pancreatic duct. EUS-GTD was performed on 28 patients (56%), CTMD on 13 patients (26%), and CTPD on 8 patients (16%), and endoscopic procedures failed in 1 patient. Technical feasibility was 98% (49/50), and clinical success was achieved in 90% of the cases and disappearance of the pseudocysts in 96% of the cases without significant differences among the 3 groups. The morbidity rate was 18% (9 cases). Five superinfections occurred in the EUS-GTD group and 1 in the CTMD group. One death occurred from late bleeding in the CTMD group. LIMITATION Randomization of patients in this prospective study was not possible because of the different characteristics of the pseudocysts. CONCLUSION With this algorithm, clinical success was achieved in 45 (90%) of the cases and disappearance of the pseudocysts in 48 (96%) of the cases with a reasonable morbidity rate. In half of the cases, EUS is required for treating pancreatic pseudocyst.

Sacral Nerve Stimulation can Improve Continence in Patients with Crohn’s Disease with Internal and External Anal Sphincter Disruption

PurposeSacral nerve stimulation is a technique commonly used for the treatment of idiopathic incontinence. This study was designed to assess the efficiency of sacral nerve stimulation as a means of treating fecal incontinence in patients with Crohn’s disease with disrupted internal and external anal sphincters.MethodsFive patients (3 women) with fecal incontinence suffering from Crohn’s disease-related anoperineal lesions were treated by applying three weeks of sacral nerve stimulation and then by permanent sacral nerve stimulation implantation. Endoanal ultrasonography showed that all of these patients had disrupted external and internal anal sphincters.ResultsContinence was improved in all treated patients. The median follow-up time was 14 (range, 3–36) months. At the end of the follow-up period, the median Wexner’s score significantly improved from 15 to 6 and the median number of daily stools decreased from 7 to 2. The patients’ quality of life also increased significantly.ConclusionsSacral nerve stimulation improves fecal continence in patients suffering from Crohn’s anoperineal lesions with internal and external anal sphincters disruption.

Is endoscopic sphincterotomy avoidable in patients with sphincter of Oddi dysfunction

Aim Endoscopic sphincterotomy is an efficient means of treating sphincter of Oddi dysfunction (SOD), but it is associated with a morbidity rate of 20%. The aim of this study was to assess how frequently endoscopic sphincterotomy was performed to treat SOD in a group of patients with a 1-year history of medical management. Methods A total of 59 patients, who had been cholecystectomized 9.3 years previously on average, were included in this study and they all underwent biliary scintigraphy. Medical treatment was prescribed for 1 year. Endoscopic sphincterotomy was proposed for patients whose medical treatment had been unsuccessful. Results Eleven patients were rated group 1 on the Milwaukee classification scale, 34 group 2 and 14 group 3. The hile–duodenum transit time (HDTT) was lengthened in 32 patients. The medical treatment was efficient or fairly efficient in 45% of the group 1 patients, 67% of the group 2 patients, and 71.4% of the group 3 patients (P=0.29). Only 14 patients out of the 21 whose medical treatment was unsuccessful agreed to undergo endoscopic sphincterotomy. HDTT was lengthened in 11 of the 14 patients undergoing endoscopic sphincterotomy and in 21 of the 45 non-endoscopic sphincterotomy patients (P=0.03). Twelve of the 14 patients who underwent endoscopic sphincterotomy were cured. Conclusion In this prospective series of patients with a 1-year history of medical management, only 23% of the patients with suspected SOD underwent endoscopic sphincterotomy although 54% had an abnormally long HDTT.

CASE REPORT: Pseudotumorous Chronic Pancreatitis Associated with Inflammatory Bowel Disease

Chronic pancreatitis associated with inflammatory bowel disease is now considered as extraintestinal manifestation of that disease. The clinical and radiological features of the new entity are markedly different from those of chronic calcifying pancreatitis. We report the case of a 68-year-old man presenting with a pseudotumorous chronic pancreatitis associated with ulcerative colitis. Diagnosis was made after endoscopic retrograde cholangiopancreatography (ERCP) and cytological analysis of stenosis brushings and was confirmed by the clinical evolution. Existence of IBD-associated pancreatitis with pseudotumorous features has to be taken into account in order to avoid inappropriate pancreatic resection.

Facteurs de récidive de la maladie de Crohn après traitementdes sténoses intestinales

Background: Postoperative recurrences of Crohn’s disease (CD) has been widely investigated in previous studies. Nevertheless, the risk factors for CD recurrence in patients presenting with intestinal stenosis are not clearly identified. Patients and method: Thirty consecutive patients out of a cohort of 134 patients with CD presented with an intestinal stenosis diagnosed between 1995 and 1999. Epidemiological, clinical, and therapeutic data were carefully recorded. A univariate analysis followed by stepwise descending discriminant analysis was performed. Results: Sixteen patients (53%) underwent surgery, six received steroid therapy, eight were given antibiotics, and seven took immunosuppressive drugs. The mean follow-up after medical or surgical management was 2.8 years. Thirteen patients (43%) had CD relapse during the follow-up. Considering the univariate analysis, the existence of a previous appendectomy and the persistence of tobacco consumption were significantly associated with the risk of CD relapse during the follow-up. The stepwise descending discriminant analysis identified three independant factors: tobacco consumption (p = 0.007), previous appendicectomy (p = 0.04) and duration of the follow-up (p = 0.02). Conclusion: The CD relapse after the management of small bowel stenosis occurred in 43% of the patients within a mean follow-up of 2.8 years. The significant factors associated with the risk of CD relapse were tobacco consumption, previous appendectomy and duration of the follow-up.

Targeting tissular immune response improves diagnostic performance of anti-Saccharomyces cerevisiae antibodies (ASCA) in Crohn's disease.

Antibodies against Saccharomyces cerevisiae (ASCA) and Escherichia coli outer membrane porin C (anti-OmpC) are known to be detectable in the serum of patients with Crohn’s disease (CD) but display a very poor sensitivity for the disease especially in forms with isolated colonic involvement. In this study we aimed at evaluating performances of these markers in supernatant of cultured colonic biopsies. Patients with colonic CD (n =  67), ulcerative colitis (UC) (n = 35) and control individuals (n = 37) were prospectively recruited for colonoscopy pinch biopsies and blood sampling. Serum and supernatant of culture tissues were analyzed for ASCA and anti-OmpC. Direct immunofluorescence was also performed on colonic tissues for total IgA detection. We detected for the first time ASCA IgA/IgG and anti-OmpC IgA in cultured colonic tissue supernatants. For both markers, sensitivities for diagnosing CD were better in supernatants (ASCA: 53.7%, anti-OmpC: 28.4%) than in serum (ASCA: 31.3%, anti-OmpC: 22.4%). Combination of results from a panel of these tests gave the greatest sensitivity ever described for CD diagnosis in colonic forms (70.2%). In this study, we described, for the first time, ASCA in supernatant of colonic tissue cultures. This assaying approach in CD diagnosis should be taken into consideration in the future especially in CD forms with isolated colonic involvement.

The usefulness of factor XIII levels in Crohn's disease.

BACKGROUND AND AIMS The assessment of inflammatory activity in Crohns disease (CD) is challenging, and no specific laboratory marker is currently available. Several studies have reported decreased serum factor XIII levels in CD patients as a function of disease activity. We aimed to determine whether the factor XIII level could be a marker for the evolution of CD. METHODS In this prospective, single-centre trial, 129 patients were included and categorised into two groups: functional bowel disorders (FBDs, n=42) and CD (n=86). The CD group was divided into two subgroups depending on disease activity, as defined by the Crohns Disease Activity Index score: active disease (CDa, n=41) and disease remission (CDb, n=45). The factor XIII levels were evaluated for each patient. Serial factor XIII levels were evaluated in the patients within the CDa subgroup. RESULTS The factor XIII levels were significantly different between the FBD (117.69%) and CD (101.89%) groups (p=0.009) but there was no significant difference between the CDa and CDb subgroups (99.04% vs 104.65%, p>0.05), and the levels did not vary during follow-up for the patients in the CDa subgroup. By multivariate analysis, factor XIII levels did not correlate with the time course of disease evolution, CRP, serum fibrin levels, platelet count, disease distribution within the bowel, or the presence of a fistulising form of CD. CONCLUSIONS Our results confirm that factor XIII levels are decreased in CD patients but cannot be recommended as a marker for the disease activity.

The Rapunzel Syndrome: A Hard-To-Swallow Tale

IntroductionRapunzel syndrome is a rare entity comprising of a large gastroduodenal trichobezoar due to trichotillomania. Its treatment is often surgical.Case ReportA 27-year-old patient was investigated after an upper gastro-intestinal tract obstruction. Computed tomography and endoscopy showed a large gastric trichobezoar with a duodenojejunal tail. Conservative treatments failed to remove the bezoar. We performed a short laparotomy which allowed the removal of the bezoar through a longitudinal gastrotomy. Postoperative course was uneventful.

Healing of anastomotic enterocutaneous fistulae due to Crohn's disease by anti-tNF-alpha antibodies

To the Editor: Since the published data by Present et al anti-tumor necrosis factor alpha (TNF-a), especially infliximab, became the treatment of choice for patients with fistulizing Crohn’s disease (CD). However, there is no consensus regarding the best management of anastomotic fistulae, which could be surgical rather than medical. In this letter we describe a case series of successful closure of anastomotic fistulae for 3 patients who were treated with antiTNF-a, and share our experience on the therapeutic effect of infliximab in this type of fistulae. The first patient was a 32-year-old woman, known to have ileocolic CD for 13 years. She was in clinical remission with immunosuppressive treatment until the occurrence of a stenosis at the terminal ileum. She was treated by ileorectal resection. One month after the establishment of continuity, an enterocutaneous fistula developed with recurrence of endoscopic lesions at the site of anastomosis. After failure of total parenteral nutrition (TPN), an anti-TNF-a treatment was started. The patient received 5 mg/kg of infliximab. After the third injection, discharges from the fistula stopped completely, which was confirmed by computed tomography (CT)-scan of the abdomen. After 8 injections of infliximab the patient was still asymptomatic. The second patient was a 25-year-old man suffering from ileocolic CD, treated with azathioprine (Imurel). He developed an ileo-sigmoid-recto-vesical fistula, treated by right ileocolectomy and temporary ileostomy with suture of sigmoid fistulae. After 6 months, gastrointestinal continuity was established. One month later the patient had discharge of fecal material secondary to anastomotic enterocutaneous fistula. A colonoscopy revealed a postoperative recurrence. A therapeutic regimen based on anti-TNFa antibodies (infliximab) was started. This treatment was effective from the first injection, and when the patient was seen after the third injection there was no discharge from the fistulous tract. Currently, after the eighth injection, the patient is still in complete remission. The third patient was a 37-year-old man, known to have ileocolic and anoperineal CD for 11 years. An occlusion led to a right ileocolic resection with protective ileostomy. One month after surgery a diagnosis of entero-cutaneo-vesical fistula was made. TPN was started and an endoscopic treatment was attempted (clips). Those treatments were unsuccessful. Given the permanent discharge from the fistula and the endoscopic recurrence of inflammation at the anastomosis, an anti-TNFa (infliximab) was started and was effective after the second injection. It was switched to adalimumab because the patient developed an allergy to infliximab after the second injection. The patient had complete closure of the fistula 10 weeks after the beginning of treatment up until now. Anastomotic fistula is a frequent complication of gastrointestinal surgery, with a high mortality rate ranging from 10%–30%. Since 1960, improvement in the outcome essentially resulted from the management of complications including sepsis, electrolytes disturbances, and malnutrition. On the other hand, discharge from the fistula is responsible for prolongation of hospital stays along with alteration of the quality of life. The use of antisecretory agents like somatostatin and its analogs may be helpful. It is well established that after 6 weeks of wellconducted medical treatment the occurrence of complications, and clinical deterioration, is an indication for surgical treatment. Over the last few years there has been an emergence of new techniques, which represent fascinating alternatives. Biological glue has been used for the treatment of perianal fistulae. However, its place in the treatment of enterocutaneous fistulae was not evaluated. Preliminary results of the treatment of such fistulae by instillation of autologous fibroblasts or adipocytes with or without biological glue seem promising but need to be confirmed. In addition, an Irish group described the closure of chronic enterocutaneous fistulas by infusion of infliximab, which developed in the absence of inflammatory disease, and confirmed by endoscopic control and histological examination done postoperatively. Unfortunately, no physiopathologic hypothesis could be proposed in this setting. In our series, despite the fact that spontaneous healing is not uncommon, surgical reintervention seems necessary in these patients who had CD, which increases the extension of surgical resection of the bowel. Fistulas and their complications usually develop during the active phases of CD, certainly due to the transmural nature of the lesions. It is possible that in the case of anastomotic fistula the treatment of underlying inflammation may be very helpful in inducing healing. Based on this hypothesis we proposed for our patients an anti-TNFa treatment. In fact, the effect of this biological therapy in active CD, and especially in the fistulous form, is well established for infliximab and adalimumab. Recently, there has been increasing evidence about the use of infliximab as an early postoperative treatment. In fact, it is well known that after surgical treatment the recurrence of clinical features along with endoscopic exacerbation in CD is very high and can reach up to 80% after 1 year. In our patients, histological examination had shown the absence of active inflammation within CopyrightVC 2010 Crohn’s & Colitis Foundation of America, Inc. DOI 10.1002/ibd.21192 Published online 13 July 2010 inWiley Online Library (wileyonlinelibrary.com).

Comment dépister le cancer colorectal associé aux MICI

de cancer digestif à 2 % à 10 ans, 8 % à 20 ans, et 18 % à 30 ans (3). Le facteur de risque le plus reconnu est la durée d’évolution. Le risque débute après 8 à 10 ans d’évolution (2), puis augmente régulièrement de 0,5 à 1 % par an (4). L’âge de début de la maladie apparaît maintenant comme un facteur indépendant (2). L’étendue de la maladie est également un facteur bien connu. Ainsi, dans l’étude suédoise, le risque relatif de cancer était de 14,8 en cas de pancolite ; de 2,8 en cas de colite gauche ; de 1,7 en cas de proctite (2,4). Le risque de cancer en cas de proctite ou de colite gauche est surtout décalé dans le temps d’une dizaine d’années (2,4). En revanche, la sévérité de l’affection ne semble pas constituer un facteur de risque particulier (2). Plusieurs études ont montré un risque plus élevé de cancer du côlon en cas de cholangite sclérosante primitive (CSP) (2). Un rôle protecteur des folates était suggéré dans cette même étude mais aussi du 5 ASA dans un autre travail (5). Ces résultats demandent à être validés sur d’autres études. Un antécédent familial de cancer sporadique du côlon multiplie par deux le risque de cancer colique en cas de RCH, de façon indépendante (2). Deux études récentes ont montré que le risque de cancer colique était identique dans la MC colique et la RCH (5,6). Le risque de cancer digestif est multiplié par un facteur de 2,6 à 3,4 ; le risque de cancer du grêle étant multiplié entre 15,6 et 50 (6). La méta-analyse de von Roon (7) à partir de 34 publications, retrouve un sur-risque de cancer colique au cours de la maladie de Crohn (12,59) justifiant un dépistage. La durée d’évolution ne semblait pas être un facteur de risque (8). Un âge de début inférieur à 30 voire à 25 ans suivant les études, augmente le risque, indépendamment de la durée d’évolution de la MC (8). Le risque de lymphome digestif en cas de MC, mais aussi en cas de RCH, est augmenté, le rôle des immunosuppresseurs étant controversé (9). Introduction