Céline Savoye-Collet

Fistulizing perianal Crohn's disease: contrast-enhanced magnetic resonance imaging assessment at 1 year on maintenance anti-TNF-alpha therapy.

Background: The aim of the study was to assess perianal fistulas by magnetic resonance imaging (MRI) in patients with severe fistulizing Crohns disease (CD) using maintenance antitumor necrosis factor alpha (TNF‐&agr;) therapy and to correlate MRI changes with clinical outcome. Methods: Perineal MRI before and after a 1‐year scheduled anti‐TNF‐&agr; maintenance therapy was performed in 20 patients (14 females; mean age = 33.7). The Van Assche score (i.e., number of fistulas, localization, and extension, importance of T2 hyperintensity, presence of abscess) was calculated. Fistula track contrast enhancement was also used. Clinical outcome was defined as no response, response, or remission. Results: Response and remission were observed in respectively 40% and 35% of cases. The Van Assche score varied from 13.8 (7–20) to 6.13 (0–12) in patients with a response or remission (P < 0.05). The T2 hyperintensity follow‐up value decreased in patients in response or remission (P < 0.01). T2 hyperintensity disappeared or decreased in 14 out of 15 patients in clinical response or remission as compared to one among the five nonresponding patients (P < 0.01). The decrease in Van Assche score and hyperintensity value was not significantly different in patients in remission compared to those with response. Only one patient in clinical remission had a persisting contrast enhancement on MRI, whereas contrast enhancement persisted in all other patients not in remission (P = 0.002). Conclusions: The clinical benefit of maintenance anti‐TNF‐&agr; therapy in perianal CD is associated with a significant improvement of the Van Assche score, particularly T2 hyperintensity. The disappearance of contrast enhancement was the only semiological MR feature associated with remission. (Inflamm Bowel Dis 2010)

Are digestive symptoms in women presenting with pelvic endometriosis specific to lesion localizations? A preliminary prospective study

STUDY QUESTION What are the types and frequency of digestive symptoms in patients with different localizations of pelvic endometriosis and which specific symptoms are related to rectal stenosis? SUMMARY ANSWER There is a high prevalence of digestive complaints in women presenting with superficial pelvic endometriosis and deep endometriosis sparing the rectum. WHAT IS KNOWN ALREADY Women presenting with pelvic endometriosis frequently report gastrointestinal complaints of increased intensity during menstruation, which are not necessarily linked to the infiltration of the disease into the rectal wall. Even though intrarectal protrusion of the nodule can have an impact on bowel movement, only a minority of women with rectal nodules seemed to be concerned by significant narrowing of the rectum. STUDY DESIGN AND SIZE This three-arm cohort prospective study included 116 women and was carried out over 22 consecutive months. PARTICIPANTS, SETTING AND METHODS Prospective recording of data was performed for women treated for Stage 1 endometriosis involving the Douglas pouch (n = 21), deep endometriosis without digestive infiltration (n = 42) and deep endometriosis infiltrating the rectum (n = 53). Patient characteristics, pelvic pain and data from preoperative standardized questionnaires The Gastrointestinal Quality of Life Index (GIQLI), the Knowles-Eccersley-Scott-Symptom Questionnaire (KESS) and the MOS 36-Item Short-Form Health Survey (SF-36) were compared according to endometriosis localization. MAIN RESULTS The values of total KESS and total GIQLI score were comparable for the three groups, as were a majority of the digestive complaints. Women presenting with rectal endometriosis were more likely to report an increase in intensity and length of dysmenorrhoea, while deep dyspareunia appeared to be more severe in women with superficial endometriosis. Women presenting with rectal endometriosis were more likely to present cyclic defecation pain (67.9%), cyclic constipation (54.7%) and a significantly longer stool evacuation time, although these complaints were also frequent in the other two groups (38.1 and 33.3% in women with Stage 1 endometriosis and 42.9 and 26.2% in women with deep endometriosis without digestive involvement, respectively). No independent clinical factor was found to be related to infiltration of the rectum by deep endometriosis. Among women with rectal endometriosis, only 26.4% presented with rectal stenosis. These women were significantly more likely to report constipation, defecation pain, appetite disorders, longer evacuation time and increased stool consistency without laxatives. LIMITATIONS Patients treated for pelvic endometriosis in a tertiary referral centre may not be representative of the general endometriosis population presenting with those lesions. Statistically significant differences were revealed between the three groups; however, the results were based on a small number of subjects, which carries an inherent risk of type II error particularly when comparing variables with closed values. WIDER IMPLICATIONS OF THE FINDINGS In women presenting with pelvic endometriosis, it seems likely that various digestive symptoms are the consequence of cyclic inflammatory phenomena leading to irritation of the digestive tract, rather than to actual infiltration of the disease itself into the rectum, with the exception of a limited number of cases where the disease leads to rectal stenosis. STUDY FUNDING/COMPETING INTEREST The North-West Inter Regional Female Cohort for Patients with Endometriosis (CIRENDO) is financed by the G4 Group (The University Hospitals of Rouen, Lille, Amiens and Caen). No financial support was specifically received for this study. The authors declare no conflict of interest.

Radiologic evaluation of pelvic floor disorders.

Several imaging modalities are available ranging from fluoroscopic techniques to ultrasonography and MRI for the evaluation of patients with pelvic floors disorders. High-resolution ultrasonography and MRI not only provide superior delineation of the pelvic floor anatomy but also reveal pathology and functional changes. This article focuses on standard imaging procedures including defecography, ultrasonography, and MRI and discusses its use in clinical practice by illustrating both normal and abnormal patterns.

Pathophysiological approach to bowel dysfunction after segmental colorectal resection for deep endometriosis infiltrating the rectum: a preliminary study

BACKGROUND Colorectal segmental resection is performed worldwide in a majority of women presenting with symptomatic deep endometriosis infiltrating the rectum. The aim of the present study was to investigate the pathophysiological mechanisms involved in post-operative digestive dysfunction. METHODS We selected patients managed by colorectal resection for rectal endometriosis, who had developed post-operative severe constipation and whose follow up was superior to 24 months. To assess the mechanisms involved in the pathogenesis of this complaint, we performed a step-by-step work up including: low digestive tract endoscopy, colonic transit time measurement and when appropriate anorectal manometry, electromyography and defecographic evaluation. RESULTS Five out of 25 (20%) patients, whose age ranged from 27 to 41 years, were investigated for severe post-operative terminal constipation. Four different mechanisms responsible for terminal constipation were identified: tight stenosis of the colorectal anastomosis, post-operative neurological sequelae, colonic intussusception through the colorectal anastomosis and transit constipation that developed post surgery. CONCLUSIONS Post-operative constipation is a frequent complaint in women managed by colorectal resection for rectal endometriosis. A multidisciplinary approach is mandatory as pathophysiologic mechanisms may vary and prove difficult to understand. The risk of post-operative bowel dysfunction following colorectal endometriosis must be taken into account whenever this technique is proposed in young women presenting with a benign disease such as deep endometriosis.

Imagerie précoce de la réduction gastrique type gastrectomie en gouttière.

Early imaging features after sleeve gastrectomy Purpose. Sleeve gastrectomy is a new bariatric surgical procedure with promising early results and low morbidity and mortality. We have evaluated the early imaging findings and value of upper GI study (UGI) and CT. Patients and methods. Twenty five patients (mean age = 38.9 years, mean BMI=51.5 kg/m2) following sleeve gastrectomy for morbid obesity underwent UGI at day 1. CT was immediately performed in patients with suspected leak or as a follow-up examinations in patients with suspected complication. The different imaging features observed were recorded. Results. UGI demonstrated 13 normal examinations (52%), an abnormal appearance in 11 cases (44%) with opacification of a lateral pouch, and one complication (leak confirmed on CT). Two patients underweent CT (day 3 and day 15) for suspected complication, with demonstration of leak in both cases. Conclusion. An abnormal appearance after sleeve gastrectomy is frequently observed on UGI. Routine UGI at day 1 is useful to detect large leaks. CT with oral contrast should be performed in all patients with imaging or clinical suspicion of leak.

Magnetic resonance colonography in rats with TNBS-induced colitis: a feasibility and validation study

Background: Magnetic resonance colonography (MRC) has been recently developed to assess bowel inflammation in inflammatory bowel disease (IBD) patients. Evaluating animal models of inflammation with MRC may be important in new drug‐screening processes. The aim of this study was to assess the feasibility of MRC in colitic rats and confront it with model characteristics. Methods: Colitis was induced by rectal injection of trinitrobenzene‐sulfonic acid (TNBS) in 13 rats while six rats received the vehicle. MRC was performed at day 2. Colon inflammation and production of inflammatory mediators were evaluated. Image quality was assessed by wall and motion artifacts. MRC criteria were bowel wall thickness, wall signal intensity on T2‐weighted (T2w) and T1w images, the appearance of a target sign pattern, and irregular patterns of mucosal surface. Results: MRC quality was good or excellent in 16/21 examinations with no difference between groups. Colitis rats were significantly different from controls in terms of wall thickness (P = 0.004), the appearance of a target sign pattern (P = 0.02), irregular patterns of mucosal surface (P = 0.01), and hyperintensity on T1w images (P = 0.03). All MRC criteria except maximal bowel wall thickness were associated with colon weight:length ratio and inflammatory biomarkers (all P < 0.05). Minimal bowel wall thickness and wall signal intensity on T2w images were associated with histological score (P < 0.05). Conclusions: MRC is feasible and reliable in rats with TNBS‐induced colitis. MRC criteria including colon wall thickness, wall signal intensity on T2w images, hyperintensity in T1w sequence, and the appearance of a target sign pattern may be potential targets for new IBD drugs. (Inflamm Bowel Dis 2012)

Endosonography in the evaluation of anal function after primary repair of a third-degree obstetric tear.

Background: Disruption of the anal sphincter occurs in 0.6%–6% of women during delivery and almost half have persistent defecatory symptoms despite primary repair. Our aim was to prospectively analyse anal endosonography and rectoanal manometry after primary repair of a third‐degree obstetric tear in order to compare the findings with the clinical outcome. Methods: Twenty‐one women aged 27–41 (mean 31.5 years) who had undergone primary suture of a third‐degree disruption of the anal sphincter were interviewed on their pelvic floor function and explored by manometry and endosonography 4 months after delivery. Results: Twelve women had anal incontinence. External sphincter defect was identified on endosonography in 22% continent and in 91% incontinent women (P < 0.01). The presence of an external sphincter defect was associated with anal incontinence in 91.7%. Surgical repair was identified on endosonography in 88% continent women and in 25% incontinent women (P < 0.03). The combination of a visible surgical repair and absence of defect was highly associated with normal continence (91.7%). Squeezing pressures were higher in continent women (87 ± 23 cm H 2 O) than in incontinent women (48 ± 36 cm H 2 O; P = 0.04), but no anal pressure threshold could achieve better results than endosonography in predicting the clinical outcome. Conclusion: After primary repair of a third‐degree obstetric tear, endosonographic pattern of the anal sphincter correlates with the continence status.

Successful management of symptoms of steroid-dependent mesenteric panniculitis with colchicine.

Mesenteric panniculitis is a rare chronic inflammatory disease of the mesentery (1). This disease has a large spectrum between fat necrosis, acute and chronic inflammation, and mesenteric fibrosis (2, 3). Depending on the predominant feature, the disease is known as mesenteric panniculitis, mesenteric lipodystrophy, and sclerosing or retractile mesenteritis (4 ). The diagnosis of panniculitis may be suggested by nonspecific abdominal pain, obstructive symptoms, unexplained fever (9–11), or the presence of an abdominal mass, however, the diagnosis is increasingly being made after computed tomography (CT) scan of the abdomen performed for others reasons (17, 18). The etiology and pathogenesis are unknown (13) but in some cases the disease has been thought to be related to the use of drugs or to be a sequela of events such as trauma (12), infections (7, 15), and ischemia (5) or has even been observed in relation to hematologic disorders (6, 8). Variable clinical courses are described, from spontaneous remission to uncontrolled disease activity leading to death (14). The need to treat patients with a diagnosis of mesenteric panniclutis remains debated; however, symptomatic patients seem to benefit from treatment. Various drugs have been used successfully, including steroids (20), azathioprine (22), cyclophosphamide (21), tamoxifen (15), progesterone (24), colchicine (23), and, more recently, thalidomide (25).

Magnetic Resonance Colonography for Fibrosis Assessment in Rats with Chronic Colitis

Background Magnetic resonance colonography (MRC) has been developed to assess inflammatory bowel diseases. We aimed to assess the feasibility of MRC in rats with TNBS-induced chronic colitis and to confront imaging results with fibrosis and stenosing features of the model. Materials and Methods Chronic colitis was induced in 12 rats by weekly intra-rectal injection of increasing doses of TNBS for 6 weeks, while 8 control rats received the vehicle. At week 7, MRC was performed. Fibrosis scores were assessed and fibrosis mediators measured. Results Chronic colitis was associated with significant body weight loss (p<0.0001) and higher colon weight/length compared to controls (p = 0.0004). Fibrosis mediators and histological scores were significantly higher in rats with TNBS than in controls: α-SMA expression (0.9 versus 0.61, p = 0.0311) and fibrosis score (p = 0.0308). Colon wall thickness was higher in rats with TNBS than in controls: maximal thickness (2.38 versus 0.74 mm, p<0.0001) and minimal thickness (1.33 versus 0.48 mm, p<0.0001). Wall signal intensity on T2w images was higher in rats with TNBS than in controls (9040 versus 6192, p = 0.0101) and correlated with fibrosis score (r = 0.5214; p = 0.04). Luminal narrowing was higher in rats with TNBS (50.08 versus 10.33%, p<0.0001) and correlated with α-SMA expression (r = 0.5618; p = 0.01). Stenosis was observed in 7/9 rats with TNBS and in no controls (p = 0.0053). Conclusions MRC is feasible and easily distinguishes rats with colitis from controls. MRC signs correlated with fibrosis parameters. MRC evaluation may be part of a new anti-fibrosis drug assessment in experimental models of chronic colitis.

How deep is remission in perianal Crohn's disease and do imaging modalities matter?

authors of the manuscript were contacted. Unfortunately, patient data pertaining to several studies were no longer available. Th e authors of two manuscripts were able to provide supplementary information. Th is diff erence in the results between the meta-analysis conducted by Krag et al. and that done by us highlights the necessity of contacting the authors when performing a meta-analysis. A response diff erential in obtaining additional data from the authors may introduce reporting bias.