E.V. Avallone

Extraintestinal manifestations in a large series of Italian inflammatory bowel disease patients

AIM To investigate prevalence, type and time of onset of extraintestinal manifestations (EIMs) in a series of Italian inflammatory bowel disease (IBD) patients. METHODS Data of 811 IBD consecutive patients, first referred to our Centre from 2000 to 2011, were retrospectively evaluated. RESULTS Eight hundred and eleven IBD patients (437 M, 374 F) were studied: 595 ulcerative colitis (UC) (73.4%) and 216 Crohns disease (CD) (26.6%). Among these, 329 (40.6%) showed EIMs: 210 UC (35.3%) and 119 CD (55.1%) (P < 0.0001). Considering the time of the diagnosis of IBD, 37 EIMs (11.2%) were developed before, 229 (69.6%) after and 63 (19.2%) were simultaneous. The type of EIM were as follows: 240 musculoskeletal (29.6%), in 72 CD patients and in 168 UC (P < 0.0001); 47 mucocutaneous (5.8%), in 26 CD and in 21 UC (P = 0.0049); 26 ocular (3.2%), in 16 CD and in 10 UC (CD 7.4% vs UC 1.7%, P = 0.0093); 6 hepatobiliary (0.8%); 10 endocrinological (1.2%). In particular, with regards to the involvement of the musculoskeletal system, arthritis Type 1 was found in 41 CD (19%) and in 61 UC (10.2%) (P = 0.0012) and Type 2 in 25 CD (11.6%) and in 100 UC (16.8%) (P = 0.0012). CONCLUSION Mucocutaneous manifestations, arthritis Type 1 and uveitis were significantly more frequent in CD than UC. The complications of the musculoskeletal system were the mostly observed ones, often with symptoms more severe than intestinal ones, confirming the need for close cooperation with rheumatologists.

Schwannoma of the rectum: A case report and literature review.

Schwannoma is a tumor originating from the Schwann cells. Gastrointestinal schwannomas are uncommon stromal tumors of the intestinal tract and, in particular, rectal schwannomas are extremely rare. In fact, it is well established that schwannomas appear more frequently in the stomach and in the small intestine, while location in the colon or in the rectum is uncommon. Reading the literature, only few cases of rectal schwannoma have been reported. Their diagnosis is confirmed by the immunohistochemical panel (S-100 protein). When these tumors are located in the colon and in the rectum, radical excision with wide margins is mandatory, due to their tendency to recur locally or become malignant, if left untreated. In the present study, we describe a case of a rectal schwannoma occured in a 72-year-old man, presented as a small polypoid lesion, which was successfully removed in toto by hot-biopsy, during the same endoscopy, due to the dimensons. No recurrence of the lesion was observed after 6 mo of follow-up.

Infliximab for the treatment of pouchitis

Pouchitis is not a rare complication that develops after an ileal-pouch anastomosis, performed after colectomy in patients refractory to treatment or with complicated ulcerative colitis. This condition may become chronic and unresponsive to medical therapies, including corticosteroids, antibiotics and probiotics. The advent of biological therapies (tumor necrosis factor-α inhibitors) has changed the course of these complications. In particular, in these cases, infliximab (IFX) may represent a safe and effective therapy in order to avoid the subsequent operation for a permanent ileostomy. This article reviews the therapeutic effects of one of the most widely used anti-tumor necrosis factor-α molecules, IFX, for the treatment of complicated pouchitis (refractory to conventional treatment and/or fistulizing).

Hydrogen Breath Test – Diet and Basal H2 Excretion: A Technical Note

Background: Hydrogen breath tests are widely used in clinical practice. For a correct evaluation of data, low basal H2 excretion is required, thus, 12-hour fasting is usually prescribed. An additional reduction in the intake of complex carbohydrates in the preceding 24 h is suggested in some centers. The issue, however, has never been directly investigated. Aim: The aim of the present study was to analyze the effect of the pretest diet on the basal H2 excretion and the number of subjects excluded from the test due to high basal H2 excretion. Methods: Two cohorts of 500 consecutive patients undergoing a lactose tolerance test in the years 1997–1998 (when 12-hour fasting was required) and in 2007–2008 (when a low-carbohydrate diet in the preceding 24 h was also prescribed) were retrospectively reviewed. Results: The mean basal H2 excretion was significantly lower (p < 0.0001) in the low-carbohydrate diet group (2.46 ± 6.8 vs. 4.73 ± 3.3 ppm). In 1997–1998, 46/500 patients (9.2%) were excluded from the test due to basal H2 values as compared to 7/500 (1.4%) in the period 2007–2008. Discussion: To the best of our knowledge, ours is the first study to provide objective data on the advantage offered by reducing the intake of complex carbohydrates before H2 breath tests.

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.

W1221 Side Effects of Azathioprine in the Treatment of Chronic Inflammatory Bowel Disease

(age, gender, study level, working status, personal status), data concerning the disease (type of IBD, year of diagnosis, number of hospital admissions, IBD-related surgical procedures), data about therapy (drug, dose, interval), self-applied adhesion declaration and self-medication. An activity index was calculated on the spot (Harvey-Bradshaw/Truelove) Results: Mean age was 41.3±11 years, 60% were women. The number of years since IBD diagnosis was 8±7; 64% were Crohns disease (71% inactive), 36% ulcerative colitis (70% inactive). A 66% was treated with aminosalicylates, 51%with immunosuppressors, 8% with glucocorticoids. A 66% needed an IBD-related hospital admission in the past, and 17% any IBD-related surgical procedure. A 69% (95%CI: 60-77%) showed some type of non-adhesion. A 66% (57-75%) acknowledged dome degree of involuntary non-adhesion: either forgetting to take their dose (63%) or being careless about having taken it (27%). A 16% (9-22%) showed some kind of voluntary non-adhesion: interrupting the therapy when feeling better (13%) or when feeling worse (6%). A 25% (17-33%) forgot at least a dose a week (mean weekly number of forgotten doses 1.6), and the most frequent cause was to be away form home when they were supposed to take the medication. This was more frequent under mesalazine therapy (30%) than with azathioprine (17%) (p=n.s.). A multivariate analysis identified as risk factors for a lower adhesion the dosing in three or more takes a day (OR 3; 95%CI 1.1-8.4; p= 0.03) and feeling little informed about their disease (OR 4.9; 95%CI 1.1-23.8; p=0.04). On the other hand, immunomodulator therapy was a predictive factor for better adhesion (OR 0.29; 95%CI 0.11-0.74; p=0.01). The concordance between patient recall and clinical records was complete in 86%, whereas in 10.3% the patients did not accurately remember the dose and in 3.7% there was confusion about the drug taken. A 9% acknowledged self-medication during flares Conclusions: In our setting, adhesion to therapy in IBD patients is not satisfactory. Patients treated with immunosuppressors have better adhesion. Optimizing the information on the disease and giving the medication in one or two daily doses could enhance therapeutic adhesion