Eduardo Moreno-Osset

Contrast-enhanced ultrasonography: Usefulness in the assessment of postoperative recurrence of Crohn's disease

AIM The aim of this study was to assess whether the contrast-enhanced ultrasonography (CEUS) can increase the value of the ultrasonography in the study of postoperative recurrence of Crohns disease (CD). MATERIALS AND METHODS 60 patients with CD who had previously undergone ileocolic resection underwent prospectively both CEUS and colonoscopy within a 3-day period. The sonographic examination included evaluation of bowel wall thickness, transmural complications, colour Doppler grade and contrast-enhanced US. In addition a sonographic score was established. The capacity of CEUS to diagnose endoscopic recurrence, as well as its severity, was assessed by calculating the sensitivity, specificity and positive and negative predictive values, accuracy and odds ratio, with their respective 95% confidence intervals. The areas under the receiver operating characteristic (ROC) curves were also calculated. RESULTS 49 out of 60 patients showed endoscopic postoperative recurrence. Severe endoscopic recurrence was present in 34 patients (57%). Classic ultrasound parameters (wall thickness >3mm and colour Doppler flow) revealed an accuracy of 88.3% for the diagnosis of recurrence. Sonographic score 2, including thickness >5mm or contrast enhancement >46%, improved the results with a sensitivity, specificity and accuracy of 98%, 100% and 98.3%, respectively, in the diagnosis of endoscopic recurrence. The area under the ROC curve was 0.99, in remarkable agreement with endoscopy (k: 0.946). Sonographic score 3, including thickness >5mm, contrast enhancement >70% or fistula identified 32 out of 34 (94.1%) severe endoscopic recurrences. The area under the ROC curve was 0.836, in good agreement with endoscopy (k: 0.688). CONCLUSION CEUS shows excellent sensitivity and specificity for the diagnosis of postoperative recurrence in CD and can also detect severe recurrences.

Esophageal cancer risk by type of alcohol drinking and smoking: a case-control study in Spain

BackgroundThe effect of tobacco smoking and alcohol drinking on esophageal cancer (EC) has never been explored in Spain where black tobacco and wine consumptions are quite prevalent. We estimated the independent effect of different alcoholic beverages and type of tobacco smoking on the risk of EC and its main histological cell type (squamous cell carcinoma) in a hospital-based case-control study in a Mediterranean area of Spain.MethodsWe only included incident cases with histologically confirmed EC (n = 202). Controls were frequency-matched to cases by age, sex and province (n = 455). Information on risk factors was elicited by trained interviewers using structured questionnaires. Multiple logistic regression was used to estimate adjusted odds ratios and 95% confidence intervals (CI).ResultsAlcohol drinking and tobacco smoking were strong and independent risk factors for esophageal cancer. Alcohol was a potent risk factor with a clear dose-response relationship, particularly for esophageal squamous-cell cancer. Compared to never-drinkers, the risk for heaviest drinkers (≥ 75 g/day of pure ethanol) was 7.65 (95%CI, 3.16–18.49); and compared with never-smokers, the risk for heaviest smokers (≥ 30 cigarettes/day) was 5.07 (95%CI, 2.06–12.47). A low consumption of only wine and/or beer (1–24 g/d) did not increase the risk whereas a strong positive trend was observed for all types of alcoholic beverages that included any combination of hard liquors with beer and/or wine (p-trend<0.00001). A significant increase in EC risk was only observed for black-tobacco smoking (2.5-fold increase), not for blond tobacco. The effects for alcohol drinking were much stronger when the analysis was limited to the esophageal squamous cell carcinoma (n = 160), whereas a lack of effect for adenocarcinoma was evidenced. Smoking cessation showed a beneficial effect within ten years whereas drinking cessation did not.ConclusionOur study shows that the risk of EC, and particularly the squamous cell type, is strongly associated with alcohol drinking. The consumption of any combination of hard liquors seems to be harmful whereas a low consumption of only wine may not. This may relates to the presence of certain antioxidant compounds found in wine but practically lacking in liquors. Tobacco smoking is also a clear risk factor, black more than blond.

Usefulness of abdominal ultrasonography in the analysis of endoscopic activity in patients with Crohn's disease: Changes following treatment with immunomodulators and/or anti-TNF antibodies

OBJECTIVE The objective of this study was to analyze the accuracy of abdominal ultrasonography (AUS) in the assessment of mucosal healing in patients with Crohns disease (CD) receiving immunomodulators and/or biological treatment, with ileocolonoscopy as the reference standard. MATERIALS AND METHODS Thirty patients were included in a prospective longitudinal study. All patients underwent ileocolonoscopy and AUS before and after a minimum of one year of treatment. The Crohns Disease Endoscopic Inflammatory Index of Severity (CDEIS) was used for endoscopic assessment whereas AUS was analyzed by means of bowel wall thickness, color Doppler grade and percentage of increase of parietal enhancement after contrast injection. RESULTS In the segmental analysis, endoscopic healing was found in 71.2% of the segments and AUS findings were normalized in 62.8%, with a significant correlation between the two techniques (κ=0.76, p<0.001). In the overall assessment performed after treatment, 18 (60%) patients exhibited endoscopic remission (CDEIS <6 points); of these patients, 15 (83.3%) had normalized sonographic findings, with a good correlation between endoscopic remission and sonographic normalization (κ=0.73, p<0.001). Of the three variables assessed by AUS, parietal thickness was the best variable to predict mucosal healing in both analyses, segmental and global. CONCLUSION Abdominal ultrasonography is a useful and reliable technique for the assessment of the endoscopic response to treatment with immunomodulators and/or biological drugs in Crohns disease. AUS is a highly accurate technique for evaluating the healing of the intestinal mucosa.

Non-invasive diagnosis and grading of postsurgical endoscopic recurrence in Crohn's disease Usefulness of abdominal ultrasonography and 99m Tc-hexamethylpropylene amineoxime-labelled leucocyte scintigraphy

UNLABELLED Non-invasive techniques aim to be an alternative to endoscopy in the assessment of postsurgical recurrence of Crohns disease (CD). The object of this study was to evaluate the accuracy of abdominal ultrasonography (AUS) and (99m)Tc-hexamethylpropylene amineoxime ((99m)Tc-HMPAO)-labelled leucocyte scintigraphy (LLS) compared with endoscopy in the diagnosis and grading of postsurgical recurrence of CD. Between January 2006 and May 2007, all patients with CD and resection with ileocolic anastomosis were included prospectively. Within three days they underwent an ileocolonoscopy, AUS with evaluation of bowel wall thickness and the presence of Doppler flow, and LLS. Forty patients who met the study conditions were included; 5 patients did not agree to have the ileocolonoscopy and it was not possible to assess the anastomosis in 2 patients. Endoscopic recurrence was detected in 26 patients (78.8%), in 15 of whom it was moderate-severe. For the diagnosis of recurrence, both AUS and LLS showed acceptable sensitivity and positive predictive value, with an accuracy of 72.7% and 78.1%, respectively. The results of the AUS and LLS for diagnosing moderate-severe recurrence were better, with an accuracy of 78.8% and 81.3%, respectively. The best assessment of the severity of the recurrence was obtained with the combination of both techniques (sensitivity, specificity, positive and negative predictive values, accuracy and kappa index were, respectively: 93.3%, 72.2%, 73.7%, 92.9%, 81.8% and 0.64). The variables evaluated, both sonographic and scintigraphic, had areas under the curve that were similar and significantly different from 0.5. CONCLUSION Abdominal ultrasonography and (99m)Tc-HMPAO-labelled leucocyte scintigraphy are two useful non-invasive techniques for the assessment of postsurgical recurrence of Crohns disease.

Association of Streptococcus gallolyticus subspecies gallolyticus with colorectal cancer: Serological evidence

The colonic opportunist Streptococcus gallolyticus subspecies gallolyticus (SGG) is potentially associated with colorectal cancer (CRC). Large‐scale seroepidemiological data for SGG antibodies and their possible association with CRC is currently missing. Associations between CRC and antibody responses to SGG were examined in 576 CRC cases and 576 controls matched by sex, age and province from a population‐based multicase–control project (MCC‐Spain). MCC‐Spain was conducted between 2008 and 2013 in 12 Spanish provinces. Antibody responses to recombinant affinity‐purified SGG pilus proteins Gallo1569, 2039, 2178 and 2179 were analysed by multiplex serology. Polyomavirus (PyV) JC VP1 and PyV 6 VP1 proteins served as disease‐specificity controls. In the control population, antibody responses to pilus proteins were mostly weak. Antibody responses to individual pilus proteins Gallo2039 (OR: 1.58, 95% CI: 1.09–2.28), Gallo2178 (OR: 1.58, 95% CI: 1.09–2.30) and Gallo2179 (OR: 1.45, 95% CI: 1.00–2.11) were significantly associated with CRC risk. The association was stronger for positivity to two or more pilus proteins of Gallo1569, Gallo2178 and Gallo2179 (OR:1.93, 95% CI: 1.04–3.56) and for double‐positivity to Gallo2178 and Gallo2179 (OR: 3.54, 95% CI: 1.49–8.44). The association between SGG infection and CRC risk was stronger among individuals younger than 65 years. For the first time we demonstrated a statistically significant association of exposure to SGG antigens and CRC in a large seroepidemiological study. These results should stimulate further studies on the role of SGG in CRC pathogenesis.

Ultrasonographic Changes at 12 Weeks of Anti-TNF Drugs Predict 1-year Sonographic Response and Clinical Outcome in Crohnʼs Disease: A Multicenter Study

Background:The objective was to assess the long-term effect of biological treatment on transmural lesions of Crohns disease evaluated with ultrasound, including contrast-enhanced ultrasound. Methods:Fifty-one patients with active Crohns disease were included in a prospective multicenter longitudinal study. All patients underwent a clinical assessment and sonographic examination at baseline, 12 weeks after treatment initiation, and after 1-year of treatment. Patients were clinically followed at least 2 years from inclusion until the end of the study. Ultrasonographic evaluation included bowel wall thickness, color Doppler grade, parietal enhancement, and presence of transmural complications or stenosis. Sonographic changes after treatment were classified as normalization, improvement, or lack of response. Results:Improvement at 52 weeks was more frequent in patients with improvement at final of induction (12 weeks) compared with patients who did not improve (85% versus 28%; P < 0.0001). One-year sonographic evolution correlated with clinical response; 28 of the 29 (96.5%) patients with sonographic improvement at 52 weeks showed clinical remission or response. Patients without sonographic improvement at 52 weeks of treatment were more likely to have a change or intensification in medication or surgery (13/20, 65%) during the next year of follow-up than patients with improvement on the sonography (3/28, 11%). Stricturing behavior was the only sonographic feature associated to a negative predictive value of response (P = 0.0001). Conclusions:Sonographic response after 12 weeks of therapy is more pronounced and predicts 1-year sonographic response. Sonographic response at 1-year examination correlates with 1-year clinical response and is a predictor of further treatments efficacy, 1-year or longer period of follow-up.

99mTc-hexamethylpropylene amineoxime leukocyte scintigraphy in acute pancreatitis : An alternative to contrast-enhanced computed tomography?

OBJECTIVES:Contrast-enhanced computed tomography (CECT) is the most efficient imaging technique for the diagnosis and staging of acute pancreatitis (AP); its use, however, may be unfeasible in some patients as a consequence of the drawbacks of intravenous (IV) contrast material. The aim of this study was to test the utility of labeled leukocyte scintigraphy (LLS) as an alternative imaging technique to CECT for the staging of AP.METHODS:Sixty-six patients with AP were prospectively studied. All patients underwent CECT and pancreatic LLS using 99mTc-hexamethylpropylene amineoxime as leukocyte label within a time interval of 2 days, in the early phase of AP. In addition, all patients had their serum C-reactive protein (CRP) concentration measured within 48–72 h after admission. CECT images were analyzed for Balthazars grade of pancreatitis and for the presence or absence of pancreatic necrosis. Scintigraphic activity of 3–4 h planar images was scored on a 0–2 scale in relation to physiological liver uptake.RESULTS:LLS score was significantly related (p < 0.001) to both components of CECT (grade of pancreatitis and pancreatic necrosis). LLS and serum CRP showed similar results for detecting the most severe pancreatic damage as showed by their respective receiver operating characteristic (ROC) curves. Sensitivities and specificities of LLS score of 2 were, respectively, 62% and 96% for the detection of grade D-E pancreatitis and 90% and 89% for the detection of pancreatic necrosis. Scintigraphic score of 2 increased the likelihood of grade D-E pancreatitis from 32% (pretest probability) to 87% (posttest probability) (likelihood ratio: 13.9) and that of pancreatic necrosis from 16% to 60% (likelihood ratio: 8.4).CONCLUSION:Our results show that leukocytes are related to the severity of local pancreatic damage in AP. Thus, LLS is a potential alternative technique to CECT for staging AP.

Patología articular en la enfermedad inflamatoria intestinal

The joint disorders taxonomically included in the group of seronegative spondyloarthropathies under the generic name of enteropathic arthropathy represent the most frequent extra-intestinal manifestation of inflammatory bowel disease (IBD), affecting 33% of patients. Their frequency is similar to that of ulcerative colitis and Crohns disease. Enteropathic arthropathy consists of two main joint alterations, peripheral and axial arthritis, as well as a variable group of other peri-articular disorders. Type 1, or pauciarticular, peripheral arthritis generally coincides with IBD exacerbations, while type 2, or polyarticular, peripheral arthritis follows an independent course from IBD. Axial involvement precedes and follows an independent course from IBD and can behave as ankylosing spondylitis or asymptomatic sacroiliitis. The treatment of these rheumatologic disorders is based on the application of general measures and the use of nonsteroidal anti-inflammatory agents; intraarticular corticosteroid administration may eventually become necessary. Sulphasalazine and/or infliximab, which are indicated when the previously mentioned measures fail, can be used to treat both the articular and intestinal diseases simultaneously.

Linfadenomegalias en pacientes con hepatopatía crónica

Resumen La presencia de linfadenomegalias abdominales es un hallazgo ecografico frecuente en pacientes con hepatopatia cronica, cuyo significado clinico no esta bien establecido. Se ha realizado este estudio en 44 pacientes con hepatopatia cronica (el 79,5% por virus de la hepatitis C) con el objeto de relacionar este hallazgo con diversas caracteristicas de la enfermedad. Para ello, a todos los pacientes se les practico de forma simultanea una biopsia hepatica y una ecografia abdominal, en la que se constato el numero y localizacion de linfadenomegalias abdominales. Asimismo, se determino la carga viral en los pacientes con infeccion cronica por el virus de la hepatitis C. No se encontraron diferencias significativas en los niveles sericos de ARN del virus de la hepatitis C segun los pacientes presentaran o no linfadenomegalias; sin embargo, la presencia de estas se asocio con un mayor grado de actividad histologica. De confirmarse este hallazgo en estudios con una mayor muestra de pacientes, la presencia de linfadenomegalias abdominales detectadas por ecografia en pacientes con hepatopatia cronica por el virus de la hepatitis C indicaria una mayor gravedad de la lesion histologica.

Usefulness of Technetium-99m Hexamethylpropylene Amine Oxime-Labeled Leukocyte Scintigraphy to Detect Pancreatic Necrosis in Patients with Acute Pancreatitis

Background: In acute pancreatitis (AP), pancreatic necrosis (PN) is an important local complication that can be identified by means of contrast-enhanced computed tomography (CECT). Pancreatic leukocyte infiltration is a significant pathogenic event in the development of PN that can be detected by labeled leukocyte scintigraphy (LLS). The aim of this study was to evaluate the utility of LLS with technetium-99m hexamethylpropylene amine oxime (99mTc-HMPAO) to detect the presence of PN in patients with AP. Methods: Prospective cohort study of 84 patients with AP. Patients underwent LLS and the activity of images was scored on a 0–3 scale. CETC was performed to assess PN. Ranson, Glasgow and APACHE-II scores were calculated. Serum C-reactive protein (CRP) was measured. Sensitivity (Sn), specificity (Sp), positive predictive values (PPV), negative predictive values (NPV), areas under receiver operating characteristic (ROC) curves, likelihood ratios, odds ratios, analysis of variances between groups and correlation coefficients between tests were calculated. Results: PN was present in 11 (13%) patients. Pancreatic labeled leukocyte uptake was present in 38 patients (45%). Sn, Sp, PPV and NPV of LLS grade 2–3 for PN diagnosis were the highest (91, 88, 53 and 98%, respectively) of all tests. Patients with LLS grade 2–3 were 71 times more likely to be at risk of PN compared to those with LLS grade 0–1. The area under ROC curve of the LLS was the largest. A significant correlation was obtained between LLS and CRP (p < 0.001). Conclusion: In patients with AP, LLS with 99mTc-HMPAO detects PN with an acceptable level of confidence and therefore could be considered an alternative technique to CECT in detecting PN.