Evangelos Voudoukis

Multipotent role of platelets in inflammatory bowel diseases: A clinical approach

There is evidence that inflammatory bowel diseases (IBD) combine both inflammation and coagulation in their pathogenesis and clinical manifestations. Although platelets (PLT) are well known for their role in hemostasis, there are a rising number of studies supporting their considerable role as inflammatory amplifiers in chronic inflammatory conditions. IBD are associated with several alterations of PLT, including number, shape, and function, and these abnormalities are mainly attributed to the highly activated state of circulating PLT in IBD patients. When PLT activate, they increase in size, release a great variety of bio-active inflammatory and procoagulant molecules/particles, and express a variety of inflammatory receptors. These inflammatory products may represent a part of the missing link between coagulation and inflammation, and can be considered as possible IBD pathogenesis instigators. In clinical practice, thrombocytosis is associated both with disease activity and iron deficiency anemia. Controlling inflammation and iron replacement in anemic patients usually leads to a normalization of PLT count. The aim of this review is to update the role of PLT in IBD and present recent data revealing the possible therapeutic implications of anti-PLT agents in future IBD remedies.

Association between thrombocytosis and iron deficiency anemia in inflammatory bowel disease.

Background Thrombocytosis and iron deficiency anemia are frequent complications of inflammatory bowel disease (IBD). The aim of this study was to investigate the correlation between iron deficiency anemia and thrombocytosis in IBD patients. Methods A total of 198 consecutive IBD patients and 102 healthy controls participated in the study. The parameters investigated were: platelets (PLT), mean platelet volume, platelet distribution width, plateletcrit, hematocrit (HCT) levels, hemoglobulin (Hb) levels, mean corpuscular volume (MCV), red cell distribution width (RDW), ferritin levels, soluble transferrin receptor (sTfR) levels, the sTfR-F index (sTfR-F=sTfR/log10 ferritin), and vitamin B12 and folate levels. Thrombocytosis was defined as an absolute number of PLT greater than 400k/&mgr;l. Disease activity indices (Crohn’s Disease Activity Index for Crohn’s disease and Simple Clinical Colitis Activity Index for ulcerative colitis) as well as C-reactive protein (CRP) were also correlated with the study parameters. Results The IBD patients demonstrated decreased HCT levels, Hb levels, MCV, mean platelet volume, and ferritin levels and an increased absolute PLT count, RDW, platelet distribution width, plateletcrit, sTfR and sTfR-F index (P<0.0001) compared with healthy controls. Twenty-seven patients exhibited thrombocytosis (13.6%). The median value for PLT (interquartile range) was 289 (228–355)k/&mgr;l, for Hb levels was 13.4 (12.0–14.7) g/dl, for ferritin levels was 36.6 (19.7–80.7) ng/ml, and for sTfR-F was 0.82 (0.61–1.37) mg/l. The PLT in IBD patients correlated with HCT levels, Hb levels, MCV, RDW, Fe levels, ferritin levels, sTfR, sTfR-F, CRP levels, Simple Clinical Colitis Activity Index, and Crohn’s Disease Activity Index (Spearman’s &rgr; correlation). In the multivariate analysis, only Hb levels, RDW, CRP levels, ferritin levels, and sTfR-F remained significant (P<0.05). None of the aforementioned was observed in the control group. Conclusion The absolute PLT count seems to correlate with iron deficiency anemia parameters and disease activity in IBD patients. Controlling the inflammation and managing iron deficiency could lead to reversal of thrombocytosis in IBD patients.

Sixty- versus thirty-seconds papillary balloon dilation after sphincterotomy for the treatment of large bile duct stones: A randomized controlled trial

BACKGROUND Endoscopic biliary sphincterotomy followed by endoscopic papillary balloon dilation is a promising method for large stones. However, there are no data on the optimal duration of papillary balloon dilation after a biliary sphincterotomy. AIMS To compare the effectiveness and complications of the endoscopic papillary balloon dilation for 60s versus 30s after endoscopic biliary sphincterotomy. METHODS A total of 124 patients with bile duct stones, submitted for endoscopic biliary sphincterotomy plus endoscopic papillary balloon dilation, were prospectively randomized to either the 60-s dilation group (G60, n = 60) or the 30-s dilation group (G30, n = 64). RESULTS The complete removal of bile duct stones was similar: group G30, 55/64 (86%) versus group G60, 51/60 (85%); p = 0.9. The rates of post-endoscopic retrograde cholangio-pancreatography pancreatitis were also similar: 2 (3.1%) in group G30 versus 2 (3.3%) in group G60, p = 0.9. Post-procedural bleeding occurred in 2 cases (3.1%) in group G30 versus 4 (6.6%) in group G60, (p = 0.17). Two perforations of moderate severity were observed, one in each group. CONCLUSIONS 30-s papillary balloon dilation, performed after endoscopic biliary sphincterotomy for the management of bile duct stones, was equally effective to the 60-s papillary balloon dilation.

Detection of CMV in pouch mucosa in a patient with acute pouchitis: The real enemy or an innocent bystander?

Dear Sir, A 30-year-old woman was diagnosed with fulminant UC in 2003 during lactation. She underwent proctocolectomy with ileal pouch–anal anastomosis due to intractable symptoms and conservative treatment failure. In August 2011, she presented with 15–20 liquid bowel movements per day accompanied with fever, abdominal tenderness and elevated laboratory markers of inflammation. A week before the onset of symptoms she reported camping holidays. A pouchoscopy revealed mild pouchitis. She was empirically treated for pouchitis with ciprofloxacin (500 mg b.i.d.) and metronidazole (500 mg t.i.d.). She exhibited a partial response after 72 h but fever remained consistent up to 38.5 °C. Stool culture turned out positive for ciprofloxacin sensitive Salmonella …

Use of a Double-Channel Gastroscope Reduces Procedural Time in Large Left-Sided Colonic Endoscopic Mucosal Resections

Background/Aims Endoscopic mucosal resection (EMR) of large colorectal lesions is associated with increased procedural time. The objective of this study was to evaluate the effect of double-channel gastroscope (DCG) use on the procedural time of EMRs in the rectosigmoid area. Methods All EMRs for sessile or flat rectosigmoid lesions ≥2 cm performed between July 2011 and September 2012 were retrospectively analyzed. Results There were 55 lesions ≥2 cm in the rectosigmoid area in 55 patients, of which 26 were removed by EMR using a DCG (DC group) and 29 by using an ordinary colonoscope or gastroscope (OS group). The mean size of the removed polyps, morphology, adverse effects, and other parameters were similar between the two groups. The mean procedural time was significantly lower in the DC group than in the OS group (24.4±18.3 minutes vs. 36.3±24.4 minutes, p=0.015). Moreover, in a subgroup of patients with polyps >40 mm, the statistical difference in the mean procedural time between the DC and OS groups was even more pronounced (33±21 minutes vs. 58.7±20.6 minutes, p=0.004). Conclusions Our data suggest that the use of a DCG in the resection of large nonpedunculated rectosigmoid lesions significantly reduces the procedural time.

P670 Efficacy of vaccination against hepatitis A and B in inflammatory bowel disease patients

Background: Infection by the Epstein Barr virus (EBV) has been related to inflammatory bowel disease (IBD), but its implication in pathogenesis or exacerbation of the disease is uncertain. Its role in development of lymphoproliferative syndromes associated to immunosuppression is however well known, mainly in transplant patients and in IBD since introduction of thiopurines. Our objective was to report the association of immunosuppression and EBV as risk factors for the lymphoproliferative syndrome, including the lymphoplasmacytic infiltrate that may precede development of lymphoma. Methods: A retrospective study of patients with IBD in which histology showed a polytypic lymphoplasmacytic infiltrate (lambda and kappa chains) or lymphoma associated to EBV between December 2010 and October 2013. General patient and IBD characteristics, prior treatments, histological findings at the time of diagnosis of EBV infection, and subsequent course were recorded. Presence of EBV was tested using EBER probe hybridization with the respective messenger RNA. Results: 13 patients with IBD with a mean disease duration since diagnosis of 125.46±84.94 months were enrolled. 7 patients (53.8%) were male, and mean age was 40.46±9.98 years. As regards type of IBD, 7/13 (53.8%) had Crohn’s disease (CD), 5/13 (38.5%) ulcerative colitis (UC), and 1/13 (7.7%) non-classifiable IBD. In 11 patients, histology revealed polytypic lymphoplasmacytic infiltrate associated to EBV with no evidence of malignancy, and lymphoma associated to EBV was found in two patients. At diagnosis, patients were being treated with corticosteroids (7/13, 53.8%), azathioprine (5/13, 38.5%), and biologics (7/13, 53.8%). Another two patients had taken azathioprine before diagnosis. Mean time of treatment with azathioprine was 75.15±34.9 months. Mean duration of treatment with azathioprine was 75.14±34.85 months. All patients were in the exacerbation phase of IBD. None of the 11 patients developed lymphoma from the polytypic lymphoplasmacytic infiltrate associated to EBV after a mean follow-up (months) of 18±7.5 despite use of immunosuppressants and/or biologics in 8/13 (72.73%) of them. Conclusions: A lymphoplasmacytic infiltrate associated to EBV is a histological finding of uncertain significance made in a subgroup of patients with long-standing IBD, severe inflammatory activity, and chronic use of immunosuppressant and/or biologic drugs. Its implication in sequential development of lymphoproliferative syndromes and follow-up measures to be taken are not clear. Because of the increased incidence of lymphoma and its association to EBV since the introduction of thiopurines, we think that, based on these findings, longer follow-up with colonoscopy should be performed to assess changes in the lesion over time. P670 Efficacy of vaccination against hepatitis A and B in inflammatory bowel disease patients K. Karmiris1 *, E. Voudoukis1, M. Choustoulaki2, A. Sfiridaki2, G.A. Paspatis1. 1Venizeleio General Hospital, Gastroenterology, Heraklion, Crete, Greece, 2Venizeleio General Hospital, Blood Bank Center, Heraklion, Crete, Greece