Fazia Mana

Consecutive fecal calprotectin measurements to predict relapse in patients with ulcerative colitis receiving infliximab maintenance therapy

Background: This study examined whether fecal calprotectin can be used in daily practice as a marker to monitor patients with ulcerative colitis (UC) receiving infliximab maintenance therapy. Methods: This prospective multicenter study enrolled adult patients with UC in clinical remission under infliximab maintenance therapy. Fecal calprotectin levels were measured every 4 weeks. Sigmoidoscopies were performed at inclusion and at study end. Relapse was defined as a clinical need for change in treatment or an endoscopic Mayo subscore of ≥2 at week 52. Sustained deep remission was defined as a partial Mayo score <3 at all points and an endoscopic Mayo score 0 at week 52. Results: Full analysis was possible for 87 of 113 included patients with UC (77%). Of these patients, 30 (34.4%) were considered to be in sustained deep remission and 13 (14.9%) to have relapsed. Calprotectin levels in patients with sustained deep remission remained very low (median < 40 mg/kg at all time points). Patients who flared had significantly higher calprotectin levels (median > 300 mg/kg) already 3 months before the flare. Further receiver operator curve analysis suggested that a calprotectin level >300 mg/kg had a reasonable sensitivity (58.3%) and specificity (93.3%) to model flare. Two consecutive calprotectin measurements of >300 mg/kg with 1-month interval were identified as the best predictor of flare (61.5% sensitivity and 100% specificity). Conclusions: Fecal calprotectin can be used in daily practice to monitor patients with UC receiving infliximab maintenance therapy. Two consecutive measurements >300 mg/kg is more specific than a single measurement for predicting relapse.

13C Urea Breath Test with Nondispersive Isotope-Selective Infrared Spectrometry: Reproducibility and Importance of the Fasting Status

Background. The 13C urea breath test (13C‐UBT) is the most convenient method for diagnosing Helicobacter pylori infection noninvasively. Nondispersive isotope‐selective infrared spectrometry (NDIRS) is an inexpensive and easy alternative to mass spectrometry. The objective of this study was to evaluate: (1) the reproducibility of the 13C‐UBT as performed by using the NDIRS method; (2) the repeatability of bags analysis and the impact of delayed analysis; and (3) the need for fasting status for the 13C‐UBT.

Cut-off point, timing and pitfalls of the 13C-urea breath test as measured by infrared spectrometry.

BACKGROUND The best timing and the best cut-off level of the 13C-urea breath test have not yet been well established. AIMS To evaluate the cut-off value and the influence of medication on the 13C-urea breath test as measured by infrared spectrometry. METHODS A series of 223 patients, sent for endoscopy performed 13C-urea breath test in fasting conditions with 75 mg of 13C-urea and 20 ml of citric acid. Breath samples were collected before and then 10, 20, 25 and 30 minutes after ingestion. As gold standard, histological examination of gastric biopsies was used. A questionnaire was completed concerning the intake of medication, likely to influence the test, in the 2 months preceding the test. Sensitivity, specificity, positive predictive value and negative predictive value at 10, 20, 25 and 30 minutes at different cut-off values (3, 3. 5, 4, 4. 5, 5.0 0/00 DOB] were calculated. RESULTS A total of 182 patients did not take medication. There was no significant difference between the different cut-off levels at different times. Compared with the group of 41 patients who did take medication, likely to influence the test, the differences were significant (Fisher exact test). CONCLUSION There was no significant difference between the different cut-off values. A 10-minute test with a cut-off level between 4 and 5% delta over baseline (sensitivity: 100%, specificity: 95%) is, therefore, proposed. To avoid false negative results due to unknown intake of medication, every patient submitted to the 13C-urea breath test should fill out a questionnaire.

Pancreatic panniculitis: A rare complication of pancreatitis secondary to ERCP

Panniculitis is an uncommon and rare complication of systemic fat necrosis in patients with pancreatic diseases. The skin manifestations are independent of the severity of the pancreatic pathology and can occur at any time. The lesions can precede, be concomitant with or rarely follow the pancreatic illness. We report a case of acute pancreatitis post Endoscopic Retrograde Cholangio Pancreatography (ERCP) for common bile duct stone, with subcutaneous panniculitis. We noted a complete resolution within two weeks after the treatment of the pancreatic pathology.

`Transient HELLP syndrome' followed by massive ascites

Introduction Maternal ascites is a rare symptom during pregnancy. It may be due to underlying primary disease of the pregnant woman or can be the result of a complication of pregnancy. When present as a complication of pregnancy, ascites is generally mild and is found in association with other clinical signs of overt disease. We describe the case of a young primaparous woman in whom eclampsia was revealed by abdomina l distension due to massive ascites as the leading symptom, preceded by a clinical picture consistent with a transient HELLP (haemolysis, elevated liver enzymes and low platelets) syndrome.

Influence of the physiological changes of gastric emptying on the simplified single sample 14C-urea breath test

The aim of this study was to assess the influence of the physiological changes of gastric emptying on the simplified 14C-urea breath test. Thirty patients performed the test in fasting conditions. Patients were orally administered 0.074 mega Bq of 14C-urea, mixed with 0.0185 mega Bq of 99mTc-S colloids in 25 ml water. A breath sample was taken before and 10 min after intake of the tracers and followed by a 2 min planar anterior scintigraphic image of the abdomen to measure gastric activity. Gastric emptying was estimated by dividing the residual gastric activity at 10 min by the total activity in the abdomen. The procedure was performed twice for each patient after a 24 h interval. The repeatability of both the gastric emptying test and the urea breath test was assessed by the method described by Bland and Altman. The coefficient of repeatability of the urea breath test was 1.18 for a confidence interval of 95%. The coefficient of repeatability of gastric emptying was 27.4. There was no significant correlation (r = 0.08) between the plot of the individual modifications of urea breath test and residual gastric activity in two successive tests. It is concluded that the physiological changes of gastric emptying do not influence the results obtained by the simplified, single-sample 14C-urea breath test.

Importance of precise timing in the simplified 10-min 14C-urea breath test procedure

Abstract: This study was performed to assess the impact of precise timing and the repeatability of the simplified 10-min 14C-urea breath test. Thirty-three patients underwent a 14C-urea breath test at 10 and 12 min (test I) and after 24 h (test II). The paired t-test was applied to assess differences between two successive measurements at 10 and 12 min, and the method of Bland and Altman was used to evaluate the repeatability of the test. Only test I (P = 0.004) showed a significant difference between two successive measurements at 10 and 12 min. The coefficients of repeatability at 10 and 12 min were 1.54 and 1.48, respectively. No bias was found. From this study, we can conclude that breath collections, delayed by 2 min (20% error), have no impact on the clinical interpretation of the results. The repeatability of the simplified 10-min 14C-urea breath test is sufficient for clinical use.

13C-urea breath test using infrared spectroscopy: practical recommendations

TO THE EDITOR: We read with interest the article by Savarinoet al. in a recent issue of this journal (1). We have also acquired clinical experience with the relatively lowpriced infrared spectroscopy over 2 yr. The advantages of this technique are the low cost (40,000 US dollars vs 115,000 US dollars for a mass spectrometer), and the fact no specialized personnel is needed to analyze the samples. This allows the opportunity to perform the test routinely, inside and also outside of specialized centers. In this setting, methodological recommendations are particularly important to avoid misinterpretations of the results. Concerning the need of a fasting status to guarantee an accurateC-urea breath test (UBT), conflicting results have been published in the literature (2, 3). We fully agree with the recommendation of Savarino et al. (1) that the UBT must be performed under fasted conditions. Indeed, we evaluated the coefficient of repeatability of the test according to Bland and Altman in about 100 consecutive patients who were fasting. The coefficient of repeatability between the two tests was 1.78, for a confidence interval of 95%. The test was performed in 30 other patients, successively fasted and after a nonstandardized meal, and this coefficient increased to 11.30, indicating a lack of reliability of the test performed under nonfasting conditions. Another methodological aspect concerns the influence of intake of proton pump inhibitors before the test, as this is known to influence the results (4). Using a systematic questionnaire in 250 patients, we could establish that about 15% of them were currently using these medications at the moment or not long before the test. We conclude that fasting conditions and attentive anamnesis are two key points to allow correct interpretation of the UBT in clinical practice.

Efficacy of vedolizumab for induction of clinical response and remission in patients with moderate to severe inflammatory bowel disease who failed at least two TNF antagonists

Background Vedolizumab is a recently available monoclonal antibody targeting α4β7 integrin for the treatment of ulcerative colitis (UC) and Crohn’s disease (CD). Objective The objective of this article is to evaluate the efficacy of vedolizumab induction therapy in anti-TNF-refractory/intolerant UC and CD patients in real life. Methods A cohort of 149 moderately to severely active UC and CD patients who failed or showed intolerance to at least two TNF antagonists participated in a medical need program and received vedolizumab in 37 Belgian centers (April–September 2015). Rates of clinical response and remission were retrospectively evaluated at Week 10 for UC and Week 14 for CD using the physician’s global assessment (PGA), Mayo score and Harvey Bradshaw index (HBI) or Crohns disease activity score (CDAI) scores. Results Eighty-four patients (29 UC, 55 CD) had sufficient data for analysis. For UC patients, clinical response was observed in 76% based on PGA and 59% based on the Mayo score. The corresponding percentages for CD patients were 80% for PGA and 65% for HBI/CDAI. Clinical remission rates were 10% and 40% for UC and CD, respectively. Steroid-free remission was observed in respectively 10% and 35%. Globally, corticosteroids were stopped in 14 out of 48 patients (29%). No new safety signals were reported. Conclusion Up to 70% TNF-refractory/intolerant UC and CD patients achieved a clinical response after 10 to 14 weeks of vedolizumab treatment in this real-life cohort.

Efficacy and safety of radiofrequency ablation of Barrett’s esophagus in the absence of reimbursement: a multicenter prospective Belgian registry

BACKGROUND  Radiofrequency ablation (RFA), combined with endoscopic resection, can be used as a primary treatment for low grade dysplasia, high grade dysplasia, and early esophageal adenocarcinoma (EAC) in Barretts esophagus (BE). The aim of the Belgian RFA registry is to capture the real-life outcome of endoscopic therapy for BE with RFA and to assess efficacy and safety outside study protocols, in the absence of reimbursement. PATIENTS AND METHODS  Between February 2008 and January 2017, data from 7 different expert centers were prospectively collected in the registry. Efficacy outcomes included complete remission of intestinal metaplasia (CR-IM), complete remission of dysplasia (CR-D), and durability of remission. Safety outcomes included immediate and late adverse events. RESULTS  684 RFA procedures in 342 different patients were registered. Of these, 295 patients were included in the efficacy analysis, with CR-IM achieved in 88 % and CR-D in 93 %, in per-protocol analysis; corresponding rates in intention-to-treat analysis were 82 % and 87 %, respectively. Sustained remission was seen in 65 % with a median (interquartile range) follow-up of 25 (12 - 47) months. No risk factors for recurrent disease were identified. Immediate complications occurred in 4 % of all procedures and 6 % of all patients, whereas late complications occurred in 9 % of all procedures and in 20 % of all patients. CONCLUSIONS  Data from the Belgian registry confirm that RFA in combination with endoscopic resection is an efficient treatment for BE with dysplasia or early EAC. In the absence of reimbursement, more rescue treatments are used, not compromising outcome. Since there is recurrent disease after CR-IM in 35 %, surveillance endoscopy remains necessary.