Georges Coremans

Magnetic resonance imaging of the effects of infliximab on perianal fistulizing Crohn's disease.

OBJECTIVES:Although the clinical efficacy of infliximab as measured by closure of fistulas in Crohns disease has been demonstrated, its influence on the inflammatory changes in the fistula tracks is less clear. The aim of the present study was to assess the behavior of perianal fistulas before and after infliximab treatment.METHODS:Magnetic resonance imaging (MRI) and clinical evaluation were performed in a total of 18 patients before and after treatment with infliximab. An MRI-based score of perianal Crohns disease severity was developed using both criteria of local extension of fistulas (complexity, supralavetoric extension, relation to the sphincters and of active inflammation (T2 hyperintensity, presence of cavities/abscesses, and rectal wall involvement).RESULTS:The MRI score was reliable in assessing the fistula tracks, with a good interobserver concordance (p < 0.001). Fistula tracks with signs of active inflammation were found in all 18 patients at baseline and collections in seven. After short-term infliximab treatment, active tracks persisted in eight of 11 patients who had clinically responded to infliximab. After long-term (46 wk) infliximab therapy, MRI signs of active track inflammation had resolved in three of six patients.CONCLUSIONS:We have developed an MRI-based score of perianal Crohns disease severity to assess the anatomical evolution of Crohns fistulas. Our study demonstrates that despite closure of draining external orifices after infliximab therapy, fistula tracks persist with varying degrees of residual inflammation, which may cause recurrent fistulas and pelvic abscesses. Whether complete fistula fibrosis occurs over time with repeated infliximab infusions needs further study.

Efficacy and safety of hydrostatic balloon dilatation of ileocolonic Crohn's strictures: a prospective longterm analysis.

Preliminary reports have suggested that dilatation using hydrostatic through the scope balloons may be useful for the treatment of Crohns strictures, A prospective longterm follow up (mean (SD) 33.6 (11.2) months) was carried out in 55 Crohns patients with 59 ileocolonic strictures submitted to 78 dilatation procedures. Hydrostatic balloons were used (Rigiflator, Microvasive) with a diameter of 18 mm on inflation. As soon as the balloons became available dilatation up to a diameter of 20 and 25 mm was attempted. The dilatations were performed under general anaesthesia using propofol (Diprivan). The patients were kept for one night in the hospital after dilatation. Seventy (90%) procedures were technically successful and passage of the stricture with a 13.6 mm diameter colonoscope was possible after 73% of the dilatations. Complications occurred in six patients (11%; 8% of procedures), including sealed perforations (n = 2), retroperitoneal perforations (n = 2), and intraperitoneal perforations (n = 2). Two of the patients were treated surgically with a one stage resection of the stricture and recovered uneventfully. Four patients were treated conservatively with intravenous fluids and antibiotics. There was no mortality. Dilatation completely relieved obstructive symptoms in 20 patients after one procedure, in another 14 patients after two (n = 13) or three (n = 1) dilatations. Total longterm success rate was 34 of 55 patients (62%). Nineteen patients (38%) were operated on because of persistent obstructive symptoms. The data show that endoscopic dilatation using the through the scope hydrostatic balloon system relieves obstructive symptoms resulting from ileocolonic Crohns strictures. The procedure, however, carries a definite risk of perforation.

Long term results of treatment of vascular malformations of the gastrointestinal tract by neodymium Yag laser photocoagulation.

The effect of Yag laser photocoagulation on the course of bleeding of gastrointestinal vascular malformations was studied in 59 patients, with a total of 482 lesions. The lesions were located in the upper gastrointestinal tract alone in 25 patients, in the lower tract alone in 31 patients and in both the lower and the upper gastrointestinal tract in three patients. In the month before laser therapy the number of bleeding episodes averaged 1.09 +/- 0.6 (SD) per patient (n = 57) and the transfusion requirements 2.4 +/- 2.6 red blood cells units per patient, while in the month after treatment the bleeding incidence averaged 0.16 +/- 0.5 and the transfusion requirements 0.21 +/- 0.8 (both p less than 0.001). Long term results were analysed considering for each patient an equally long pretreatment and follow up period. After a mean follow up period of 11.5 months (1-48 months), 17 of the 57 patients available for follow up rebled. The reduction of the bleeding rate was statistically significant at one, six, 12, and 18 months of follow up, while transfusion rate was significantly decreased at one, six, and 12 months. The results were disappointing in patients with Osler-Weber-Rendu (n = 4) and in patients with angiomas associated with Von Willebrands disease (n = 3), who all rebled. In angiodysplasia the treatment was successful in 82% of the 49 patients. The more numerous the lesions, the less effective the reduction in bleeding rate by laser treatment was. Histological studies showed that the haemostatic effect of Yag laser photocoagulation was obtained by destruction of the lesion. Rebleeding was due to lesions missed at the first treatment, incompletely treated lesions and recurrence of new lesions. In two patients a free caecal perforation necessitated a right hemicolectomy. In both patients numerous or very large lesions had been treated in the caecum.

Long Term outcome of endoscopic dilatation in patients with Crohn’s disease is not affected by disease activity or medical therapy

Background Endoscopic dilatation of Crohns disease-related strictures is an alternative to surgical resection in selected patients. The influence of disease activity and concomitant medical therapy on long-term outcomes is largely unknown. Aim and methods To study the long-term safety and efficacy of stricture dilatation in a single centre cohort. Results Between 1995 and 2006, 237 dilatations where performed in 138 patients (mean age 50.6±13.4, 56% female) for a clinically obstructive stricture (<5 cm, 84% anastomotic). Immediate success of a first dilatation was 97% with a 5% serious complication rate. After a median follow-up of 5.8 years (IQR 3.0–8.4), recurrent obstructive symptoms led to a new dilatation in 46% or surgery in 24%. Niether elevated levels of C-reactive protein nor endoscopic disease activity predicted the need for new intervention. None of the concomitant therapies influenced the outcome. Conclusion This largest series ever reported confirms that long term efficacy of endoscopic dilatation of Crohns disease outweighs the complication risk. Neither active disease at the time of dilatation nor medical therapy afterwards predict recurrent dilatation or surgery.

Controlled Trial of YAG Laser Treatment of Upper Digestive Hemorrhage

A trial of neodymium-yttrium-aluminum-garnet laser treatment was conducted in 152 patients with upper gastrointestinal hemorrhage. Laser photocoagulation was applied in 0.5- to 1-s pulses of 55-80 W power. A first part of the trial studying patients with arterial bleeding was uncontrolled. Spurting arterial bleedings could be stopped in 87% of the 23 patients with acute arterial hemorrhage. The recurrence rate after endoscopic treatment of this type of bleeding was high (55%). The operation rate of 61% was, however, lower than the operative indications amounting to 95% in patients with arterial spurters admitted previously to our department. One hundred twenty-nine patients were included in a controlled randomized trial of laser photocoagulation. In 86 patients with active, nonspurting bleeding, the laser was significantly better (p less than 0.001) at stopping the bleeding than conservative treatment in randomized controls, and there was a numerical although not significant reduction of the rate of bleeding recurrence and the necessity for surgery (both p less than 0.1). In 43 patients with fresh stigmata of bleeding (i.e., fresh clot or visible vessel) laser treatment resulted in a numerical reduction in the rate of rebleeding and in the operative indications, but the difference did not reach statistical significance. The mortality rates were not influenced in any of the groups.

Ambulatory gastrojejunal manometry in severe motility-like dyspepsia: lack of correlation between dysmotility, symptoms, and gastric emptying

Background—Previous studies have failed to identify manometric patterns of gastrointestinal motor activity that can distinguish dyspepsia from health. Aims—To test the hypothesis that the combined use of prolonged, ambulatory, antrojejunal manometry and computer aided analysis in patients selected for the severity of their symptoms could reveal new insights into gastrointestinal motor activity in patients with severe motility-like dyspesia Methods—Twenty four hour antrojejunal ambulatory manometry was performed in 14 patients and 10 healthy volunteers. Parameters characterising digestive and fasted motility were obtained by a validated computer program and visual analysis. Scoring systems quantified the degree of dysmotility as well as the severity of symptoms. Gastric emptying times were measured in each patient. Results—There was a high prevalence of antral and jejunal dysmotility both during the interdigestive period (71% of patients) and in the postprandial period (78%). During the interdigestive period there was a reduced incidence of antral and jejunal phases, a larger contribution of phase 2 during migrating motor complex cycles, and aberrant configuration of jejunal phase 3 in 29% of patients. Postprandially, the most frequent finding was antral (29% of patients) or jejunal (29%) hypomotility or hypermotility. Minute rhythm was present both during the postprandial (29% of patients) and the interdigestive period (21%). There was no positive correlation between symptom scores, gastric half emptying times, or motility scores. Conclusion—Even with the use of prolonged recordings and advanced computer aided analysis, it is not possible to identify a specific motor pattern which can discriminate patients with severe motility-like dyspepsia from those with other diseases or even healthy individuals. Clinical symptoms or gastric half emptying times are poor predictors of gastrointestinal dysmotility in patients with functional dyspepsia.

Endoscopic balloon dilation of colonic and ileo-colonic Crohn’s strictures: long-term results

The long-term effects of endoscopic dilation of colonic or ileo-colonic Crohns disease strictures were analyzed. In 18 patients with a Crohns disease-related low gastrointestinal stricture, the stenosis was dilated using through-the-scope (TTS) balloon catheters. A dilation to a diameter of 18 mm was always attempted. Treatment was successfully carried out in 16 patients, and was followed by immediate symptomatic relief in 14 patients. Long-term success was observed in nine patients. There were no complications. Balloon catheter dilation of a colonic stricture or stricture of an ileo-colonic anastomosis was found to be safe and effective. This treatment modality can be an alternative to surgery in a selected group of patients.

Comparison of endoscopic polidocanol injection and YAG laser therapy for bleeding peptic ulcers

392 patients were examined by endoscopy for acute upper gastrointestinal bleeding; 140 had ulcers containing an actively bleeding visible vessel or a non-bleeding visible vessel and were enrolled in a randomised trial of three endoscopic methods of haemostasis--adrenaline (1/10(4] alone, adrenaline plus polidocanol 1%, and adrenaline followed by yttrium-aluminium-garnet (YAG) laser photocoagulation. For patients with non-bleeding visible vessels sham treatment was significantly less effective in achieving haemostasis (8 of 20 patients) than were adrenaline plus polidocanol (18 of 20; p = 0.002) and adrenaline plus laser (16 of 20; p = 0.012). All three treatments significantly reduced total transfusion needs compared with sham treatment. For the whole group of patients, adrenaline plus polidocanol was significantly more effective than adrenaline alone in achieving permanent haemostasis; adrenaline plus laser was also more effective than adrenaline alone, but not significantly so. The efficacy of the three treatments was enhanced by repeated application on recurrence of bleeding. Since injection therapy with adrenaline and polidocanol was at least as effective as adrenaline plus laser therapy, it should be preferred over laser therapy because it is cheaper, easier to use, and perhaps also safer.

Gastrointestinal motility disorders

A classification of gastrointestinal motility disorders is offered based upon the type of disorder in transit (delay or acceleration), and the region of the gastrointestinal tract affected. Specific abnormalities of myoelectrical patterns are identified when possible and related to disturbances in transit in the stomach and small bowel.

The value of ileoscopy with biopsy in the diagnosis of intestinal Crohn’s disease

Studies to determine the diagnostic value of ileoscopy and biopsy are not available. In an attempt to clarify the role of this technique in the diagnosis of intestinal Crohns disease, 110 patients with a radiological diagnosis of inflammatory disease of the terminal ileum were examined in a prospective study. Suspicion of Crohns disease was rejected in 28 patients. In 18 patients the terminal ileum was normal, while 10 patients had lymphoid nodular hyperplasia. Endoscopic lesions with a predictive value of 0.96 were found in 25 of 48 patients with the final diagnosis of Crohns disease. Diagnostic granulomas were only found in 4 patients, but lesions consistent with Crohns disease were present in the pathology sections of 17 patients. It was concluded that ileoscopy with biopsy is a valuable tool in the diagnosis of inflammatory ileal disease and can provide useful information about the nature and extent of the inflammation.