Gianpiero Manes

Mucosal Healing Predicts Late Outcomes After the First Course of Corticosteroids for Newly Diagnosed Ulcerative Colitis

BACKGROUND & AIMS It is uncertain whether mucosal healing after the first course of corticosteroids therapy predicts outcome in patients with ulcerative colitis (UC). We evaluated whether early clinical and endoscopic responses to this therapy are associated with late outcomes in UC. METHODS Patients with newly diagnosed UC who were prescribed corticosteroid therapy (n = 157) were followed up for 5 years. They were evaluated using clinical (Powel-Tuck [PT]) and endoscopic (Baron) indexes after 3 and 6 months, then every 6 months. Outcomes at month 3 (early response) were used to identify patients with complete (group A: PT, 0-1; Baron, 0), partial (group B: PT, 0-1; Baron, 1-3), or no response (group C: persistence of clinical and endoscopic activity). The association between early and late outcomes was assessed. RESULTS After 5 years, there were significant differences between complete and partial responders in the rates of hospitalization (25% in group A vs 48.7% in group B; P = .0152; odds ratio [OR], 2.85; 95% confidence interval [CI], 1.21-6.72), immunosuppression therapy (5% in group A vs 25.6% in group B; P = .0030; OR, 6.55; 95% CI, 1.67-25.67), colectomy (3.3% in group A vs 18.0% in group B; P = .0265; OR, 6.34; 95% CI, 1.24-32.37), and their combination (26.7% in group A vs 48.7% in group B; P = .0249; OR, 2.61; 95% CI, 1.12-6.11). After multivariate analysis, lack of mucosal healing was the only factor associated with negative outcomes at 5 years (immunosuppressors: hazard risk [HR], 10.581; 95% CI, 2.193-51.039; P = .0033; hospitalization: HR, 3.634; 95% CI, 1.556-8.485; P = .0029; colectomy: HR, 8.397; 95% CI, 1.278-55.186; P = .0268). CONCLUSIONS No mucosal healing after corticosteroid therapy is associated with a more aggressive disease course.

Intestinal metaplasia at the gastro-oesophageal junction: Helicobacter pylori gastritis or gastro-oesophageal reflux disease?

Background—Intestinal metaplasia, whether in the cardia or the distal oesophagus, has been uniformly defined as specialised columnar epithelium, suggesting a relation with Barrett’s oesophagus. It is, however, not clear whether the risk factors associated with intestinal metaplasia are identical at both sites. Aims—To investigate biopsy specimens obtained below the squamocolumnar junction (SCJ) in relation to endoscopic aspect, gastric histology, and clinical presentation. Patients and methods—In 423 patients investigated the endoscopic aspect of the SCJ was classified as unremarkable (group I, n=315) or suggestive of Barrett’s oesophagus (group II, n=108). Standardised biopsy specimens from the antrum, corpus, and directly below the SCJ were investigated. Results—Intestinal metaplasia was detected at the SCJ in 13.4% of group I patients, where it was significantly associated with gastric intestinal metaplasia (odds ratio (OR) 6.96; confidence interval (CI) 2.48 to 19.54) andH pylori (OR 7.85; CI 2.82 to 21.85), and in 34.3% of group II patients where it was significantly associated with reflux symptoms (OR 19.98; CI 6.12 to 65.19), erosive oesophagitis (OR 12.16; CI 3.86 to 38.24), and male sex (OR 6.25, CI 2.16 to 18.14), but not with H pylori or gastric intestinal metaplasia. Conclusion—This study suggests that the pathogenesis of intestinal metaplasia at the SCJ is not uniform: at an endoscopically unremarkable SCJ it is a sequela ofH pylori gastritis, but coexisting with endoscopic features of Barrett’s oesophagus it is associated with male sex and gastro-oesophageal reflux disease.

Pseudocysts in Acute Nonalcoholic Pancreatitis (Incidence and Natural History)

Epidemiological studies on pancreaticpseudocysts are retrospective analyses on alcoholicpatients. The aims of this study were to investigate theincidence, natural history, and predictors of theappearance and disappearance of pancreatic fluidcollections and pseudocysts after nonalcoholic acutepancreatitis. We carried out a prospective cohort studyin a series of 926 patients with acute pancreatitis.Pancreatic fluid collections or pseudocysts were treatedonly after complications. We studied pancreatic fluidcollections from 83 patients (8.9%): 48 of whomdeveloped pseudocysts (5.1%). Both were less frequent after biliary pancreatitis (P < 0.0001). Inthe first 60 days of follow-up, patients with fluidcollections or pseudocysts showed more complicationsthan spontaneous disappearance; two of them died. After the 60th day, spontaneous disappearancewas more frequent, and at one year the cumulativeincidence of complications and spontaneous disappearancewas 36% and 56%, respectively. A total of 33 patients with fluid collection needed interventionaltreatment (surgery or percutaneous or endoscopicdrainage). Pseudocysts that were small (<5 cm) ordeveloped in the tail had a higher incidence ofspontaneous disappearance: 22/24 (91.7%) and 11/12 (91.7%),respectively. In conclusion, fluid collections andpseudocysts after nonalcoholic pancreatitis have a lowincidence of complications and mortality with a high rate of spontaneous disappearance. Wesuggest treating them only aftercomplications.

Prophylaxis with meropenem of septic complications in acute pancreatitis: a randomized, controlled trial versus imipenem.

Objectives Prophylactic antibiotics are helpful in decreasing the incidence of septic complications in acute pancreatitis. The aim of this study was to compare the efficacy of meropenem, a new carbapenem antibiotic, with that of imipenem, which is the standard prophylactic treatment in patients with severe acute pancreatitis. Methods One hundred seventy-six patients with necrotizing pancreatitis were prospectively randomized to prophylactic treatment with 0.5 g meropenem t.i.d. intravenously or 0.5 g imipenem q.i.d. intravenously. The occurrence of infection of pancreatic necrosis, rate of extrapancreatic infections, systemic and local complications, need for surgery, mortality rate, and length of hospitalization were recorded for each group. When a septic complication of pancreatic necrosis was suspected, fine needle aspiration with cultures of the sample was performed. Surgery was performed in cases of verified infected necrosis. Conclusion No difference was observed between patients treated with meropenem and those treated with imipenem in terms of incidence of pancreatic infection (11.4% versus 13.6%) and extrapancreatic infections (21.6% versus 23.9%) and clinical outcome. Meropenem is as effective as imipenem in preventing septic complications of patients with severe acute pancreatitis.

Empirical prescribing for dyspepsia: randomised controlled trial of test and treat versus omeprazole treatment

Abstract Objective To compare the efficacy of a “Helicobacter pylori test and treat” strategy with that of an empirical trial of omeprazole in the non-endoscopic management by empirical prescribing of young patients with dyspepsia. Design Randomised controlled trial. Setting Hospital gastroenterology unit. Participants 219 patients under 45 years old presenting with dyspepsia without alarm symptoms. Intervention Patients received treatment with omeprazole 20 mg (group A) or with a urea breath test followed by an eradication treatment in case of H pylori infection or omeprazole alone in non-infected patients (group B). Lack of improvement or recurrence of symptoms prompted endoscopy. Main outcome measures Improvement in symptoms assessed by a dyspepsia severity score every two months; use of medical resources (endoscopic workload and medical consultation); clinical outcome. Results 96/109 (88%) patients in group A and 61/110 (55%) in group B (P < 0.0001) had endoscopy: in 19 patients in group A and 32 in group B (20/67 infected and 12/43 non-infected) because of no improvement; in 77 further patients in group A and 29 in group B (7 infected and 22 non-infected) because of recurrence of symptoms during follow up. Endoscopy showed peptic ulcers only in group A; oesophagitis occurred significantly more often in group B than in group A. About 80% of examinations were normal in both groups, but nine duodenal scars occurred in group A. Conclusions Eradication treatment allows resolution of symptoms in a large number of patients with dyspepsia and reduces the endoscopic workload. After a trial of omeprazole, symptoms recur in nearly every patient. Such treatment is also likely to mask an appreciable number of peptic ulcers and cases of oesophagitis.

Timing of antibiotic prophylaxis in acute pancreatitis : A controlled randomized study with meropenem

OBJECTIVES:Antibiotic prophylaxis improves the outcome of acute pancreatitis. Since bacterial translocation from the gut occurs in the first h of disease, early therapy is likely to achieve the maximal effect. The study compares early antibiotic treatment with treatment started after the demonstration of pancreatic necrosis.METHODS:Two hundred fifteen patients with pancreatitis were randomized to either group A (N = 108), who started antibiotic therapy (meropenem 500 mg t.i.d.) at admission, or group B (N = 107), who received antibiotics after the demonstration of necrosis at computed tomography (CT). CT was performed in both groups after at least 48 hr of hospitalization. The clinical course of disease was compared in the two groups.RESULTS:Thirty patients in group A and 29 in B showed necrosis on CT. The two groups were similar in demographics and characteristics of disease. Antibiotic treatment was started after 4.56 ± 1.2 days from hospitalization in group B and after 1.07 ± 0.6 days in A. Pancreatic infection occurred in four patients in group A (13.3%) and in nine in B (31%) (p = 0.1). Extrapancreatic infection occurred in 16.6% of patients in group A and in 44.8% in B (p < 0.05). Need for surgery and length of hospitalization were also higher in group B. Mortality rates were similar in the two groups, but, 3 of 4 patients with infected necrosis in group A and only 2 of 9 in group B died.CONCLUSIONS:Early antibiotic treatment is associated with a significant improvement in the prognosis of necrotizing acute pancreatitis (AP), because of a reduction in the occurrence of septic complications.

Is increased pancreatic pressure related to pain in chronic pancreatitis

SummaryIn this study, we investigated the relationship between pain and pancreatic pressure in patients with chronic pancreatitis (CP). We studied 12 patients with CP undergoing surgery and five controls with cancer of the pancreatic tail. CP was staged on the basis of morphological (ERP) and functional (serum-pancreolauryl test) criteria. Patients kept daily records of the intensity of pain on a linear analog scale. Intraoperatively, pressure within the pancreas was assessed by the introduction of a fine needle into the pancreatic parenchyma connected to a pressure transducer. In controls, pressure was determined in macroscopically normal tissue in the head of the pancreas. Pancreatic pressure was significantly higher in CP than in controls (29.9 ± 3.1 vs 7.2 ± 1.1 mmHg, p < 0.001). No relationship was found between the pain score and the pancreatic pressure. Pressure was positively correlated with ductal changes (r = 0.831;p<0.001), but not with exocrine function of the pancreas. Postoperatively, pancreatic pressure fell by 15.3% in four patients with CP in whom pressure assessment was repeated after surgical decompression. We conclude that pancreatic parenchy pressure is not closely related to pain in CP.

The incidence of main pancreatic duct disruption in severe biliary pancreatitis

BACKGROUND Little is known regarding the incidence of main pancreatic duct disruption in patients suffering from acute necrotizing pancreatitis and whether the occurrence of this disruption may contribute to the decision to intervene surgically. The aim of this prospective study was to assess these findings in a group of patients with acute necrotizing biliary pancreatitis. PATIENTS AND METHODS Seventy-five consecutive patients with necrotizing acute pancreatitis and suspected biliary etiology underwent endoscopic retrograde cholangiopancreatography within the first week upon admission. Biliary pancreatitis (common bile duct stones or endoscopic features probative for recent transpapillary stone migration in patients with gallstones) was confirmed in 70 patients. Imaging not only of the biliary tract but also of the pancreatic ducts was pursued. Fifty-one patients (72.8%) were conservatively treated, 19 (27.1%) underwent surgery: indication for surgery was infection of necrosis in 15 cases, pseudocysts in 3 cases, and fistula in 1 case. RESULTS Satisfactory visualization of the main pancreatic duct was achieved in 59 cases (84.3%). Disruption of the main pancreatic duct was observed in 18 cases (30.5%), ie, 5 of the 17 patients who underwent surgery and 13 of the 42 patients who were nonoperatively managed (NS). CONCLUSIONS Our results suggest that the loss of integrity of the main pancreatic duct, as verified with endoscopic pancreatography, constitutes quite a frequent event in acute biliary pancreatitis, and it should not be considered as an absolute indication for surgery in patients with sterile necrosis. Most of these patients can be safely managed without surgery.

Squamous papilloma of the esophagus: long-term follow up.

Abstract Background and Aim: Squamous papilloma of the esophagus is a rare benign tumor; less than 200 cases have been reported in the literature. The prevalence of endoscopically diagnosed squamous papilloma of the esophagus has been reported in only a very few series, and varies from 0.01 to 0.43%. Clinical relevance and possible association with other pathological conditions, namely if it is a premalignant lesion, remain a matter of debate. The etiology is controversial, although a role of human papilloma virus has been recently proposed. The aim of this study was to try to determine the prevalence, clinical relevance, possible association with other pathological conditions of the upper digestive tract, and possible etiological role of human papilloma virus on our series of squamous esophageal papillomas.

Endoscopic sphincterotomy and recurrence of acute pancreatitis in gallstone patients considered unfit for surgery

The aim of the present prospective study was to investigate whether endoscopic sphincterotomy may be useful in preventing recurrence of acute pancreatitis in patients with gallstones and a high anesthesiological risk of cholecystectomy. Twenty-six elderly patients with severe cardiopulmonary, hepatic, and renal diseases were considered. Endoscopic sphincterotomy was successful in 19 cases (group A: mean age, 78.4 years; range, 71–87) and failed in 7 patients (group B: mean age, 79.8 years; range 73–85). In the follow-up period biliary pain without an increase in pancreatic serum enzymes occurred in six patients in group A and in all patients in group B (p = 0.002); recurrence of acute biliary pancreatitis with a need for hospitalization occurred in one patient in group A and in four patients in group B (p = 0.01). These results suggest that endoscopic sphincterotomy may be considered a very useful option in reducing the recurrence of acute biliary pancreatitis in elderly patients with gallstones and a high anesthesiological risk of cholecystectomy.