Lawrence Cohen

Thalidomide therapy for patients with refractory Crohn's disease: An open-label trial

BACKGROUND & AIMS Inhibition of tumor necrosis factor is a proposed mechanism for the anti-inflammatory properties of thalidomide. We performed an open-label trial of thalidomide in refractory Crohns disease. METHODS Twenty-two patients with refractory Crohns disease (Crohns Disease Activity Index [CDAI] > 200 and/or draining perianal disease) initiated therapy with thalidomide, 200 mg at bedtime (18 patients), or 300 mg at bedtime (4 patients). CDAI and goal interval scores (GIS) were assessed at weeks 0, 4, and 12. Clinical response for patients with luminal disease was defined as reduction in CDAI score of >150 points and for fistula patients was 2 scores of >/=1+ in 3 parameters of the GIS. Clinical remission was defined as a total CDAI < 150 (luminal patients) or >/=2+ for all parameters of the GIS (fistula patients). RESULTS Nine patients with luminal disease and 13 with fistulas (16 male, 6 female) were enrolled. The median CDAI score at entry was 371 (95-468). Sixteen patients completed 4 weeks of treatment (12 clinical responses, 4 clinical remissions). All 14 patients completing 12 weeks met criteria for clinical response. Nine achieved clinical remission (3 luminal, 6 fistula patients). The median CDAI score was 175 (30-468; P < 0.001 vs. baseline). CONCLUSIONS Thalidomide is efficacious in some patients with refractory Crohns disease.

Acute Pancreatitis Due to 5-Aminosalicylate

Excerpt Acute pancreatitis has been described as a complication of sulfasalazine therapy in patients with inflammatory bowel disease (1-3). In a critical review, Mallory and Kern (4) suggested that...

Alcoholic Liver Disease: Role of Cytokines

The present review spans a broad spectrum of topics dealing with alcoholic liver disease (ALD), including clinical and translational research. It focuses on the role of the immune system and the signaling pathways of cytokines in the pathogenesis of ALD. An additional factor that contributes to the pathogenesis of ALD is lipopolysaccharide (LPS), which plays a central role in the induction of steatosis, inflammation, and fibrosis in the liver. LPS derived from the intestinal microbiota enters the portal circulation, and is recognized by macrophages (Kupffer cells) and hepatocytes. In individuals with ALD, excessive levels of LPS in the liver affect immune, parenchymal, and non-immune cells, which in turn release various inflammatory cytokines and recruit neutrophils and other inflammatory cells. In this review, we elucidate the mechanisms by which alcohol contributes to the activation of Kupffer cells and the inflammatory cascade. The role of the stellate cells in fibrogenesis is also discussed.

How Well Is Helicobacter pylori Treated in Usual Practice

BACKGROUND Helicobacter pylori is a WHO class I carcinogen also associated with nonmalignant gastrointestinal diseases. Effective treatment exists, and all persons infected with H pylori should receive treatment. However, data regarding the rates of treatment prescription in clinical practice are lacking. OBJECTIVE To determine the rates of H pylori treatment in usual practice. METHODS Patients with histological evidence of H pylori infection between January 1, 2007, and December 31, 2007, at Sunnybrook Health Sciences Centre (Toronto, Ontario) were identified. Charts were reviewed to determine the rates of H pylori treatment and confirmation of eradication, when indicated. Questionnaires were subsequently sent to endoscopists of patients identified as not having received treatment to determine the reasons for lack of treatment. RESULTS A total of 102 patients were H pylori positive and were appropriate candidates for treatment, of whom 58 (57%) were male and 78 (76%) were outpatients, with 92 (90%) receiving eradication therapy. When indicated, 15 of 22 (68%) patients received confirmation of eradication, 13 of 18 (72%) patients underwent repeat endoscopy and 86% received complete therapy. Outpatients were more likely to receive eradication therapy (OR 10.3 [95% CI 2.6 to 40.4]; P=0.001) and complete therapy (OR 13.2 [95% CI 3.8 to 45.7]; P=0.0001) compared with inpatients. Having a follow-up appointment resulted in higher treatment rates (OR 12.0 [95% CI 3.0 to 47.5]; P=0.001). CONCLUSION During the time period studied, adequate rates of H pylori treatment were achieved in outpatients and patients who had formal follow-up at Sunnybrook Health Sciences Centre. However, some aspects of care remain suboptimal including treatment of inpatients and care following treatment. Additional studies are required to identify strategies to improve the care of patients infected with H pylori.

Spontaneous fracture of a covered self-expandable biliary metal stent and endoscopic technique for removal

1Department of Medicine, McMaster University, Hamilton; 2Department of Gastroenterology, Sunnybrook Health Science, Toronto, Ontario Correspondence: Dr Lawrence Cohen, Department of Gastroenterology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, HG-63, Toronto, Ontario M4N 3N5. Telephone 416-480-4725, fax 416-480-5977, e-mail lawrence.cohen@sunnybrook.ca Received for publication June 21, 2014. Accepted July 1, 2014 CASE PRESENTATION A 67-year-old woman was brought to the endoscopy unit in May 2014 for removal of a covered self-expanding metal stent (SEMS) from the common bile duct (CBD), initially placed in May 2013 to manage recurrent cholangitis. The patient developed idiopathic pancreaticobiliary dysmotility following cholecystectomy in 2001. She experienced recurrent episodes of pancreatitis and cholangitis for which she required numerous endoscopic retrograde cholangiopancreatograms, including the insertion of biliary plastic stents to facilitate drainage, extraction of CBD stones and/or clearing debris from the biliary tree. Her most recent intervention had been the insertion of a SEMS, which was effective in preventing recurrent cholangitis over the year. On physical examination, she appeared to be fit, well-nourished and in no distress, with no pallor, jaundice or lymphadenopathy. An abdominal examination was unremarkable. Laboratory investigations were within normal limits, without any contraindications to endoscopy.

Metastatic bladder carcinoma to ampulla of Vater.

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