M. Coletta

Is the subjective perception of lactose intolerance influenced by the psychological profile

Symptoms of lactose intolerance are often attributed to lactose malabsorption but, as this relationship has not been demonstrated when a small dose of lactose similar to that contained in one cup of milk is ingested by intolerant patients, psychological factors may play a role in altered symptom perception.

Chronic constipation: A critical review

Chronic constipation is a very common symptom that is rarely associated with life-threatening diseases, but has a substantial impact on patient quality of life and consumption of healthcare resources. Despite the large number of affected patients and the social relevance of the condition, no cost-effectiveness analysis has been made of any diagnostic or therapeutic algorithm, and there are few data comparing different diagnostic and therapeutic approaches in the long term. In this scenario, increasing emphasis has been placed on demonstrating that a number of older and new therapeutic options are effective in treating chronic constipation in well-performed randomised controlled trials, but there is still debate as to when these therapeutic options should be included in diagnostic and therapeutic algorithms. The aim of this review is to perform a critical evaluation of the current diagnostic and therapeutic options available for adult patients with chronic constipation in order to identify a rational patient approach; furthermore we attempt to clarify some of the more controversial points to aid clinicians in managing this symptom in a more efficacious and cost-effective manner.

Ultrasound Elasticity Imaging Predicts Therapeutic Outcomes of Patients With Crohn’s Disease Treated With Anti-Tumour Necrosis Factor Antibodies

Background and Aims Ultrasound elasticity imaging is a non-invasive technique developed to evaluate fibrosis. Measuring tissue strain by ultrasound elasticity imaging can reliably detect severe ileal fibrosis in patients with Crohns disease [CD]. We have hypothesised that a more severe range of fibrosis might influence the therapeutic response to anti-tumour necrosis factor [TNF] treatment. The aim of this study was to assess the ability of ultrasound elasticity imaging to predict the therapeutic outcome for CD patients. Methods Consecutive patients with ileal/ileocolonic CD, starting anti-TNF treatment, were enrolled for the study. These patients underwent bowel ultrasound and ultrasound elasticity imaging at baseline and at 14 and 52 weeks after anti-TNF treatment. Bowel wall stiffness was quantified by calculating the strain ratio between the mesenteric tissue and the bowel wall. Strain ratio ≥ 2 was used to identify severe ileal fibrosis. Transmural healing at 14 and 52 weeks was defined as bowel wall thickness ≤ 3 mm. Results Thirty patients with CD were enrolled. Five patients underwent surgery for bowel obstruction. The frequency of surgeries was significantly greater in patients with a strain ratio ≥ 2 at baseline [p = 0.003]. A significant reduction of the bowel thickness was observed after 14 and 52 weeks of anti-TNF treatment [p < 0.005]. A significant inverse correlation was observed between the strain ratio values at baseline and the thickness variations following anti-TNF therapy [p = 0.007]; 27% of patients achieved transmural healing at 14 weeks. The baseline strain ratio was significantly lower in patients with transmural healing [p < 0.05]. Conclusions This study shows that ultrasound elasticity imaging predicts therapeutic outcomes for CD patients treated with anti-TNF.

Evolving roles of cross-sectional imaging in Crohn's disease

The implementation of cross-sectional imaging techniques for the clinical management of Crohns disease patients has steadily grown over the recent years, thanks to a series of technological advances, including the evolution of contrast media for magnetic resonance, computed tomography and bowel ultrasound. This has resulted in a continuous improvement of diagnostic accuracy and capability to detect Crohns disease-related complications. Additionally, a progressive widening of indications for cross-sectional imaging in Crohns disease has been put forward, thus leading to hypothesize that in the near future imaging techniques can increasingly complement endoscopy in most clinical settings, including the grading of disease activity and the assessment of mucosal healing or Crohns disease post-surgical recurrence.

Magnetic resonance imaging of rectal volume in patients with irritable bowel syndrome

BACKGROUND Extreme stool forms (1 and 2, or 6 and 7 of the Bristol stool scale) are frequent in patients with irritable bowel syndrome and are associated with colonic transit, but it is not known whether these alterations influence rectal reservoir function. AIMS To investigate rectal reservoir function by assessing magnetic resonance imaging reconstructions of rectal volume in healthy subjects and patients with irritable bowel syndrome, and to establish whether it varies depending on the bowel habits of the patients. METHODS Twelve healthy subjects and 20 patients with irritable bowel syndrome (with constipation, diarrhoea, mixed or undefined bowel habit according to the Rome III criteria) underwent pelvic magnetic resonance imaging in the absence of rectal sensations. T2 sagittal images were used to calculate rectal volume by multiplying inter-slice thickness by rectal area, and summing the inter-slice volumes. RESULTS Stool form was significantly different in the irritable bowel syndrome patients with diarrhoea or constipation, and bowel movements were more frequent in the irritable bowel syndrome patients than in the healthy subjects. Rectal volume was significantly smaller in the irritable bowel syndrome patients (27 ± 13 mL vs. 44 ± 21 mL; P=0.04), with no significant differences between the bowel habit sub-types. CONCLUSION The reduced rectal volume in irritable bowel syndrome patients suggests that rectal tone is increased and that, at least in the absence of rectal sensations, the rectum is not over-distended by stools.

Previous colonic resection is a risk factor for surgical relapse in Crohn’s disease

BACKGROUND Despite the improvement of medical therapies, nearly half of patients with Crohns disease require surgery within 10 years after diagnosis. However, intestinal resection is not curative and recurrence may occur. AIMS To evaluate post-surgical outcomes for patients with Crohns disease in a large monocentric cohort, and to identify variables associated with clinical and surgical relapse. METHODS Patients with Crohns disease who had surgery for ileal and colonic Crohns disease between 2004 and 2016 and on at least one-year follow-up following surgery were included. RESULTS One hundred ninety-three patients were included in the study. Crohns disease recurrence concerned 53% of patients after a median 56-month (6-158) follow-up and 29% of patients required a second surgical intervention. At logistic regression analysis, active smoking and young age at diagnosis were identified as independent risk factor for post-surgical relapse (p = 0.01), while colonic or ileocolonic resection was recognized as a risk factor for surgical Crohns disease relapse (p = 0.003). CONCLUSIONS Post-surgery recurrence is frequent for patients with Crohns disease. Active smoking and young age at diagnosis are risk factors for Crohns disease recurrence. As compared with patients undergoing small-bowel surgery, patients with colonic resection are proner to relapse requiring a second surgical intervention.

Study of somatization in IBS

Sirs: Thank you for your interest in our paper and this opportunity to compare our results with those of your recent study of somatization in IBS. The prevalence of a high somatization score was confirmed in 36% of our IBS, even after the exclusion of the only gastrointestinal (GI) item (‘nausea or upset stomach’) included in the SCL90-R somatization subscale. The discrepancy with your findings may be due to the differences in the questionnaires, the cut-off values used to define a ‘high’ level of somatization, or the enrolled patients (tertiary vs secondary). As somatization scores are significantly higher in patients with more severe IBS, our inclusion of patients with more severe IBS in a tertiary referral center may have increased the prevalence of altered scores. Unlike your findings, our analysis of somatization scores by bowel subtype showed that the prevalence of high scores was lower among patients with IBS-M/U (9%) than in those of IBS-D (16%) or IBS-C (10%). It may be worth considering whether the use of questionnaires instead of diary cards to define bowel subtype may have influenced your results. We have also re-analyzed the relationship between somatization and bloating scores (as reported in the IBS-SS questionnaire) and, even after the exclusion of the item ‘nausea or upset stomach’, bloating symptoms were not significantly different in the patients with high or low somatization scores. However, consistent with your observations, there was a significant relationship between the two scores (Spearman’s rank correlation test = 0.33; p = 0.01). Finally, we would like to comment on your statement that the exclusion of all GI symptoms from the questionnaire to assess somatization in IBS patients is a more realistic approach to evaluating the degree of association between the two conditions. We fully agree that the exclusion of items such as constipation or loose stools, which are part of the definition of IBS, should be excluded to avoid unrealistic high scores. However, it is less clear why items such as ‘nausea or upset stomach’ should be excluded, because the tendency of somatizing patients to amplify their visceral sensations may also apply to these symptoms. Therefore, although the exclusion of all GI symptoms might be a practical approach, the rationale underlying the exclusion of upper GI symptoms from the somatization subscale remains to be demonstrated.

Discrepancy between recalled and recorded bowel habits in irritable bowel syndrome: Bowel habit subtypes in irritable bowel syndrome

Aliment Pharmacol Ther 2010; 32: 282ash;288