R. de Franchis

European evidence based consensus on the diagnosis and management of Crohn’s disease: special situations

This third section of the European Crohn’s and Colitis Organisation (ECCO) Consensus on the management of Crohn’s disease concerns postoperative recurrence, fistulating disease, paediatrics, pregnancy, psychosomatics, extraintestinal manifestations, and alternative therapy. The first section on definitions and diagnosis reports on the aims and methods of the consensus, as well as sections on diagnosis, pathology, and classification of Crohn’s disease. The second section on current management addresses treatment of active disease, maintenance of medically induced remission, and surgery of Crohn’s disease.

European Society of Gastrointestinal Endoscopy (ESGE): recommendations (2009) on clinical use of video capsule endoscopy to investigate small-bowel, esophageal and colonic diseases.

These recommendations on video capsule endoscopy, an emerging technology with an impact on the practice of endoscopy, were developed by the European Society of Gastrointestinal Endoscopy (ESGE) Guidelines Committee. The first draft of each section was prepared by one or two members of the writing team, who were selected as experts on the content of that section on the basis of their published work. They used evidence-based methodology, performing MEDLINE and PubMed literature searches to identify relevant clinical studies. Abstracts from scientific meetings were included only if there was no published full paper on a particular topic. If there was disagreement, the first author of the Guideline made the final decision. Recommendations were graded according to the strength of the supporting evidence. The draft guideline was critically reviewed by all authors and submitted to the ESGE councillors for their critical review before approval of the final document. The ESGE Guidelines Committee acknowledges that this document is based on a critical review of the data available at the time of preparation and that further studies may be needed to clarify some aspects. Moreover, this Guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. This document should be regarded as supplying recommendations only to gastroenterologists in providing care to their patients. It is not a set of rules and should not be construed as establishing a legal standard of care, or as encouraging, advocating, requiring, or discouraging any particular treatment. These recommendations must be interpreted according to the clinicians knowledge, expertise, and clinical judgment in the management of individual patients and, if necessary, a course of action that varies from recommendations must be undertaken.

Small-bowel neoplasms in patients undergoing video capsule endoscopy : a multicenter European study

BACKGROUND AND STUDY AIM Small-bowel tumors account for 1% - 3% of all gastrointestinal neoplasms. Recent studies with video capsule endoscopy (VCE) suggest that the frequency of these tumors may be substantially higher than previously reported. The aim of the study was to evaluate the frequency, clinical presentation, diagnostic/therapeutic work-up, and endoscopic appearance of small-bowel tumors in a large population of patients undergoing VCE. PATIENTS AND METHODS Identification by a questionnaire of patients with VCE findings suggesting small-bowel tumors and histological confirmation of the neoplasm seen in 29 centers of 10 European Countries. RESULTS Of 5129 patients undergoing VCE, 124 (2.4%) had small-bowel tumors (112 primary, 12 metastatic). Among these patients, indications for VCE were: obscure gastrointestinal bleeding (108 patients), abdominal pain (9), search for primary neoplasm (6), diarrhea with malabsorption (1). The main primary small-bowel tumor type was gastrointestinal stromal tumor (GIST) (32%) followed by adenocarcinoma (20%) and carcinoid (15%); 66% of secondary small-bowel tumors were melanomas. Of the tumors, 80.6% were identified solely on the basis of VCE findings. 55 patients underwent VCE as the third procedure after negative bidirectional endoscopy. The lesions were single in 89.5% of cases, and multiple in 10.5%. Retention of the capsule occurred in 9.8% of patients with small-bowel tumors. After VCE, 54/124 patients underwent 57 other examinations before treatment; in these patients enteroscopy, when performed, showed a high diagnostic yield. Treatment was surgery in 95% of cases. CONCLUSIONS Our data suggest that VCE detects small-bowel tumors in a small proportion of patients undergoing this examination, but the early use of this tool can shorten the diagnostic work-up and influence the subsequent management of these patients.

Colon capsule endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

PillCam colon capsule endoscopy (CCE) is an innovative noninvasive, and painless ingestible capsule technique that allows exploration of the colon without the need for sedation and gas insufflation. Although it is already available in European and other countries, the clinical indications for CCE as well as the reporting and work-up of detected findings have not yet been standardized. The aim of this evidence-based and consensus-based guideline, commissioned by the European Society of Gastrointestinal Endoscopy (ESGE) is to furnish healthcare providers with a comprehensive framework for potential implementation of this technique in a clinical setting.

High prevalence of Helicobacter pylori infection in patients with colonic adenomas and carcinomas

In some uncontrolled studies, a high prevalence of Helicobacter pylori infection unexpectedly has been found in patients with colorectal cancer. The purpose of the study was to investigate the prevalence of H. pylori infection in patients with colonic polyps or cancer. We reviewed 50 consecutive patients with either colonic adenomas or cancer who entered a preliminary case-control study. For each patient, 2 age- and gender-matched control subjects were selected (72 males; mean age, 63.1 years). A further 44 consecutive patients (30 with polyps and 14 with cancer) subsequently were enrolled. The H. pylori prevalence in patients with either polyps or cancer was compared with that in control subjects. Anti-H. pylori immunoglobulin G antibodies were assayed by an immunoenzymatic method. The prevalence of H. pylori antibodies was 49 (49%) of 100 in control subjects, 40 (71.4%) of 56 in patients with polyps (p < 0.006 vs. control subjects), and 21 (55%) of 38 in patients with cancer (not significant). Among patients with colorectal cancer, H. pylori prevalence was 9 (69.2%) of 13 for patients evaluated at the time of diagnosis and 12 (48%) of 25 for patients evaluated 1 to 9 years after surgery. We conclude that colonic neoplastic lesions, especially adenomas, are associated with an increased prevalence of H. pylori infection. The mechanisms underlying this association need to be elucidated.

Mesalazine (5-Aminosalicylic Acid) Suppositories in the Treatment of Ulcerative Proctitis or Distal Proctosigmoiditis: A Randomized Controlled Trial

A multicentre double-blind study was conducted to evaluate the efficacy and tolerability of 1 g or 1.5 g mesalazine daily compared with placebo in 94 patients with mild to moderate distal proctosigmoiditis (less than 20 cm). The study end point was the determination of clinical, endoscopic, and histologic remission rates at 4 weeks. Eleven patients, nine receiving placebo and two receiving 1.5 g mesalazine, withdrew during trial, mostly because of worsening of symptoms. At 4 weeks clinical remission was achieved in 7 of 31 (39%) patients with placebo, in 22 of 32 (69%) patients in the 1 g mesalazine group, and 23 of 31 (74%) patients in the 1.5 g mesalazine group. No serious clinical or biochemical side effect of treatment was reported. Mesalazine suppositories are safe, well tolerated, and very effective in patients with active distal proctosigmoiditis: 500 mg twice daily appears a suitable dose regimen.

Oral versus combination mesalazine therapy in active ulcerative colitis: a double‐blind, double‐dummy, randomized multicentre study

Oral and topical mesalazine formulations are effective in active ulcerative colitis, but little is known on the efficacy of combined treatment.

High rate of positive anti-tissue transglutaminase antibodies in chronic liver disease: Role of liver decompensation and of the antigen source

Background: Since the recognition of tissue transglutaminase (tTG) as the target antigen of anti-endomysium antibodies, several ELISA assays using either guinea pig or human recombinant tTG have been developed. The aim of the study was to compare the behaviour of anti-tTG and anti-endomysium antibodies assays in coeliacs and in patients with chronic liver disease. Methods: 34 patients (24 women, 34.9 ± 12.5 years) with coeliac disease and 41 with chronic liver disease (14 women, 57 ± 11.2 years), including 19 cirrhotics, were evaluated for anti-endomysium antibodies by indirect immunofluorescence and for anti-tTG IgA antibodies by ELISA, using guinea pig liver or human recombinant transglutaminase. Results: The prevalences of anti-tTG and anti-endomysium antibodies were 100% in patients with coeliac disease at diagnosis, 75% and 64.3% in patients on a gluten-free diet. All liver disease patients were negative for anti-endomysium antibodies, while 11 (26.8%) were positive for anti-tTG. All these patients had liver cirrhosis and represented 57.9% of all cirrhotics. The presence of anti-tTG was associated with higher Child-Pugh scores. The use of human transglutaminase determined a reduction in the rate of positive results; however, the rate of positive anti-tTG was still 17.1% in all liver disease patients and 31.6% in cirrhotics. Conclusions: Our data confirm that anti-tTG have a similar sensitivity compared with anti-endomysium antibodies assay in coeliacs. However, a high prevalence of positive anti-tTG results is observed in cirrhotic patients, even when human recombinant tTG is used. The high prevalence of positive results among cirrhotic patients is associated with more advanced liver disease.

Assessment of Thrombin-Activatable Fibrinolysis Inhibitor (TAFI) Plasma Levels in Inflammatory Bowel Diseases

OBJECTIVES:Hypofibrinolysis has been proposed as a possible mechanism underlying the known risk of thrombosis observed in patients with inflammatory bowel diseases (IBD). Thrombin-activatable fibrinolysis inhibitor (TAFI) is a recently described inhibitor of fibrinolysis. Increased TAFI plasma levels are associated with a risk for venous thrombosis. The objective was to evaluate TAFI plasma levels and their possible correlations with clinical features and acute-phase reactants in IBD patients.METHODS:Eighty-one IBD patients (47 Crohns disease and 34 ulcerative colitis) and 81 sex- and age-matched healthy controls were enrolled in the study; moreover, we studied 30 inflammatory controls (13 Reiters syndrome, 4 Behçets syndrome, and 13 patients with newly diagnosed celiac disease). TAFI plasma levels were assessed by means of a commercially available ELISA kit. Erythrocytes sedimentation rate, C-reactive protein, and α1-acid glycoprotein were measured as acute-phase reactants. Statistical analysis was performed by means of nonparametric tests and Fishers exact test and χ2 test for independence.RESULTS:Median TAFI plasma levels were significantly higher in IBD patients (116.0%, range: 39.0–232.0%) and in inflammatory controls (176.0%, 50.0–435.0%) than in healthy controls (99.0%, 40.0–170.0%) (p≤ 0.05 and p≤ 0.001, respectively). TAFI plasma levels higher than the 95th percentile of control values were significantly more frequent in IBD patients (19.7%) and in inflammatory controls (53.3%) than in healthy controls (4.9%) (p≤ 0.008 and p≤ 0.0001, respectively) and more frequent in clinically active IBD than in clinically quiescent IBD (31.4% vs 10.9%, p≤ 0.03). Finally, in IBD, significant correlations were observed between TAFI plasma levels and erythrocytes sedimentation rate (p≤ 0.02), C-reactive protein (p≤ 0.001), and α1-acid glycoprotein (p≤ 0.05).CONCLUSIONS:TAFI plasma levels are increased in IBD patients and correlate with acute-phase reactants. Increased TAFI plasma levels might contribute to the prothrombotic state observed in IBD through the induction of hypofibrinolysis.

Antibodies to Neutrophil Cytoplasm in Italian Patients with Ulcerative Colitis: Sensitivity, Specificity and Recognition of Putative Antigens

We studied the prevalence of perinuclear antineutrophil cytoplasmic antibody (p-ANCA), as detected by immunofluorescence, in 290 Italian subjects. One hundred and two were affected by ulcerative colitis, 48 by Crohns disease, 40 by gluten-sensitive enteropathy and 100 were normal subjects. The prevalence of p-ANCA was significantly higher in ulcerative colitis patients (45.1%) as compared to Crohns disease patients (4.8%), gluten-sensitive enteropathy (0%) and normal subjects (1%; p < 0.0001 ulcerative colitis vs. all other groups). In this setting, the overall specificity of the test was 98.1% with a sensitivity of 45.1%. The specificity slightly decreased to 95.1% when ulcerative colitis patients were compared to patients with Crohns colitis. In our series, p-ANCA appeared to be more prevalent in ulcerative colitis patients with more aggressive disease. ELISA experiments performed in order to identify the putative antigen(s) recognized by p-ANCA-positive sera showed that 8 of 12 sera positive at immunofluorescence reacted with at least one of the neutrophil preparations tested. The reactivities were directed towards various neutrophil preparations. Preabsorption with the specific antigen recognized by ELISA significantly inhibited the p-ANCA immunofluorescence reactivity indicating that p-ANCA reactivity might derive from the recognition of heterogeneous neutrophil-associated antigens.