Samuel Raimundo Fernandes

Impact of Early Surgery and Immunosuppression on Crohnʼs Disease Disabling Outcomes

Background and Aims: The definition of early therapeutic strategies to control Crohns disease aggressiveness and prevent recurrence is key to improve clinical practice. This study explores the impact of early surgery and immunosuppression onset in the occurrence of disabling outcomes. Methods: This was a multicentric and retrospective study with 754 patients with Crohns disease, who were stratified according to the need for an early surgery (group S) or not (group I) and further divided according to the time elapsed from the beginning of the follow-up to the start of immunosuppression therapy. Results: The rate of disabling events was similar in both groups (S: 77% versus I: 76%, P = 0.700). The percentage of patients who needed surgery after or during immunosuppression therapy was higher among group S, both for first surgeries after the index event (38% of groups S versus 21% of group I, P < 0.001) and for reoperations (38% of groups S versus 12% of group I, P < 0.001). The time elapsed to reoperation was shorter in group I (HR = 2.340 [1.367–4.005]), stratified for the onset of immunosuppression. Moreover, reoperation was far more common among patients who had a late start of immunosuppression (S36: 50% versus S0–6: 27% and S6–36: 25%, P < 0.001) and (I36: 16% versus I0–6: 5% and I6–36: 7%, P < 0.001). Conclusions: Although neither early surgery nor immunosuppression seem to be able to prevent global disabling disease, an early start of immunosuppression by itself is associated with fewer surgeries and should be considered in daily practice as a preventive strategy.

Ascitic Calprotectin is a Novel and Accurate Marker for Spontaneous Bacterial Peritonitis

Spontaneous bacterial peritonitis (SBP) is a known complication of advanced cirrhosis and presents a high mortality rate. A polymorphonuclear (PMN) cell count >250/μl in the ascitic fluid is the current gold standard for diagnosing SBP.

Portuguese Consensus on the Diagnosis, Prevention and Treatment of Anaemia in Inflammatory Bowel Disease

INTRODUCTION Anaemia can be considered the most common extra-intestinal manifestation in inflammatory bowel disease. Nevertheless, anaemia is often under-diagnosed and under-treated both in adults and children with inflammatory bowel disease. Herein, we report the consensus statements on the management of anaemia in inflammatory bowel disease developed by the Portuguese Working Group on Inflammatory Bowel Disease (known as Grupo de Estudo da Doença Inflamatória Intestinal - GEDII) to aid clinicians in daily management of inflammatory bowel disease patients. MATERIAL AND METHODS A comprehensive literature review was conducted in order to prepare consensus statements on the following topics: (1) prevalence and diagnosis of anaemia in inflammatory bowel disease, (2) iron supplementation for the prevention of anaemia in inflammatory bowel disease and (3) treatment of anaemia in inflammatory bowel disease. The final statements for each topic were discussed at a consensus meeting and rated according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence. CONSENSUS It was concluded that anaemia has a high incidence and prevalence in inflammatory bowel disease, particularly in those with active disease and hospitalised. Patients with anaemia had decreased quality of life and frequently complained of fatigue. Absolute indications for intravenous therapy should be considered: (1) moderate to severe anaemia (haemoglobin < 10.5 g/dL) or clearly symptomatic anaemia; (2) previous intolerance to oral iron supplements; (3) inappropriate response to oral iron; (4) active severe intestinal disease; (5) need for a quick therapeutic response (e.g. surgery in the short term); (6) concomitant therapy with erythropoiesis-stimulating agent; and (7) patients preference.

Extensive Neuroendocrine Adenocarcinoma in Ulcerative Colitis

A 42-year-old male with a known history of extensive ulcerative colitis [UC] and Leiden factor V mutation was admitted with abdominal pain and bloody diarrhoea of 4 days’ duration. He had uncontrolled, steroid-dependent UC since age 23. He was intolerant to thiopurines and had failed adalimumab. Four months earlier, he was hospitalised with deep venous and renal vein thrombosis. On examination, the patient looked unwell and emaciated and presented diffuse abdominal tenderness. Blood tests revealed severe …

Haemophilus parainfluenzae endocarditis with systemic embolisation following maxillary sinusitis

The authors present a case of a man with Haemophilus parainfluenzae endocarditis complicated with embolisation to the central nervous system. The patient had no evidence of endocarditis by transoesophageal and transthoracic echocardiograms at baseline, but shortly after developed large mitral valve vegetations with valve rupture. The case highlights how rapidly structural valve damage can ensue despite good clinical and laboratorial antibiotic response.

Disagreement Among Gastroenterologists Using the Mayo and Rutgeerts Endoscopic Scores

Background Endoscopy is routinely performed in patients with inflammatory bowel disease to evaluate disease severity and guide important clinical decisions. However, variability in the interpretation of endoscopic findings can significantly impact patient management. Methods Fifty-eight gastroenterologists were invited to participate in an online survey including pictures and video recordings of colonoscopies performed in patients with ulcerative colitis (UC) and Crohns disease (CD). Participants were asked to rate the colorectal mucosa in patients with UC using the Mayo endoscopic subscore (MES), and the neo-terminal ileum and anastomosis in operated patients with CD using the Rutgeerts score (RS). Overall interrater agreement (IRA) and for several key end points was assessed using Krippendorffs alpha test. Results The IRAs for the MES and RS were 0.47 (95% confidence interval [CI], 0.41-0.54) and 0.33 (95% CI, 0.28-0.38). The IRAs for UC mucosal healing (MES ≤ 1) and complete mucosal healing (MES = 0) were 0.57 (95% CI, 0.40-0.72) and 0.89 (95% CI, 0.73-1) and for CD postoperative recurrence (RS ≥ i2), and IRAs for severe postoperative recurrence (RS ≥ 3) were 0.44 (95% CI, 0.24-0.62) and 0.54 (95% CI, 0.36-0.71), respectively. Unexpectedly, although clinical information significantly influenced the IRA, participant expertise and consultation of scores did not produce significant changes in the IRA. Conclusions A high rate of disagreement in endoscopic scoring was found in this study, even among experienced physicians. The variability in the assessment of mucosal healing and postoperative recurrence may translate into relevant differences in patient management.

The risk of disabling, surgery and reoperation in Crohn’s disease – A decision tree-based approach to prognosis

Introduction Crohn’s disease (CD) is a chronic inflammatory bowel disease known to carry a high risk of disabling and many times requiring surgical interventions. This article describes a decision-tree based approach that defines the CD patients’ risk or undergoing disabling events, surgical interventions and reoperations, based on clinical and demographic variables. Materials and methods This multicentric study involved 1547 CD patients retrospectively enrolled and divided into two cohorts: a derivation one (80%) and a validation one (20%). Decision trees were built upon applying the CHAIRT algorithm for the selection of variables. Results Three-level decision trees were built for the risk of disabling and reoperation, whereas the risk of surgery was described in a two-level one. A receiver operating characteristic (ROC) analysis was performed, and the area under the curves (AUC) Was higher than 70% for all outcomes. The defined risk cut-off values show usefulness for the assessed outcomes: risk levels above 75% for disabling had an odds test positivity of 4.06 [3.50–4.71], whereas risk levels below 34% and 19% excluded surgery and reoperation with an odds test negativity of 0.15 [0.09–0.25] and 0.50 [0.24–1.01], respectively. Overall, patients with B2 or B3 phenotype had a higher proportion of disabling disease and surgery, while patients with later introduction of pharmacological therapeutic (1 months after initial surgery) had a higher proportion of reoperation. Conclusions The decision-tree based approach used in this study, with demographic and clinical variables, has shown to be a valid and useful approach to depict such risks of disabling, surgery and reoperation.

Severe ischemic colitis following olanzapine use: a Case Report

Ischemic colitis is the most common subtype of intestinal ischemia usually resulting from vasospasm, vessel occlusion or mesenteric hypoperfusion. Neuroleptics have seldom been linked to ischemic colitis by blocking peripheral anticholinergic and antiserotonergic receptors inducing severe gastrointestinal paresis. We report a young patient with severe ischemic colitis requiring surgery due to necrosis of the bowel. After exclusion of other potential causes, olanzapine was admitted as the cause of ischemia. Clinicians should be aware of how to recognize and treat the potentially life-threatening effects of neuroleptics.

Predicting the Course of Disease in Hospitalized Patients With Acute Severe Ulcerative Colitis

BACKGROUND Up to one-third of patients with acute severe ulcerative colitis (ASUC) will fail intravenous steroid (IVS) treatment, requiring rescue therapy with cyclosporin (Cys), infliximab (IFX), or colectomy. Although several scores for predicting response to IVS exist, formal comparison is lacking. METHODS We performed a single-center retrospective analysis including 489 patients with ulcerative colitis. In patients with ASUC, the Mayo endoscopic subscore and the Oxford, Edinburgh, and Lindgren scores were assessed. Outcomes included IVS failure, need for rescue medical therapy, and surgery. RESULTS One hundred twelve patients presented with ASUC. Forty-two percent showed an incomplete or absent response to IVS, 28.6% received rescue therapy (22 with IFX, 10 with Cys, and 1 with sequential treatment), and 26.8% required surgery. The Lindgren score showed the highest performance in predicting IVS failure (are under the curve [AUC], 0.856; 95% confidence interval [CI], 0.784-0.928), need for medical rescue therapy (AUC, 0.826; 95% CI, 0.749-0.902), and surgery (AUC, 0.836; 95% CI, 0.712-0.960; all P < 0.01). CONCLUSIONS In our series, the Lindgren score was superior to the Mayo, Oxford, and Edinburgh scores in predicting major clinical outcomes in ASUC.

The Dark Side of the Long-Term Use of Proton Pump Inhibitors in Chronic Liver Disease

Proton pump inhibitors (PPIs) are among the most widely prescribed drugs in the world today. Accepted indications include an array of acid-related disorders such as peptic ulcer disease and gastroesophageal reflux, and the prevention of non-steroid anti-inflammatory drug (NSAID)-induced ulcers. Despite little evidence of efficacy, PPIs are also frequently prescribed for other indications including functional dyspepsia and for the prevention of gastroduodenal side effects of polypharmacy. Alarmingly, up to two-thirds of PPI prescriptions in ambulatory patients may be inadequate [1–3]. In recent years, several observational studies have raised concern regarding the potential long-term side effects of PPIs, including acute and chronic kidney disease, hypomagnesemia, cardiovascular events, bone fractures, dementia, and infections such as Clostridium difficile colitis, bacterial pneumonia, and spontaneous bacterial peritonitis (SBP) [4, 5]. SBP is a well-known complication in patients with cirrhosis and ascites. Despite improvements in medical care with timely diagnosis and treatment with antibiotics, short-term mortality of SBP amounts to about 30% and increases to over 65% at 1 year without liver transplantation [6]. Therefore, means of reducing the rates of SBP in patients with cirrhosis are welcomed. SBP is thought to result from bacterial translocation across the intestinal wall leading to infection of the ascitic fluid. Proliferation of bacteria in the ascitic fluid is favored in patients with cirrhosis by a dysfunctional immune system with low levels of immunoglobulins, opsonizing proteins, and complement [7]. Hypothetically, by increasing intragastric pH, PPIs facilitate proliferation of intestinal bacteria (i.e., bacterial overgrowth). Abnormal gastrointestinal motility is also common in patients with cirrhosis and may further be worsened by PPIs [8, 9]. Even more preoccupying is the fact that over 63% of prescriptions of PPIs in patients with cirrhosis may be inadequate [10]. At a time of growing concern over rising health care costs, substantial cost savings can be achieved by limiting inappropriate prescribing of PPIs according to the clinical guidelines [11].