Non-Invasive Assessment of Inflammation and Treatment Response in Patients with Crohn's Disease and Ulcerative Colitis using Contrast-Enhanced Ultrasonography Quantification

BACKGROUND AND AIM

Novel biological therapies in Crohn's disease (CD) or Ulcerative colitis (UC) require a proper follow-up for the assessment of bowel inflammation. While endoscopy is the standard method, the imaging techniques using contrast, particularly contrast enhanced ultrasonography (CEUS), are better tolerated by the patients and can be used more frequently. Our aim was to find the usefulness of dynamic CEUS quantification as compared to endoscopy in the assessment of disease activity and in the follow-up under therapy of the patients suffering from either CD or UC.

METHOD

We have prospectively evaluated 67 patients with UC and 46 with CD, diagnosed by ileo-colonoscopy and biopsy, comparing the endoscopic scores with clinical scores, C reactive protein (CRP), intestinal wall thickness, layer scores after CEUS and TIC parameters (using SonoLiver® software - Imax, RT, TTP, mTT and AUC). For 25 patients with UC and 13 with CD we performed comparisons of the parameters before and after 3 months of treatment and correlated them with the changes in the endoscopic scores.

RESULTS

For UC, time-intensity curves (TIC) volume parameters (AUC) correlated better with endoscopy (ρ=0.64) than the clinical score (ρ =0.62). Other parameters such as CRP and thickness showed significant but less strong correlation, while TIC flow parameters (RT, TTP and mTT) did not show a significant correlation. Results were similar for CD (ρ=0.64 for Imax vs ρ=0.58 for CDAI). The best predictor for endoscopic improvement in both UC and CD was ln(AUC), with a Wilcoxon Z score of 3.76 and 2.61, respectively. There was also a good correlation between the difference of its values and the difference in endoscopic scores before and after the treatment (rho is 0.68 in UC and 0.73 in CD).

Bleeding Dieulafoy’s-like lesions of the gut identified by capsule endoscopy

Dieulafoy’s-like lesions (DLs-like) represent a cause of obscure gastrointestinal bleeding, enteroscopy being the main diagnostic and therapeutic procedure. Frequently, more than one enteroscopy is needed to identify the bleeding vessel. In our practice, video capsule endoscopy (VCE) identified and guided therapy in four cases of DLs-like; three of them were localized on the small bowel. We report, for the first time, a diagnosis of colonic DL-like performed by colon capsule endoscopy. Two patients presented with severe cardiovascular disorders, being hemodynamically unstable during VCE examination. Based on the VCE findings, only one invasive therapeutic procedure per patient was necessary to achieve hemostasis. VCE and enteroscopy may be regarded as complementary procedures in patients with gut DLs-like.

Genetic Variants in the Manganese Superoxide Dismutase 2 Gene and in the Catalase Gene are not Associated With Alcoholic Chronic Pancreatitis

Aims

Oxidative stress may contribute to the development of chronic pancreatitis (CP). The enzymes manganese superoxide dismutase 2 (MnSOD, SOD2) and catalase (CAT) counteract free radical activity within the mitochondria and the cytosol. Moreover, CAT activity contributes to the transformation of ethanol to acetaldehyde, a toxic intermediate product of ethanol metabolism, which has been associated with pancreatic damage. Common functional polymorphisms have been described in the MnSOD gene [rs4880, NM_000636.3:c.47 T > C, alanine (ALA) to valine (Val)] and in the CAT promoter region [rs1001179, NG_013339.1:g.4760 C > T]. We investigated whether these polymorphisms are associated with alcoholic CP.

Methods

We genotyped 470 patients with alcoholic CP for these MnSOD and CAT polymorphisms. We also analysed these variants in 357 healthy control subjects, and in an additional control group of 113 individuals with non-alcoholic CP. We used the age at onset of CP as marker of disease severity and investigated whether different genotypes are associated with different ages at onset. In patients with alcoholic CP, we investigated whether an interaction exists between smoking behaviour and genotypes by comparing genotype distributions in smokers and non-smokers.

Results

We did not observe significant differences of genotype frequencies between patient groups and controls. In patient groups, we did not find significant differences in the ages at onset between different genotypes. We did not observe an interaction between these polymorphisms. We did not find an association of these variants with smoking behaviour.

Conclusions

The investigated MnSOD and CAT polymorphisms do not predispose to the development of alcoholic CP.

Short summary

Patients with alcoholic pancreatitis and controls were genotyped for polymorphisms in oxidative stress genes. There were no significant differences of genotype frequencies between patients and controls, and no association with the age at onset of disease was observed. The polymorphisms are not associated with the development of alcoholic pancreatitis.

Survival and quality of life of cholangiocarcinoma patients: a prospective study over a 4 year period

BACKGROUND AND AIMS

Cholangiocarcinomas (CCAs) are tumors with a poor prognosis and a lower quality of life (QoL). The aim of this study was to evaluate the survival rate and quality of life in CCA patients.

METHOD

We prospectively enrolled 133 patients diagnosed with CCA in the 3rd Medical Clinic, Cluj Napoca, over a 4-year period (2005-2009). The QoL was evaluated by means of a QoL questionnaire (EORTC QLQ-C30).

RESULTS

The mean age of the patients was 65 +/- 10.6 years: 55% were males. 71% of the patients had hilar tumor (Klatskin), 23% distal and 6% intrahepatic CCA (IH). Only 11.3% of the patients were eligible to receive curative treatment. The 1-year overall survival was 22.3 +/- 4.4% and the 2-year survival was 3.4 +/- 2.1%. The patients receiving metallic stents had better survival than those receiving plastic stents (40.4% vs 12.5% at 1 year, 9.1% vs 5.0% at 2 years, respectively). The 1-year survival was significantly improved for patients who underwent surgery plus adjuvant chemotherapy. The post-therapy QoL demonstrated a less improvement in Klatskin tumor patients than in patients with other types of tumors. Endoscopic palliative therapy allowed a faster community reintegration, but with variable evolution.

CONCLUSIONS

The highest 2-year survival rate was 5.5%. Slightly longer survival was recorded when chemotherapy was added and also after endoscopic placement of metallic stents. Endoscopic biliary decompression improved the QoL faster than surgery.

Contribution of ultrasound to the diagnosis of chronic pancreatitis and to evaluating its main complications

Chronic pancreatitis is a disease with a potentially severe evolution due to the pain altering life quality and to the possibility of causing exocrine and endocrine pancreatic insufficiency. Ultrasound represents the main imaging technique to be used in this disease since the identification of pancreatic calcifications has diagnostic significance. Endoscopic ultrasound may sometimes identify parenchymal changes facilitating diagnosis in the early stages of chronic pancreatitis when transabdominal ultrasound and endoscopic retrograde cholangiopancreatography show normal situations or non-characteristic changes.

Effects of rifaximin on indomethacin-induced intestinal damage in guinea-pigs

AIM

Enterobacterial translocation into the gut mucosa is the first step required for activation of neutrophils and inducible nitric oxide synthase (iNOS), involved in the pathogenesis of indomethacin-induced intestinal lesions. Rifaximin may limit NSAID-associated intestinal damage by decreasing the bacterial load. We aimed to study the effect of rifaximin on indomethacin-induced intestinal damage in guinea-pigs.

MATERIALS AND METHODS

Twenty-four guinea pigs, equally divided in four interventional groups (A-D), received indomethacin, given orally once daily (30 mg/kg) for three consecutive days. In groups B, C, D different doses of rifaximin (50 mg/kg, 100 mg/kg and 200 mg/kg) were given orally two hours before indometachin administration. Semi-quantitative grades were measure for gross findings, degenerative lesions, neutrophils and eosinophils infiltrates and iNOS immunopositivity. Statistical comparisons used Mann Whitney Test, with a Bonferroni correction for alpha (p ≤ 0.016).

RESULTS

Statistical analysis of graded gross findings, microscopic degenerative lesions, endothelium damage and iNOS immunopositivity found no difference between A and B groups. Significant fewer gross findings (U = 3, p = 0.015), microscopic degenerative lesions (U = 2, p = 0.008) and lower grades for iNOS immunopositivity (U = 0, p = 0.002) were found in group C compared with group A. In group D, significant lower grades for iNOS immunopositivity were obtained (U = 0, p = 0.002) compared with group A and fewer degenerative lesions without reaching statistical significance (U = 4, p = 0.026).

CONCLUSIONS

100 mg/kg of rifaximin proved efficient in preventing gut degenerative lesions induced by indomethacin in a guinea pig model, the iNOS activity being significantly decreased.

Investigation of the SPINK1 N34S mutation in Romanian patients with alcoholic chronic pancreatitis. A clinical analysis based on the criteria of the M-ANNHEIM classification

BACKGROUND AND AIMS

The N34S mutation in the serine protease inhibitor Kazal type I (SPINK1) gene has been associated with chronic pancreatitis. Clinical data about the phenotypic expression of alcoholic chronic pancreatitis with the N34S variant are limited. The prevalence of the N34S mutation in patients with chronic pancreatitis and healthy individuals from Eastern Europe is unknown.

METHODS

We studied Romanian patients with chronic pancreatitis and investigated the clinical presentation in patients with N34S mutation. The SPINK1 N34S variant was analysed in 94 chronic pancreatitis patients and 96 healthy controls by an allele specific PCR method and a restriction fragment length polymorphism method. A meta-analysis was conducted with previous N34S association studies. The clinical course of alcoholic pancreatitis was evaluated according to the severity criteria of the M-ANNHEIM classification system of chronic pancreatitis.

RESULTS

A heterozygous N34S mutation was found in 1 of 96 healthy individuals (1%) and in 4 of 80 patients (5%) with alcoholic chronic pancreatitis. The meta-analysis confirmed the status of N34S as a risk factor for the development of alcoholic chronic pancreatitis (OR=5.3). However, the clinical course of the disease was similar in patients with and without N34S mutation.

CONCLUSION

The N34S mutation is a weak risk factor for alcoholic chronic pancreatitis.

Contrast-enhanced ultrasound of the pancreas--a method beyond its potential or a new diagnostic standard?

Contrast-enhanced ultrasound is a relatively new technique, currently used for liver tumors diagnosis. Newer contrast agents are composed of stabilized micro-bubbles capable of traversing the capillary circulation. Lately, the method has also been used in the assessment of pancreatic disorders. Pulse inversion harmonic imaging allows the assessment of the hypervascularised masses as neuroendocrine tumors, of the hypoperfused masses as adenocarcinomas and of the necrotic areas in acute pancreatitis. Also, this imaging method allows a better assessment of the pancreatic tumor resectability and the identification of septa inside the cystic lesion. Contrast-enhanced ultrasound might represent a valuable additional imaging method to contrast CT for selected cases.