Magnetic resonance imaging of the effects of infliximab on perianal fistulizing Crohn's disease

OBJECTIVES

Although the clinical efficacy of infliximab as measured by closure of fistulas in Crohn's disease has been demonstrated, its influence on the inflammatory changes in the fistula tracks is less clear. The aim of the present study was to assess the behavior of perianal fistulas before and after infliximab treatment.

METHODS

Magnetic resonance imaging (MRI) and clinical evaluation were performed in a total of 18 patients before and after treatment with infliximab. An MRI-based score of perianal Crohn's disease severity was developed using both criteria of local extension of fistulas (complexity, supralavetoric extension, relation to the sphincters and of active inflammation (T2 hyperintensity, presence of cavities/abscesses, and rectal wall involvement).

RESULTS

The MRI score was reliable in assessing the fistula tracks, with a good interobserver concordance (p < 0.001). Fistula tracks with signs of active inflammation were found in all 18 patients at baseline and collections in seven. After short-term infliximab treatment, active tracks persisted in eight of 11 patients who had clinically responded to infliximab. After long-term (46 wk) infliximab therapy, MRI signs of active track inflammation had resolved in three of six patients.

CONCLUSIONS

We have developed an MRI-based score of perianal Crohn's disease severity to assess the anatomical evolution of Crohn's fistulas. Our study demonstrates that despite closure of draining external orifices after infliximab therapy, fistula tracks persist with varying degrees of residual inflammation, which may cause recurrent fistulas and pelvic abscesses. Whether complete fistula fibrosis occurs over time with repeated infliximab infusions needs further study.

The rectum: a window to irritable bowel syndrome?

This report summarizes current concepts and information gathered to date about the rectum in the irritable bowel syndrome (IBS) that were presented at the 10th meeting of IBiS Club held in Leuven, Belgium. A working group of experts in the field of IBS discussed whether the rectum or the whole colon is the better site to test in IBS patients and provided suggestions for a number of areas where further advances are required.

Epidemiological aspects of irritable bowel syndrome in Europe and North America

The epidemiology of irritable bowel syndrome (IBS) in Europe and North America was analyzed from published material. The percentage of the population of Western civilisation with IBS symptoms is between 10 and 15% in most studies. The proportion of a Western population visiting a doctor for IBS symptoms is around 5%. The prevalence of IBS and the proportion of consulters do not seem to depend on age in an adult population. The female-to-male ratio of IBS in the population is close to 2. It is higher in IBS consulters in primary care and may be as high as 3 or 4 in tertiary referral centers. At least in patients from these centers, the number of physician visits and colonoscopies is considerable. Most of the consulters get a drug prescription.

Success and failure after repair of rectovaginal fistula in Crohn's disease: analysis of prognostic factors

OBJECTIVE

To compare the healing rate after several types of surgical repair of rectovaginal fistula (RVF) in Crohn's disease, and to identify factors predicting a successful outcome.

PATIENTS AND METHODS

A Medline review of the literature since 1980 and analysis of our results in 32 consecutive patients was done.

RESULTS

All types of repair (rectal, vaginal, anocutaneous advancement flap, or perineoproctotomy with fistula closure) seem to be equally effective. Healing after a first repair is observed in 58 (46-71)%. Healing can still be obtained at subsequent attempts in 62 (40-71)% of the patients. The reported overall healing rate is 75 (56-93)%. The need for proctectomy after an attempt to repair was 6 (0-27)% in these series. Using a tailored surgical approach, we observed primary healing in 57%, healing after one or more supplementary procedures in 71%, for a total 'definitive' closure rate of 75%. Anal continence was never compromised and all temporary stomas (12 patients) could be closed. Univariate analysis identified number of Crohn's sites, presence of extra-intestinal disease and previous Crohn's proctitis to be related with problematic healing after a surgical repair. A positive relation was found between extra-intestinal disease and the number of repairs needed to ultimately obtain healing, whereas the relation with previous right hemicolectomy was negative. Multivariate analysis revealed the number of Crohn's sites as the only factor predicting problematic healing. A defunctioning stoma was not related to the healing rate and had its intrinsic morbidity with supplementary hospitalization (9.6 days). After a median follow-up of 40.4 (range 8-87) months, we observed 4 late recurrences in 25 patients with healed RVF (16%).

CONCLUSION

Closure of a RVF in Crohn's disease should not be considered an easy undertaking, especially in patients with several Crohn's sites. In this very heterogeneous group of patients the technique is adapted to the nature and the extent of accompanying anorectal disease. Construction of a temporary stoma is not mandatory and can be limited to complex cases. Healing can be obtained in 75% of all patients, although a late recurrence might occur.

Nongastrointestinal disorders in the irritable bowel syndrome

A large proportion of irritable bowel syndrome (IBS) patients also complain of other functional disorders, such as headache, noncardiac chest pain, low back pain, and dysuria. Some of these features, particularly headache, may have a negative influence on the outcome of IBS. In a large proportion of female IBS patients, sexual intercourse triggers the symptoms, and frequently IBS symptoms exacerbate during menses. These gynecological-type symptoms often mislead the patients to the gynecological clinic, which may imply unnecessary investigations and inappropriate treatments. The diagnostic criteria of the fibromyalgia syndrome include IBS, and hence, the apparent relationship of both syndromes is difficult to analyze. On the other hand, no convincing evidence has been produced to date to sustain an association between IBS and the chronic fatigue syndrome.

Sweet's syndrome in a patient with Crohn's disease

Crohn's disease is rarely associated with Sweet's syndrome. We report a 32-year old woman who presented with diarrhea, fever and disseminated erythematous plaques on the arms and the trunk. After colonoscopy with biopsies, Crohn's disease was diagnosed. Skin biopsy showed a dense infiltration of neutrophilic polymorphonuclear leukocytes, establishing also the diagnosis of Sweet's syndrome. Crohn's disease is one of several systemic diseases that may underlie Sweet's syndrome. Treatment with methylprednisolone resulted in a rapid improvement of both gastro-intestinal symptoms and skin lesions.

Ambulatory gastrojejunal manometry in severe motility-like dyspepsia: lack of correlation between dysmotility, symptoms, and gastric emptying

BACKGROUND

Previous studies have failed to identify manometric patterns of gastrointestinal motor activity that can distinguish dyspepsia from health.

AIMS

To test the hypothesis that the combined use of prolonged, ambulatory, antrojejunal manometry and computer aided analysis in patients selected for the severity of their symptoms could reveal new insights into gastrointestinal motor activity in patients with severe motility-like dyspesia.

METHODS

Twenty four hour antrojejunal ambulatory manometry was performed in 14 patients and 10 healthy volunteers. Parameters characterising digestive and fasted motility were obtained by a validated computer program and visual analysis. Scoring systems quantified the degree of dysmotility as well as the severity of symptoms. Gastric emptying times were measured in each patient.

RESULTS

There was a high prevalence of antral and jejunal dysmotility both during the interdigestive period (71% of patients) and in the postprandial period (78%). During the interdigestive period there was a reduced incidence of antral and jejunal phases, a larger contribution of phase 2 during migrating motor complex cycles, and aberrant configuration of jejunal phase 3 in 29% of patients. Postprandially, the most frequent finding was antral (29% of patients) or jejunal (29%) hypomotility or hypermotility. Minute rhythm was present both during the postprandial (29% of patients) and the interdigestive period (21%). There was no positive correlation between symptom scores, gastric half emptying times, or motility scores.

CONCLUSION

Even with the use of prolonged recordings and advanced computer aided analysis, it is not possible to identify a specific motor pattern which can discriminate patients with severe motility-like dyspepsia from those with other diseases or even healthy individuals. Clinical symptoms or gastric half emptying times are poor predictors of gastrointestinal dysmotility in patients with functional dyspepsia.

Ambulatory small intestinal manometry. Detailed comparison of duodenal and jejunal motor activity in healthy man

The aim of this study were to provide a detailed comparison of duodenal and jejunal motor activity in healthy individuals by utilizing prolonged ambulatory manometry in combination with computer-aided analysis. Intraluminal pressure profiles were studied in the duodenum and jejunum of 18 healthy volunteers over 24 hr. The subjects ingested two meals, both of 800 kcal and of equal chemical composition, at two different times of the day. Over the whole interdigestive period, phase III motor activity started more frequently distal than proximal to the ligament of Treitz. However, an increasing time of fasting was linearly related to an increasing number of phase IIIs originating proximal to the ligament of Treitz (r = 0.95). Both meals induced a postprandial motor pattern of similar duration and contractile activity. As compared to the jejunum, individual duodenal contractions during the postprandial period and during phase II had a higher duration and amplitude. Propagated clustered contractions occurred more frequently in the duodenum than in the jejunum, both in the interdigestive and digestive state. Jejunal clusters comprised a higher number of individual contractions of lower amplitude and duration. In healthy man duodenal and jejunal motor activity are different, both in the digestive and interdigestive state. The differences include the number of activity fronts traversing these segments of the gut, the number and organization of propagated clustered contractions, and subtle changes in the amplitude, duration, and coordinated propagation of individual contractions. These changes presumably reflect a regulatory capability of the small intestine to modulate the rate of transit of intraluminal content through different segments of the gut.

Computer-supported analysis of continuous ambulatory manometric recordings in the human small bowel

An algorithm has been developed for the offline analysis of prolonged manometric recordings in the upper small intestine of humans. Sample data are acquired in the human duodenum and jejunum six solid-state strain-gauge transducers mounted on a silicon catheter that is connected to a portable digital recording device. The data are sampled at 4 Hz and filtered. For accurate calculations, the filtered signals are converted to cubic B-spline functions of order four. Based on an exponential weighted moving average, a base-line is calculated from the signal. Contractions are recognised on the basis of thresholds for minimum amplitude and duration. The developed algorithm calculates properties of these contractions, such as amplitude, duration, area and a motility index. In addition, the program automatically recognises normal motor patterns of the fasted human small intestine, such as the migrating motor complex, and aids in the identification of the postprandial motor pattern. Motor patterns are defined in terms of properties such as contraction frequency and propagation. In a validation procedure using conventional manual analysis, the program correctly identifies the number of individual contractions with a 98% confidence interval and also correctly recognises 96% of phase 3 motor activity.

A risk-benefit assessment of cisapride in the treatment of gastrointestinal disorders

Cisapride is a substituted benzamide compound that stimulates motor activity in all segments of the gastrointestinal tract by enhancing the release of acetylcholine from the enteric nervous system. Cisapride is administered orally in the treatment of gastro-oesophageal reflux disease, functional dyspepsia, gastroparesis, chronic intestinal pseudo-obstruction syndromes and chronic constipation. In gastro-oesophageal reflux disease in both adults and children, cisapride provides symptomatic improvement and mucosal healing. Long term treatment with cisapride is effective in the prevention of relapse of oesophagitis. Cisapride improves gastric emptying rates and improves symptoms in patients with gastroparesis of various origins. Unlike domperidone and metoclopramide, long term administration of cisapride seems to result in persistently enhanced gastric emptying. Cisapride is also effective in improving symptoms in patients with functional dyspepsia. In comparative studies in patients with functional dyspepsia, cisapride was at least as effective as metoclopramide, domperidone, clebopride, ranitidine and cimetidine. Cisapride increases stool frequency and reduces laxative consumption in patients with idiopathic constipation. Severe cases of slow transit constipation seem refractory to cisapride. Clinical studies also indicate that cisapride might be effective in the treatment of chronic intestinal pseudo-obstruction, postoperative ileus, peptic ulcer and irritable bowel syndrome. Further clinical studies are warranted to define the role of cisapride in these conditions. The dosage of cisapride ranges from 5mg 3 times daily to 20mg twice daily. Cisapride is generally well tolerated, both during short and long term treatment. In children, cisapride is also well tolerated in doses of 0.2 to 0.3 mg/kg, 3 to 4 times daily.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy and safety of hydrostatic balloon dilatation of ileocolonic Crohn's strictures: a prospective longterm analysis

Preliminary reports have suggested that dilatation using hydrostatic through the scope balloons may be useful for the treatment of Crohn's strictures, A prospective longterm follow up (mean (SD) 33.6 (11.2) months) was carried out in 55 Crohn's patients with 59 ileocolonic strictures submitted to 78 dilatation procedures. Hydrostatic balloons were used (Rigiflator, Microvasive) with a diameter of 18 mm on inflation. As soon as the balloons became available dilatation up to a diameter of 20 and 25 mm was attempted. The dilatations were performed under general anaesthesia using propofol (Diprivan). The patients were kept for one night in the hospital after dilatation. Seventy (90%) procedures were technically successful and passage of the stricture with a 13.6 mm diameter colonoscope was possible after 73% of the dilatations. Complications occurred in six patients (11%; 8% of procedures), including sealed perforations (n = 2), retroperitoneal perforations (n = 2), and intraperitoneal perforations (n = 2). Two of the patients were treated surgically with a one stage resection of the stricture and recovered uneventfully. Four patients were treated conservatively with intravenous fluids and antibiotics. There was no mortality. Dilatation completely relieved obstructive symptoms in 20 patients after one procedure, in another 14 patients after two (n = 13) or three (n = 1) dilatations. Total longterm success rate was 34 of 55 patients (62%). Nineteen patients (38%) were operated on because of persistent obstructive symptoms. The data show that endoscopic dilatation using the through the scope hydrostatic balloon system relieves obstructive symptoms resulting from ileocolonic Crohn's strictures. The procedure, however, carries a definite risk of perforation.

Efficacy and safety of hydrostatic balloon dilation of ileocolonic Crohn's strictures. A prospective long-term analysis

Gastro-intestinal stricture frequently is a complication in Crohn's disease and often recurs after surgical resection. Stenosis with acute inflammation can be treated by anti-inflammatory medication. A conservative approach of sclerotic strictures has been possible since the introduction of Gruentzig balloon catheters for dilating stenosis in different parts of the gastro-intestinal tract. We present a prospective follow-up study in 55 patients, on the long-term results and safety of hydrostatic balloon dilations of ileo-colonic Crohn's strictures.

5-hydroxytryptamine-3 receptors are involved in the initiation of gastric phase-3 motor activity in humans

BACKGROUND

5-hydroxytryptamine-3 (5-HT3) receptor antagonists inhibit gastric phase-3 motor activity in the dog. This study examined the role of 5-HT3 receptors in the generation of gastric phase 3 of the migrating motor complex in humans.

METHODS

Interdigestive motor activity was recorded manometrically in 16 subjects before and after administration of ondansetron, a selective 5-HT3 receptor antagonist. Plasma motilin values were also assayed in 7 individuals. The incidence of gastric activity fronts before and after ondansetron was compared with a control group that had not received ondansetron. The ability of erythromycin to induce a gastric activity front in the presence of ondansetron was also evaluated in 7 subjects.

RESULTS

The incidence of gastric activity fronts was 69% before ondansetron vs. 19% after ondansetron. In contrast, in the control group there was no significant change in the incidence of gastric activity fronts over time. Activity fronts preceding ondansetron were associated with motilin peaks while activity fronts after ondansetron were not. Despite the previous administration of ondansetron, erythromycin induced gastric activity fronts in 89% of cases.

CONCLUSIONS

Selective antagonism of 5-HT3 receptors suppresses the gastric component of phase-3 motor activity and simultaneously suppresses plasma motilin peaks. The results suggest that the suppression of gastric activity fronts is achieved via the suppression of plasma motilin peaks because in the presence of ondansetron a motilin agonist like erythromycin restores the gastric phase 3.

Endoscopic balloon dilation of colonic and ileo-colonic Crohn's strictures: long-term results

The long-term effects of endoscopic dilation of colonic or ileo-colonic Crohn's disease strictures were analyzed. In 18 patients with a Crohn's disease-related low gastrointestinal stricture, the stenosis was dilated using through-the-scope (TTS) balloon catheters. A dilation to a diameter of 18 mm was always attempted. Treatment was successfully carried out in 16 patients, and was followed by immediate symptomatic relief in 14 patients. Long-term success was observed in nine patients. There were no complications. Balloon catheter dilation of a colonic stricture or stricture of an ileo-colonic anastomosis was found to be safe and effective. This treatment modality can be an alternative to surgery in a selected group of patients.

Is the irritable bowel really irritable?

We studied 5 healthy volunteers and 9 patients with irritable bowel syndrome (IBS) during infusion of the colon with saline solution, bile acids, fatty acids and balloon distension. Our results show that the pain threshold was significantly (p less than 0.001) higher in controls than in IBS patients. Bile acids and fatty acids brought on the habitual pain in 5/7 and 7/8 patients respectively, while they did not have any effect in the control group. On the basis of our data we can conclude that the IBS patients are more sensitive to colonic distension and perfusions, thus suggesting a non-specific irritability of the colon which could be a characteristic of these patients.