Follow-up of adult celiac patients: which noninvasive test reflects mucosal status most reliably?1

SPECIFIC AUTHOR CONTRIBUTIONS: Andreas Vécsei, MD, and Ulrike Graf wrote the manuscript. All authors contributed to study design, data collection and analysis, and approved the final draft for submission. The corresponding author declares that the manuscript is submitted on behalf of all authors.

BACKGROUND AND STUDY AIMS

The best mode of follow-up in celiac disease has not yet been established. The intention of this study was to clarify which noninvasive follow-up investigation - serological tests or intestinal permeability test (IPT) - correlates best with histology and whether the interval between diagnosis and follow-up affects the accuracy of these tests.

PATIENTS AND METHODS

Data from adult patients with celiac disease (diagnosed between December 1989 and July 2006) followed up with biopsy, IPT, and serological tests [IgG anti-gliadin antibodies (AGA-IgG), AGA-IgA, and endomysial antibodies (EMA)] were retrieved from a computerized database. Results of noninvasive tests were compared with the persistence of villous atrophy on biopsy. Patients were divided into groups A, which comprised patients followed up within 2 years after diagnosis, and B, comprising patients followed up later than 2 years.

RESULTS

Forty-seven patients were evaluable. The lactulose/mannitol (L/M) ratio had a sensitivity of 85 % and a specificity of 46.2 % for mucosal atrophy, whereas saccharose excretion showed a sensitivity of 60 % and a specificity of 52.6 %. The sensitivities of AGA-IgA and AGA-IgG were 15 % and 20 %, respectively, while specificity was 100 % for both. Validity of AGA was limited due to low number of positive results. EMA assay was 50 % sensitive and 77.8 % specific. In group A (n = 23) L/M ratio performed best in terms of sensitivity (88.9 %), whereas EMA achieved a higher specificity (71.4 %). In group B, the sensitivity of the L/M ratio decreased to 85.7 %, while the specificity of EMA increased to 91.7 %.

CONCLUSIONS

In this study, none of the noninvasive tests was an accurate substitute for follow-up biopsy in detecting severe mucosal damage.

[Organisation of acute pain therapy]

Orthopaedic and traumatized patients often suffer from severe pain after surgery or trauma. Their early recovery also depends on an efficient acute pain relief based on a combination of systemic medication, local drug application and physical therapy. In 2007, new guidelines for the treatment of perioperative and traumatic pain were published. Based on these guidelines standard operating procedures for each hospital should be developed and implemented. Courses on analgesic concepts should be offered regularly for the involved staff. It is helpful to establish an acute pain service for daily rounds and documentation. The individual patient should be informed about his specific acute pain therapy before the operation. Pain scores should be frequently documented by the patient.

Efficacy and safety of antiviral therapy in patients with Crohn's disease and chronic hepatitis C

BACKGROUND

Efficacy and safety of antiviral combination therapy in patients with Crohn's disease (CD) and chronic hepatitis C (CHC) is presently not established and consequently CHC is rarely treated in CD patients.

AIM

To analyse the efficacy and tolerability of antiviral interferon/ribavirin therapy in patients with CHC and CD.

METHODS

Eleven HCV-infected CD patients received either 3 x 1.5 microg/kg/week interferon-alpha-2b or 180 microg/week peginterferon-alpha-2a (PEGASYS; Roche, Basel, Switzerland) as monotherapy (n = 1) or in combination with 800-1200 mg/day ribavirin (COPEGUS; Roche) (n = 10) for 24-54 weeks according to HCV-genotype and initial response respectively. Eight patients were under CD-specific therapy.

RESULTS

Five (46%) patients (HCV-1: a = 3; HCV-2: n = 0; HCV-3: n = 1; unknown: n = 1) achieved a sustained virological response, three (27%) patients relapsed, three (27%) were nonresponders (all GT 1b). At baseline, the Harvey--Bradshaw Index was 0 (0-8) [median (range)], increased on antiviral therapy to 4 (1-15) (P = 0.005) and decreased to baseline level 0 (0-6) after 6-month follow-up.

CONCLUSIONS

This preliminary experience demonstrates that treatment of CHC in patients with CD is comparable to the treatment of CHC in those without CD. However, gastrointestinal symptoms may be temporarily exacerbated and haemopoietic growth factors may be required.

The immune system in healthy adults and patients with atopic dermatitis seems to be affected differently by a probiotic intervention

BACKGROUND

Probiotic bacteria are proposed to alleviate atopic dermatitis (AD) in infants. There are few indications about the effect of probiotics on AD in adults.

OBJECTIVE

The purpose of this study was to elucidate the influence of a probiotic drink containing a combination of the probiotics Lactobacillus paracasei Lpc-37, Lactobacillus acidophilus 74-2 and Bifidobacterium animalis subsp. lactis DGCC 420 (B. lactis 420) in healthy volunteers and in patients with AD on clinical and immunological parameters and their detection in feces.

METHODS

A double-blind, placebo-controlled, randomized cross-over study was conducted in 15 healthy adults and 15 patients with AD. The probiotic product or placebo was given over 8 weeks. A 2-week washout period was interconnected before the intervention was crossed. At the end of each period, blood and stool samples were collected. In patients, the severity of AD was evaluated using the Scoring of Atopic Dermatitis (SCORAD).

RESULTS

L. paracasei and B. lactis were recovered in high numbers in feces after supplementation, whereas L. acidophilus marginally increased. In patients, the SCORAD tended to decrease by 15.5% (P=0.081). Major lymphocyte subsets were not affected by the probiotic intervention. However, CD57(+) increased significantly (P=0.034) in healthy subjects after probiotic intake and was not changed in patients, whereas CD4(+)CD54(+) decreased significantly (P=0.031) in patients with AD and remained uninfluenced in healthy subjects. The expression of CD4(+)CD25(+) T cells was similar in healthy subjects and AD patients. The phagocytic activity of monocytes and granulocytes was significantly increased in healthy subjects after probiotic intervention (P=0.014).

CONCLUSION

L. paracasei Lpc-37 and B. lactis 420 are able to colonize the intestine transiently. This study reveals that the probiotics differently modulate peripheral immune parameters in healthy subjects and patients with AD.

Infliximab in der Therapie der Colitis ulcerosa

Infliximab, a chimeric monoclonal anti-tumour necrosis factor alpha (TNF) antibody has dramatically changed the management of various chronic inflammatory disorders such as Crohn's disease (CD), rheumatoid arthritis, ankylosing spondylitis or psoriasis. This drug is well established for the treatment of CD in case of steroid-refractoriness, failure to respond to an immunosuppressant agent or fistulizing disease. The immunological concept that ulcerative colitis (UC) reflects primarily a T-helper cell type-2 mediated disease prevented the earlier use of anti-TNF agents in this disease. Promising initial pilot studies in steroid-refractory UC patients led to two large placebo-controlled trials in patients with moderate to severe UC. These studies clearly showed a benefit for infliximab treatment in UC with mucosal healing and improved life quality. Infliximab therefore can be used in patients not responding adequately to steroids and/or immunosuppressants. Furthermore, one study showed evidence that infliximab might also be effective in severe, intravenous steroid-refractory UC. Therefore, infliximab might be used alternatively to cyclosporine A or tacrolimus in this patient group. Infliximab has now been established as an additional treatment option in patients with chronic-active UC not responding to an immunosuppressive agent and/or in case of severe acute UC. Experienced gastroenterologists should be involved in the decision making for such a therapy to balance thoroughly the benefit/risk ratio for our patients.

Lactobacillus acidophilus 74-2 and Bifidobacterium animalis subsp lactis DGCC 420 modulate unspecific cellular immune response in healthy adults

OBJECTIVE

It was determined whether a combination of Lactobacillus acidophilus (L. acidophilus) 74-2 and Bifidobacterium animalis subsp lactis DGCC 420 (B. lactis 420) affect the faecal microbiota as well as immunological parameters and blood lipids in healthy adults.

DESIGN

A placebo-controlled, double-blinded, randomized crossover trial was conducted.

SUBJECTS

Twenty-six healthy volunteers (mean age 25 years) were recruited by advertising in academical buildings. All of them completed the study.

METHODS

After 3-week run-in period, half of the volunteers consumed 300 g/day of yoghurt supplement containing probiotic strains L. acidophilus 74-2 and B. lactis 420, and the other half received the placebo product for a period of 5 weeks. The two groups were crossed during the following 5-week period. Blood and faecal samples were collected at the end of each period. The faecal content of probiotic bacteria, faecal short-chain fatty acids (SCFA), serum lipids and plasma immune system biomarkers were evaluated.

RESULTS

Faecal proportions of L. acidophilus and of B. lactis increased significantly from 0.02 to 0.19 and 0.4 to 1.4% (P<0.05), respectively. Percentages of granulocytes and monocytes showing phagocytic activity were significantly elevated from 92 to 95% during probiotic intervention, whereas their oxidative burst activity and specific immune parameters remained unaffected. Fecal SCFA and serum cholesterol levels were not influenced by the probiotics. However, serum concentrations of triacylglyceroles decreased significantly by 11.6% (P<0.05) in the probiotic supplementation period.

CONCLUSIONS

L. acidophilus and B. lactis were recovered in faeces in significantly elevated numbers after supplementation. They are able to modulate unspecific cellular immune response indicated by the increased phagocytic activity.

Characterization of sensations induced by capsaicin in the upper gastrointestinal tract

Intraluminal capsaicin induces perception in the jejunum, but chemosensitivity of proximal gastrointestinal regions is unclear. Our aim was to evaluate the quality of perception induced by intraluminal capsaicin in different regions of the upper gastrointestinal tract. Healthy volunteers received either an oral tube for distension and capsaicin perfusion of the mid-duodenum or jejunum or swallowed a capsule containing 0.75 mg capsaicin powder. Graded questionnaires evaluated quality and severity of sensations during distensions, capsaicin infusion and 30 min after ingestion of capsaicin capsules respectively. Duodenal capsaicin induced sensations at lower doses than jejunal capsaicin (P < 0.05). Most prominent sensations evoked by capsaicin infusion were pressure, cramps, pain and nausea; nausea and warmth were more intense during capsaicin infusion than distension (P < 0.05,for the duodenum and jejunum), pain was more intense during distension (P < 0.05, duodenum only). Gastric ingestion of capsaicin capsules mainly induced sensations of pressure, heartburn and warmth. Capsaicin application into the upper gastrointestinal tract reproducibly induced upper abdominal sensation. Qualitative features distinguished chemically from mechanically induced sensations, but both sensitivity for chemical and mechanical stimulation decreased along the intestine. Activation of chemical pathways could be a useful human pain model activating nociceptors apart from mechanical stimulation.

Endoskopie bei CED

Ileocolonoscopy including biopsies is the first line investigation in suspected inflammatory bowel disease (IBD). In up to 90 % of the cases ulcerative colitis and Crohn's disease are differentiated on endoscopic presentation. Standardised reporting of endoscopic results increases the validity and comparability of IBD findings. When there is a firm diagnosis of IBD, colonoscopy should only be performed for specific questions. An upper gastrointestinal endoscopy is only indicated in patients with upper gastrointestinal symptoms. Push and capsule endoscopy should also be limited to specific questions and situations. IBD with extended colitis is associated with an increased risk for colorectal cancer. Endoscopic surveillance with accurate biopsy sampling is a valuable tool for the prevention of colorectal cancer.

6-Thioguanine treatment in inflammatory bowel disease: a critical appraisal by a European 6-TG working party

Recently, the suggestion to use 6-thioguanine (6-TG) as an alternative thiopurine in patients with inflammatory bowel disease (IBD) has been discarded due to reports about possible (hepato) toxicity. During meetings arranged in Vienna and Prague in 2004, European experts applying 6-TG further on in IBD patients presented data on safety and efficacy of 6-TG. After thorough evaluation of its risk-benefit ratio, the group consented that 6-TG may still be considered as a rescue drug in stringently defined indications in IBD, albeit restricted to a clinical research setting. As a potential indication for administering 6-TG, we delineated the requirement for maintenance therapy as well as intolerance and/or resistance to aminosalicylates, azathioprine, 6-mercaptopurine, methotrexate and infliximab. Furthermore, indications are preferred in which surgery is thought to be inappropriate. The standard 6-TG dosage should not exceed 25 mg daily. Routine laboratory controls are mandatory in short intervals. Liver biopsies should be performed after 6-12 months, three years and then three-yearly accompanied by gastroduodenoscopy, to monitor for potential hepatotoxicity, including nodular regenerative hyperplasia (NRH) and veno-occlusive disease (VOD). Treatment with 6-TG must be discontinued in case of overt or histologically proven hepatotoxicity.

Aminosalicylate und Steroide in der Behandlung von chronisch entzündlichen Darmerkrankungen - Konsensuspapier der Arbeitsgruppe für chronisch entzündliche Darmerkrankungen der ÖGGH

5-aminosalicylates (5-ASA) and steroids constitute a cornerstone of medical therapy in patients with inflammatory bowel diseases (IBD). Whereas the efficacy of 5-ASA in Crohn's disease (CD) is equivocal, ulcerative colitis (UC) is the main indication for this drug. In UC, 5-ASA is effective in the treatment of mild to moderate acute disease and in maintenance of remission. Furthermore, 5-ASA topical therapy is an important treatment option in patients with mild to moderate proctitis and/or left-sided UC and shows additive efficacy to oral therapy. From retrospective data a chemo-preventative activity of long-term 5-ASA therapy in UC is delineated. Steroids are treatment of first choice for moderate to severe cases of CD and UC. Budesonide, a modified steroid with less side effects, plays a major role in the treatment of ileocolonic CD +/- involvement of the right colon and is used as treatment of choice in mild-to-moderate cases. In case of acute, severe disease conventional steroids are superior compared to budesonide and therefore budesonide should only be used after considerable improvement of disease activity. The necessity to apply steroids in a given patient represents a negative prognostic indicator for the course of disease and should incite the early introduction of immunosuppressive therapy in this case. Steroids are only effective as short term therapy of IBD and are to be avoided for maintenance treatment. In all cases of steroid therapy an osteoporosis prophylaxis with calcium and vitamin D is recommended. Topical steroid treatment is less effective in left-sided UC compared to 5-ASA.

Safety and efficacy of endoscopic balloon dilation for treatment of Crohn's disease strictures

BACKGROUND AND STUDY AIMS

Strictures are a substantial cause of morbidity in patients with Crohn's disease. Endoscopic balloon dilation is a therapeutic option in limited strictures to avoid intestinal surgery, although there have been few reports regarding the long-term outcome.

PATIENTS AND METHODS

Balloon dilation was scheduled for 46 patients (26 women, 20 men; median age 34) with Crohn's-associated symptomatic and radiographically confirmed intestinal stenosis. The study plan envisaged up to four consecutive treatments within the first 2 months until relief of symptoms, and thereafter dilations depending on clinical requirements.

RESULTS

Dilation was not possible in seven of the 46 patients (15 %), due to technical problems (n = 2), internal fistulas (n = 3), or absence of a stenosis (n = 2). Thirty-nine patients received at least one treatment. The site of obstruction was the ileocolonic anastomosis in 23 of the 39 patients (59 %) and surgically untreated areas in 16 patients (41 %). After the initial dilation series (median 1, interquartile range 1-2), strictures were traversed in 37 of the 39 patients (95 %). During a median follow-up period of 21 months (range 3-98 months), 24 of the 39 patients (62 %) underwent a repeat intervention, including 12 (31 %) with repeat dilation, 11 (28 %) with surgical resection, and one patient who received an intestinal stent. The cumulative percentages of patients without a repeat intervention or surgery at 6, 12, 24, and 36 months were 68 %, 48 %, 36 %, and 31 %, and 97 %, 91 %, 84 % and 75 %, respectively. Two perforations and one case of severe bleeding were seen in the 73 dilation procedures (4 %) performed.

CONCLUSIONS

Endoscopic balloon dilation is a safe and effective method that allows surgery to be avoided in approximately 75 % of patients with Crohn's-associated short intestinal strictures. However, recurrent symptoms frequently make it necessary to repeat the procedure.

Radio-guided surgery for persistent differentiated papillary thyroid cancer: case presentations and review of the literature

BACKGROUND AND AIMS

Persistent differentiated papillary thyroid cancer following radical locoregional surgery with metastases is an indication for limited reoperation or radioiodine therapy. Following injection of radioiodine, radio-guided surgery with application of an intraoperative gamma probe offers detection of metastases not seen by conventional imaging and control of completeness of resection.

PATIENTS/METHODS

We demonstrate four patients with locoregional metastases, two of them with additional distant metastases of papillary thyroid cancer following radical neck surgery. Postoperative radioiodine scans demonstrated persistent ipsilateral or contralateral cervical and mediastinal lymph node and isolated rib metastases.

RESULTS

Radio-guided surgery (RGS) leads to complete clearance of persistent lymph node metastases by limited recurrent neck surgery, resection of metastases not seen by conventional imaging and control of complete mediastinal lymph node dissection. Post-RGS scans allowed early diagnosis of occult diffuse or nodal pulmonary metastases in two patients. At last follow-up, 23 to 48 months following RGS and radioiodine therapy, there was no evidence of disease.

CONCLUSIONS

Radio-guided surgery is an additive surgical technique with low morbidity in selected patients with persistent thyroid cancer individualizing tumor therapy options in multimode oncological therapy.