[Diagnostic and therapeutic management of patients with chronic inflammatory bowel disease]

BACKGROUND

The period of time required for the diagnosis of a chronic illness depends on initial clinical symptoms and their perception by the patient and the physicians. The aim of this study was to describe the procedures of diagnosis of incident cases of Inflammatory Bowel Disease (IBD).

METHODS

Patients reported by the Registry of inflammatory bowel disease of northern France (EPIMAD) in 1994 were included. Standardized questionnaires describing clinical history, patient behavior, medical consultations and examinations were collected by an interviewer practitioner from three sources: patients, general practitioners (GP) and gastroenterologists (GE). Patients were divided in 2 groups according to the time between symptom onset and diagnosis: more than 9 months or less than 9 months (D > 9 and D < or = 9).

RESULTS

258 patients were included: 144 Crohn's disease (CD) (56%), 106 ulcerative colitis (UC) (41%) and 8 chronic unclassifiable colitis (CUC). Median time between symptom onset and diagnosis was 3 months, 196 (76%) patients belonged to the group D < or = 9 and 62 (24%) to the group D > 9. There was no difference between the 2 groups for initial clinical symptoms. The delay between symptom onset and the consultation to the GP and the GE was longer in the group D > 9: respectively 1 month vs 0 and 7.6 vs 2. Thirty-five percent of patients in the group D > 9 had consulted more than one GP vs 14% (p < 0.05). Diagnosis management by the GE was the same in both groups. Patients of group D < or = 9 had more often perceived their symptoms as serious (p < 0.05).

CONCLUSIONS

Delay to diagnosis in a quarter of patients with IBD was more than 9 months. This later diagnosis was not due to patient management by the GE but rather to a longer delay to consulting the GP and between GP and GE referral. Patient interpretation of the symptoms could also explain the variability of this delay.

Enteral nutrition modifies gut-associated lymphoid tissue in rat regardless of the molecular form of nitrogen supply

BACKGROUND

It has been suggested that beneficial effect of elemental enteral diets in the treatment of inflammatory bowel diseases could be mediated by the suppression of protein dietary antigens. The objective of the present work was to study the effect of enteral diet on gut associated lymphoid tissue and on gastric Lactobacillus flora, in rat.

METHODS

The effects of three molecular forms of nitrogen supply: amino acids, oligopeptides or whole casein, were compared in rats on continuous enteral diet. Frozen sections of small bowel were studied with monoclonal antibodies anti-CD5, -CD4, -CD8, -CD25, -macrophages, -MHC II. The Lactobacillus flora was also enumerated in the stomach, in order to assess the effect of ED on rat flora.

RESULTS

Growth and mucosa morphology were identical in control and enteral groups. Rats on enteral diet showed, whatever was the molecular form of nitrogen supply, a decrease in CD5+, CD4+ and CD8+ intraepithelial cell numbers, but not in lamina propria cell number, and a decreased MHC II epithelial expression, when compared to control rats. The enterally fed rats also showed a decrease in Lactobacillus gastric contents.

CONCLUSIONS

The current study demonstrates that continuous enteral nutrition modifies MHC II epithelial expression and gut associated lymphoid tissue cell number in rat, whatever is the molecular form of nitrogen supply. Intestinal flora could be responsible, at least for part, for these results.

[Compared efficiency of three strategies of management of chronic hepatitis C. Effect on the risk of cirrhosis 8 years after diagnosis]

OBJECTIVES AND METHODS

The goal of treating chronic hepatitis C with alfa interferon is to eradicate HCV infection. The actual influence of this treatment on the development of cirrhosis is unknown. Moreover, the poor results and the high cost of this treatment have caused a public health problem. Three strategies were evaluated by decision analysis: no treatment (S1), treatment of chronic active hepatitis only (S2), treatment of all chronic hepatitis (S3). For each strategy, we estimated the probability of the occurrence of the following events based on data in the literature: presence of chronic active hepatitis, chronic persistent hepatitis or cirrhosis at the time of diagnosis; discontinuation of interferon because of adverse events; biological response to treatment; incidence of cirrhosis 8 years after diagnosis without treatment or in case of response to treatment.

RESULTS

The risk of cirrhosis was 28.5% with S1, 25.4% with S2, and 25.2% with S3, 8 years after diagnosis. If HCV infection was detected early before cirrhosis, the number of cases of cirrhosis occurring in an 8 year-followup period would be 45,600 with S1, 40,640 with S2, and 40,320 with S3 and the cost of S2 and S3 would be 1.23 10(9) French Francs (FF), and 2.57 10(9) FF, respectively. The mean cost to prevent one case of cirrhosis would vary from 248,000 FF with S2 to 487,000 FF with S3.

CONCLUSION

This decision analysis study suggests that the S3 strategy is not suitable for a population of HCV infected patients, because of its low efficiency and high cost.