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Le PH, Chen CM, Kuo CJ, Su MY, Chiu CT, Tsou YK. Dual Biologic Therapy for Refractory Crohn's Disease With Perforation in a Patient Declining Surgical Intervention. ACG Case Rep J 2023; 10:e01203. [PMID: 37941582 PMCID: PMC10629729 DOI: 10.14309/crj.0000000000001203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 10/10/2023] [Indexed: 11/10/2023] Open
Abstract
Dual biologic therapy can improve clinical, biomarker, and endoscopic outcomes in selected patients with refractory Crohn's disease in whom multiple biologics had failed. We presented a patient with refractory Crohn's disease who was admitted for terminal ileal perforation, massive bloody stool, shock, and disseminated intravascular coagulation. He refused further surgical resection because of the fear of short bowel syndrome. He was successfully treated with dual biologic therapy, antimicrobial agents, and percutaneous needle decompressions. Dual biologic treatment could be a viable option for patients with refractory Crohn's disease with complications in selected critical conditions who refuse surgery.
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Affiliation(s)
- Puo-Hsien Le
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Taiwan Association of the Study of Small Intestinal Disease
| | - Chien-Ming Chen
- Department of Medical Imaging and Interventions, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chia-Jung Kuo
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Taiwan Association of the Study of Small Intestinal Disease
| | - Ming-Yao Su
- Taiwan Association of the Study of Small Intestinal Disease
- Department of Gastroenterology and Hepatology, New Taipei City Municipal Tucheng Hospital
| | - Cheng-Tang Chiu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Taiwan Association of the Study of Small Intestinal Disease
| | - Yung-Kuan Tsou
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
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Kim DS, Yoon J, Kim YJ, Lee JW, Hong SW, Hwang HW, Park SH, Yang DH, Ye BD, Byeon JS, Myung SJ, Yang SK. Risk factors for rebleeding in Crohn's disease patients with acute severe lower gastrointestinal bleeding: With special reference to the role of anti-tumor necrosis factor therapy. J Gastroenterol Hepatol 2021; 36:2455-2462. [PMID: 33734479 DOI: 10.1111/jgh.15495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/05/2021] [Accepted: 03/12/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Acute severe lower gastrointestinal bleeding (LGIB) in patients with Crohn's disease (CD) is uncommon; however, it is a potentially life-threatening complication, and its recurrence is common. We thus aimed to identify the predictors for rebleeding in CD patients with acute severe LGIB and particularly focused on whether anti-tumor necrosis factor (TNF) therapy lowers the risk of rebleeding compared with conventional medical therapy (CMT) or surgery. METHODS The risk of rebleeding was analyzed in 131 CD patients with acute severe LGIB. Patients were classified into the CMT group (n = 99), anti-TNF therapy group (n = 22), and surgery group (n = 10). No patients in the surgery group received anti-TNF therapy. RESULTS During the median follow-up of 98 months after the first episode of acute severe LGIB, rebleeding occurred in 50.5%, 18.2%, and 30.0% of the CMT group, anti-TNF therapy group, and surgery group, respectively (P = 0.015). The cumulative risks of rebleeding at 1 and 10 years were 20.0% and 64.7% in the CMT group, 13.6% and 18.4% in the anti-TNF therapy group, and 0% and 40.7% in the surgery group, respectively (P = 0.020). Multivariable Cox regression analysis showed that anti-TNF therapy was associated with a lower risk of rebleeding compared with CMT (hazard ratio, 0.303; 95% confidence interval, 0.108-0.849; P = 0.023). CONCLUSIONS In CD patients with acute severe LGIB, anti-TNF therapy may reduce the risk of rebleeding compared with CMT. Although surgery is considered effective in preventing early rebleeding, concomitant anti-TNF therapy may be helpful in further lowering the long-term risk of rebleeding.
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Affiliation(s)
- Dae Sung Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jiyoung Yoon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ye-Jee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jin Wook Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seung Wook Hong
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ha Won Hwang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Yoon J, Kim DS, Kim YJ, Lee JW, Hong SW, Hwang HW, Hwang SW, Park SH, Yang DH, Ye BD, Byeon JS, Myung SJ, Yang SK. Risk factors and prognostic value of acute severe lower gastrointestinal bleeding in Crohn’s disease. World J Gastroenterol 2021; 27:2353-2365. [PMID: 34040327 PMCID: PMC8130046 DOI: 10.3748/wjg.v27.i19.2353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/05/2021] [Accepted: 04/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute severe lower gastrointestinal bleeding (LGIB) is an uncommon but challenging complication of Crohn’s disease (CD).
AIM To identify the predictors of acute severe LGIB and to evaluate the impact of acute severe LGIB on the subsequent clinical course in CD patients.
METHODS A retrospective inception cohort study was conducted in 75 CD patients with acute severe LGIB and 1359 CD patients without acute severe LGIB who were diagnosed between February 1991 and November 2019 at Asan Medical Center, a tertiary university hospital in Korea. Multivariable analysis with Cox proportional hazard regression was performed to identify the risk factors for acute severe LGIB. A matched analysis using 72 patients with bleeding and 267 matched patients without within the cohort was also conducted to investigate whether acute severe LGIB is a predictor of clinical outcomes of CD.
RESULTS Multivariable Cox regression analysis revealed that early use of thiopurines [hazard ratio (HR): 0.23, 95% confidence interval (CI): 0.12-0.48; P < 0.001] and female sex (HR: 0.51, 95%CI: 0.27-0.94; P = 0.031) were significantly associated with a lower risk of acute severe LGIB. The cumulative risks of behavioral progression and intestinal resection were not significantly different between the two matched groups (P = 0.139 and P = 0.769, respectively). The hospitalization rate was higher in the bleeding group than in the matched non-bleeding group (22.1/100 vs 13.2/100 patient-years; P = 0.012). However, if hospitalizations due to bleeding episodes were excluded from the analysis, the hospitalization rate was not significantly different between the bleeding group and the matched non-bleeding group (14.5/100 vs 13.2/100 patient-years; P = 0.631).
CONCLUSION Early use of thiopurines may reduce the risk of acute severe LGIB. History of acute severe LGIB may not have a significant prognostic value in patients with CD.
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Affiliation(s)
- Jiyoung Yoon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, South Korea
| | - Dae Sung Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, South Korea
| | - Ye-Jee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, South Korea
| | - Jin Wook Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, South Korea
| | - Seung Wook Hong
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, South Korea
| | - Ha Won Hwang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, South Korea
| | - Sung Wook Hwang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, South Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, South Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, South Korea
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, South Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, South Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, South Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, South Korea
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Lee S, Ye BD, Park SH, Lee KJ, Kim AY, Lee JS, Kim HJ, Yang SK. Diagnostic Value of Computed Tomography in Crohn's Disease Patients Presenting with Acute Severe Lower Gastrointestinal Bleeding. Korean J Radiol 2018; 19:1089-1098. [PMID: 30386140 PMCID: PMC6201975 DOI: 10.3348/kjr.2018.19.6.1089] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 05/30/2018] [Indexed: 12/22/2022] Open
Abstract
Objective To investigate the diagnostic yield of contrast-enhanced computed tomography (CT) in Crohn's disease (CD) patients presenting with acute severe lower gastrointestinal bleeding (LGIB), and the role of CT in predicting the risk of rebleeding. Materials and Methods A consecutive series of 110 CD patients presenting with acute severe LGIB between 2005 and 2016 were analyzed. Among them, 86 patients who had undergone contrast-enhanced CT constituted the study cohort. The diagnostic yield of CT for detecting contrast extravasation was obtained for the entire cohort and compared between different CT techniques. In a subgroup of 62 patients who had undergone CT enterography (CTE) and showed a negative result for extravasation on CTE, the association between various clinical and CTE parameters and the risk of rebleeding during subsequent follow-up was investigated using Cox regression analysis. Results The diagnostic yield of CT was 10.5% (9 of 86 patients). The yield did not significantly differ between single-phase and multiphase examinations (p > 0.999), or between non-enterographic CT and CTE (p = 0.388). Extensive CD (adjusted hazard ratio [HR], 3.27; 95% confidence interval [CI], 1.09–9.80; p = 0.034) and bowel wall-to-artery enhancement ratio (adjusted HR, 2.81; 95% CI, 1.21–6.54; p = 0.016) were significantly independently associated with increased rebleeding risks, whereas anti-tumor necrosis factor-α therapy after the bleeding independently decreased the risk of rebleeding (adjusted HR, 0.26; 95% CI, 0.07–0.95; p = 0.041). Conclusion The diagnostic yield of contrast-enhanced CT was not high in CD patients presenting with acute severe LGIB. Nevertheless, even a negative CTE may be beneficial as it can help predict the risk of later rebleeding.
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Affiliation(s)
- Sunyoung Lee
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Byong Duk Ye
- Department of Gastroenterology and Inflammatory Bowel Disease Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Seong Ho Park
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Kyung Jin Lee
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Ah Young Kim
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Jong Seok Lee
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Hyun Jin Kim
- Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology and Inflammatory Bowel Disease Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
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Podugu A, Tandon K, Castro FJ. Crohn's disease presenting as acute gastrointestinal hemorrhage. World J Gastroenterol 2016; 22:4073-4078. [PMID: 27122659 PMCID: PMC4837426 DOI: 10.3748/wjg.v22.i16.4073] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 03/11/2016] [Accepted: 03/30/2016] [Indexed: 02/06/2023] Open
Abstract
Severe gastrointestinal (GI) hemorrhage is a rare complication of Crohn’s disease (CD). Although several surgical and non-surgical approaches have been described over the last 2 decades this complication still poses significant diagnostic and therapeutic challenges. Given the relative infrequency of severe bleeding in CD, available medical literature on this topic is mostly in the form of retrospective case series and reports. In this article we review the risk factors, diagnostic modalities and treatment options for the management of CD presenting as GI hemorrhage.
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Li G, Ren J, Wang G, Wu Q, Gu G, Ren H, Liu S, Hong Z, Li R, Li Y, Guo K, Wu X, Li J. Prevalence and risk factors of acute lower gastrointestinal bleeding in Crohn disease. Medicine (Baltimore) 2015; 94:e804. [PMID: 25984665 PMCID: PMC4602567 DOI: 10.1097/md.0000000000000804] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Acute lower gastrointestinal bleeding (ALGIB) is a rare but potentially life-threatening complication of Crohn disease (CD). Thus far, few studies of ALGIB in the context of CD have been published, most of which were case reports with limited value. We aimed to explore the prevalence of ALGIB in CD patients, evaluate risk factors for hemorrhagic CD and its recurrence, and analyze clinical data of the death cases.A total of 1374 CD patients registered from January 2007 to June 2013 were examined. Medical records of 73 patients with ALGIB and 146 matched as controls were reviewed and analyzed retrospectively. Logistic regression and Cox proportional hazards analyses were performed to identify risk factors for ALGIB and the cumulative probability of rebleeding. Kaplan-Meier curves with log-rank tests were used to demonstrate the cumulative survival rates of rebleeding.The prevalence of ALGIB was 5.31% (73/1374) in this study. In the univariate analysis, possible risk factors for ALGIB were duration of CD (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.33-1.09, P = 0.095), perianal disease (OR 1.96, 95% CI 0.92-4.20, P = 0.082), left colon involvement (OR 2.16, 95% CI 1.10-4.24, P = 0.025), azathioprine use ≥1 year (OR 0.46, 95% CI 0.23-0.90, P = 0.023), and previous hemorrhage history (OR 11.86, 95% CI 5.38-26.12, P < 0.0001). In the multivariate analysis, left colon involvement (OR 2.26, 95% CI 1.04-4.91, P = 0.039), azathioprine use ≥1 year (OR 0.44, 95% CI 0.20-0.99, P = 0.044), and previous hemorrhage history (OR 13.04, 95% CI 5.66-30.04, P < 0.0001) remained independent influencing factors. Older age (HR 0.23, 95% CI 0.07-0.77, P = 0.018), surgical treatment (HR 0.17, 95% CI 0.06-0.50, P < 0.001), and having bleeding episodes >3 months ago (HR 0.24, 95% CI 0.07-0.82, P = 0.022) resulted to be predictors associated with rebleeding after discharge. Patients who died often suffered severe concomitant diseases, and the overall mortality rate was 8.22% (6/73).We speculated that a special hemorrhagic phenotype of CD that was predisposed to rebleeding may exist. Further studies are warranted to investigate the pathogenesis and discover the optimum treatments of choice.
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Affiliation(s)
- Guanwei Li
- From the Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P.R. China
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Akazawa Y, Takeshima F, Yajima H, Imanishi D, Kanda T, Matsushima K, Minami H, Yamaguchi N, Ohnita K, Isomoto H, Hayashi T, Nakashima M, Nakao K. Infliximab therapy for Crohn's-like disease in common variable immunodeficiency complicated by massive intestinal hemorrhage: a case report. BMC Res Notes 2014; 7:382. [PMID: 24952714 PMCID: PMC4229744 DOI: 10.1186/1756-0500-7-382] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 06/19/2014] [Indexed: 12/25/2022] Open
Abstract
Background Common variable immune deficiency is the most frequently encountered immunodeficiency in adults, which is characterized by low levels of serum immunoglobulins. Common variable immune deficiency can present with inflammatory bowel disease-like colitis because of the dysregulated immune system; paradoxically activated T cell receptor pathways are thought to be pivotal in pathogenesis of common variable immune deficiency-related colitis. Treatment for severe complications, such as gastrointestinal bleeding, is not established. We report a case of common variable immune deficiency-related Crohn’s-like disease presenting massive melena, which was successfully treated by short course infliximab therapy. Case presentation A 26-year-old Japanese man with history of common variable immune deficiency presented with diarrhea, abdominal pain, and fever. Venous administration of antibiotics did not improve his symptoms. Colonoscopy revealed multiple longitudinal ulcers as well as cobblestone-like change in the ileum end and the ascending colon. Histopathological examination of biopsy specimen showed erosion and infiltration of T lymphocytes with lack of B cells. Intravenous hyperalimentation, mesalazine, and steroid did not improve the symptoms and the patient subsequently presented with massive melena. Colonoscopy revealed a protuberant vessel on one of the ulcers in the ascending colon. Endoscopic clipping was repeatedly performed for hemostasis, which was only temporarily successful. In an attempt to manage the bleeding and colitis, a trial of infliximab was given on week 0, week 2 and week 6. Gastrointestinal hemorrhage from the ulcer halted immediately after the first infliximab injection. Colonoscopy performed after the third infliximab showed remarkable improvement in the ileocolitis. No evidence of increased susceptibility to infections was observed and the patient has been in clinical remission for 3 years. Conclusions We present this case together with review of literature to share our experience of encountering common variable immune deficiency complicating severe Crohn’s-like disease and to support that infliximab is a safe and effective treatment that can promptly manage life-threatening intestinal hemorrhage in common variable immune deficiency-related colitis.
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Affiliation(s)
- Yuko Akazawa
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, 1-7-1 Sakamoto, 852-8501 Nagasaki, Japan.
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The role of endoscopy in the patient with lower GI bleeding. Gastrointest Endosc 2014; 79:875-85. [PMID: 24703084 DOI: 10.1016/j.gie.2013.10.039] [Citation(s) in RCA: 127] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 10/22/2013] [Indexed: 02/06/2023]
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Ueno F, Matsui T, Matsumoto T, Matsuoka K, Watanabe M, Hibi T. Evidence-based clinical practice guidelines for Crohn's disease, integrated with formal consensus of experts in Japan. J Gastroenterol 2013; 48:31-72. [PMID: 23090001 PMCID: PMC3541931 DOI: 10.1007/s00535-012-0673-1] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 08/16/2012] [Indexed: 02/04/2023]
Abstract
Crohn's disease is a disorder of unknown etiology and complicated pathogenesis. A substantial amount of evidence has accumulated recently and has been applied to clinical practice. The present guidelines were developed based on recent evidence and the formal consensus of experts relevant to this disease. Here we provide an overview of these guidelines, as follows. Target disease: Crohn's disease Users: Clinical practitioners in internal medicine, surgery, gastroenterology, and general practice Purpose: To provide appropriate clinical indicators to practitioners Scope of clinical indicators: Concept of Crohn's disease, epidemiology, classifications, diagnosis, treatment, follow up, and special situations Intervention: Diagnosis (interview, physical examination, clinical laboratory tests, imaging, and pathology) and treatment (lifestyle guidance, drug therapy, nutritional therapy, surgery, etc.) Outcome assessment: Attenuation of symptoms, induction and maintenance of remission, imaging findings, quality of life (QOL), prevention of complications and harm of therapy Methods for developing these guidelines: Described in the text Basis of recommendations: Integration of evidence level and consensus of experts Cost-benefit analysis: Not implemented Evaluation of effectiveness: Yet to be confirmed Status of guidelines: Updated version of the first Guidelines published in 2010 Publication sources: Printed publication available and electronic information in preparation Patient information: Not available Date of publication: October 2011 These guidelines were intended primarily to be used by practitioners in Japan, and the goal of these guidelines is to improve the outcomes of patients with Crohn's disease.
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Affiliation(s)
| | - Toshiyuki Matsui
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Takayuki Matsumoto
- Division of Lower Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Katsuyoshi Matsuoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinano-machi Shinjuku, Tokyo, 160-8582 Japan
| | - Mamoru Watanabe
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshifumi Hibi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinano-machi Shinjuku, Tokyo, 160-8582 Japan
| | - On Behalf of the Guidelines Project Group of the Research Group of Intractable Inflammatory Bowel Disease subsidized by the Ministry of Health, Labour and Welfare of Japan and the Guidelines Committee of the Japanese Society of Gastroenterology
- Ofuna Chuo Hospital, Kanagawa, Japan
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
- Division of Lower Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinano-machi Shinjuku, Tokyo, 160-8582 Japan
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, Tokyo, Japan
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Kim KJ, Han BJ, Yang SK, Na SY, Park SK, Boo SJ, Park SH, Yang DH, Park JH, Jeong KW, Ye BD, Byeon JS, Myung SJ, Kim JH. Risk factors and outcome of acute severe lower gastrointestinal bleeding in Crohn's disease. Dig Liver Dis 2012; 44:723-8. [PMID: 22497905 DOI: 10.1016/j.dld.2012.03.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Revised: 02/29/2012] [Accepted: 03/04/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Acute severe lower gastrointestinal bleeding in Crohn's disease is uncommon, but is a diagnostic and therapeutic challenge. We aimed to identify risk factors for acute lower gastrointestinal bleeding in patients with Crohn's disease and assess the cumulative probability of rebleeding in relation to therapeutic modality. METHODS We retrospectively reviewed the medical records of 70 Crohn's patients (4.0%) with acute severe lower gastrointestinal bleeding and compared these with matched 140 Crohn's patients without bleeding. RESULTS The cumulative probability of bleeding after diagnosis of Crohn's disease was 1.7%, 3.6%, 6.5%, and 10.3% after 1, 5, 10, and 20 years respectively. At presentation, the median haemoglobin concentration was 8.4g/dL (range, 4.7-11.6g/dL). Use of azathioprine/6-mercaptopurine decreased the risk of lower gastrointestinal bleeding (OR: 0.525, 95% CI: 0.304-0.906, p=0.021). Bleeding recurred in 29 patients (41.4%) after a median time of 3.2 months (range, 15 days-94.7 months). One out of eleven patients treated with infliximab rebled. The cumulative probability of rebleeding tended to be lower in patients treated with infliximab than in those receiving other treatments (p=0.076). CONCLUSIONS Azathioprine/6-mercaptopurine may reduce the risk of acute severe lower gastrointestinal bleeding. The rebleeding is common, but infliximab may decrease rebleeding.
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Affiliation(s)
- Kyung-Jo Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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Aniwan S, Eakpongpaisit S, Imraporn B, Amornsawadwatana S, Rerknimitr R. Infliximab stopped severe gastrointestinal bleeding in Crohn's disease. World J Gastroenterol 2012; 18:2730-4. [PMID: 22690085 PMCID: PMC3370013 DOI: 10.3748/wjg.v18.i21.2730] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Revised: 02/20/2012] [Accepted: 02/26/2012] [Indexed: 02/06/2023] Open
Abstract
To report the result of rapid ulcer healing by infliximab in Crohn’s patients with severe enterocolic bleeding. During 2005 and 2010, inflammatory bowel disease database of King Chulalongkorn Memorial and Samitivej hospitals were reviewed. There were seven Crohn’s disease (CD) patients (4 women and 3 men; mean age 52 ± 10.4 years; range: 11-86 years). Two of the seven patients developed severe gastrointestinal bleeding (GIB) as a flare up of CD whereas the other five patients presented with GIB as their first symptom for CD. Their mean hemoglobin level dropped from 12 ± 1.3 g/dL to 8.7 ± 1.3 g/dL in a 3-d period. Median packed red blood cells units needed for resuscitation was 4 units. Because of uncontrolled bleeding, surgical resection was considered. However, due to the poor surgical candidacy of these patients (n = 3) and /or possible development of short bowel syndrome (n = 6), surgery was not pursued. Likewise angiographic embolization was not considered in any due to the risk of large infarction. All severe GIBs successfully stopped by one or two doses of intravenous infliximab. Our data suggests that infliximab is an alternative therapy for CD with severe GIB when surgery has limitation or patient is a high risk.
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Chowdhury M, Kudara N, Chiba T, Endo M, Akasaka R, Tomita K, Fujiwara S, Mizutani T, Sugai T, Takikawa Y, Suzuki K. Evaluation of Infliximab Effects on Gastrointestinal Bleeding in Crohn's Disease Using Double-Balloon Endoscopy. Case Rep Gastroenterol 2009; 3:193-197. [PMID: 21103274 PMCID: PMC2988956 DOI: 10.1159/000224712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Tumor necrosis factor α plays an important role in the pathogenesis of Crohn's disease (CD). The effects of infliximab on gastrointestinal bleeding in CD have not yet been fully evaluated. Herein we describe three CD cases who presented with gastrointestinal bleeding and received infliximab treatment. In case 1, double-balloon endoscopy showed a large ulcer with several irregularly shaped ulcers in the terminal ileum; 8 weeks after infliximab administration, complete healing of all lesions was observed. In case 2, double-balloon endoscopy showed linear ulcers and mucosal edema in the jejunum and ileum; 5 weeks after infliximab administration, all lesions were decreased in size and were healed. In case 3, double-balloon endoscopy revealed ulcerations and stenosis in the terminal ileum; 12 weeks after infliximab administration, ulcer healing and an increased diameter of the ileal stenosis were observed. These three cases have been receiving ongoing infliximab maintenance therapy and are currently symptom-free. Infliximab thus appears to be useful for treatment of gastrointestinal bleeding in CD patients.
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Affiliation(s)
- Manzurul Chowdhury
- Department of Gastroenterology and Hepatology, Iwate Medical University, Morioka, Japan
- Ministry of Health and Family Welfare, Government of Bangladesh, Dhaka, Bangladesh
| | - Norihiko Kudara
- Department of Gastroenterology and Hepatology, Iwate Medical University, Morioka, Japan
| | - Toshimi Chiba
- Department of Gastroenterology and Hepatology, Iwate Medical University, Morioka, Japan
- *Toshimi Chiba, MD, Department of Gastroenterology and Hepatology, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate 020-8505 (Japan), Tel. +81 19 651 5111, Fax +81 19 652 6664, E-Mail
| | - Masaki Endo
- Department of Gastroenterology and Hepatology, Iwate Medical University, Morioka, Japan
| | - Risaburo Akasaka
- Department of Gastroenterology and Hepatology, Iwate Medical University, Morioka, Japan
| | - Kazumitsu Tomita
- Department of Gastroenterology and Hepatology, Iwate Medical University, Morioka, Japan
| | - Saori Fujiwara
- Department of Gastroenterology and Hepatology, Iwate Medical University, Morioka, Japan
| | - Tomomi Mizutani
- Department of Gastroenterology and Hepatology, Iwate Medical University, Morioka, Japan
| | - Tamotsu Sugai
- Division of Molecular Diagnostic Pathology, Department of Pathology, Iwate Medical University, Morioka, Japan
| | - Yasuhiro Takikawa
- Department of Gastroenterology and Hepatology, Iwate Medical University, Morioka, Japan
| | - Kazuyuki Suzuki
- Department of Gastroenterology and Hepatology, Iwate Medical University, Morioka, Japan
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Ando Y, Matsushita M, Kawamata S, Shimatani M, Fujii T, Okazaki K. Infliximab for severe gastrointestinal bleeding in Crohn's disease. Inflamm Bowel Dis 2009; 15:483-4. [PMID: 18668673 DOI: 10.1002/ibd.20635] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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15
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Godart B, Beau P, Benchellal Z, Bumsel F, Metman E. [Ulcerative colitis associated with rectocolitis hemorrhagic: successful treatment with infliximab]. ACTA ACUST UNITED AC 2007; 31:88-90. [PMID: 17273137 DOI: 10.1016/s0399-8320(07)89332-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Jiang H, Deng CS, Zhang M, Xia J. Curcumin-attenuated trinitrobenzene sulphonic acid induces chronic colitis by inhibiting expression of cyclooxygenase-2. World J Gastroenterol 2006; 12:3848-53. [PMID: 16804969 PMCID: PMC4087932 DOI: 10.3748/wjg.v12.i24.3848] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To explore the possible mechanisms of curcumin in rat colitis induced by trinitrobenzene sulfonic (TNBS) acid.
METHODS: Rats with TNBS acid-induced colitis were treated with curcumin (30 mg/kg or 60 mg/kg per day ip). Changes of body weight and histological scores as well as survival rate were evaluated. Leukocyte infiltration was detected by myeloperoxidase (MPO) activity assay. The expression of cyclooxygenase-2 (COX-2) was detected by RT-PCR and Western blot. Inflammation cytokines were determined by RT-PCR. Local concentration of prostaglandin E2 (PGE2) in colon mucosa was determined by ELISA.
RESULTS: Curcumin improved survival rate and histological image, decreased the macroscopic scores and MPO activity. Also curcumin reduced the expression of COX-2 and inflammation cytokines. In addition, treatment with curcumin increased the PGE2 level.
CONCLUSION: Curcumin has therapeutic effects on TNBS acid-induced colitis, the mechanisms seem to be related to COX-2 inhibition and PGE2 improvement.
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Affiliation(s)
- Hua Jiang
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Hubei Province, China.
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Abstract
Although acute LGIB is only about one fifth as common and is usually less hemodynamically significant than upper gastrointestinal bleeding, it presents numerous unique clinical challenges. The best diagnostic approach for patients with active bleeding is unknown, but urgent prepared colonoscopy is safe and likely to be beneficial (Fig. 3, Table 2). In patients who have aggressive bleeding or recurrent bleeding, it is critical for the practitioner to judge when angiography and surgery are necessary.
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Affiliation(s)
- Bryan T Green
- Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA.
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