Surgical therapy for ulcerative colitis and Crohn's disease

Emergency surgery for acute rectal bleeding in a newly diagnosed case of fulminant ulcerative colitis

INTRODUCTION

The incidence of ulcerative colitis is rising among Asian population. Massive bleeding per rectum is an uncommon, but serious, complication of UC accounting for 0.1-1.4 % of admissions.

CASE PRESENTATION

A 22-year-old male, reported persistent abdominal pain, bloody diarrhea, and intermittent vomiting for one week. Physical examination revealed signs of dehydration and pallor. Laboratory tests showed elevated inflammatory markers. CT and colonoscopy confirmed ulcerative colitis, refractory to corticosteroids, leading to a subtotal colectomy followed by Ileal Pouch-Anal Anastomosis. The patient was symptom free at a 24-month follow-up.

DISCUSSION

Bleeding that occurs during the initial stages of the disease or in cases where the diagnosis of ulcerative colitis hasn't been confirmed makes it challenging for patients to accept the need for extensive surgery and the creation of a stoma. Conservative procedures are advised in such settings.

CONCLUSION

Acute severe bleeding in ulcerative colitis is rare but demands a multidisciplinary approach for timely diagnosis and treatment. In resource and expertise limited situation, where patients are noncompliant to regular follow-ups surgical treatment can still be intervention of choice for these cases.

Delivery Strategies of Probiotics from Nano- and Microparticles: Trends in the Treatment of Inflammatory Bowel Disease-An Overview

Inflammatory bowel disease (IBD) is a chronic inflammatory disorder, most known as ulcerative colitis (UC) and Crohn's disease (CD), that affects the gastrointestinal tract (GIT), causing considerable symptoms to millions of people around the world. Conventional therapeutic strategies have limitations and side effects, prompting the exploration of innovative approaches. Probiotics, known for their potential to restore gut homeostasis, have emerged as promising candidates for IBD management. Probiotics have been shown to minimize disease symptoms, particularly in patients affected by UC, opening important opportunities to better treat this disease. However, they exhibit limitations in terms of stability and targeted delivery. As several studies demonstrate, the encapsulation of the probiotics, as well as the synthetic drug, into micro- and nanoparticles of organic materials offers great potential to solve this problem. They resist the harsh conditions of the upper GIT portions and, thus, protect the probiotic and drug inside, allowing for the delivery of adequate amounts directly into the colon. An overview of UC and CD, the benefits of the use of probiotics, and the potential of micro- and nanoencapsulation technologies to improve IBD treatment are presented. This review sheds light on the remarkable potential of nano- and microparticles loaded with probiotics as a novel and efficient strategy for managing IBD. Nonetheless, further investigations and clinical trials are warranted to validate their long-term safety and efficacy, paving the way for a new era in IBD therapeutics.

Management of Crohn's Disease and Complications in Patients With Ostomies

Fecal diversion with ostomy construction can be a temporary or definitive surgical measure for the treatment of refractory inflammatory bowel disease (IBD). However, the fecal diversion surgery is associated with various stoma, peristomal complications, and recurrence or occurrence of de novo small bowel Crohn's disease (CD). Stoma complications often need enterostomal therapy or surgical revision. Peristomal cutaneous lesions, such as pyoderma gangrenosum, usually require immunomodulator or biological therapy. Routine monitoring for occurrence or recurrence of CD with endoscopy or imaging should be performed, and prophylaxis with mesalamines, antibiotics, immunomodulators, or anti-TNFα or anti-integrin agents is needed for patients at risk. Those agents, along with corticosteroids, may also be used for the treatment of CD of the neo-small intestine, particularly inflammatory and fistulizing phenotypes. Endoscopic balloon dilation or endoscopic stricturotomy via stoma is safe and feasible to treat short (<4-5 cm), straight strictures in the neo-small intestine. Medically or endoscopically refractory fibrostenotic disease usually requires surgical intervention, with bowel-sparing stricturoplasty being the surgical treatment of choice.

Postoperative prophylaxis in Crohn's disease after intestinal resection: a retrospective analysis

INTRODUCTION

Up to 80% of patients with Crohn's disease (CD) may require surgery at some point in their lives, and it is estimated that as many as 40% may require several surgeries. It has been suggested that prophylactic medication decreases the rate of clinical and endoscopic recurrence following intestinal resection. This study aims to describe real-world clinical outcomes observed from a pragmatic, individualised strategy in postoperative CD.

METHODS

All patients undergoing intestinal resection for CD between 2009 and 2013 were identified. The endpoint of the study, treatment success, was defined as glucocorticosteroid-free, resection-free survival, at the last point of follow-up, without requiring an escalation or change of therapy during this time. Clinical information was extracted from chart reviews, endoscopy and radiology reports, and from prescribing databases. Patients were followed from the date of surgery, and the last point of follow-up was 31 January 2015.

RESULTS

149 patients were analysed. Median duration of follow-up was 32 months (range 1-69 months). 101 patients received postoperative prophylactic therapy, and 48 did not. In 77 (51.7%) patients, thiopurines were used as first-line therapy, with treatment success occurring in 32 (41.6%) with a median follow-up of 25 months. 11 patients (7.4%) received anti-tumour necrosis factor (TNF)-α monotherapy, with treatment success occurring in 5 patients (45.5%) with a median follow-up of 35 months. 13 (8.7%) patients received first-line combination therapy, with 11 (84.6%) patients achieving treatment success with a median follow-up of 21 months.

CONCLUSIONS

In our study, combination therapy with anti-TNF-α and immunomodulator therapy was well tolerated, efficacious (efficacy appeared durable for patients with postoperative CD) and superior to monotherapy with either thiopurines or anti-TNF-α drugs. Several limitations notwithstanding, our data suggest that there may be merit in the use of combination therapy in carefully selected postoperative patients whose care has been individualised via a multidisciplinary team meeting format. Prospective, controlled studies are therefore required to further assess the efficacy and safety of combination therapy for postoperative prophylaxis in CD.

Optimized cultivation of Campylobacter concisus from gut mucosal biopsies in inflammatory bowel disease

Background

Campylobacter concisus is a commensal of the human oral flora that has been linked to prolonged diarrhea and inflammatory bowel disease (IBD). It has been detected more often from intestinal biopsies in patients with IBD compared to healthy controls using PCR-based techniques, whereas the number of C. concisus culture-positive biopsies in previous studies has been very limited. Determining the rate of viable isolates present in the gut mucosa is of great importance when evaluating the role in different disease presentations. We therefore investigated a novel two-step cultivation procedure combining anaerobic and microaerobic incubation from several gut mucosal sites to improve isolate yield, and compared this to PCR results, from IBD patients and healthy controls.

Results

Cultivation with the novel two-step procedure yielded a higher rate of C. concisus isolates from mucosal biopsies than previously reported by other methods. From 52 IBD patients, 52/245 (21 %) biopsies were culture positive for C. concisus, while 121/245 (49 %) of biopsies were PCR positive. For 26 healthy controls, the numbers were 23/182 (13 %) and 66/182 (36 %), respectively (p < 0.001). The rate of cultivation and PCR detection was higher for IBD patients compared to healthy controls (p = 0.021, p = 0.008, respectively).

Conclusions

Patients with IBD had a higher prevalence of C. concisus than healthy controls, by both cultivation and PCR detection. We found a higher rate of C. concisus isolates from gut mucosal biopsies in both IBD patients and healthy controls than in preceding studies, indicating that colonization of C. concisus in the gastrointestinal tract is more extensive than previously assumed.

Pathogenic aspects and therapeutic avenues of intestinal fibrosis in Crohn's disease

In Crohn's disease, one of the two major forms of inflammatory bowel diseases in human beings, persistent and chronic inflammation promotes fibrotic processes thereby facilitating formation of strictures, the most common indication for surgical intervention in this disorder. The pathogenesis of Crohn's disease-associated fibrosis is not fully understood, but variants of genes involved in the recognition of microbial components/products [e.g. CARD15 (caspase-activating recruitment domain 15) and ATG16L1 (autophagy-related 16-like 1)] are associated with this phenotype, and experimental evidence suggests that intestinal fibrosis results from an altered balance between deposition of ECM (extracellular matrix) and degradation of ECM by proteases. Studies have also contributed to identify the main phenotypic and functional alterations of cells involved in the fibrogenic process, as well as molecules that stimulate such cells to produce elevated amounts of collagen and other ECM-related proteins. In the present review, we assess the current knowledge about cellular and molecular mediators of intestinal fibrosis and describe results of recent studies aimed at testing the preventive/therapeutic effect of compounds in experimental models of intestinal fibrosis.

[Long-term results of medical treatment in patients with a severe attack of ulcerative colitis]

AIM

To assess the long-term result of medical treatment in patients with a severe attack (SA) of ulcerative colitis (UC).

SUBJECTS AND METHODS

The course of UC was analyzed in 56 patients who were accessible by telephone contact and consecutively recruited for a year after therapy for a SA of UC. All the patients were stated to have a SA of UC according to the Truelove-Witts' criteria; they received therapy with intravenous glucocorticosteroids (GCS) (prednisolone 2 mg/kg) along with anti-recurrence therapy with mesalasine (5-ASA) or azathioprine (AZA). Ten (17.9%) GCS-resistant patients were given infliximab (INF) (5 mg/ kg), followed by its maintenance infusions. Anti-recurrence therapy using 5-ASA, AZA, and INF was performed in 33 (58.9%), 13 (23.2%), and 10 (17.9%) patients, respectively.

RESULTS

During one year, 14 (25%) patients continued to be in clinical remission on maintenance therapy or to have attacks stopped without using GCS, immunosuppressive agents, or INF (a satisfactory response group). Colectomy was carried out in 23 (41.1%) patients; due to recurrent UC when decreasing the dose of GCS, 5 (8.9%) patients continued to take the latter during a year. A GCS cycle was repeated in 3 patients who had received AZA (the basic therapy was not corrected) and 11 patients who had taken 5-ASA. The prognostic factors for a long-term result of medical therapy included the choice of AZA as an anti-recurrent drug (57.1 and 11.9% in the satisfactory and poor treatment outcome groups, respectively; p = 0.004) and patient age (34.4 and 42.8 years, respectively; p = 0.0357).

CONCLUSION

During 1 year after a SA of UC, indications for colectomy and repeated GCS use occurred in 41 and 34% of the patients, respectively. The long-term efficiency of medical therapy for a SA of UC declines with advancing age. The use of AZA as an anti-recurrence agent after termination of GCS intake increases the probability of long-term clinical response.

Tripterygium wilfordii Hook. f. versus azathioprine for prevention of postoperative recurrence in patients with Crohn's disease: a randomized clinical trial

BACKGROUND

Tripterygium wilfordii Hook. f. (TwHF) has been used for many years to induce the remission of Crohn's disease in China.

AIMS

To compare TwHF versus azathioprine for the prevention of postoperative recurrence in Crohn's disease.

METHODS

90 Crohn's disease patients who had undergone resection were treated with TwHF 1.5mg/kg/day or azathioprine 2.0 mg/kg/day. The primary endpoint was clinical recurrence, and the secondary endpoint was endoscopic recurrence.

RESULTS

47 patients completed the trial. Clinical recurrence was observed in 6/45 patients in the TwHF group and 4/45 patients in the azathioprine group at week 26 (P=0.74). At week 52, 8/45 azathioprine patients and 12/45 TwHF patients had clinical recurrence (P = 0.45). During the first 26 weeks, 56.8% of the patients in the TwHF group versus 47.7% in the azathioprine group experienced endoscopic recurrence (P = 0.52). However, at week 52, 74.4% of patients in the TwHF group and 50% in the azathioprine group had endoscopic recurrence (P = 0.03).

CONCLUSIONS

TwHF was less effective in maintaining endoscopic remission at week 52, even though TwHF was comparable to azathioprine for preventing postoperative clinical recurrence.

Innate immune factors in the development and maintenance of pouchitis

BACKGROUND

Tight junction proteins (TJPs) and dendritic cells (DC) are critical in the pathogenesis of inflammatory bowel diseases. The ileal pouch formed by restorative proctocolectomy provides a unique human model for studying the pathogenesis of inflammatory bowel diseases. Data implicate the microbiota in the pathogenesis of pouchitis, while the role of innate immune factors remains unclear. We performed longitudinal and cross-sectional studies of patients after restorative proctocolectomy and assessed TJP and DC characteristics in the ileal pouch.

METHODS

Mucosal biopsies were taken from the ileal pouch of patients with ulcerative colitis (UC) and familial adenomatous polyposis (n = 8). Of patients with UC, one group (n = 5) was followed longitudinally over the first year after ileostomy closure, another group had pouchitis (n = 15), and another group no inflammation (n = 18). Dendritic cell phenotype and epithelial cell TJP expression were assessed using flow cytometric analysis.

RESULTS

Increased epithelial expression of the "pore-forming" TJP claudin 2, and DC expression of gut-homing markers CCR 9 and integrin β7, occurred early after ileostomy closure. In patients with UC with pouchitis, epithelial expression of ZO-1 and claudin 1 were reduced, DC were activated with increased CD40, and Toll-like receptor 4 expression increased. In pouchitis, DC expressing CCR 9 were decreased, whereas DC expressing β7 increased.

CONCLUSIONS

Abnormalities were found in TJP expression in the pouch of patients with UC, in particular, increased expression of the pore-forming claudin 2 as an early event in the development of pouch inflammation and an aberrant DC phenotype was characterized in the ileal pouch of patients with UC.

Can we change the natural history of Crohn's disease with early immunomodulation?

In both children and adults, the natural history of Crohn's disease (CD) is characterized by relapsing and remitting bouts of intestinal inflammation, often associated with a progressive shift from inflammatory to complicated stricturing or penetrating disease behavior. The past 2 decades have seen a dramatic shift in therapeutic approach with the increasingly common use of early thiopurine immunomodulation. These maintenance medications were initially introduced primarily as corticosteroid-sparing agents capable of minimizing recurrent flares of inflammatory disease and have proven to be quite efficacious. Increasing evidence suggests, however, that thiopurines may only delay rather than prevent the development of complicated disease behavior. Data from both adult and pediatric CD populations from around the world are reviewed in terms of the effect of early immunomodulation on progression to complicated disease behavior, need for surgery, and prevention of recurrent disease after resection. The effect of thiopurines on the growth of children is also reviewed.

Insight into Crohn's disease pathomorphology

Crohn's disease (CD) belongs together with ulcerative colitis to the two major forms of inflammatory bowel diseases (IBD). Although its etiology remains poorly understood, several genetic and immune factors and cells (especially T cells) have been shown to be involved in the pathogenesis of IBD. Among these factors, proinflammatory T cells and their secreted cytokines seem to be the main effectors in induction and perpetuation of the intestinal inflammation. Beside the local inflammatory effect, there is a very clear defined mechanism where T cells and inflammatory complexes migrate and induce extraintestinal manifestation and complications. This article reviews current knowledge of the pathomorphology of mucosal inflammation in CD focusing especially on the immune mechanisms of T-cell homing, extraintestinal manifestations and fibrogenesis.

The surgical management of active ulcerative colitis complicated by Clostridium difficile infection

INTRODUCTION

Clostridium difficile stool toxin is detected in 5-20 % of patients with acute exacerbations of ulcerative colitis (UC). There is little data regarding the safety of surgery for UC with concurrent C. difficile.

METHODS

A retrospective review was performed of 23 patients undergoing colectomy for refractory UC complicated by C. difficile infection between January 2002 and June 2012. Patients were stratified into those who completed a full antibiotic course for C. difficile infection prior to surgery (group A, n = 7) and those who proceeded directly to surgery (group B, n = 16). The primary endpoints of perioperative mortality, ICU requirement, reoperation, readmission, and surgical site infection were assessed within 30 days after surgery.

RESULTS

Postoperatively, no mortalities, ICU admissions, readmission, or reoperations occurred. One group A patient developed a superficial wound infection, which resolved with a course of outpatient antibiotics (14 vs. 0 %, p = 0.12). Average days until return of bowel function and average length of postoperative stay were comparable between group A and B (3.9 vs. 3.6 days, p = 0.70; 7.0 vs. 6.9 days, p = 0.87; respectively). Ninety-one percent of patients subsequently underwent ileal pouch-anal anastomosis.

CONCLUSION

Colectomy for ulcerative colitis complicated by C. difficile can be performed safely without completing a course of antibiotic therapy.

Prevention of postoperative recurrence of Crohn's disease: Tripterygium wilfordii polyglycoside versus mesalazine

OBJECTIVES

To explore effectiveness and safety of polyglycosides of Tripterygium wilfordii (GTW) and mesalazine (5-aminosalicylic acid [5-ASA]) in preventing postoperative clinical and endoscopic recurrence of Crohn's disease.

METHODS

In this prospective, single-centre, single-blind study, postoperative Crohn's disease patients in remission were randomized to receive 1 mg/kg GTW daily, orally, or 4 g 5-ASA daily, orally, for 52 weeks. Patients underwent physical examinations, ileocolonoscopies and biochemical analyses at baseline and weeks 13, 26 and 52, or when clinical recurrence was suspected. Outcome measures were proportion of patients showing clinical or endoscopic recurrence at week 52, and changes in Rutgeerts' and Crohn's Disease Activity Index (CDAI) scores.

RESULTS

Twenty-one patients were assigned to receive GTW and 18 to 5-ASA; two patients on GTW and one on 5-ASA were withdrawn. Clinical and endoscopic recurrences were less common in the GTW group (n = 4) versus the 5-ASA group (n = 9). There were improvements in Rutgeerts' scores for those taking GTW. Mean between-group CDAI scores were similar. No serious adverse events were reported.

CONCLUSION

These findings indicate that GTW appears to be an effective, well-tolerated prophylactic regimen, superior to oral 5-ASA, for preventing clinical and endoscopic recurrence in postsurgical Crohn's disease.

Comparison of small bowel follow through and abdominal CT for detecting recurrent Crohn's disease in neoterminal ileum

PURPOSE

To assess the findings of recurrent Crohn's disease in the neoterminal ileum on small bowel follow through (SBFT) and computed tomography (CT) as well as the overall diagnostic performance of these imaging tests.

METHODS

Our radiology database yielded 52 patients with an ileocolic anastomosis for Crohn's disease who underwent SBFT and CT. The images were reviewed to determine the sensitivity, specificity, PPV, and NPV for individual findings of recurrent Crohn's disease in the neoterminal ileum. The overall sensitivity, specificity, PPV, and NPV of these tests for recurrent Crohn's disease were determined by comparing imaging reports to endoscopic and surgical findings in 45 patients (87%) and clinical response to treatment in seven (13%).

RESULTS

SBFT had a sensitivity of 90%, specificity of 85%, PPV of 95%, and NPV of 73% for detecting recurrent Crohn's disease, and CT had a sensitivity of 77%, specificity of 69%, PPV of 88%, and NPV of 50%. These tests combined had a sensitivity of 95%, specificity of 69%, PPV of 90%, and NPV of 82%. The most common findings were luminal narrowing, thickened folds, and ulcers (especially aphthoid lesions) on SBFT and bowel wall thickening on CT. CT also revealed extraenteric collections not visualized on SBFT in three patients (8%).

CONCLUSIONS

Our experience suggests that SBFT is more sensitive and specific than CT for detecting recurrent Crohn's disease in the neoterminal ileum, mainly because of the ability of barium studies to depict aphthoid lesions not visualized on CT. Conversely, CT is better for detecting extraenteric findings such as abscesses. When combined, these tests have a higher sensitivity for detecting recurrent Crohn's disease than either test alone.

Value of concomitant endoscopic balloon dilation for intestinal stricture during long-term infliximab therapy in patients with Crohn's disease

AIM

We assessed the long-term outcome of infliximab (IFX) therapy in patients with Crohn's disease (CD) and investigated the efficacy of concomitant endoscopic balloon dilation (EBD) for intestinal stricture during treatment.

METHODS

The effectiveness of maintenance therapy with IFX was retrospectively evaluated in 185 patients with CD in a single center (median observation period 24 months). IFX effectiveness with and without immunomodulators (IMM) and enteral nutrition (EN), as well as cumulative surgery-free rates, were compared. The efficacy of concomitant EBD in patients with obstructive symptoms and high-level stricture was evaluated.

RESULTS

In 185 patients receiving the maintenance therapy, the long-term efficacy rate was 84.9% at 24 months and 79.0% at 48 months. The cumulative surgery-free rate was significantly higher in the maintenance group (P < 0.001). Concomitant IMM and EN did not significantly affect the effectiveness of IFX. IFX was discontinued in only 18 cases (7.3%). Symptomatic high-level stricture occurred in 33 patients (17.8%) in the maintenance group and the cumulative surgery-free rate was significantly higher in the EBD combination compared with the non-EBD group (P < 0.05). If EBD were considered invasive intervention, the actual cumulative surgery rate in the maintenance group was significantly lower compared with the cumulative invasive intervention rate (P < 0.001).

CONCLUSION

Long-term treatment with IFX is highly effective. The surgery-free rate was clearly higher in the maintenance group. Only concomitant EBD for intestinal stricture helped in the avoidance of surgery.

Etiology of pouchitis

Restorative proctocolectomy with ileal-pouch anal anastomosis (RPC) is the operation of choice for ulcerative colitis (UC) patients requiring surgery. It is also used for patients with familial adenomatous polyposis (FAP). Pouchitis accounts for 10% of pouch failures. It is an idiopathic inflammatory condition that may occur in up to 50% of patients after RPC for UC. It is rarely seen in FAP patients after RPC. The etiology of pouchitis remains unclear. An overlap with UC is suggested by the frequency with which pouchitis affects patients with UC compared with FAP patients. There is significant clinical evidence implicating bacteria in the pathogenesis of pouchitis. Studies using culture and molecular methods demonstrate a dysbiosis of the pouch microbiota in pouchitis. Risk factors, genetic associations, and serological markers of pouchitis suggest that the interactions between the host immune responses and the pouch microbiota underlie the etiology of this idiopathic inflammatory condition. Here we present a detailed review of the data focusing on the pouch microbiota and the immune responses that support this hypothesis. We also discuss the contribution of luminal metabolic factors and the epithelial membrane in the etiology of this inflammatory process. The ileoanal pouch offers a unique opportunity to study the inter-relationships between the gut microbiota and host immune responses from before the onset of disease. For this reason the study of pouchitis could serve as a human model that significantly enhances our understanding of inflammatory bowel diseases in general.

Surgical treatment of ulcerative colitis in the biologic therapy era

Recently introduced in the treatment algorithms and guidelines for the treatment of ulcerative colitis, biological therapy is an effective treatment option for patients with an acute severe flare not responsive to conventional treatments and for patients with steroid dependent disease. The reduction in hospitalization and surgical intervention for patients affected by ulcerative colitis after the introduction of biologic treatment remains to be proven. Furthermore, these agents seem to be associated with increase in cost of treatment and risk for serious postoperative complications. Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice in ulcerative colitis patients. Surgery is traditionally recommended as salvage therapy when medical management fails, and, despite advances in medical therapy, colectomy rates remain unchanged between 20% and 30%. To overcome the reported increase in postoperative complications in patients on biologic therapies, several surgical strategies have been developed to maintain long-term pouch failure rate around 10%, as previously reported. Surgical staging along with the development of minimally invasive surgery are among the most promising advances in this field.

Current strategies in the management of intra-abdominal abscesses in Crohn's disease

Crohn's disease is characterized by inflammation that involves the full thickness of the bowel wall, which can lead to serious complications including intra-abdominal and pelvic abscesses. The combination of an intra-abdominal abscess with active Crohn's disease poses a particular dilemma for the treating physician, who must weigh the benefits of using immunosuppressive therapies for the inflammatory bowel disease against the risks of immunosuppression in the presence of serious abdominal infection. Traditionally, Crohn's-related abscesses were managed with early surgery, which often involved external drainage procedures, bowel resection, and the creation of diverting ostomies in acutely ill patients. Today such abscesses often can be managed initially with antibiotics and percutaneous drainage, with evaluation for the need for delayed surgery in selected patients. With delayed surgery performed electively, the surgeon frequently can resect the diseased bowel and create a primary anastomosis, thus avoiding emergency operations and multistage procedures. In highly selected cases, surgery might be avoided entirely. This report reviews the literature on the pathophysiology and management of intra-abdominal abscesses in Crohn's disease (including the roles of percutaneous drainage, immunosuppressive therapy, and surgery), and provides a suggested approach to the management of patients with this difficult problem.

Outcome after restorative proctocolectomy in children and adolescents

AIM

The results including function and quality of life (QOL) of restorative proctocolectomy (RPC) performed in children and adolescents with ulcerative colitis (UC), familial adenomatous polyposis (FAP) and idiopathic megarectum were determined.

METHOD

Twenty-one patients of a median age of 15 (10-17) years underwent RPC between 1995 and 2006. The indication, use of covering ileostomy, morbidity and mortality were recorded. A structured questionnaire was completed by telephone interview to assess long-term function. The Cleveland Clinic Scoring (CCS) System was used for the assessment of faecal incontinence and the modified McMaster proforma for QoL.

RESULTS

There was no mortality. At a median follow-up of 65.5 (26-168) months, all patients had an intact pouch. One had a long-standing ileostomy. Median daytime and nocturnal stool frequencies were 4 (2-16) and 0 (0-3). The mean CCS was 1.47, with only one patient scoring more than 10. Eighteen of 20 patients were satisfied with the result; two patients had a worse QoL (McMaster score >8). One patient had a permanent stoma following pouch sepsis and one had symptoms of pouchitis.

CONCLUSION

RPC can be performed in children and adolescents with good functional outcome and acceptable QoL.

Role of conventional therapies in the era of biological treatment in Crohn’s disease

Outstanding progress regarding the pathophysiology of Crohn’s disease (CD) has led to the development of innovative therapeutic concepts. Numerous controlled trials have been performed in CD. This review concentrates on the results of randomized, placebo-controlled trials, and meta-analyses when available, that provide the highest degree of evidence. Current guidelines on the management of CD recommend a step-up approach to treatment involving the addition of more powerful therapies as the severity of disease and refractoriness to therapy increase. The advent of biological drugs has opened new therapeutic horizons for treating CD, modifying the treatment goals. However, the large majority of patients with CD will be managed through conventional therapy, even if they are a prelude to biological therapy.

Oral 5-aminosalicylic acid for maintenance of surgically-induced remission in Crohn's disease

BACKGROUND

The use of 5-aminosalicylates (5-ASAs) in Crohn's disease (CD) is controversial.  A recent Cochrane review found that 5-ASAs are not effective for the maintenance of medically-induced remission in CD, but their role in the maintenance of surgically-induced remission is unclear.

OBJECTIVES

The objectives were to evaluate the efficacy and safety of 5-ASA agents for the maintenance of surgically-induced remission in CD.

SEARCH STRATEGY

The search was standardised and not limited by language and included electronic searching (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Inflammatory Bowel Disease Group Specialized Trials Register), reference searching of all included studies, abstracts from major meetings, personal contacts and drug companies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) which compared 5-ASAs with either placebo or another intervention, with treatment durations of at least 6 months were considered for inclusion. Participants were patients of any age with CD in remission following surgery. Primary outcome measures were clinical relapse or endoscopic recurrence as defined by the primary studies. Secondary endpoints were the occurrence of adverse events.

DATA COLLECTION AND ANALYSIS

Relevant papers were identified and the authors independently assessed the eligibility of trials. Methodological quality was assessed using the Cochrane risk of bias tool.The Cochrane RevMan software was used for analyses. Patients with final missing outcomes were assumed to have relapsed. Odds ratio (OR) and 95% confidence intervals (95% CI) were calculated based on the fixed effects model. The chi square and I(2) statistics were used to assess statistical heterogeneity.

MAIN RESULTS

Nine RCTs were included in the review. Seven studies compared oral 5-ASA with placebo and two compared oral 5-ASA with purine antimetabolites (azathioprine or 6-mercaptopurine). 5-ASA was significantly more effective than placebo for preventing relapse (OR 0.68, 95% CI, 0.52 to 0.90). There was no statistically significant heterogeneity among the 8 trials comparing 5-ASA with placebo (P=0.47). No statistically significant difference in adverse events was found for 5-ASA versus placebo (OR 1.02, 95%CI, 0.60 to 1.76). No statistically significant difference was found between 5-ASA and purine antimetabolites for preventing relapses (OR 1.08 95% CI, 0.63 to 1.85).

AUTHORS' CONCLUSIONS

The pooled analyses suggest that 5-ASA preparations may be superior to placebo for the maintenance of surgically-induced remission in patients with CD. The results of the pooled analyses should be interpreted with caution because adequately powered studies demonstrated no difference and publication bias (failure to publish negative studies) may be an issue. The potential benefit provided by 5-ASA drugs is modest with a number needed to treat of approximately 16 to 19 patients to avoid one relapse which raises issues about the cost-effectiveness of this therapy. However, 5-ASA drugs are safe and well tolerated. The incidence of adverse events was not different in patients receiving 5-ASA compared with those receiving placebo. There is insufficient evidence to allow any conclusions on how 5-ASA preparations compare with azathioprine or 6-mercaptopurine.

Ulcerative colitis: the fate of the retained rectum

Ileal pouch-anal anastomosis has clearly diminished the role of colectomy and ileorectal anastomosis (IRA) in the management of patients with ulcerative colitis. Nonetheless, IRA probably still has an appropriate place in highly selected patients, and many others maintain an "out of circuit" rectal remnant after subtotal colectomy. Although symptomatic proctitis is the most common reason for completion proctectomy, these patients are also at a significant risk to develop rectal cancer. Routine surveillance appears to be warranted.

Current surgical management of ulcerative colitis

Inflammatory bowel disease is divided into 2 major disease entities: Crohn's disease and ulcerative colitis. Ulcerative colitis is characterized by contiguous inflammation of the colorectal mucosa, always beginning in and involving the rectum and progressing for variable distances proximally within the colon. In ulcerative colitis, medical therapy, which is not curative, is directed at controlling symptoms and reducing the underlying inflammatory process. However, emergent or elective removal of the colon and rectum does cure the disease and also eliminates the possibility of developing a malignancy. Here we present the current surgical treatment of ulcerative colitis and issues in the management of ulcerative colitis. We discuss indications for surgical treatment, elective and emergent operative management, early and late complications of surgery, and functional results.

Taming the elephant: Salmonella biology, pathogenesis, and prevention

Salmonella infections continue to cause substantial morbidity and mortality throughout the world. However, recent discoveries and new paradigms promise to lead to novel strategies to diagnose, treat, and prevent Salmonella infections. This review provides an update of the Salmonella field based on oral presentations given at the recent 3rd ASM Conference on Salmonella: Biology, Pathogenesis and Prevention.

Suspected anastomotic recurrence of Crohn disease after ileocolic resection: evaluation with CT enteroclysis

PURPOSE

To determine the utility of computed tomographic (CT) enteroclysis for characterization of the status of the anastomotic site in patients with Crohn disease who had previously undergone ileocolic resection.

MATERIALS AND METHODS

Written informed consent was prospectively obtained from all patients, and the institutional review board approved the study protocol. CT enteroclysis findings in 40 patients with Crohn disease who had previously undergone ileocolic resection were evaluated independently by two readers. Endoscopic findings, histopathologic findings, and/or the Crohn disease activity index was the reference standard. Interobserver agreement between the two readers was calculated with kappa statistics. Associations between CT enteroclysis findings and anastomotic site status were assessed at univariate analysis. The sensitivity, specificity, and accuracy of CT enteroclysis, with corresponding 95% confidence intervals (CIs), for the diagnosis of normal versus abnormal anastomosis and the diagnosis of anastomotic recurrence versus fibrostenosis were estimated.

RESULTS

Interobserver agreement regarding CT enteroclysis criteria was good to perfect (kappa = 0.72-1.00). At univariate analysis, stratification and anastomotic wall thickening were the two most discriminating variables in the differentiation between normal and abnormal anastomoses (P < .001). Stratification (P < .001) and the comb sign (P = .026) were the two most discriminating variables in the differentiation between anastomotic recurrence and fibrostenosis. In the diagnosis of anastomotic recurrence, severe anastomotic stenosis was the most sensitive finding (95% [20 of 21 patients]; 95% CI: 76.18%, 99.88%), both comb sign and stratification had 95% specificity (18 of 19 patients; 95% CI: 73.97%, 99.87%), and stratification was the most accurate finding (92% [37 of 40 patients]; 95% CI: 79.61%, 98.43%). In the diagnosis of fibrostenosis, both severe anastomotic stenosis and anastomotic wall thickening were 100% sensitive (eight of eight patients; 95% CI: 63.06%, 100.00%), and using an association among five categorical variables, including severe anastomotic stenosis, anastomotic wall thickening with normal or mild mucosal enhancement, absence of comb sign, and absence of fistula, yielded 88% sensitivity (seven of eight patients; 95% CI: 47.35%, 99.68%), 97% specificity (31 of 32 patients; 95% CI: 83.78%, 99.92%), and 95% accuracy (38 of 40 patients; 95% CI: 83.08%, 99.39%).

CONCLUSION

CT enteroclysis yields objective and relatively specific morphologic criteria that help differentiate between recurrent disease and fibrostenosis at the anastomotic site after ileocolic resection for Crohn disease.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.09091165/-/DC1.

Halofuginone, a specific inhibitor of collagen type 1 synthesis, ameliorates oxidant colonic damage in rats with experimental colitis

To evaluate the effect of halofuginone on trinitrobenzene sulfonic acid (TNBS)-induced colonic injury, rats were given halofuginone (40 microg/kg, intraperitoneally) or saline 1 h before the induction of colitis, and the injections were continued twice daily for 3 days until they were decapitated. High macroscopic and microscopic damage scores, elevated colonic wet weights, colonic myeloperoxidase activity, malondialdehyde and tissue collagen level, and luminol chemiluminescence values, and marked reduction in glutathione level of the saline-treated colitis group were all reversed by treatment with halofuginone. In conclusion, halofuginone exerts beneficial effects in TNBS-induced colonic inflammation in rats. The anti-inflammatory effects of halofuginone appear to involve suppression of neutrophil accumulation, preservation of endogenous glutathione, and inhibition of reactive oxidant generation. Halofuginone also shows antifibrotic effect via inhibition of tissue collagen production. The present data encourage possible use of the antifibrotic halofuginone as an anti-inflammatory agent in improving oxidative injury in colitis.

Clinical and surgical recurrence of Crohn's disease after ileocolonic resection in a specialist unit

BACKGROUND

Postoperative clinical and endoscopic recurrence is common in Crohn's disease.

AIM

We aimed to assess postoperative recurrence and management in a cross-sectional patient cohort in one specialist unit, before the introduction of a uniform postoperative preventive strategy.

METHODS

Review of patients who had an ileocolonic resection for Crohn's disease between 2002 and 2005 in a secondary and tertiary care specialist centre.

RESULTS

Ninety-nine patients (42 male; 57 female; mean age, 37 years) with a median disease duration of 10 years, were reviewed. Indications for surgery were obstruction (n=61), failed medical therapy (n=31) and internal fistula(e) (n=7). Thirty patients (30%) were active smokers at the time of resection. Fifty patients (51%) had at least one previous Crohn's resection. Clinical and surgical recurrence rates were 28 and 5%, respectively, at 1 year. All five patients had the same indication for their further surgery as for their index operation (four fistulizing or stricturing). Median time to clinical recurrence was 10 months in those with recurrence. Nineteen percent of patients had an ileocolonoscopy at a median of 6 months after surgery, and 60% had been reviewed by a gastroenterologist, after surgery. Clinical recurrence occurred in nine of 28 (32%) without and 19 of 71 with (26%) postoperative medical therapy (P=NS).

CONCLUSION

Postoperative recurrence of Crohn's disease was high in the short term. The indication for repeat surgery stayed true within patients. Prospective treatment strategies, based on recent trial evidence, are needed to diminish postoperative recurrence.

Abdominal Surgery Impact Scale (ASIS) is responsive in assessing outcome following IPAA

PURPOSE

Various generic and disease-specific quality of life instruments are available to assess outcome following surgery. However, they may not be sensitive to changes in outcome in the early postoperative period, which is important when assessing changes in surgical technique and perioperative care. The Abdominal Surgery Impact Scale (ASIS) is a validated instrument designed to assess short-term outcome following surgery. Thus, the aims of this study were to assess the impact of surgery on patients undergoing ileal pouch anal anastomosis (IPAA), assess factors which might impact on outcome, and lastly, further evaluate the reliability and internal consistency of the ASIS.

METHODS

Patients over the age of 18 who had an IPAA between March 2005 and October 2007 completed the ASIS on postoperative day 3 and at the time of discharge. The ASIS contains 18 items within six domains with possible scores ranging from 18 to 126. Demographic, clinical and surgical data, postoperative complications, and length of stay were also recorded. Internal reliability of the ASIS was measured using Cronbach's alpha coefficient.

RESULTS

Ninety-two patients (36 female, 56 male, mean age = 36.8 +/- 10.8) completed the ASIS at two time intervals (mean 3 days and mean 7 days postoperatively). Forty-seven patients had an IPAA performed with an ileostomy; 11 patients had the IPAA performed laparoscopically. The mean hospital stay was 10.8 days. The overall mean ASIS score significantly increased over the two time periods (mean 56.9 +/- 18.3 vs. 81.8 +/- 17.3, p < 0.001). Patients who had an ileostomy had a significantly lower mean score at discharge (77.32 vs. 86.82), secondary to lower scores on the physical limitations, functional impairment, and visceral function domains. Seven (7.8%) patients had ileo-anal anastomotic leaks, and seven (7.8%) patients had small bowel obstructions. These patients had an increased length of stay, whereas patients having laparoscopic surgery had a significantly shorter length of stay (8.8 days vs. 11.1 days), but there was no significant difference in mean ASIS scores. Cronbach's alpha coefficient was 0.94 overall and ranged from 0.69 to 0.91 for subscales indicating internal reliability.

CONCLUSIONS

ASIS is a valid instrument for measuring quality of life in the postoperative period and is responsive to changes over time. Although quality of life increases postoperatively during hospital stay, at discharge, patients with IPAA still have decreased quality of life. Patients with ileostomies have further decreased scores.

Anastomotic recurrence of Crohn's disease after ileocolic resection: comparison of MR enteroclysis with endoscopy

The purpose of this study was to assess the accuracy of MR enteroclysis in patients with Crohn's disease recurrence after ileocolic resection and to establish an MR scoring sytem. MR enteroclysis and endoscopy were performed in 30 patients with suspected Crohn's disease recurrence after ileocolic resection. Findings were evaluated by three radiologists, using an MR score based on image quality, contrast enhancement, and mural and extramural bowel-wall changes: MR0 (no abnormal features), MR1 (minimal mucosal changes), MR2 (diffuse aphtoid ileitis, moderate recurrence), and MR3 (severe recurrence with trans- and extramural changes). The endoscopic Rutgeerts score defines changes at the ileum on a scale from I0 to I4. In 3/30 (10%) patients, evaluation was not possible. The mean overall image quality was rated as 1.7 (kappa 0.78). Comparing MR and Rutgeerts score, the mean observer agreement for the total score rating was 77.8% (kappa 0.67). When comparing only scores below or above MR2-the threshold indicative of the necessity of medical treatment-there was a total agreement of 95.1% (kappa 0.84). MR enteroclysis allows assessment of Crohn's disease recurrence after ileocolic resection. The MR score is reproducible and shows high agreement with the approved endoscopic Rutgeerts score.

Acute abdominal pain

Acute abdominal pain is a complaint seen commonly in the outpatient setting that has a broad and often confusing differential diagnosis. Although many presentations can be managed on an outpatient basis, several gastrointestinal causes of abdominal pain demand thoughtful consideration with subsequent referral to a higher level of care for appropriate diagnosis and treatment. To achieve this goal, outpatient physicians must have an understanding of the mechanisms of abdominal pain, as well as the common gastrointestinal causes that carry potentially higher morbidity and mortality.

Pouch outcomes among children with ulcerative colitis treated with calcineurin inhibitors before ileal pouch anal anastomosis surgery

PURPOSE

The purpose of this article is to describe the outcomes of the pouches of 14 children with ulcerative colitis (UC) who were pretreated with calcineurin inhibitors before they underwent their ileal pouch anal anastomosis (IPAA) surgery.

METHODS

An institutional review board-approved retrospective review of the charts of consecutive patients with UC treated with calcineurin inhibitors before undergoing IPAA surgery at a tertiary pediatric center between 1998 and 2003 was performed. The primary endpoint was pouch outcome after at least 2 years of follow-up (healthy pouch, acute pouchitis, chronic refractory pouchitis, or pouch failure); the secondary endpoints were early postoperative complications, number of stages, and time between stages.

RESULTS

Fourteen of 53 consecutive patients who underwent IPAA for UC were treated with calcineurin inhibitors before their surgery (26%; 6 with cyclosporine and 8 with tacrolimus). All 14 patients were concomitantly treated with systemic steroids. Ten patients (71%) were also taking 6-mercaptopurine or azathioprine, and 9 (64%) were also taking mesalamine. Three patients (21%) had healthy pouches with no clinical evidence of pouchitis, 6 (43%) had at least one episode of acute pouchitis (average of 2 episodes per year), 3 (21%) had chronic relapsing pouchitis, and 2 (14%) were later determined to have Crohn's disease. There was no pouch failure. Two patients (14%) had an early postoperative complication (intraabdominal abscess, anastomotic stricture). Five patients (36%) had a 2-staged procedure, and 8 (64%) had a 3-staged procedure. For the 2-staged procedures, the mean time between the first and second stages was 3.14 months (range, 3-4 months). For the 3-staged procedures, the mean time between the first and second stages was 4.25 months (range, 2-6 months) and that between the second and third stages was 4 months (range, 2.5-6 months).

CONCLUSIONS

In this series, chronic pouchitis was an infrequent complication among children who were pretreated with calcineurin inhibitors. Calcineurin inhibitor use did not lead to or portend increased early postoperative complications or affect the number or duration of surgical stages. Further studies are required to determine if preoperative calcineurin inhibitors improve pouch outcomes or facilitate the performance of 2-staged procedures.

Conventional therapy for Crohn’s disease

Crohn’s disease (CD) is a multifactorial disorder of unknown cause. Outstanding progress regarding the pathophysiology of CD has led to the development of innovative therapeutic concepts. Numerous controlled trials have been performed in CD over the last years. However, many drugs have not been approved by regulatory authorities due to lack of efficacy or severe side effects. Therefore, well-known drugs, including 5-ASA, systemic or topical corticosteroids, and immunosuppressants such as azathioprine, are still the mainstay of CD therapy. Importantly, biologicals such as infliximab have shown to be efficacious in problematic settings such as fistulizing or steroid-dependent CD. This review is intended to give practical guidelines to clinicians for the conventional treatment of CD. We concentrated on the results of randomized, placebo-controlled trials and meta-analyses, when available, that provide the highest degree of evidence. We provide evidence-based treatment algorithms whenever possible. However, many clinical situations have not been answered by controlled clinical trials and it is important to fill these gaps through expert opinions. We hope that this review offers a useful tool for clinicians in the challenging treatment of CD.

Pediatric inflammatory bowel disease

Inflammatory bowel disease is an important cause of gastrointestinal pathology in children and adolescents. The incidence of pediatric inflammatory bowel disease is increasing; therefore, it is important for the clinician to be aware of the presentation of this disease in the pediatric population. Laboratory tests, radiology studies, and endoscopic procedures are helpful in diagnosing inflammatory bowel disease and differentiating between Crohn’s disease and ulcerative colitis. Once diagnosed, the goal of medical management is to induce remission of disease while minimizing the side effects of the medication. Specific attention needs to be paid to achieving normal growth in this susceptible population. Surgical management is usually indicated for failure of medical management, complication, or malignancy. Algorithms for diagnostic evaluation and treatment of pediatric inflammatory bowel disease are presented. The specific psychosocial issues facing these patients are also discussed in this review as are the future goals of research in the complex problem of pediatric inflammatory bowel disease.

Outcome following emergency surgery for refractory severe ulcerative colitis in a tertiary care centre in India

Background

Steroid-based intensive medical therapy for severe ulcerative colitis is successful in 60–70% of such patients. Patients with complications or those refractory to medical therapy require emergency colectomy for salvage. Little is known about the impact of timing of surgical intervention and surgical outcomes of such patients undergoing emergency surgery in India where the diagnosis is often delayed or missed in patients who are poor, malnourished and non-compliant to medical treatment.

Methods

The clinical records of all patients undergoing emergency surgery for severe ulcerative colitis or its complication in the Department of GI surgery AIIMS, New Delhi, India, between January 1985 and December 2003 were retrieved and data pertaining to demographic features, duration of intensive medical therapy, presence of complications, time from admission to emergency surgery, surgical procedure, in-hospital morbidity and mortality and follow up status extracted.

Results

A total of 72 patients underwent emergency surgery (Subtotal colectomy: 60; ileostomy alone under local anaesthesia: 12). Poor nutritional status was seen in 61% of the patients.

Twenty-one patients (29%) underwent emergency surgery for complications of severe ulcerative colitis such as colonic perforation (spontaneous 6, iatrogenic 4), massive lower gastrointestinal haemorrhage (5), toxic megacolon (4) and large bowel obstruction (2). The remaining patients (n = 51) underwent emergency surgery following failed intensive therapy; 17 underwent surgery ≤5 days (Group I) and 34 were operated >5 days (Group II) after initiation of intensive therapy. In this group all the post-operative deaths (n = 8) occurred in those who were operated after 5 days. The difference in mortality in these two groups (i.e. surgical intervention ≤ or >5 days) was statistically significant {0/17 (Group I) vs 8/34 (Group II); p = 0.03}.

Overall, 12 patients died (in-hospital mortality: 16.7%). The mortality was higher (10/43; 23.3%) in our early experience (i.e. 1985–1995) when compared to our subsequent experience (2/29; 6.9%) (1996–2003).

A total of 48 patients (including 3 awaiting a restorative procedure) are alive on follow up (66.7%; 3 patients lost to follow up). A restorative procedure could be successfully completed in 81% of the survivors of the emergency procedure.

Conclusion

To optimize the outcome, a combined team of physicians and surgeons should be involved in the management of patients with severe ulcerative colitis with focus on nutritional support, correction of metabolic derangements, close clinical monitoring and timely assessment for the need for emergency surgery. This retrospective analysis shows that improved results can be achieved with experience and by following a policy of early surgical intervention within 5 days, especially in patients who have failed intensive medical therapy.

TGF-beta1 gene transfer to the mouse colon leads to intestinal fibrosis

Crohn's disease (CD) is a chronic, relapsing inflammatory bowel disease, characterized by transmural inflammation. In CD, the recurrent inflammatory injury and tissue repair that occurs in the intestine can progress uncontrollably, leading to the proliferation of mesenchymal cells as well as fibrosis, characterized by excessive extracellular matrix deposition. These processes thicken the bowel wall, reducing flexibility, and often culminate in obstructive strictures. Because no effective measures are currently available to specifically treat or prevent intestinal stricturing, we sought to gain a better understanding of its pathogenesis by developing a mouse model of intestinal fibrosis. Because transforming growth factor (TGF)-beta1 can mediate both fibrosis and mesenchymal cell proliferation; we studied the effects of delivering adenoviral vectors encoding spontaneously active TGF-beta1 into the colons of mice. We first demonstrated that enema delivery of marker adenoviral vectors led to the transfection of the colonic epithelium and transient transgene expression. Histologically, control vectors caused an acute inflammatory response, involving the recruitment of neutrophils and mononuclear cells into the colonic lamina propria; however, infection caused little if any fibrosis. In contrast, the TGF-beta1 vector caused a more severe and prolonged inflammatory response as well as localized collagen deposition, leading to severe and progressive fibrosis. This was accompanied by the emergence of cells with a myofibroblast phenotype. Ultimately the fibrosis resulted in many of the TGF-beta1-transfected mice developing profound colonic obstruction. Through adenoviral gene transfer technology, we describe a novel mouse model of colitis and implicate TGF-beta1 in the pathogenesis of obstructive intestinal fibrosis.

Growth hormone reduces the severity of fibrosis associated with chronic intestinal inflammation

BACKGROUND & AIMS

Growth hormone (GH) is used to treat growth delay in children with Crohn's disease and in patients with short-bowel syndrome. GH can increase collagen accumulation in intestinal mesenchymal cells, raising concern that GH therapy could exacerbate fibrosis in patients with Crohn's disease. We tested if GH treatment altered inflammation or fibrosis during chronic, experimental granulomatous enterocolitis.

METHODS

Ileum and cecum of Lewis rats were subserosally injected with peptidoglycan-polysaccharide (PG-APS) or control human serum albumin. At the onset of chronic PG-APS-induced inflammation, rats were administered recombinant human GH or vehicle for 14 days. Fibrosis and inflammation were quantified by gross gut disease scoring, histologic scoring, type I collagen, and cytokine expression in cecum. Abundance and localization of suppressor of cytokine signaling-3 (SOCS-3) messenger RNA and/or protein were determined in cecum. Effect of GH, cytokines, or PG-APS on SOCS-3 synthesis was measured in intestinal myofibroblasts. Myofibroblasts overexpressing SOCS-3 were used to test whether SOCS-3 inhibits collagen accumulation.

RESULTS

In PG-APS-injected rats, GH modestly reduced gross adhesions and mesenteric contractions, cecal fibrosis score, and collagen expression, but had no effect on intestinal inflammation. GH increased SOCS-3 messenger RNA and protein abundance in PG-APS rats and SOCS-3 messenger RNA was localized to the periphery of granulomas. GH in combination with cytokines or PG-APS, but not alone, induced SOCS-3 synthesis in intestinal myofibroblasts. Myofibroblasts overexpressing SOCS-3 showed reduced cytokine-induced collagen accumulation.

CONCLUSIONS

GH modestly reduces intestinal fibrosis associated with chronic experimental enterocolitis and stimulates expression of antifibrogenic SOCS-3, suggesting that GH therapy in inflammatory bowel disease should not exacerbate fibrosis.

Crohn's disease--when to operate?

Crohn's disease is a chronic bowel condition, which can present as a number of different clinical and pathological presentations, depending on localization and activity of the inflammatory process. The aethiology of the disease has not been explained. In each case the treatment should be individually tailored depending on the type of the changes. The indications for surgical intervention are continuous bleedings, recurrent ileus, perforation of the intestine, abscesses, fistulas, failure of pharmacological treatment, resistance to steroids and steroid dependence. In case of the mild type of the disease with few symptoms pharmacological treatment is the right choice In case of the mild type of the disease with few symptoms pharmacological treatment is the right choice process. In malign form of Crohn's disease lack of improvement after 7-10 days of intensive treatment is generally accepted indication for surgical treatment. Fulminant form of the disease is still a clear-cut indication for immediate surgical intervention. Decision on surgical intervention is more difficult and controversial when patient presents with series of subileus recurrences subsiding after conservative treatment. Patients with stenotic form of Crohn's disease usually require multiple operations most of which are bowel resections. Patients with stenotic form of Crohn's disease usually require multiple operations most of which are bowel resections therapy. External and internal asymptomatic fistulas should be treated conservatively. The timing of surgical treatment is essential in Crohn's disease however the prevention from recurrences is also fundamental. It is well proved that preventive administration of 5-ASA (especially mesalazine) and metronidazol can reduce the risk of early recurrences after surgery.

Ornidazole for prophylaxis of postoperative Crohn's disease recurrence: a randomized, double-blind, placebo-controlled trial

BACKGROUND & AIMS

Crohn's disease almost inevitably recurs after ileocolonic resection, and effective prophylactic therapy has not been identified. We investigated the efficacy and safety of ornidazole, a nitroimidazole antibiotic, for the prevention of clinical recurrence of Crohn's disease after curative ileocolonic resection in a placebo-controlled double-blind clinical trial.

METHODS

Eighty patients were randomized to ornidazole 1 g/day or placebo started within 1 week of resection and continued for 1 year. The primary end point was the proportion of patients with clinical recurrence at 1 year. Secondary end points were endoscopic recurrence at 3 months and 12 months after resection.

RESULTS

Two patients in the ornidazole group withdrew consent and were not dosed. Ornidazole significantly reduced the clinical recurrence rate at 1 year from 15 of 40 (37.5%) patients in the placebo group to 3 of 38 (7.9%) patients in the ornidazole group (Fisher exact test, 8.03; P = .0046; odds ratio, 0.14; 95% confidence interval, 0.037-0.546). Ornidazole reduced endoscopic recurrence at 12 months from 26 of 33 (79%) in the placebo group to 15 of 28 (53.6%) in the ornidazole group (chi2 , 4.37; P = .037; odds ratio, 0.31; 95% confidence interval, 0.10-0.94). Endoscopic recurrence at 3 and 12 months predicted clinical recurrence. Significantly more patients in the ornidazole group dropped out from the study because of side effects (P = .041).

CONCLUSIONS

Ornidazole 1 g/day is effective for the prevention of recurrence of Crohn's disease after ileocolonic resection.

Growth factors in inflammatory bowel disease: the actions and interactions of growth hormone and insulin-like growth factor-I

Multiple growth hormones (GHs) and factors are relevant to inflammatory bowel disease (IBD) due to their trophic effects on epithelial cells to promote mucosal integrity, renewal, and repair, on mesenchymal cells to promote wound healing, and on intestinal immune cells to modulate inflammation. The anabolic effects of GHs and factors outside the intestine are relevant to minimizing nutritional insufficiency, catabolic state, and the inability to maintain body weight due to inflammation-induced malabsorption. GHs and factors can, however, have a dual role, whereby trophic effects can be beneficial but, if excessive, can promote complications including the increased risk of intestinal tumors/adenocarcinoma and fibrosis. This review focuses on GH and insulin-like growth factor (IGF-I), for which evidence suggests such a dual role may exist. The actions of GH and IGF-I on the healthy intestine are compared with effects during intestinal inflammation or associated complications. Interactions between these growth factors and others relevant to IBD are considered. The role of the newly discovered suppressors of cytokine signaling proteins, which may dictate the balance between beneficial and excessive actions of GH and IGF-I, is also addressed.

Postoperative maintenance of Crohn's disease remission with 6-mercaptopurine, mesalamine, or placebo: a 2-year trial

BACKGROUND & AIMS

No therapy has been shown to reliably prevent the evolution of postoperative recurrence of Crohn's disease. The aim of the current trial was to compare 6-mercaptopurine (6-MP) and mesalamine with placebo for the prevention of clinical, endoscopic, and radiographic recurrence of Crohn's disease after resection and ileocolic anastomosis.

METHODS

Five centers randomized 131 patients to receive 6-MP (50 mg), mesalamine (3 g), or placebo daily in a double-blind, double-dummy trial. Patients had clinical assessments at 7 weeks and then every 3 months; colonoscopy at 6, 12, and 24 months; and small bowel series at 12 and 24 months. End points were clinical, endoscopic, and radiographic recurrence rates at 24 months.

RESULTS

Clinical recurrence rates (intent to treat) by life-table analysis at 24 months were 50% (95% confidence interval [CI], 34%-68%), 58% (95% CI, 41%-75%), and 77% (95% CI, 61%-91%) in patients receiving 6-MP, mesalamine, and placebo, respectively. Endoscopic recurrence rates were 43% (95% CI, 28%-63%), 63% (95% CI, 47%-79%), and 64% (95% CI, 46%-81%), and radiographic recurrence rates were 33% (95% CI, 19%-54%), 46% (95% CI, 29%-66%), and 49% (95% CI, 30%-72%), respectively. 6-MP was more effective than placebo ( P < 0.05) at preventing clinical and endoscopic recurrence over 2 years. Patient withdrawals resulted in 69% of the study population evaluable for the clinical recurrence end point.

CONCLUSIONS

6-MP, 50 mg daily, was more effective than placebo at preventing postoperative recurrence of Crohn's disease and should be considered as a maintenance therapy after ileocolic resection.

Medical management of postoperative recurrence in Crohn's disease

More than half of Crohn's disease patients require surgery during the course of their disease. Although endoscopic recurrence does not necessarily imply that patients have symptom recurrence, the high need for repeated surgery indicates that lesions gradually developing after surgical remission lead to fibrostenosis or other complications. Despite multiple clinical trials a clear medical strategy to prevent disease recurrence has not been identified. Future well designed collaborative trials with specified end points are needed to optimize clinical practice in the prevention of postoperative Crohn's disease recurrence.

Surgical indications and procedures in ulcerative colitis

Chronic ulcerative colitis (CUC) is an inflammatory bowel disease limited to the mucosa of the rectum and colon. The inflammation begins in the rectum and progresses uninterrupted for variable distances. To date, no etiologic factor has been identified. However, population studies suggest there is both a genetic and environmental component contributing to the development of CUC. The natural history is one of a chronic inflammatory state, characterized by intermittent flares of disease activity. In a small number of patients, the initial presentation of CUC is of a fulminant nature. Medical therapy for the intestinal manifestations of CUC is directed at controlling symptoms through treatment of the underlying inflammatory process. Medical therapy is not curative for either the intestinal or extraintestinal manifestation of CUC. However, surgical removal of the colon and rectum cures the intestinal manifestations of the disease and eliminates or markedly reduces the associated risk of malignancy in longstanding CUC. The indications for surgical intervention are divided into two broad categories that influence the type of surgery performed: emergent and elective surgery. Emergency operations are directed at life-threatening complications of CUC and are not intended as definitive surgical treatment for CUC. Alternatively, elective surgery is intended as definitive treatment for the intestinal component of the disease. In appropriately selected patients, the best surgical treatment option is the total proctocolectomy with an ileal pouch-anal anastomosis (IPAA). The IPAA avoids the need for a permanent stoma and maintains the normal route of defecation. This is a technically demanding operation and should be performed by surgeons comfortable with the procedure. The severity and frequency of complications related to IPAA have decreased significantly since the introduction of the operations in the early 1980s. More importantly, long-term follow-up of IPAA patients has demonstrated that the functional results are durable and patient satisfaction remains high.

Pediatric ileal pouch-anal anastomosis: functional outcomes and quality of life

BACKGROUND/PURPOSE

The aim of this study was to assess and correlate functional outcomes and surgical results with health-related quality of life after ileal pouch-anal anastomosis (IPAA) in pediatric patients.

METHODS

Functional outcome was determined by questionnaire and telephone interview. Surgical results were determined by retrospective chart review.

RESULTS

Data were gathered from 26 patients (mean age at IPAA, 12 years; mean follow-up, 3.7 years). Diagnoses were ulcerative colitis in 18, indeterminate colitis in 4, and familial polyposis in 4. Indications for IPAA included intractability, medication toxicity, growth delay, and cancer prophylaxis. Short-term complications (5 patients; 19%) included partial small bowel obstruction, stomal revision, pouch abscess, and negative exploration. Long-term complications (8 patients; 31%) were chronic pouchitis and anal stricture. The average number of stools per 24 hours was 3.9. No incontinence was reported; dietary restrictions were negligible. Although there were minimal differences from population norms, parental anxiety remained high. Chronic pouchitis correlated negatively with physical summary score. Nocturnal stooling negatively affected psychosocial quality of life.

CONCLUSIONS

Pediatric IPAA resulted in excellent bowel health. Quality of life, physical function, mental health, and self-esteem were equivalent to those of healthy children. These data may help families and physicians make informed surgical decisions.

Imaging of the postsurgical small bowel

The small bowel is subject to a variety of surgical interventions for the treatment of a broad spectrum of disease processes. Most operative procedures applied to the small bowel are straightforward techniques encumbered by few complications, whereas other procedures are considerably more complex and can be associated with significant postoperative morbidity. Familiarity with the anatomic alterations related to the various operations is essential, both for evaluation of early postoperative complications and those abnormalities that manifest late in the postoperative course. The surgeon and radiologist should carefully coordinate clinical suspicion with the strengths of the various imaging modalities to optimize postsurgical assessment and provide timely and accurate diagnosis. Enteric anastomoses, the different forms of enterostomy, and the varied constructions of small bowel pouches and reservoirs are each associated with unique anatomy and therefore optimal techniques of assessment. Small bowel contrast studies such as enteroclysis--including its recent modification, CT enteroclysis--and CT imaging represent the primary modalities for imaging of the postoperative bowel and its related abnormalities. Small bowel transplantation continues to progress as a realistic treatment for intestinal failure, and the role of diagnostic imaging in these unique and challenging patients is evolving.