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Gaytan-Fuentes IA, Ore AS, Vigna C, Cordova-Cassia CA, Crowell KT, Fabrizio AC, Cataldo TE, Messaris E. Perioperative use of NSAIDs and the risk of short-term endoscopic recurrence in Crohn's disease patients: A retrospective cohort study. Am J Surg 2022; 225:1045-1049. [PMID: 36509584 DOI: 10.1016/j.amjsurg.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/15/2022] [Accepted: 12/04/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND More evidence is needed on the use of NSAID based postoperative pain regimens for Crohn's disease (CD) and its association with recurrence. Our goal is to assess the impact of perioperative use of NSAIDs on endoscopic disease recurrence in patients with CD. METHODS A retrospective cohort study was conducted. The primary outcome measured was endoscopic disease recurrence within 24 months of surgery, defined as a Rutgeerts score ≥ i2. RESULTS We identified 107 patients with CD that underwent index ileocolectomy with primary anastomosis between January 2009 and July 2019. Endoscopic disease recurrence was identified in 28 (26.2%) and clinical recurrence in 18 (16.8%) patients. Exposure to NSAIDs did not increase 24-month endoscopic recurrence risk (22.2% vs. 38.5% patients, p = 0.12). CONCLUSION In patients with CD undergoing elective ileocolic resection and primary ileocolic anastomosis, NSAID use in the perioperative period did not impact endoscopic or clinical disease recurrence rate.
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Affiliation(s)
- Israel A Gaytan-Fuentes
- Division of Colorectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States; Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Ana Sofia Ore
- Division of Colorectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Carolina Vigna
- Division of Colorectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Carlos A Cordova-Cassia
- Division of Colorectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Kristen T Crowell
- Division of Colorectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Anne C Fabrizio
- Division of Colorectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Thomas E Cataldo
- Division of Colorectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Evangelos Messaris
- Division of Colorectal Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
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Zhuang X, Tian Z, Li N, Mao R, Li X, Zhao M, Xiong S, Zeng Z, Feng R, Chen M. Gut Microbiota Profiles and Microbial-Based Therapies in Post-operative Crohn's Disease: A Systematic Review. Front Med (Lausanne) 2021; 7:615858. [PMID: 33585513 PMCID: PMC7876235 DOI: 10.3389/fmed.2020.615858] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 12/14/2020] [Indexed: 12/19/2022] Open
Abstract
Background and Aims: Gut microbiota recolonization after intestinal resection had been reported to be associated with post-operative recurrence in Crohn's disease (CD). However, the results of different studies are inconsistent and even contradictory. In addition, knowledge on the efficacy of microbial-based therapies in preventing post-operative recurrence of CD is limited. Therefore, the aim of this review was to investigate gut microbiota profiles in patients with CD before and after surgery and evaluate microbial-based therapies in preventing post-operative recurrence. Methods: Electronic databases were searched from inception to 31 June 2020 using predefined terms. Studies that investigated gut microbiota pre- and post-intestinal resection, and microbial-based therapies in preventing post-operative recurrence, were eligible. Study quality was assessed using either the Newcastle-Ottawa scale or Jadad scoring system. Results: Twelve studies investigating gut microbiota of CD patients suffering from operation, and other 12 studies evaluating the efficacy of antibiotics and probiotics, were included in our review. The mucosa-associated microbiota in surgical biopsy of CD patients is significantly distinct from that in normal mucosa from healthy subjects. Gut microbiota recolonization following surgery might be associated with post-operative recurrence in CD patients. Furthermore, CD patients with post-operative recurrence presented a gain in pro-inflammatory pathogenic bacteria and a loss in short-chain fatty acid-producing bacteria before and after surgery. However, no consistent bacteria or metabolites were found to predict the post-operative recurrence of CD. Additionally, microbial-based therapies are deficient and present restricted widespread clinical utility due to several deficiencies. Conclusion: Recurrence-associated bacteria observed pre- and post- operation might be promising in preventing the post-operative recurrence of CD. Furthermore, potential microbe biomarkers for predicting subsequent disease recurrence should be validated with larger sample sizes using more rigorous and standardized methodologies.
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Affiliation(s)
- Xiaojun Zhuang
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhenyi Tian
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Na Li
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaozhi Li
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Min Zhao
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shanshan Xiong
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhirong Zeng
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Rui Feng
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Minhu Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Glick LR, Sossenheimer PH, Ollech JE, Cohen RD, Hyman NH, Hurst RD, Rubin DT. Low-Dose Metronidazole is Associated With a Decreased Rate of Endoscopic Recurrence of Crohn's Disease After Ileal Resection: A Retrospective Cohort Study. J Crohns Colitis 2019; 13:1158-1162. [PMID: 30809655 PMCID: PMC6939874 DOI: 10.1093/ecco-jcc/jjz047] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND AIMS Recurrence of Crohn's disease after surgical resection and primary anastomosis is an important clinical challenge. Previous studies have demonstrated the benefit of imidazole antibiotics, but have been limited by adverse events and medication intolerance. We evaluated whether administration of low-dose metronidazole [250 mg three times per day] for 3 months reduces endoscopic postoperative recurrence rates. METHODS We performed a retrospective cohort study of patients with Crohn's disease who underwent ileal resection with a primary anastomosis and subsequently received care at our center. We compared the cases who received low-dose metronidazole for 3 months with control patients who did not receive this therapy. Data collected included demographics, risk factors for recurrence, and medications before and after surgery. The primary end point was the number of patients with ≥i2 [Rutgeerts] endoscopic recurrence by 12 months. Variables found to be predictive in univariate analysis at p < 0.10 were introduced in the Cox model for multivariate analysis. RESULTS In all, 70 patients with Crohn's disease [35 cases and 35 controls] met inclusion criteria. Risk factors for Crohn's recurrence were similar between groups. The number of patients with ≥i2 endoscopic recurrence within 12 months following ileal resection was significantly lower in the metronidazole group [7 of 35 patients; 20%] compared with the number in the control group [19 of 35 patients; 54.3%] [p = 0.0058]. Eight participants [22.9%] in the metronidazole group experienced adverse events, and 3 of these patients [8.6%] discontinued the therapy. CONCLUSION Low-dose metronidazole reduces endoscopic recurrence of Crohn's disease postoperatively and is well tolerated. This intervention should be considered as a therapy option following ileocolonic resection.
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Affiliation(s)
- Laura R Glick
- Pritzker School of Medicine, University of Chicago, Chicago, USA
| | | | - Jacob E Ollech
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
- Department of Medicine, University of Chicago Medicine, Chicago, USA
| | - Russell D Cohen
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
- Department of Medicine, University of Chicago Medicine, Chicago, USA
| | - Neil H Hyman
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
- Department of Surgery, University of Chicago Medicine, Chicago, USA
| | - Roger D Hurst
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
- Department of Surgery, University of Chicago Medicine, Chicago, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, USA
- Department of Medicine, University of Chicago Medicine, Chicago, USA
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4
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Regueiro M, Feagan BG, Zou B, Johanns J, Blank MA, Chevrier M, Plevy S, Popp J, Cornillie FJ, Lukas M, Danese S, Gionchetti P, Hanauer SB, Reinisch W, Sandborn WJ, Sorrentino D, Rutgeerts P. Infliximab Reduces Endoscopic, but Not Clinical, Recurrence of Crohn's Disease After Ileocolonic Resection. Gastroenterology 2016; 150:1568-1578. [PMID: 26946343 DOI: 10.1053/j.gastro.2016.02.072] [Citation(s) in RCA: 217] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 02/16/2016] [Accepted: 02/25/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND & AIMS Most patients with Crohn's disease (CD) eventually require an intestinal resection. However, CD frequently recurs after resection. We performed a randomized trial to compare the ability of infliximab vs placebo to prevent CD recurrence. METHODS We evaluated the efficacy of infliximab in preventing postoperative recurrence of CD in 297 patients at 104 sites worldwide from November 2010 through May 2012. All study patients had undergone ileocolonic resection within 45 days before randomization. Patients were randomly assigned (1:1) to groups given infliximab (5 mg/kg) or placebo every 8 weeks for 200 weeks. The primary end point was clinical recurrence, defined as a composite outcome consisting of a CD Activity Index score >200 and a ≥70-point increase from baseline, and endoscopic recurrence (Rutgeerts score ≥i2, determined by a central reader) or development of a new or re-draining fistula or abscess, before or at week 76. Endoscopic recurrence was a major secondary end point. RESULTS A smaller proportion of patients in the infliximab group had a clinical recurrence before or at week 76 compared with the placebo group, but this difference was not statistically significant (12.9% vs 20.0%; absolute risk reduction [ARR] with infliximab, 7.1%; 95% confidence interval: -1.3% to 15.5%; P = .097). A significantly smaller proportion of patients in the infliximab group had endoscopic recurrence compared with the placebo group (30.6% vs 60.0%; ARR with infliximab, 29.4%; 95% confidence interval: 18.6% to 40.2%; P < .001). Additionally, a significantly smaller proportion of patients in the infliximab group had endoscopic recurrence based only on Rutgeerts scores ≥i2 (22.4% vs 51.3%; ARR with infliximab, 28.9%; 95% confidence interval: 18.4% to 39.4%; P < .001). Patients previously treated with anti-tumor necrosis factor agents or those with more than 1 resection were at greater risk for clinical recurrence. The safety profile of infliximab was similar to that from previous reports. CONCLUSIONS Infliximab is not superior to placebo in preventing clinical recurrence after CD-related resection. However, infliximab does reduce endoscopic recurrence. ClinicalTrials.gov ID NCT01190839.
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Affiliation(s)
- Miguel Regueiro
- Inflammatory Bowel Disease Center and Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Brian G Feagan
- Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
| | - Bin Zou
- Janssen Research & Development, LLC, Spring House, Pennsylvania
| | - Jewel Johanns
- Janssen Research & Development, LLC, Spring House, Pennsylvania
| | | | - Marc Chevrier
- Janssen Research & Development, LLC, Spring House, Pennsylvania
| | - Scott Plevy
- Janssen Research & Development, LLC, Spring House, Pennsylvania
| | - John Popp
- Janssen Scientific Affairs, LLC, Horsham, Pennsylvania
| | | | | | | | - Paolo Gionchetti
- S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Stephen B Hanauer
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Walter Reinisch
- McMaster University, Hamilton, Ontario, Canada; Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | | | - Dario Sorrentino
- Virginia Tech, Carilion School of Medicine, Roanoke, Virginia; Department of Clinical and Experimental Pathology, University of Udine School of Medicine, Udine, Italy
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Hashash JG, Regueiro M. A Practical Approach to Preventing Postoperative Recurrence in Crohn's Disease. Curr Gastroenterol Rep 2016; 18:25. [PMID: 27086006 DOI: 10.1007/s11894-016-0499-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Postoperative Crohn's disease recurrence remains common, and preventing additional surgery remains a challenge. A critical step to postoperative management of Crohn's disease is being able to identify patients who should receive immediate postoperative therapy from the patients who can wait for recurrence prior to starting medications. All patients, regardless of their risk for recurrence, are advised to undergo a colonoscopy at 6 to 12 months after surgery to evaluate for endoscopic evidence of Crohn's disease. Further management of patients depends on symptoms and the presence or absence of endoscopic recurrence.
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Affiliation(s)
- Jana G Hashash
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Mezzanine Level, C Wing, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Miguel Regueiro
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Mezzanine Level, C Wing, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
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6
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Dietary patterns and self-reported associations of diet with symptoms of inflammatory bowel disease. Dig Dis Sci 2013; 58:1322-8. [PMID: 22923336 PMCID: PMC3552110 DOI: 10.1007/s10620-012-2373-3] [Citation(s) in RCA: 173] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2012] [Accepted: 08/10/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND There are insufficient data to make firm dietary recommendations for patients with inflammatory bowel disease (IBD). Yet patients frequently report that specific food items influence their symptoms. In this study, we describe patients' perceptions about the benefits and harms of selected foods and patients' dietary patterns. METHODS CCFA Partners is an ongoing internet-based cohort study of patients with IBD. We used a semi-quantitative food frequency questionnaire to measure dietary consumption patterns and open-ended questions to elicit responses from patients about food items they believe ameliorate or exacerbate IBD. We categorized patients into four mutually exclusive disease categories: CD without an ostomy or pouch (CD), UC without an ostomy or pouch (UC), CD with an ostomy (CD-ostomy), and UC with a pouch (UC-pouch). RESULTS Yogurt, rice, and bananas were more frequently reported to improve symptoms whereas non-leafy vegetables, spicy foods, fruit, nuts, leafy vegetables, fried foods, milk, red meat, soda, popcorn, dairy, alcohol, high-fiber foods, corn, fatty foods, seeds, coffee, and beans were more frequently reported to worsen symptoms. Compared to CD patients, CD-ostomy patients reported significantly greater consumption of cheese (odds ratio [OR] 1.56, 95 % CI 1.03-2.36), sweetened beverages (OR 2.14, 95 % CI 1.02-1.03), milk (OR 1.84, 95 % CI 1.35-2.52), pizza (OR 1.57, 95 % CI 1.12-2.20), and processed meats (OR 1.40; 95 % CI 1.04-1.89). CONCLUSIONS Patients identified foods that they believe worsen symptoms and restricted their diet. Patients with ostomies ate a more liberal diet. Prospective studies are needed to determine whether diet influences disease course.
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7
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Hashash JG, Regueiro MD. The evolving management of postoperative Crohn's disease. Expert Rev Gastroenterol Hepatol 2012; 6:637-48. [PMID: 23061713 DOI: 10.1586/egh.12.45] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Two-thirds to three-quarters of Crohn's disease patients require intestinal surgery for medically refractory disease or complications. Surgery is not a cure and most patients develop recurrent Crohn's disease and require additional intestinal resections. There are a number of medications that have been investigated for preventing and treating recurrence. Risk factors for postoperative disease recurrence help guide the physician in determining the appropriate treatment strategy after Crohn's disease surgery. The approach to Crohn's disease treatment has evolved over the years. No longer should surgery be considered a failure of treatment, rather an important intervention to correct irreversible disease. In combination with a better understanding of postoperative medication strategies, patients with Crohn's disease may achieve longer term remission than previously realized. This review elucidates current understanding of the natural course of postoperative Crohn's disease, monitoring for recurrence, the risk factors for recurrence, and provides insight into an evolving new paradigm for postoperative Crohn's disease treatment.
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Affiliation(s)
- Jana G Hashash
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, 200 Lothrop Street-PUH, M2, C-Wing, Pittsburgh, PA 15213, USA.
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8
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Li Y, Zhu W, Zuo L, Zhang W, Gong J, Gu L, Cao L, Li N, Li J. Frequency and risk factors of postoperative recurrence of Crohn's disease after intestinal resection in the Chinese population. J Gastrointest Surg 2012; 16:1539-47. [PMID: 22555673 DOI: 10.1007/s11605-012-1902-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 04/24/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Data on risk factors of postoperative recurrence in patients with Crohn's disease (CD) have shown conflicting results. The aim of this retrospective study is to identify predictors of early symptomatic recurrence of CD after surgical intestinal resection in the Chinese population. MATERIALS AND METHODS Patients diagnosed as CD who underwent intestinal resection in Jinling Hospital between May 2004 and December 2010 were included in our study. Clinical data of these patients were reviewed. Multivariable survival analysis was performed to elucidate risk factors of early postoperative symptomatic recurrence. RESULTS There were a total of 141 CD patients who had at least one previous curative resection for CD under regular follow-up in our unit. Our data indicated disease behavior (95 % CI 1.01-1.70, P = 0.044), smoking habits (95 % CI 1.32-2.84, P = 0.001), indication of perforation (95 % CI 1.09-4.02, P = 0.026), and location of anastomosis (95 % CI 1.09-3.39, P = 0.023) which are, as a result, strong independent predictors of symptomatic recurrence, while the anastomosis type as side-to-side anastomosis (SSA) was significantly associated with a decreased risk of symptomatic recurrence when compared with other anastomosis type (95 % CI 0.26-0.94, P = 0.038). Medical prophylaxes also played a role in the prevention of postoperative symptomatic recurrence. CONCLUSIONS A smoking habits and perforation indication for surgery at the time of resection are associated with an increased risk of symptomatic recurrence. Anastomosis type with SSA is associated with a reduced risk of symptomatic recurrence. This population-based study supports the concept that environmental factors, disease character, and surgical technique influence the risk of postoperative symptomatic recurrence of CD.
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Affiliation(s)
- Yi Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, No. 305 East Zhongshan Road, Nanjing 210002, China
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9
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Wagner IJ, Rombeau JL. Nutritional support of surgical patients with inflammatory bowel disease. Surg Clin North Am 2011; 91:787-803, viii. [PMID: 21787968 DOI: 10.1016/j.suc.2011.04.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Patients with inflammatory bowel disease (IBD) in need of surgery are often malnourished, which in turn increases the risk for postoperative complications. Malnutrition in IBD patients who must undergo surgery is due to the disordered activity of the diseased intestine, decreased dietary intake, and adverse effects of potent medications. IBD operations predispose patients to both macronutrient and micronutrient deficiencies. If the gut can be used safely it is the preferential route for feeding, though preoperative and postoperative parenteral nutrition remains a viable alternative for severely malnourished patients. New nutrient therapies include immunonutrition, fish oils, and probiotics.
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Affiliation(s)
- I Janelle Wagner
- Department of Surgery, Temple University School of Medicine, 3401 North Broad Street, Parkinson Pavilion, Suite 400, Philadelphia, PA 19140, USA.
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Abstract
Postsurgical bowel dysfunction is a potential complication for patients undergoing ileoanal anastomosis, restorative proctocolectomy, and low anterior anastomosis. In our setting, these patients are referred to the Anorectal Physiology Clinic at the Townsville Hospital, Queensland, for comprehensive behavioral therapy. The goals of the therapy are as follows: improve stool consistency, improve control over stool elimination, decrease fecal frequency and rectal urgency, fecal continence without excessive restrictions on food and fluid intake, and increase quality of life. This article outlines our holistic approach and specific treatment strategies, including assessment, education, support and assistance with coping, individualized dietary and fluid modifications, medications, and exercise. Biofeedback is used to help patients improve anal sphincter and pelvic floor muscle function and bowel elimination habits. Information on the biofeedback component of the treatment program will be described in a subsequent article.
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El-Hachem S, Regueiro M. Postoperative Crohn's disease: prevention and treatment. Expert Rev Gastroenterol Hepatol 2009; 3:249-56. [PMID: 19485807 DOI: 10.1586/egh.09.21] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Crohn's disease is a chronic, relapsing-remitting inflammatory disease of the intestinal tract that commonly requires surgical treatment. Unfortunately, the majority of patients will ultimately develop postoperative disease recurrence and require subsequent surgery. A number of medications have been researched for the maintenance of postoperative remission. Of these, few have demonstrated consistent efficacy. A recently published randomized, controlled trial indicated that infliximab is effective in the maintenance of postoperative remission.
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Affiliation(s)
- Sandra El-Hachem
- Department of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
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Zídek Z, Anzenbacher P, Kmonícková E. Current status and challenges of cytokine pharmacology. Br J Pharmacol 2009; 157:342-61. [PMID: 19371342 PMCID: PMC2707982 DOI: 10.1111/j.1476-5381.2009.00206.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2008] [Revised: 01/13/2009] [Accepted: 01/19/2009] [Indexed: 12/12/2022] Open
Abstract
The major concern of pharmacology about cytokines has originated from plentiful data showing association between gross changes in their production and pathophysiological processes. Despite the enigmatic role of cytokines in diseases, a number of them have become a subject of cytokine and anti-cytokine immunotherapies. Production of cytokines can be influenced by many endogenous and exogenous stimuli including drugs. Cells of the immune system, such as macrophages and lymphocytes, are richly endowed with receptors for the mediators of physiological functions, such as biogenic amines, adenosine, prostanoids, steroids, etc. Drugs, agonists or antagonists of these receptors can directly or indirectly up- and down-regulate secretion of cytokines and expression of cytokine receptors. Vice versa, cytokines interfere with drug pharmacokinetics and pharmacodynamics through the interactions with cytochrome P450 and multiple drug resistance proteins. The aim of the review is to encourage more intensive studies in these fields of cytokine pharmacology. It also outlines major areas of searching promising candidates for immunotherapeutic interventions.
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Affiliation(s)
- Z Zídek
- Department of Pharmacology, Institute of Experimental Medicine, Academy of Sciences of the Czech Republic, v.v.i., Vídenská 1083, 142 20 Prague 4, Czech Republic.
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13
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Clinical course of Crohn's disease first diagnosed at surgery for acute abdomen. Dig Liver Dis 2009; 41:269-76. [PMID: 18955023 DOI: 10.1016/j.dld.2008.09.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2008] [Revised: 09/04/2008] [Accepted: 09/04/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND The severity of clinical activity of Crohn's disease is high during the first year after diagnosis and decreases thereafter. Approximately 50% of patients require steroids and immunosuppressants and 75% need surgery during their lifetime. The clinical course of patients with Crohn's disease first diagnosed at surgery has never been investigated. AIM To assess the clinical course of Crohn's disease first diagnosed at surgery for acute abdomen and to evaluate the need for medical and surgical treatment in this subset of patients. PATIENTS AND METHODS Hospital clinical records of 490 consecutive Crohn's disease patients were reviewed. Patients were classified according to the Vienna criteria. Sex, extraintestinal manifestations, family history of inflammatory bowel diseases, appendectomy, smoking habit and medical/surgical treatments performed during the follow-up period were assessed. STATISTICAL ANALYSIS Kaplan-Meier survival method and Cox proportional hazards regression model. RESULTS Of the 490 Crohn's disease patients, 115 had diagnosis of Crohn's disease at surgery for acute abdomen (Group A) and 375 by conventional clinical, radiological, endoscopic and histologic criteria (Group B). Patients in Group A showed a low risk of further surgery (Log Rank test p<0.001) and a longer time interval between diagnosis and first operation compared to Group B (10.8 years vs. 5.8 years, p<0.01, respectively). Furthermore, patients in Group A used less steroids and immunosuppressants (OR 0.3, p<0.0001; OR 0.6, p<0.004, respectively). CONCLUSIONS Crohn's disease patients first diagnosed at surgery for acute abdomen showed a low risk for reintervention and less use of steroids and immunosuppressants during follow-up than those not operated upon at diagnosis. Early surgery may represent a valid approach in the initial management of patients with Crohn's disease, at least in the subset of patients with ileal and complicated disease.
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Abstract
Ileal pouch-anal anastomosis is the procedure of choice in the surgical management of refractory ulcerative colitis. Pouchitis affects up to 60% of patients following ileal pouch-anal anastomosis for ulcerative colitis. It overlaps significantly with ulcerative colitis such that improvements in our understanding of one will impact considerably on the other. The symptoms are distressing and impinge significantly on patients' quality of life. Despite 30 years of scientific and clinical investigation, the pathogenesis of pouchitis is unknown; however, recent advances in molecular and cell biology make a synergistic hypothesis possible. This hypothesis links interaction between epithelial metaplasia, changes in luminal bacteria (in particular sulfate-reducing bacteria), and altered mucosal immunity. Specifically, colonic metaplasia supports colonization by sulfate-reducing bacteria that produce hydrogen sulfide. This causes mucosal depletion and subsequent inflammation. Although in most cases antibiotics lead to bacterial clearance and symptom resolution, immunogenetic subpopulations can develop a chronic refractory variant of pouchitis. The aims of this paper are to discuss proposed pathogenic mechanisms and to describe a novel mechanism that combines many hypotheses and explains several aspects of pouchitis. The implications for the management of both pouchitis and ulcerative colitis are discussed.
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Abstract
Prevention of the postoperative recurrence of Crohn's disease (CD) remains a challenging clinical problem. The majority of patients with CD will need surgery for treatment of the disease, most of these patients will develop recurrent symptoms within 5 years postoperatively, and many patients will need reoperation within 10 years. In patients with an ileocolic anastomosis, endoscopic recurrence precedes clinical recurrence and the severity of endoscopic recurrence correlates with the risk of clinical recurrence. Despite multiple studies, the best postoperative prophylactic therapy remains uncertain. Numerous randomized controlled trials of 5-aminosalicylates have shown only modest effect. Antibiotics, including metronidazole and ornidazole, decrease short-term, but not long-term endoscopic recurrence and are limited by side effects. Immunomodulators have yet to be extensively evaluated, although limited data suggest possible efficacy in preventing postoperative recurrence, particularly in high-risk patients. This review will evaluate the current state of the art therapy for postoperative prophylaxis in CD, with an emphasis on critical analysis of the available randomized controlled trials.
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Affiliation(s)
- Eric Blum
- Division of Gastroenterology, Case Western Reserve University School of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio 44106-5066, USA
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Ortu S, Felis G, Marzotto M, Deriu A, Molicotti P, Sechi L, Dellaglio F, Zanetti S. Identification and functional characterization of Lactobacillus strains isolated from milk and Gioddu, a traditional Sardinian fermented milk. Int Dairy J 2007. [DOI: 10.1016/j.idairyj.2007.02.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Katz JA. Postoperative endoscopic surveillance in Crohn's disease: bottom up or top down? Gastrointest Endosc 2007; 66:541-3. [PMID: 17725943 DOI: 10.1016/j.gie.2007.02.060] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Accepted: 02/24/2007] [Indexed: 12/15/2022]
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Affiliation(s)
- Ferenc Nagy
- Szegedi Tudományegyetem, Szent-Györgyi Albert Orvos- és Gyógyszerésztudományi Centrum, Altalános Orvostudományi Kar, I. Belgyógyászati Klinika, Szeged.
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Abstract
Probiotics have preventive as well as curative effects on several types of diarrhea of different etiologies. Prevention and therapy (or alleviation) of diarrhea have been successfully investigated for numerous dietary probiotics to establish probiotic properties and to justify health claims (the medicinal use of probiotic food and the therapy of gastrointestinal diseases itself may not be advertised under current food laws). Other probiotic microorganisms (e.g., Lactobacillus rhamnosus GG, L. reuteri, certain strains of L. casei, L. acidophilus, Escherichia coli strain Nissle 1917, and certain bifidobacteria and enterococci (Enterococcus faecium SF68) as well as the probiotic yeast Saccharomyces boulardii have been investigated with regard to their medicinal use, either as single strains or in mixed-culture probiotics. However, the effects on humans have been assessed mainly in smaller (n<100) randomized, controlled clinical studies or in open label trials, but large intervention studies and epidemiological investigations of long-term probiotic effects are largely missing. Perhaps with the exception of nosocomial diarrhea or antibiotic-associated diarrhea, the results of these studies are not yet sufficient to give specific recommendations for the clinical use of probiotics in the treatment of diarrhea.
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Affiliation(s)
- Michael de Vrese
- Institute of Physiology and Biochemistry of Nutrition, Federal Research Centre for Nutrition and Food, 24103 Kiel, Germany.
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