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Cai X, Cai J, Fang L, Xu S, Zhu H, Wu S, Chen Y, Fang S. Design, synthesis and molecular modeling of novel D-ring substituted steroidal 4,5-dihydropyrazole thiazolinone derivatives as anti-inflammatory agents by inhibition of COX-2/iNOS production and down-regulation of NF-κB/MAPKs in LPS-induced RAW264.7 macrophage cells. Eur J Med Chem 2024; 272:116460. [PMID: 38704943 DOI: 10.1016/j.ejmech.2024.116460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 04/24/2024] [Accepted: 04/26/2024] [Indexed: 05/07/2024]
Abstract
It has been reported that 4,5-dihydropyrazole and thiazole derivatives have many biological functions, especially in the aspect of anti-inflammation. According to the strategy of pharmacophore combination, we introduced thiazolinone and dihydropyrazole moiety into steroid skeleton to design and synthesize a novel series of D-ring substituted steroidal 4,5-dihydropyrazole thiazolinone derivatives, and assessed their in vitro anti-inflammatory profiles against Lipopolysaccharide (LPS)-induced inflammation in RAW 264.7 macrophage cells. The anti-inflammatory activities assay demonstrated that compound 12e was considered as the most effective anti-inflammatory drug, which suppressed the expression of pro-inflammatory mediators including nitric oxide (NO), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α), it also dose-dependently inhibited the expression of inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2) in LPS-induced RAW 264.7 macrophage cells. Furthermore, the results of the Western blot analysis showed a correlation between the inhibition of the Nuclear factor-kappa B (NF-κB) and Mitogen-activated protein kinases (MAPKs) signaling pathways and the suppressive effects of compound 12e on pro-inflammatory cytokines. Molecular docking studies of compound 12e into the COX-2 protein receptor (PDB ID: 5IKQ) active site was performed to rationalize their COX-2 inhibitory potency. The results were found to be in line with the biological findings as they exerted more favorable interactions compared to that of dexamethasone (DXM), explaining their remarkable COX-2 inhibitory activity. The findings revealed that these candidates could be identified as potent anti-inflammatory agents, compound 12e could be a promising drug for the treatment of inflammatory diseases.
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Affiliation(s)
- Xiaorui Cai
- Department of Pharmacy, The Affiliated Cancer Hospital of Shantou University Medical College, Shantou 515041, Guangdong, China
| | - Jianfeng Cai
- Department of Interventional Therapy, The Affiliated Cancer Hospital of Shantou University Medical College, Shantou 515041, Guangdong, China
| | - Ling Fang
- Department of Pharmacy, The Affiliated Cancer Hospital of Shantou University Medical College, Shantou 515041, Guangdong, China
| | - Siqi Xu
- Department of Pharmacy, The Affiliated Cancer Hospital of Shantou University Medical College, Shantou 515041, Guangdong, China
| | - Huide Zhu
- Department of Pharmacy, The Affiliated Cancer Hospital of Shantou University Medical College, Shantou 515041, Guangdong, China
| | - Shuteng Wu
- Department of Pharmacy, Shenzhen People's Hospital, Shenzhen 518020, Guangdong, China
| | - Yicun Chen
- Department of Pharmacology, Shantou University Medical College, Shantou 515041, Guangdong, China.
| | - Shuopo Fang
- Department of Pharmacy, The Affiliated Cancer Hospital of Shantou University Medical College, Shantou 515041, Guangdong, China.
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Atrial Natriuretic Peptide (ANP) Suppress λ-Carrageenan-Induced Acute Paw Edema by Modulating Pro-inflammatory Genes in Swiss Albino Mice. Int J Pept Res Ther 2022. [DOI: 10.1007/s10989-022-10444-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Ahmed A, Shaikh A, Rajwana Y, Ahlawat S. Effects of Systemic Lupus Erythematosus on Clinical Outcomes and In-Patient Mortality Among Hospitalized Patients With Diverticulitis. Cureus 2022; 14:e26603. [PMID: 35936158 PMCID: PMC9354919 DOI: 10.7759/cureus.26603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2022] [Indexed: 11/05/2022] Open
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Crinum latifolium extract inhibits lipopolysaccharide-induced inflammation in human macrophages. REV ROMANA MED LAB 2022. [DOI: 10.2478/rrlm-2022-0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
Introduction: Crinum latifolium is a natural plant showing the anti-inflammatory effects. We aimed to evaluate the effects of Crinum latifolium extract on proinflammatory cytokine production and maturation of early and late endosomes in the lipopolysaccharide (LPS)-induced human macrophages at light microscopic and biochemical levels.
Material and Methods: The effects of Crinum latifolium extract in human macrophages stimulated with LPS was evaluated to optic densities of the lysosome-associated membrane protein-1 (LAMP-1) and early endo-some antigen 1 (EEA1) by immunohistochemistry staining and to level of the proinflammatory cytokine interleukin (IL)-6 by enzyme-linked immunosorbent assay (ELISA).
Results: Crinum latifolium group exhibited a significant decreased in the levels of IL-6 in the supernatant as compared to the LPS group for 2 and 72 hours (p<0.0001). Crinum latifolium group exhibited a significant increased in the optic density of the EEA1 and LAMP-1 in coverslips as compared to the control and lipopolysaccharide groups after 2 and 72 hours (p<0.0001).
Conclusions: Crinum latifolium may a therapeutic plant in the inflammatory diseases, such as sepsis, through anti-inflammatory effects, such as decrease in production of the proinflammatory cytokine and increase in maturations of the early and late endosomes in macrophages.
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Valenzuela A, Rieger KE, Blish CA, Chung L, Fiorentino D. Gastrointestinal Perforation in a Patient With Antinuclear Matrix Protein 2 Antibody-Positive Dermatomyositis. Arthritis Care Res (Hoboken) 2022; 74:1409-1415. [PMID: 35287251 DOI: 10.1002/acr.24879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/23/2022] [Accepted: 03/08/2022] [Indexed: 11/08/2022]
Affiliation(s)
| | - Kerri E Rieger
- Stanford University School of Medicine, Redwood City, California
| | | | - Lorinda Chung
- Stanford University School of Medicine, Redwood City, California
| | - David Fiorentino
- Stanford University School of Medicine, Redwood City, California
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Longley MJ, Baines SJ, Chanoit G. Colonic perforation in 4 dogs following treatment with meloxicam. J Vet Emerg Crit Care (San Antonio) 2022; 32:413-419. [PMID: 35043544 DOI: 10.1111/vec.13170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 08/31/2020] [Accepted: 09/24/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe the clinical findings and treatment of 4 dogs that developed colonic perforation shortly after meloxicam administration. SERIES SUMMARY Three cases were treated with meloxicam for variable nonspecific signs including lethargy and pyrexia. Hemorrhagic diarrhea developed following meloxicam administration in 2 cases. Gastrointestinal perforation was suspected on diagnostic imaging leading to exploratory celiotomy in all 3 cases. Partial colectomy was performed in 2 cases and suture repair with serosal patching in 1 followed by broad spectrum antimicrobials. All 3 dogs recovered from surgery well. One dog that had undergone perineal herniorrhaphy and received meloxicam perioperatively collapsed and died 7 days postsurgery. Postmortem examination revealed ulceration and perforation of the ascending colon with resultant generalized septic peritonitis. Histopathologic findings in all cases showed full thickness infiltration of the colonic wall with inflammatory cells along with ulceration and perforation. Thrombosis of vessels underlying the ulcerated areas was also noted. NEW OR UNIQUE INFORMATION PROVIDED This report suggests that colonic perforation may be a complication of nonsteroidal anti-inflammatory drug use in some cases. To the authors' knowledge, this has not previously been described in dogs. Colonic perforation associated with NSAIDs administration may be more commonly identified in dogs with concurrent morbidities. Caution may be warranted when using NSAIDs in dogs with colonic pathology or possible risk factors to develop such pathology. Prompt diagnosis and treatment is essential for a positive outcome.
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Morel J, Tournadre A, Sellam J, Bouhnik Y, Cornec D, Devauchelle-Pensec V, Dieudé P, Goupille P, Kluger N, Lazaro E, Le Goff B, de Lédinghen V, Lequerré T, Nocturne G, Seror R, Truchetet ME, Verhoeven F, Pham T, Richez C. Practical Management of patients on anti-IL6R therapy: Practical guidelines drawn up by the Club Rhumatismes et Inflammation (CRI). Joint Bone Spine 2021; 88:105221. [PMID: 34183155 DOI: 10.1016/j.jbspin.2021.105221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jacques Morel
- Service de Rhumatologie, CHU Montpellier, Montpellier, France
| | - Anne Tournadre
- Service de Rhumatologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Jérémie Sellam
- Service de Rhumatologie, CHU Saint-Antoine, Paris, France
| | - Yoram Bouhnik
- Service de Gastro-entérologie, CHU Hôpital Beaujon, Clichy, France
| | - Divi Cornec
- Service de Rhumatologie, CHRU La Cavale Blanche, Brest, France
| | | | - Philippe Dieudé
- Service de Rhumatologie, CHU Bichat-Claude Bernard, Paris, France
| | | | - Nicolas Kluger
- Dpt Dermatology, Helsinki, Finland & Service de Dermatologie, CHU Bichat-Claude Bernard, Paris, France
| | - Estibaliz Lazaro
- Service de Médecine interne, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac, France
| | | | - Victor de Lédinghen
- Unité d'Hépatologie et transplantation hépatique, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac, France
| | | | | | - Raphaèle Seror
- Service de Rhumatologie, Bicêtre, Le Kremlin-Bicêtre, France
| | | | | | - Thao Pham
- Service de Rhumatologie, CHU Sainte-Marguerite, Marseille, France
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Bashar S, Al Sbihi AF, Manasrah N, Chaudhary AJ, Iqbal S. Silent Sigmoid Colon Diverticular Perforation: A Case Report. Cureus 2021; 13:e14900. [PMID: 34109086 PMCID: PMC8183156 DOI: 10.7759/cureus.14900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Colonic perforation is associated with high mortality rates, and it requires prompt diagnosis and intervention to ensure favorable patient outcomes. The condition usually presents with typical peritoneal signs and symptoms, but atypical presentations can be a diagnostic challenge. In this report, we present a case of sigmoid diverticulosis perforation in an elderly patient who had no symptoms after the perforation developed. This case highlights the importance of detailed history, physical examination, and a low threshold of suspicion in patients with risk factors for atypical presentations.
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Affiliation(s)
- Sifullah Bashar
- Internal Medicine, Detroit Medical Center/Wayne State University Sinai-Grace Hospital, Detroit, USA
| | - Ali F Al Sbihi
- Internal Medicine, Detroit Medical Center Sinai-Grace Hospital, Detroit, USA
| | - Nouraldeen Manasrah
- Internal Medicine, Detroit Medical Center Sinai-Grace Hospital, Detroit, USA
| | | | - Sana Iqbal
- Internal Medicine, Detroit Medical Center Sinai-Grace Hospital, Detroit, USA
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10
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Fereydouni Z, Amirinezhad Fard E, Mansouri K, Mohammadi Motlagh HR, Mostafaie A. Saponins from Tribulus terrestris L. Extract Down-regulate the Expression of ICAM-1, VCAM-1 and E-selectin in Human Endothelial Cell Lines. INTERNATIONAL JOURNAL OF MOLECULAR AND CELLULAR MEDICINE 2020; 9:73-83. [PMID: 32832486 PMCID: PMC7422852 DOI: 10.22088/ijmcm.bums.9.1.73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Atherosclerosis is an inflammatory disease in which intracellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), and E-selectin (SELE) are consistently expressed in the vascular endothelium. Several evidence support the crucial role of adhesion molecules in the development of atherosclerosis and plaque instability. Due to the anti-inflammatory activity of Tribulus terrestris (TT), the present study investigated the effect of aqueous extract and saponin fraction of TT on the expression of ICAM-1, VCAM-1, and SELE genes in endothelial cells during normal and lipopolysaccharide (LPS) induced conditions. Human umbilical vein endothelial cells (HUVEC) and human bone marrow endothelial cells (HBMEC) were cultured, stimulated by LPS, and treated with aqueous extract and saponin fraction of TT. Finally, the expression of ICAM-1, VCAM-1, and SELE genes were measured using quantitative real-time polymerase chain reaction. LPS-induced HUVECs and HBMECs significantly increased the expression of ICAM-1, VCAM-1, and SELE in comparison with control groups (P<0.001). Treatment of LPS-induced HUVECs and HBMECs by aqueous extract and saponin fraction of TT decreased the expression of all three mentioned genes significantly (P<0.001) in comparison with LPS-induced cells. Taken together, our data suggest that TT has an anti-inflammatory effect. In vivo study about anti-inflammatory effect of this herb may provide new insights into the development of a herbal drug for the prevention/therapy of atherosclerosis.
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Affiliation(s)
- Zahra Fereydouni
- Medical Biology Research Center, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Elahe Amirinezhad Fard
- Medical Biology Research Center, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Kamran Mansouri
- Medical Biology Research Center, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Hamid-Reza Mohammadi Motlagh
- Medical Biology Research Center, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Ali Mostafaie
- Medical Biology Research Center, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
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11
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Arnold MH. The management of diverticulitis: a review of the guidelines. Med J Aust 2020; 212:434-434.e1. [DOI: 10.5694/mja2.50526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Mark H Arnold
- School of Rural HealthUniversity of Sydney Dubbo NSW
- University of Sydney Sydney NSW
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12
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Zullo A, Gatta L, Vassallo R, Francesco VD, Manta R, Monica F, Fiorini G, Vaira D. Paradigm shift: the Copernican revolution in diverticular disease. Ann Gastroenterol 2019; 32:541-553. [PMID: 31700230 PMCID: PMC6826076 DOI: 10.20524/aog.2019.0410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022] Open
Abstract
Diverticular disease (DD) is an umbrella definition that includes different clinical conditions ranging from diverticulosis to severe and potentially life-threatening complications. In the last decade, new concepts regarding pathogenetic alterations have been developed, while the diagnostic, clinical and therapeutic approaches to the management of DD patients have changed. The protective role of dietary factors (i.e., fiber) has been questioned, whilst some drugs widely used in clinical practice have been found to have a deleterious effect. The use of antibiotics in all patients with acute uncomplicated diverticulitis was reconsidered, as well as the need for a surgical approach in these patients. Conflicting recommendations in different guidelines were proposed for the treatment of symptomatic uncomplicated DD. An endoscopic classification of DD was introduced, and a "curative" endoscopic approach has been pioneered. Based on these observations, which together amount to a kind of "Copernican revolution" in the management of DD patients, we performed a comprehensive and critical reappraisal of the proposed modifications, aiming to discriminate between certainties and doubts on this issue.
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Affiliation(s)
- Angelo Zullo
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome (Angelo Zullo)
| | - Luigi Gatta
- Gastroenterology and Endoscopy Unit, Versilia Hospital, Lido di Camaiore (Luigi Gatta)
| | - Roberto Vassallo
- Gastroenterology and Digestive Endoscopy; “Buccheri la Ferla, Fatebenefratelli”, Hospital, Palermo (Roberto Vassallo)
| | - Vincenzo De Francesco
- Section of Gastroenterology, Department of Medical Sciences, University of Foggia (Vincenzo De Francesco)
| | - Raffaele Manta
- Gastroenterology and Digestive Endoscopy, “Generale” Hospital, Perugia (Raffaele Manta)
| | - Fabio Monica
- Gastroenterology and Digestive Endoscopy, Academic Hospital Cattinara, Trieste (Fabio Monica)
| | - Giulia Fiorini
- Department of Medical and Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna (Giulia Fiorini, Dino Vaira), Italy
| | - Dino Vaira
- Department of Medical and Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna (Giulia Fiorini, Dino Vaira), Italy
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Saliba C, Rabah H, Nicolas G, Emmanuel N, Sleiman A, Hashem M, Hussein R, El Masri A, Abboud R, Fawaz M, Haidar Ahmad H. Recurrent Asymptomatic Sigmoid Diverticular Perforation in a Patient with Pemphigus Vulgaris on Immunosuppressive Therapy: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:735-738. [PMID: 31123245 PMCID: PMC6543948 DOI: 10.12659/ajcr.913485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Patient: Male, 57 Final Diagnosis: Perforated diverticuli Symptoms: Asymptomatic Medication: — Clinical Procedure: — Specialty: Surgery
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Affiliation(s)
- Christian Saliba
- Division of Surgery, Saint George Hospital University Medical Center, Hadath, Lebanon
| | - Hussein Rabah
- Division of Internal Medicine, Lebanese University, Faculty of Medical Sciences, Hadath, Lebanon
| | - Gregory Nicolas
- Division of Surgery, Saint George Hospital University Medical Center, Hadath, Lebanon
| | - Nancy Emmanuel
- Lebanese American University Medical Center, Beirut, Lebanon
| | - Ahmad Sleiman
- Division of Cardio-Thoracic Surgery, Rafic Hariri University Hospital, Beirut, Lebanon
| | - Mohammad Hashem
- Division of Surgery, Saint George Hospital University Medical Center, Hadath, Lebanon
| | - Rola Hussein
- Department of Gastroenterology, Saint George Hospital University Medical Center, Hadath, Lebanon
| | - Ali El Masri
- Division of Surgery, Saint George Hospital University Medical Center, Hadath, Lebanon
| | - Rim Abboud
- Division of Surgery, Saint George Hospital University Medical Center, Hadath, Lebanon
| | - Mohammad Fawaz
- Division of Surgery, Saint George Hospital University Medical Center, Hadath, Lebanon
| | - Houssein Haidar Ahmad
- Division of Surgery, Saint George Hospital University Medical Center, Hadath, Lebanon
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Nadaraia NS, Amiranashvili LS, Merlani M, Kakhabrishvili ML, Barbakadze NN, Geronikaki A, Petrou A, Poroikov V, Ciric A, Glamoclija J, Sokovic M. Novel antimicrobial agents' discovery among the steroid derivatives. Steroids 2019; 144:52-65. [PMID: 30776376 DOI: 10.1016/j.steroids.2019.02.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 02/12/2019] [Indexed: 02/07/2023]
Abstract
Fourteen steroid compounds were in silico evaluated using computer program PASS as antimicrobial agents. The experimental studies evaluation revealed that all compounds have good antibacterial activity with MIC at range of 0.003-0.96 mg/mL and MBC 0.06-1.92 mg/mL. Almost all compounds except of compound 4 (3β-acetoxy-1/-p-chlorophenyl-3/-methyl-5α-androstano[17,16-d]pyrazoline) were more potent than Ampicillin, and they were equipotent or more potent than Streptomycine. All compounds exhibited good antifungal activity with MIC at 0.003-0.96 mg/mL and MFC at 0.006-1.92 mg/mL but with different sensitivity against fungi tested. According to docking studies 14-alpha demethylase inhibition may be responsible for antifungal activity. Prediction of toxicity by PROTOX and GUSAR revealed that compounds have low toxicity and can be considered as potential lead compounds for the further studies.
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Affiliation(s)
- Nanuli Sh Nadaraia
- TSMU I.Kutateladze Institute of Pharmacochemistry, Tbilisi 0159, Georgia
| | | | - Maia Merlani
- TSMU I.Kutateladze Institute of Pharmacochemistry, Tbilisi 0159, Georgia
| | | | - Nana N Barbakadze
- TSMU I.Kutateladze Institute of Pharmacochemistry, Tbilisi 0159, Georgia
| | - Athina Geronikaki
- Aristotle University, School of Pharmacy, Thessaloniki 54124, Greece.
| | - Anthi Petrou
- Aristotle University, School of Pharmacy, Thessaloniki 54124, Greece
| | | | - Ana Ciric
- Mycological Laboratory, Department of Plant Physiology, Institute for Biological Research, Siniša Stanković, University of Belgrade, Bulevar Despota Stefana, Serbia
| | - Jarmila Glamoclija
- Mycological Laboratory, Department of Plant Physiology, Institute for Biological Research, Siniša Stanković, University of Belgrade, Bulevar Despota Stefana, Serbia
| | - Marina Sokovic
- Mycological Laboratory, Department of Plant Physiology, Institute for Biological Research, Siniša Stanković, University of Belgrade, Bulevar Despota Stefana, Serbia
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Intestinal Perforation in ACTH-Dependent Cushing's Syndrome. BIOMED RESEARCH INTERNATIONAL 2019; 2019:9721781. [PMID: 31001560 PMCID: PMC6436364 DOI: 10.1155/2019/9721781] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 02/21/2019] [Indexed: 01/25/2023]
Abstract
Previous studies have linked systemic glucocorticoid use with intestinal perforation. However, the association between intestinal perforation and endogenous hypercortisolism has not been well described, with only 14 previously published case reports. In this study, we investigated if intestinal perforation occurred more frequently in patients with ectopic ACTH syndrome and in those with a greater than 10-fold elevation of 24-hour urinary free cortisol level. Of 110 patients with ACTH-dependent Cushing's syndrome followed in two clinics in Canada, six cases with intestinal perforation were identified over 15 years. Age of patients ranged from 52 to 72, five females and one male, four with Cushing's disease and two with ectopic ACTH production, one from a pancreatic neuroendocrine tumor and one from medullary carcinoma of the thyroid. Five had diverticular perforation and one had intestinal perforation from a stercoral ulcer. All cases had their lower intestinal perforation when the cortisol production was high, and one patient had diverticular perforation 15 months prior to the diagnosis of Cushing's disease. As in previously reported cases, most had hypokalemia and abdominal pain with minimal or no peritoneal symptoms and this occurred during the active phase of Cushing's syndrome. Whereas all previously reported cases occurred in patients with 24-hour urinary free cortisol levels greater than 10-fold the upper limit of normal when measured and 11 of 14 patients had ectopic ACTH production, only one of our patients had this degree of hypercortisolism and four of our six patients had Cushing's disease. Similar to exogenous steroid use, patients with endogenous hypercortisolism also have a higher risk of intestinal, in particular diverticular, perforation and should be monitored closely for its occurrence with a low threshold for investigation and surgical intervention. Elective colonoscopy probably should be deferred until Cushing's syndrome is under control.
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The Association between Absence of Abdominal Pain and Mortality in Lower Intestinal Perforation in Patients with Autoimmune Rheumatic Diseases. BIOMED RESEARCH INTERNATIONAL 2019; 2019:5381453. [PMID: 30906775 PMCID: PMC6398054 DOI: 10.1155/2019/5381453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 01/28/2019] [Indexed: 01/13/2023]
Abstract
Objective To determine mortality and predictive factors for lower intestinal perforation (LIP) among patients with autoimmune rheumatic diseases. Methods This retrospective, single-center, observational study analyzed mortality rates in 31 autoimmune rheumatic disease patients with LIP who were admitted to our hospital from January 2002 to June 2017. The primary outcome was the mortality rate during hospitalization. Results The median age at the time of LIP was 61 years, and the survival rate at discharge was 64.5%. Eleven patients died of sepsis during hospitalization. Cox univariable analysis for mortality during hospitalization showed that absence of abdominal pain (hazard ratio (HR) 5.61, 95% confidence interval (CI) 1.38–22.9), higher age (HR 1.06, 95% CI 1.01–1.11), chronic kidney disease (HR 6.89, 95% CI 1.85–25.7), systemic vasculitis (HR 3.95, 95% CI 1.14–13.6), higher blood urea nitrogen (HR 1.02, 95% CI 1.01–1.04), higher serum creatinine (HR 1.41, 95% CI 1.06–1.87), and LIP due to malignancy (HR 14.3, 95% CI 1.95–105.1) significantly increased mortality. Conclusion Abdominal pain was absent in 16% of LIP patients with autoimmune rheumatic diseases, and this absence was a poor prognostic factor in this cohort. Moreover, higher age, chronic kidney disease, systemic vasculitis, and LIP due to malignancy were associated with significantly increased mortality. Physicians should be aware of LIP in autoimmune disease patients with higher age, chronic kidney diseases, or systemic vasculitis even if patients reveal mild abdominal symptoms.
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Gastrointestinal Perforations with Biologics in Patients with Rheumatoid Arthritis: Implications for Clinicians. Drug Saf 2018; 41:545-553. [PMID: 29392593 DOI: 10.1007/s40264-018-0639-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Gastrointestinal (GI) perforations are rare events in rheumatoid arthritis (RA) patients, but cause significant morbidity and mortality. Several studies indicate that RA patients may be at higher risk of GI perforation. Traditional RA treatments such as glucocorticoids and non-steroidal anti-inflammatory drugs increase the risk of perforation. In the past two decades, a new class of therapeutic agents called biologics has been added to the RA treatment armamentarium. Biologics are effective in controlling disease activity and are generally well tolerated; however, reports of GI perforations in association with biologics have arisen. In particular, drugs that inhibit the interleukin (IL)-6 cytokine receptor have demonstrated a higher risk of perforation compared with other therapies. Recent reports also suggest that janus kinase inhibitors may increase the risk of perforation, perhaps via downstream effects on IL-6 signaling. In this review, we discuss current data on the risk of GI perforations among RA patients receiving targeted therapies and its clinical relevance.
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Anti-Inflammatory Effect of Columbianetin on Lipopolysaccharide-Stimulated Human Peripheral Blood Mononuclear Cells. Mediators Inflamm 2018; 2018:9191743. [PMID: 29849500 PMCID: PMC5907401 DOI: 10.1155/2018/9191743] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 10/25/2017] [Accepted: 02/12/2018] [Indexed: 12/15/2022] Open
Abstract
Dysregulated inflammation is increasingly considered as the main cause of many diseases on which NOD1/NF-κB pathway plays an important role. Columbianetin (CBT) is derived from the root of the Chinese herb Radix Angelicae Pubescentis for treating inflammatory diseases. Although the anti-inflammatory effect of CBT has been reported, its anti-inflammatory mechanism was poorly studied. In this study, we explored the anti-inflammatory pathway of CBT in lipopolysaccharide- (LPS-) stimulated human peripheral blood mononuclear cell (PBMC) model. Inflammatory cytokine production in culture supernatant was assessed using ELISA assay, and the possible anti-inflammatory pathway of CBT was screened using qPCR array and enrichment analysis with DAVID6.8. To further confirm the targeted pathway of CBT, we pretreated PBMC with the selective NOD1 inhibitor ML130 and then measured the protein levels of the pathway by Western blotting. The result showed that CBT effectively suppressed the expressions of TNF-α, IL-6, MCP-1, and IL-1β in a dose-dependent manner and significantly downregulated 19 out of 32 differentially expressed genes, most of which were involved in the NOD1/NF-κB pathway, and also showed that CBT remarkably inhibited LPS-induced NOD1, RIP2, and NF-κB activation. Furthermore, the inhibitory effects of CBT on NOD1/NF-κB pathways were blocked by ML130. These findings indicated that CBT inhibits the production of inflammatory cytokines induced by LPS involved in the downregulation of NOD1/NF-κB pathways.
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Reichert MC, Krawczyk M, Appenrodt B, Casper M, Friesenhahn-Ochs B, Grünhage F, Jüngst C, Zimmer V, Lammert F, Dauer M. Selective association of nonaspirin NSAIDs with risk of diverticulitis. Int J Colorectal Dis 2018; 33:423-430. [PMID: 29411119 DOI: 10.1007/s00384-018-2968-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/14/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study is to investigate the association of intake of nonsteroidal anti-inflammatory drugs (NSAIDs) and in particular nonaspirin NSAIDs and compare it with other risk factors for the progression of diverticulosis to diverticulitis in patients who underwent colonoscopy. METHODS A total of 194 patients who underwent complete colonoscopy in our center between 2012 and 2016 were recruited: 144 with diverticulosis without prior diverticulitis (median age 71 years, 59.7% men) and 50 with diverticulitis (median age 64 years, 54.0% men). Data concerning current and previous medication as well as concomitant diseases were collected using a structured questionnaire and by revision of patients medical charts. RESULTS Patients with diverticulitis were significantly (p < 0.001) younger as compared to individuals with plain diverticulosis (median age 64 versus 71 years, respectively). The intake of NSAIDs significantly (p = 0.002) increased the risk of prior diverticulitis (OR 3.2, 95% CI 1.5-6.9). In the multivariate model, both age (p < 0.001) and NSAIDs (p = 0.03) proved to be independent determinants of diverticulitis. When analyzing aspirin intake, it was not associated with diverticulitis. CONCLUSIONS Our study demonstrates, in line with previous reports, that intake of NSAIDs is associated with diverticulitis. We show in particular that nonaspirin NSAIDs might be selectively associated with diverticulitis. These results point to divergent role of aspirin and nonaspirin NSAIDs in the development of diverticulitis.
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Affiliation(s)
- Matthias C Reichert
- Department of Medicine II, Saarland University Medical Center, 66421, Homburg, Germany.
| | - Marcin Krawczyk
- Department of Medicine II, Saarland University Medical Center, 66421, Homburg, Germany
- Laboratory of Metabolic Liver Diseases, Centre for Preclinical Research, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Beate Appenrodt
- Department of Medicine II, Saarland University Medical Center, 66421, Homburg, Germany
| | - Markus Casper
- Department of Medicine II, Saarland University Medical Center, 66421, Homburg, Germany
| | | | - Frank Grünhage
- Department of Medicine II, Saarland University Medical Center, 66421, Homburg, Germany
| | - Christoph Jüngst
- Department of Medicine II, Saarland University Medical Center, 66421, Homburg, Germany
| | - Vincent Zimmer
- Department of Medicine II, Saarland University Medical Center, 66421, Homburg, Germany
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, 66421, Homburg, Germany
| | - Marc Dauer
- Department of Medicine II, Saarland University Medical Center, 66421, Homburg, Germany
- Department Medicine 2, Klinikum St. Marien, Amberg, Germany
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Is focal active colitis of greater clinical significance in pediatric patients? A retrospective review of 68 cases with clinical correlation. Hum Pathol 2018; 74:164-169. [PMID: 29360496 DOI: 10.1016/j.humpath.2018.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 12/31/2017] [Accepted: 01/07/2018] [Indexed: 11/23/2022]
Abstract
Focal active colitis (FAC) is a histopathologic finding of uncertain clinical significance in individual patients. In adults, infection accounts for approximately 50%, Crohn's disease (CD) for 0-13%, and 20%-30% are idiopathic. One previous study of 29 cases of pediatric FAC showed a 28% rate of CD. This study reviewed a larger cohort of pediatric patients to determine what proportion had IBD, and whether an amount or pattern of inflammation could predict IBD. Sixty-eight patients aged ≤18years with FAC were identified and reviewed. Patients with a prior diagnosis of IBD or chronic colitis in the index biopsies were excluded. Slides were assessed for a number of inflammatory criteria. Clinical data and final diagnoses were recorded. Data were analyzed using Pearson correlations and Fisher's exact χ2 analyses. Sixteen patients (24%) had a final diagnosis of IBD. When cases with terminal ileal (TI) inflammation were excluded, 6 of 54 patients had a final diagnosis of IBD (11%). A final diagnosis of IBD was significantly associated with crypt abscesses and elevated serum inflammatory markers. IBD was significantly associated with TI inflammation. An amount or pattern of inflammation that could be used to predict IBD was not determined. This study demonstrated a 24% rate of IBD in pediatric patients with FAC; however, when patients with associated TI inflammation were excluded, the rate was 11%, similar to reported rates in adults. FAC in pediatric patients without terminal ileal inflammation does not appear to warrant more aggressive follow-up.
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Abstract
BACKGROUND Corticosteroids are commonly used in the management of primary central nervous system (CNS) tumors and CNS metastases to treat cancer- and treatment-related cerebral edema and improve neurologic function. However, they are also associated with significant morbidity and mortality, given their wide range of adverse effects. PURPOSE OF REVIEW To review the mechanism of action, pharmacology, and toxicity profile of corticosteroids and to critically appraise the evidence that supports their use in neuro-oncologic practice based on the latest scientific and clinical data. RECENT FINDINGS Recent data suggest that corticosteroids may negatively impact survival in glioma patients. In addition, corticosteroids should be incorporated as a standard criterion to assess a patient's clinical and radiographic response to treatment. Corticosteroids should be used judiciously in neuro-oncologic patients, given the potential deleterious effects on clinical outcome and patient survival. Anti-angiogenic agents, which lack these adverse effects, may be a reasonable alternative to corticosteroids.
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Affiliation(s)
- K Ina Ly
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA
- Stephen E. and Catherine Pappas Center for Neuro-Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA.
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Marginean EC. The Ever-Changing Landscape of Drug-Induced Injury of the Lower Gastrointestinal Tract. Arch Pathol Lab Med 2017; 140:748-58. [PMID: 27472233 DOI: 10.5858/arpa.2015-0451-ra] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
CONTEXT -There is an ever-growing armamentarium of pharmacologic agents that can cause gastrointestinal (GI) mucosal injury, the most common symptoms being diarrhea, constipation, nausea, and vomiting. These are often self-limiting and without serious sequelae, but some symptoms are of greater concern, like drug-induced mucosal ulceration that can manifest as GI hemorrhage, stricture formation, and even perforation. Histologically, there is significant overlap between drug-induced injuries and various disease entities. A single type of medication may cause multiple patterns of injury, which can involve the entire GI tract or just some parts of it. OBJECTIVE -To review the most common drug-induced injury patterns affecting the colon, which may be recognized by the surgical pathologist on colonic mucosal biopsies. This review does not address the injuries occurring in the upper GI tract. DATA SOURCES -A PubMed review of English-language literature, up to December 2015, on drug-induced injury of GI tract was performed. CONCLUSIONS -There are numerous drugs that damage the colonic mucosa. The most common drugs are included in this review according to their histologic pattern of injury. It is important for the pathologist to keep in mind that a single drug type can induce many histologic patterns of mucosal injury that can mimic many disease entities. Although there are some histologic clues helpful in the diagnosis of drug-induced colonic injury, correlation with clinical history and especially medication history is essential to improve diagnostic accuracy.
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Affiliation(s)
- Esmeralda Celia Marginean
- From the Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, Ontario, Canada
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23
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Nguyen MHK, Isaac KM, Dougherty R. Gastrointestinal perforation: relation to corticosteroid use and COPD - a case report. J Community Hosp Intern Med Perspect 2016; 6:32129. [PMID: 27609727 PMCID: PMC5016752 DOI: 10.3402/jchimp.v6.32129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 07/11/2016] [Accepted: 07/15/2016] [Indexed: 11/29/2022] Open
Abstract
Gastrointestinal perforations are a complication of 2–10% of duodenal ulcers. There are a variety of etiologies associated with duodenal ulcer formation and its complications. Corticosteroid use is associated with an increased risk of duodenal ulcer perforation, with the first documented case in 1950. Other important medications associated with perforation include NSAIDS and opioids. Beyond medication, one of the most common disease processes, chronic obstructive pulmonary disease (COPD), has been found to be associated with peptic ulcer disease. Up to 30% of COPD patients have been found to have peptic ulcers, and COPD frequency in peptic ulcer disease is 2–3 times the general population. We herein present a case of an acute duodenal ulcer perforation in a patient receiving corticosteroid treatment for an acute COPD exacerbation.
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Affiliation(s)
- Michael H K Nguyen
- Department of Internal Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA;
| | - Krista M Isaac
- Department of Internal Medicine, Lankenau Medical Center, Philadelphia, PA, USA
| | - Rebecca Dougherty
- Department of Internal Medicine, Lankenau Medical Center, Philadelphia, PA, USA
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Strangfeld A, Richter A, Siegmund B, Herzer P, Rockwitz K, Demary W, Aringer M, Meißner Y, Zink A, Listing J. Risk for lower intestinal perforations in patients with rheumatoid arthritis treated with tocilizumab in comparison to treatment with other biologic or conventional synthetic DMARDs. Ann Rheum Dis 2016; 76:504-510. [PMID: 27405509 PMCID: PMC5445993 DOI: 10.1136/annrheumdis-2016-209773] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 05/20/2016] [Accepted: 06/19/2016] [Indexed: 01/28/2023]
Abstract
Objective To investigate the risk of developing lower intestinal perforations (LIPs) in patients with rheumatoid arthritis (RA) treated with tocilizumab (TCZ). Methods In 13 310 patients with RA observed in the German biologics register Rheumatoid Arthritis: Observation of Biologic Therapy, 141 serious gastrointestinal events possibly associated with perforations were reported until 31 October 2015. All events were validated independently by two physicians, blinded for treatment exposure. Results 37 LIPs (32 in the colon/sigma) were observed in 53 972 patient years (PYs). Only two patients had a history of diverticulitis (one in TCZ). Age, current/cumulative glucocorticoids and non-steroidal anti-inflammatory drugs were significantly associated with the risk of LIP. The crude incidence rate of LIP was significantly increased in TCZ (2.7/1000 PYs) as compared with all other treatments (0.2−0.6/1000 PYs). The adjusted HR (ref: conventional synthetic (cs) disease-modifying anti-rheumatic drugs (DMARDs)) in TCZ was 4.48 (95% CI 2.0 to 10.0), in tumour necrosis factor-α inhibitor (TNFi) 1.04 (0.5 to 2.3) and in other biologic DMARDs 0.33 (0.1 to 1.4). 4/11 patients treated with TCZ presented without typical symptoms of LIP (acute abdomen, severe pain). Only one patient had highly elevated C reactive protein (CRP). One quarter of patients died within 30 days after LIP (9/37), 5/11 under TCZ, 2/13 under TNFi and 2/11 under csDMARD treatment. Conclusions The incidence rates of LIP under TCZ found in this real world study are in line with those seen in randomised controlled trials of TCZ and higher than in all other DMARD treatments. To ensure safe use of TCZ in daily practice, physicians and patients should be aware that, under TCZ, LIP may occur with mild symptoms only and without CRP elevation.
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Affiliation(s)
- A Strangfeld
- Department of Epidemiology, German Rheumatism Research Centre, Berlin, Germany
| | - A Richter
- Department of Epidemiology, German Rheumatism Research Centre, Berlin, Germany
| | - B Siegmund
- Centrum Innere Medizin mit Gastroenterologie und Nephrologie CC 13, Charité University Medicine Berlin, Berlin, Germany
| | - P Herzer
- Scientific Advisory Board, Munich, Germany
| | | | | | - M Aringer
- Department of Internal Medicine III, Division of Rheumatology, University Medicine Dresden, Dresden, Germany
| | - Y Meißner
- Department of Epidemiology, German Rheumatism Research Centre, Berlin, Germany
| | - A Zink
- Department of Epidemiology, German Rheumatism Research Centre, Berlin, Germany.,Centrum Innere Medizin mit Gastroenterologie und Nephrologie CC 13, Charité University Medicine Berlin, Berlin, Germany
| | - J Listing
- Department of Epidemiology, German Rheumatism Research Centre, Berlin, Germany
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Strate LL, Peery AF, Neumann I. American Gastroenterological Association Institute Technical Review on the Management of Acute Diverticulitis. Gastroenterology 2015; 149:1950-1976.e12. [PMID: 26453776 DOI: 10.1053/j.gastro.2015.10.001] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Lisa L Strate
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Anne F Peery
- Division of Gastroenterology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Ignacio Neumann
- Department of Internal Medicine, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Abstract
Diverticular disease is a common condition in Western countries and the incidence and prevalence of the disease is increasing. The pathogenetic factors involved include structural changes in the gut that increase with age, a diet low in fibre and rich in meat, changes in intestinal motility, the concept of enteric neuropathy and an underlying genetic background. Current treatment strategies are hampered by insufficient options to stratify patients according to individual risk. One of the main reasons is the lack of an all-encompassing classification system of diverticular disease. In response, the German Society for Gastroenterology and Digestive Diseases (DGVS) has proposed a classification system as part of its new guideline for the diagnosis and management of diverticular disease. The classification system includes five main types of disease: asymptomatic diverticulosis, acute uncomplicated and complicated diverticulitis, as well as chronic diverticular disease and diverticular bleeding. Here, we review prevention and treatment strategies stratified by these five main types of disease, from prevention of the first attack of diverticulitis to the management of chronic complications and diverticular bleeding.
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A Case of Diverticular Perforation in a Young Patient with Rheumatoid Arthritis on Methotrexate. Case Rep Med 2015; 2015:617268. [PMID: 26064129 PMCID: PMC4429201 DOI: 10.1155/2015/617268] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 04/14/2015] [Indexed: 12/22/2022] Open
Abstract
Background. Disease-modifying antirheumatic drugs (DMARDs), such as methotrexate (MTX), are associated with gastrointestinal toxicity. MTX inhibits dihydrofolate reductase, but it is unclear if polymorphisms of the methylenetetrahydrofolate reductase (MTHFR) gene predict toxicity. Case. We describe a 33-year-old male with polyarticular rheumatoid arthritis who developed sigmoid diverticular perforation while receiving methotrexate, folic acid, prednisone, and naproxen. He tested heterozygous for the C677T allele MTHFR gene. Discussion. Rheumatoid arthritis and its treatments are associated with increased risk of gastrointestinal disease. In one study, perforation was highest among individuals with concomitant exposure to NSAIDs, nonbiologic DMARDs, and glucocorticoids. Multiple mutations of the MTHFR gene have been identified, but their association with MTX toxicity is unclear. This case adds to a growing body of literature that could help inform the treatment of others in the future.
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Böhm SK. Risk Factors for Diverticulosis, Diverticulitis, Diverticular Perforation, and Bleeding: A Plea for More Subtle History Taking. VISZERALMEDIZIN 2015; 31:84-94. [PMID: 26989377 PMCID: PMC4789955 DOI: 10.1159/000381867] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Diverticulosis is a very common condition. Around 20% of diverticula carriers are believed to suffer from diverticular disease during their lifetime. This makes diverticular disease one of the clinically and economically most significant conditions in gastroenterology. The etiopathogenesis of diverticulosis and diverticular disease is not well understood. Epidemiological studies allowed to define risk factors for the development of diverticulosis and the different disease entities associated with it, in particular diverticulitis, perforation, and diverticular bleeding. Methods A comprehensive literature search was performed, and the current knowledge about risk factors for diverticulosis and associated conditions reviewed. Results Non-controllable risk factors like age, sex, and genetics, and controllable risk factors like foods, drinks, and physical activity were identified, as well as comorbidities and drugs which increase or decrease the risk of developing diverticula or of suffering from complications. In naming risk factors, it is of utmost importance to differentiate between diverticulosis and the different disease entities. Conclusion Risk factors for diverticulosis and diverticular disease may give a clue towards the possible etiopathogenesis of the conditions. More importantly, knowledge of comorbidities and particularly drugs conferring a risk for development of complicated disease is crucial for patient management.
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Affiliation(s)
- Stephan K Böhm
- Medizinische Universitätsklinik, Kantonsspital Baselland, Bruderholz, Switzerland
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29
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Cuomo R, Barbara G, Pace F, Annese V, Bassotti G, Binda GA, Casetti T, Colecchia A, Festi D, Fiocca R, Laghi A, Maconi G, Nascimbeni R, Scarpignato C, Villanacci V, Annibale B. Italian consensus conference for colonic diverticulosis and diverticular disease. United European Gastroenterol J 2014; 2:413-42. [PMID: 25360320 PMCID: PMC4212498 DOI: 10.1177/2050640614547068] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 07/18/2014] [Indexed: 02/05/2023] Open
Abstract
The statements produced by the Consensus Conference on Diverticular Disease promoted by GRIMAD (Gruppo Italiano Malattia Diverticolare, Italian Group on Diverticular Diseases) are reported. Topics such as epidemiology, risk factors, diagnosis, medical and surgical treatment of diverticular disease (DD) in patients with uncomplicated and complicated DD were reviewed by a scientific board of experts who proposed 55 statements graded according to level of evidence and strength of recommendation, and approved by an independent jury. Each topic was explored focusing on the more relevant clinical questions. Comparison and discussion of expert opinions, pertinent statements and replies to specific questions, were presented and approved based on a systematic literature search of the available evidence. Comments were added explaining the basis for grading the evidence, particularly for controversial areas.
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Affiliation(s)
- Rosario Cuomo
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
- Rosario Cuomo, Department of Clinical Medicine and Surgery, Federico II University Hospital School of Medicine via S. Pansini 5, 80131 Napoli, Italy.
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Fabio Pace
- Department of Biochemical and Clinical Sciences, University of Milan, Milan, Italy
| | - Vito Annese
- Department of Gastroenterology, AOU Careggi, Florence, Italy
| | - Gabrio Bassotti
- Gastroenterology and Hepatology Section, University of Perugia School of Medicine, Perugia, Italy
| | | | | | - Antonio Colecchia
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Davide Festi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Roberto Fiocca
- Pathology Unit, IRCCS San Martino-IST University Hospital, Genoa, Italy
| | - Andrea Laghi
- Department of Radiological Sciences, Oncology and Pathology, La ‘Sapienza' University, Rome, Italy
| | - Giovanni Maconi
- Gastroenterology Unit, L. Sacco University Hospital, Milan, Italy
| | - Riccardo Nascimbeni
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Carmelo Scarpignato
- Clinical Pharmacology & Digestive Pathophysiology Unit, University of Parma, Parma, Italy
| | | | - Bruno Annibale
- Medical-Surgical and Translational Medicine Department, La Sapienza University, Rome, Italy
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Dunning T, Savage S, Duggan N, Martin P. Palliative and end of life care for people with diabetes: a topical issue. ACTA ACUST UNITED AC 2014. [DOI: 10.2217/dmt.14.33] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Kvasnovsky CL, Papagrigoriadis S, Bjarnason I. Increased diverticular complications with nonsteriodal anti-inflammatory drugs and other medications: a systematic review and meta-analysis. Colorectal Dis 2014; 16:O189-96. [PMID: 24320820 DOI: 10.1111/codi.12516] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 10/11/2013] [Indexed: 02/08/2023]
Abstract
AIM Complications of colonic diverticula, perforation and bleeding are a source of morbidity and mortality. A variety of drugs have been implicated in these complications. We present a systemic review and meta-analysis of the literature to assess the importance of this relationship. METHOD A systematic review of articles in PubMed, Cochrane Reviews, Embase and Google Scholar was undertaken in February 2013. An initial literature search yielded 2916 results that were assessed for study design and topicality. Twenty-three articles were included in the review. A qualitative data synthesis was conducted using forest plots of studies comparing single medication with complications. RESULTS Individual studies demonstrated the odds of perforation and abscess formation with nonsteridal anti-inflammatory drugs (NSAIDs) (1.46-10.30), aspirin (0.66-2.40), steroids (2.17-31.90) and opioids (1.80-4.51) and the odds of bleeding with NSAIDs (2.01-12.60), paracetamol (0-3.75), aspirin (1.14-3.70) and steroids (0.57-5.40). Pooled data showed significantly increased odds of perforation and abscess formation with NSAIDs (OR = 2.49), steroids (OR = 9.08) and opioids (OR = 2.52). They also showed increased odds of diverticular bleeding from NSAIDs (OR = 2.69), aspirin (OR = 3.24) and calcium-channel blockers (OR = 2.50). Most studies did not describe the duration or dosage of medication used and did not systematically describe the severity of diverticular complications. CONCLUSION Various common medications are implicated in complications of diverticular disease.
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Affiliation(s)
- C L Kvasnovsky
- Department of Colorectal Surgery, King's College Hospital, London, UK
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32
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Seminerio J, McGrath K, Arnold CA, Voltaggio L, Singhi AD. Medication-associated lesions of the GI tract. Gastrointest Endosc 2014; 79:140-50. [PMID: 24119504 DOI: 10.1016/j.gie.2013.08.027] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 08/22/2013] [Indexed: 02/08/2023]
Affiliation(s)
- Jennifer Seminerio
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kevin McGrath
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christina A Arnold
- Department of Pathology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Lysandra Voltaggio
- Department of Pathology, George Washington University, Washington, District of Columbia
| | - Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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33
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Walz B. [Incidence rates and risk factors for gastrointestinal perforation in patients with rheumatoid arthritis]. Z Rheumatol 2013; 73:85-6. [PMID: 24306840 DOI: 10.1007/s00393-013-1277-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- B Walz
- Innere Medizin, Rheumatologie und Immunologie, Kreiskliniken Esslingen, Eugenstr. 3, 73230, Kirchheim unter Teck, Deutschland,
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Hara T, Akutsu H, Yamamoto T, Ishikawa E, Matsuda M, Matsumura A. Cushing's disease presenting with gastrointestinal perforation: a case report. Endocrinol Diabetes Metab Case Rep 2013; 2013:130064. [PMID: 24616779 PMCID: PMC3922247 DOI: 10.1530/edm-13-0064] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 10/30/2013] [Indexed: 11/08/2022] Open
Abstract
Gastrointestinal perforation is a complication associated with steroid therapy or hypercortisolism, but it is rarely observed in patients with Cushing's disease in clinical practice, and only one case has been reported as a presenting symptom. Herein, we report a rare case of Cushing's disease in which a patient presented with gastrointestinal perforation as a symptom. A 79-year-old man complained of discomfort in the lower abdomen for 6 months. Based on the endocrinological and gastroenterological examinations, he was diagnosed with Cushing's disease with a perforation of the descending colon. After consultation with a gastroenterological surgeon, it was decided that colonic perforation could be conservatively observed without any oral intake and treated with parenteral administration of antibiotics because of the mild systemic inflammation and lack of abdominal guarding. Despite the marked elevated levels of serum cortisol, oral medication was not an option because of colonic perforation. Therefore, the patient was submitted to endonasal adenomectomy to normalize the levels of serum cortisol. Subsequently, a colostomy was successfully performed. Despite its rarity, physicians should be aware that gastrointestinal perforation may be associated with hypercortisolism, especially in elderly patients, and immediate diagnosis and treatment of this life-threatening condition are essential. If a perforation can be conservatively observed, endonasal adenomectomy prior to laparotomy is an alternative treatment option for hypercortisolism.
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Affiliation(s)
- Takuma Hara
- Department of Neurosurgery, Faculty of Medicine University of Tsukuba 1-1-1 Tennodai Tsukuba Ibaraki, Tsukuba, 305-0006 Japan
| | - Hiroyoshi Akutsu
- Department of Neurosurgery, Faculty of Medicine University of Tsukuba 1-1-1 Tennodai Tsukuba Ibaraki, Tsukuba, 305-0006 Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Faculty of Medicine University of Tsukuba 1-1-1 Tennodai Tsukuba Ibaraki, Tsukuba, 305-0006 Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine University of Tsukuba 1-1-1 Tennodai Tsukuba Ibaraki, Tsukuba, 305-0006 Japan
| | - Masahide Matsuda
- Department of Neurosurgery, Faculty of Medicine University of Tsukuba 1-1-1 Tennodai Tsukuba Ibaraki, Tsukuba, 305-0006 Japan
| | - Akira Matsumura
- Department of Neurosurgery, Faculty of Medicine University of Tsukuba 1-1-1 Tennodai Tsukuba Ibaraki, Tsukuba, 305-0006 Japan
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Moyano C, Beldjerd M, Pécourneau V, Billey T, Lassoued S. Infection of the sigmoid colon during TNFα antagonist therapy for chronic inflammatory joint disease. Joint Bone Spine 2013; 81:254-6. [PMID: 24176737 DOI: 10.1016/j.jbspin.2013.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2013] [Indexed: 11/28/2022]
Abstract
We report 7 cases of sigmoid colon infection in patients taking TNFα antagonist therapy to treat chronic inflammatory joint disease. There were 5 women and 2 men with a mean age of 57.5 years (range, 21-77 years). The presenting symptoms were abdominal pain, bowel habit changes, and a fever. These symptoms developed within 6 months after starting TNFα antagonist therapy in 5 of the 7 patients. Empirical antibiotic therapy was used in all 7 patients. Surgical colectomy was performed in 4 patients, including 1 who required a temporary Hartmann's procedure. The risk of infection associated with TNFα antagonist therapy is well documented. However, few cases of colon infection have been reported and little is known about this potentially severe complication. Glucocorticoids or non-steroidal anti-inflammatory drugs may worsen the infection, particularly as they can attenuate the clinical symptoms, thereby delaying the diagnosis. A history of sigmoid colon infection, diverticulosis, and/or diverticulitis must be sought before starting treatment with a biological agent. Prophylactic treatment may be considered if such a history is found. Diagnostic investigations are in order to develop a standardized management strategy in patients with a history of intestinal tract infection.
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Affiliation(s)
- Chantal Moyano
- Service de Rhumatologie et Rééducation Fonctionnelle, Centre Hospitalier Jean-Rougier, 338, rue Wilson, 46000 Cahors, France.
| | - Mounir Beldjerd
- Service de Rhumatologie et Rééducation Fonctionnelle, Centre Hospitalier Jean-Rougier, 338, rue Wilson, 46000 Cahors, France
| | - Virginie Pécourneau
- Service de Rhumatologie et Rééducation Fonctionnelle, Centre Hospitalier Jean-Rougier, 338, rue Wilson, 46000 Cahors, France
| | - Thierry Billey
- Service de Rhumatologie et Rééducation Fonctionnelle, Centre Hospitalier Jean-Rougier, 338, rue Wilson, 46000 Cahors, France
| | - Slim Lassoued
- Service de Rhumatologie et Rééducation Fonctionnelle, Centre Hospitalier Jean-Rougier, 338, rue Wilson, 46000 Cahors, France
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Abstract
Recently, a monoclonal antibody to cytotoxic T-lymphocyte-associated antigen 4, ipilimumab, was approved for the treatment of metastatic melanoma. One of the most common side effects associated with this therapy is diarrhea and colitis. We report 3 cases of perforating colitis induced by ipilimumab requiring colectomy. The histologic findings of mucosal biopsies have been previously described. Herein, we describe novel associated histologic findings (pseudopolyp formation, fissuring ulcers, dilated crypts, and lack of intraepithelial lymphocytosis and epithelial apoptosis) of segmental resections in patients who required subtotal colectomy after perforation due to the severity of their ipilimumab-induced colitis. Although steroid therapy is the standard treatment for ipilimumab-induced colitis, surgery may be necessary. In the setting of progressive or worsening diarrhea after steroid therapy in patients with colitis, bowel perforation should be considered.
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Gravante G, Yahia S. Medical influences, surgical outcomes: Role of common medications on the risk of perforation from untreated diverticular disease. World J Gastroenterol 2013; 19:5947-5952. [PMID: 24106394 PMCID: PMC3785615 DOI: 10.3748/wjg.v19.i36.5947] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 07/06/2013] [Accepted: 08/13/2013] [Indexed: 02/06/2023] Open
Abstract
Numerous drugs, largely used in the wards or at home, have a significant influence on patients with untreated diverticular disease. The consequences can be disastrous, may require an emergency operation, postoperative intensive care, and overall influence the patient’s length of stay and the final outcomes. Bearing these considerations in mind the routine or chronic administration of pain-killers, steroids and non-steroidal anti-inflammatory should be balanced in patients with known diverticular disease as it normally happens with other conditions potentially affected by these drugs (i.e., peptic ulcer disease or chronic obstructive pulmonary disease). This is even more important in the old and frail patient where an eventual surgical treatment may not always be possible.
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Liu DSH, Mignanelli E. Acute surgical abdomen in an immunocompromised patient. ANZ J Surg 2012; 82:660-1. [PMID: 22943089 DOI: 10.1111/j.1445-2197.2012.06166.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Turner EJH, Raza SA. Long-term steroids and an extensive diverticular abscess. BMJ Case Rep 2012; 2012:bcr.10.2011.4926. [PMID: 22761231 DOI: 10.1136/bcr.10.2011.4926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The authors report a case of a 70-year-old lady who was on steroids for over 40 years for asthma and presented with a subcutaneous abscess related to diverticular disease of the colon. This case illustrates how steroids can mask the disease process and also highlights that diverticular abscess perforation is one of the many complications of corticosteroid therapy.
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Symeonidis N, Psarras K, Lalountas M, Baltatzis M, Micha A, Pavlidis E, Sakantamis A. Clinical features of colonic diverticular disease. Tech Coloproctol 2012; 15 Suppl 1:S5-8. [PMID: 21887570 DOI: 10.1007/s10151-011-0738-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Colonic diverticular disease is extremely common in developed countries. Although the majority of patients with diverticulosis remain asymptomatic, about one-third of the patients manifest the disease with either hemorrhage or inflammation. Diverticulitis may be uncomplicated or complicated by abscess formation, perforation with peritonitis, fistula, intestinal obstruction, or stricture. Controversy exists regarding the aggressiveness of diverticulitis during recurrent attacks of the disease as well as in special groups of patients including immunocompromised patients, young patients, and patients with right-sided disease. Clinical characteristics of symptomatic uncomplicated disease can be similar to irritable bowel syndrome, while acute diverticulitis is sometimes difficult to distinguish from segmental colitis associated with diverticulosis. The considerable clinical overlap between those entities with diverticular disease demonstrates that there are still areas of uncertainty in their physiopathology.
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Affiliation(s)
- N Symeonidis
- 2nd Propedeutical Department of Surgery, Medical School, Hippokratio General Hospital, Aristotle University of Thessaloniki, 49 Konstantinoupoleos str, PC, 54642 Thessaloniki, Greece.
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Myasoedova E, Matteson EL, Talley NJ, Crowson CS. Increased incidence and impact of upper and lower gastrointestinal events in patients with rheumatoid arthritis in Olmsted County, Minnesota: a longitudinal population-based study. J Rheumatol 2012; 39:1355-62. [PMID: 22467929 DOI: 10.3899/jrheum.111311] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To assess the incidence and mortality impact of upper and lower gastrointestinal (GI) events in rheumatoid arthritis (RA) compared to non-RA subjects. METHODS We identified incident upper and lower GI events and estimated their incidence rates using person-year methods in a population-based incident RA cohort of residents of Olmsted County, Minnesota, USA (1987 American College of Rheumatology criteria first fulfilled between January 1, 1980, and January 1, 2008) and non-RA subjects from the same population. RESULTS The study included 813 patients with RA and 813 non-RA subjects (mean followup 10.3 and 10.8 yrs, respectively); 68% women; mean age 55.9 yrs in both cohorts. The rate of upper GI events/100 person-years was 2.9 in RA versus 1.7 in the non-RA cohort (rate ratio 1.7, 95% CI 1.4, 2.2); for lower GI events, the rates were 2.1 in RA versus 1.4 in the non-RA cohort (rate ratio 1.5, 95% CI 1.1, 1.9). The incidence of upper GI bleed, perforation, ulcer, obstruction, and any upper GI event in RA declined over calendar time; the incidence of lower GI events remained unchanged. Exposure to glucocorticoids, prior upper GI disease, abdominal surgery, and smoking were associated with lower GI events in RA. Both upper and lower GI events were associated with increased mortality risk in RA. CONCLUSION There is increased risk of serious upper and lower GI events in RA compared to non-RA subjects, and increased GI-related mortality in RA. Prominent declines in incidence of upper, but not lower GI events in RA highlight the need for studies investigating lower GI disease in patients with RA.
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Affiliation(s)
- Elena Myasoedova
- Department of Health Sciences Research and Division of Rheumatology, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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Kaya B, Aras O, Bat O, Bulut NE, Memisoglu K. Steroid-induced sigmoid diverticular perforation in a patient with temporal arteritis: a rare clinical pathology. Clin Med Insights Pathol 2012; 5:11-4. [PMID: 22493565 PMCID: PMC3320117 DOI: 10.4137/cpath.s7924] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Corticosteroids are used in the treatment of many rheumatological diseases including temporal arteritis. The gastrointestinal perforation during corticosteroid treatment is a serious complication. Colon perforation after steroid use was first reported by Beck et al in 1950.1 Although the pathophysiological mechanism is not understood clearly, it is claimed that steroids probably by disturbing the intestinal mucosal barrier, facilitate the intestinal perforation. The long term treatment with corticosteroids increases the risk of colon perforation. We are presenting a patient who was taking corticosteroid due to temporal arteritis for two years and operated with sigmoid diverticular perforation.
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Affiliation(s)
- Bulent Kaya
- Fatih Sultan Mehmet Training and Research Hospital, Department of General Surgery, Istanbul, Turkey
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de Havenon A, Ehrenkranz J. A perforated diverticulum in Cushing's disease. Int J Surg Case Rep 2011; 2:215-7. [PMID: 22096731 DOI: 10.1016/j.ijscr.2011.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Accepted: 06/22/2011] [Indexed: 11/30/2022] Open
Abstract
We report a case of perforated colonic diverticulum in Cushing's disease. Although perforated diverticuli have been described in patients with Cushing's syndrome secondary to exogenous glucocorticoids, this complication has not been described in patients with Cushing's disease. Patients with hypercortisolism, from either exogenous or endogenous sources, should be monitored for diverticular perforation.
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Affiliation(s)
- Adam de Havenon
- Department of Neurology, University of Utah School of Medicine, 175 N Medical Drive East, Salt Lake City, UT 84132, United States
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Lower gastrointestinal perforation in rheumatoid arthritis patients treated with conventional DMARDs or tocilizumab: a systematic literature review. Clin Rheumatol 2011; 30:1471-4. [PMID: 21833686 DOI: 10.1007/s10067-011-1827-x] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Revised: 07/13/2011] [Accepted: 08/01/2011] [Indexed: 02/07/2023]
Abstract
Tocilizumab, a monoclonal antibody targeting the IL-6 receptor, has recently been added to the therapeutic armamentarium against rheumatoid arthritis (RA). Despite its overall safety, concerns have been raised regarding diverticular perforation in patients receiving the drug. The aim of our research was to document the incidence of diverticular disease in RA patients treated in the pre-disease-modifying anti-rheumatic drug (DMARD) era, following treatment with conventional DMARDs, and subsequent to tocilizumab therapy. We performed a systematic literature review in MEDLINE, EMBASE, Conference Proceedings Citation Index-Science, Cochrane Central Register of Controlled Trials and Current Controlled Trials up to Nov. 2010. The publication titles and abstracts were independently assessed by two reviewers for relevance and quality, and the review was conducted following guidelines from the Centre for Reviews and Dissemination. In the pre-DMARD period of RA management, where patients were largely treated with NSAIDs and corticosteroids, gastrointestinal (GI) complications were a substantial cause of mortality with diverticulitis and colonic ulcers accounting for almost a third of GI-related deaths. In contrast, our search did not reveal any evidence of diverticular perforation in patients treated with conventional DMARDs. Eighteen cases of lower GI perforation (16 of whom had diverticulitis) have been documented in recent conference proceedings following tocilizumab treatment in clinical trials, with a lower GI perforation rate of 1.9 per 1,000 patient years (PY). This lies between the reported rate of GI perforations for corticosteroids and anti-TNF-α agents in the United Health Care database, with rates of 3.9 per 1,000 PY (95% CI 3.1-4.8) and 1.3 per 1,000 PY (95% CI 0.8-1.9), respectively. The majority of these patients were concurrently prescribed NSAIDs and/or long-term corticosteroids. Traditional DMARD therapy for RA appears not only to have modified the risk of lower GI perforation but prevented it. The risk of diverticular perforation may be slightly higher in patients treated with tocilizumab compared with conventional DMARDs or anti-TNF agents, but lower than that for corticosteroids. The mechanism of action of IL-6 antagonism in the pathophysiology of diverticular perforation has yet to be elucidated.
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Multiple transverse colonic perforations associated with slow-release nonsteroidal anti-inflammatory drugs and corticosteroids: a case report. Case Rep Crit Care 2011; 2011:824639. [PMID: 24826325 PMCID: PMC4010013 DOI: 10.1155/2011/824639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2011] [Accepted: 06/22/2011] [Indexed: 11/17/2022] Open
Abstract
The patient was a 36-year-old woman with sarcoidosis and Sjogren's syndrome, and had been prescribed slow-release diclofenac sodium and prednisolone for the treatment of pain associated with uveitis and erythema nodosum. She was admitted to our emergency center with abdominal pain and distention. A chest X-ray showed free air under the diaphragm on both sides, and an emergency laparotomy was performed for suspected panperitonitis associated with intestinal perforation. Laparotomy revealed several perforations on the antimesenteric aspect of the transverse colon. The resected specimen showed 11 punched-out ulcerations, many of which were up to 10 mm in diameter. The microscopic findings were non-specific, with leukocytic infiltration around the perforations. She showed good postoperative recovery, as evaluated on day 42. The present case highlights the need for exercising caution while prescribing slow-release nonsteroidal anti-inflammatory drugs with corticosteroids to patients with autoimmune diseases, as such treatment may exacerbate intestinal epithelial abnormalities.
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Strate LL, Liu YL, Huang ES, Giovannucci EL, Chan AT. Use of aspirin or nonsteroidal anti-inflammatory drugs increases risk for diverticulitis and diverticular bleeding. Gastroenterology 2011; 140:1427-33. [PMID: 21320500 PMCID: PMC3081980 DOI: 10.1053/j.gastro.2011.02.004] [Citation(s) in RCA: 158] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Revised: 01/24/2011] [Accepted: 02/04/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, have been implicated in diverticular complications. We examined the influence of aspirin and NSAID use on risk of diverticulitis and diverticular bleeding in a large prospective cohort. METHODS We studied 47,210 US men in the Health Professionals Follow-up Study cohort who were 40-75 years old at baseline in 1986. We assessed use of aspirin, nonaspirin NSAIDs, and other risk factors biennially. We identified men with diverticulitis or diverticular bleeding based on responses to biennial and supplementary questionnaires. RESULTS We documented 939 cases of diverticulitis and 256 cases of diverticular bleeding during a 22-year period of follow-up evaluation. After adjustment for risk factors, men who used aspirin regularly (≥2 times/wk) had a multivariable hazard ratio (HR) of 1.25 (95% confidence interval [CI], 1.05-1.47) for diverticulitis and a HR of 1.70 (95% CI, 1.21-2.39) for diverticular bleeding, compared with nonusers of aspirin and NSAIDs. Use of aspirin at intermediate doses (2-5.9 standard, 325-mg tablets/wk) and frequency (4-6 days/wk) were associated with the highest risk of bleeding (multivariable HR, 2.32; 95% CI, 1.34-4.02, and multivariable HR, 3.13; 95% CI, 1.82-5.38, respectively). Regular users of nonaspirin NSAIDs also had an increased risk of diverticulitis (multivariable HR, 1.72; 95% CI, 1.40-2.11) and diverticular bleeding (multivariable HR, 1.74; 95% CI, 1.15-2.64), compared with men who denied use of these medications. CONCLUSIONS Regular use of aspirin or NSAIDs is associated with an increased risk of diverticulitis and diverticular bleeding. Patients at risk of diverticular complications should carefully consider the potential risks and benefits of using these medications.
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de Silva P, Pranesh N, Vautier G. Presentations of perforated colonic pathology in patients with polymyalgia rheumatica: two case reports. J Med Case Rep 2010; 4:299. [PMID: 20819228 PMCID: PMC2944188 DOI: 10.1186/1752-1947-4-299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Accepted: 09/06/2010] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Polymyalgia rheumatica is an increasingly common disease in older people, which gives rise to arthralgia and is mainly treated with corticosteroids. Patients in this age group also have a higher incidence of other co-morbidities including colonic pathology. Corticosteroid usage may mask signs of sepsis or complications secondary to intra-abdominal pathology, thereby delaying diagnosis and treatment, with eventual adverse outcome. These two cases highlight the importance of awareness and prompt recognition of this condition in order to avoid significant morbidity and mortality. CASE PRESENTATION CASE 1: A 73-year-old Caucasian woman with a diagnosis of polymyalgia presented with symptoms of an exacerbation in her right hip joint. Despite standard therapy with corticosteroids she failed to improve and started to develop features of widespread sepsis. Specific questioning revealed that, at the very onset of her symptoms, she had experienced mild diarrheal symptoms. Investigations revealed perforated diverticular disease with a peri-femoral abscess. CASE 2: A 69-year-old Caucasian woman with polymyalgia presented with left thigh pain and weakness associated with weight loss. A diagnosis of exacerbation of polymyalgia rheumatica was made and she was treated with corticosteroid therapy. Shortly afterwards she was admitted with generalized peritonitis. Laparotomy revealed a retroperitoneal abscess secondary to a perforated sigmoid colonic tumor. CONCLUSIONS Patients with polymyalgia may have perforated colonic diverticular disease which mimics their rheumatic pathology. In such cases steroid therapy, which is the mainstay of polymyalgia therapy, can be detrimental. Primary and hospital practitioners are encouraged to be vigilant regarding non-specific gastrointestinal symptoms and consider alternative diagnoses in those patients whose symptoms do not resolve with standard therapy, as this can lead to an overall better outcome.
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Affiliation(s)
- Punyanganie de Silva
- Department of Gastroenterology, James Paget University Hospital, Lowestoft Road, Great Yarmouth, NR31 6LA, UK.
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Pham T, Claudepierre P, Constantin A, de Bandt M, Fautrel B, Gossec L, Gottenberg JE, Goupille P, Guillaume S, Hachulla E, Masson C, Morel J, Puéchal X, Saraux A, Schaeverbeke T, Wendling D, Bruckert E, Pol S, Mariette X, Sibilia J. Tocilizumab: therapy and safety management. Joint Bone Spine 2010; 77 Suppl 1:S3-100. [PMID: 20610315 DOI: 10.1016/s1297-319x(10)70001-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To develop fact sheets about tocilizumab, in order to assist physicians in the management of patients with inflammatory joint disease. METHODS 1. selection by a committee of rheumatology experts of the main topics of interest for which fact sheets were desirable; 2. identification and review of publications relevant to each topic; 3. development of fact sheets based on three levels of evidence: evidence-based medicine, official recommendations, and expert opinion. The 20 experts were rheumatologists and invited specialists in other fields, and they had extensive experience with the management of RA. They were members of the CRI (Club Rhumatismes et Inflammation), a section of the Société Francaise de Rhumatologie. Each fact sheet was revised by several. experts and the overall process was coordinated by three experts. RESULTS Several topics of major interest were selected: contraindications of tocilizumab; the management of adverse effects and concomitant diseases that may develop during tocilizumab therapy; and the management of everyday situations such as pregnancy, surgery, and immunizations. After a review of the literature and discussions among experts, a consensus was developed about the content of the fact sheets presented here. These fact sheets focus on several points: Several topics of major interest were selected: contraindications of tocilizumab; the management of adverse effects and concomitant diseases that may develop during tocilizumab therapy; and the management of everyday situations such as pregnancy, surgery, and immunizations. After a review of the literature and discussions among experts, a consensus was developed about the content of the fact sheets presented here. These fact sheets focus on several points: 1. in RA, initiation and monitoring of tocilizumab therapy, management of patients with specific past histories, and specific clinical situations such as pregnancy; 2. diseases other than RA, such as juvenile idiopathic arthritis; 3. models of letters for informing the rheumatologist and general practitioner; 4. and patient information. CONCLUSION These tocilizumab fact sheets built on evidence-based medicine and expert opinion will serve as a practical tool for assisting physicians who manage patients on tocilizumab therapy. They will be available continuously at www.cri-net.com and updated at appropriate intervals.
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Affiliation(s)
- Thao Pham
- Service de Rhumatologie, CHU Conception, Marseille, France.
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Perforation of rectal diverticulum with amyloidosis secondary to rheumatoid arthritis: case report and review of the literature. Clin J Gastroenterol 2009; 3:30-5. [DOI: 10.1007/s12328-009-0132-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2009] [Accepted: 11/22/2009] [Indexed: 10/20/2022]
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