Improvement of cholestatic episodes in patients with benign recurrent intrahepatic cholestasis (BRIC) treated with rifampicin. A long-term follow-up

OBJECTIVE

Patients with benign recurrent intrahepatic cholestasis (BRIC) suffer from recurrent episodes of cholestatic jaundice. Treatment options remain limited and are mainly symptomatic. In case reports rifampicin, plasmapheresis, and nasobiliary drainage have been reported to be effective. In this case series, we present long-term experience indicating disease-modifying effects of non-invasive treatment with rifampicin for recurrent cholestasis in BRIC type 1 (BRIC1).

MATERIALS AND METHODS

We included all adult BRIC1 patients diagnosed and followed up at a single centre in Bergen, Norway. Data regarding clinical and biochemical features during BRIC attacks with and without rifampicin treatment were retrieved from medical journals and a data registry.

RESULTS

Five males with BRIC1 were included. Median age at diagnosis was 22 years (range 15-41). Together they had suffered from 65 cholestatic attacks (including four documented abortive attacks). Twenty-eight attacks were treated with rifampicin alone over the last 12 years; all cases showed symptomatic relief and reduction in the levels of bilirubin and alkaline phosphatase in blood. The attacks treated with rifampicin seemed to have shorter duration and were less likely to result in complications or hospitalization compared to attacks prior to the introduction of rifampicin. No side effects attributable to rifampicin were noted.

CONCLUSIONS

Episodic treatment of recurrent BRIC1 attacks with rifampicin seems to ameliorate severity and shorten the duration of attacks. Timely diagnosis and effective treatment are of major importance in BRIC, not only to decrease complications but also improving patients' quality of life.

Drug-induced esophageal injuries with an atypical presentation mimicking acute coronary syndrome

Background

Pill-induced esophageal injury may cause severe complications if not diagnosed in a timely fashion. The condition is under-recognized and under-reported, and some patients present with atypical clinical or endoscopic features mimicking other common conditions. If the diagnosis is missed the patient will continue to take the offending drug, potentially worsening the illness. We present a case in which acute coronary syndrome was the initial working diagnosis leading to a delay in diagnosis of doxycycline-induced esophageal injury. The patient developed multiple esophageal ulcers and hemorrhage.

Case presentation

A 50-year-old male driver with a history of hypertension and dyslipidemia was brought to the emergency department with complaints of severe retrosternal chest pain, vomiting, diaphoresis and syncope. On initial evaluation, acute coronary syndrome was considered due to the clinical presentation and history of cardiovascular risk factors. Electrocardiogram and serum troponins were normal. On the second day of his admission, the patient developed odynophagia and bloody vomitus. Esophagogastroduodenoscopy revealed extensive esophageal ulcerations with hemorrhage. The patient was taking Doxycycline capsules for an acute febrile illness. Doxycycline is the oral medication most commonly reported to cause esophageal injury. Doxycycline was discontinued, and the patient was treated with intravenous omeprazole and oral antacid suspension. The patient improved, was discharged after 6 days of hospitalization, and reported resolution of all symptoms at an outpatient follow-up visit 3 weeks later.

Conclusion

Medication-induced esophageal injury can present with atypical symptoms mimicking acute coronary syndrome. This condition should be included in the initial differential diagnosis of patients presenting with acute chest pain, especially those taking oral medications known to cause esophageal injury.

Benign recurrent intrahepatic cholestasis: review and long-term follow-up of five cases

OBJECTIVE

Benign recurrent intrahepatic cholestasis (BRIC) is a rare autosomal recessive inherited disorder characterized by intermittent episodes of cholestatic jaundice. For the patients, the disease is a physical and psychological challenge. There is no curable treatment, but symptomatic relief is described following treatment with rifampicin or plasmapheresis.

MATERIAL AND METHODS

Five patients suffering from BRIC followed up for 17 years by one consultant are described. Two patients were treated with rifampicin and plasmapheresis, two with rifampicin alone, and one with plasmapheresis.

RESULTS

The treatments showed symptomatic relief, effect on biochemical parameters, and earlier clinical remission compared with no treatment or treatment with other substances like cholestyramine, antihistamines, and ursodeoxycholic acid.

CONCLUSIONS

Both rifampicin and plasmapheresis represent important therapeutic options of acute cholestatic attacks in patients with BRIC. As a noninvasive treatment, rifampicin may be the first choice.

High dose ursodeoxycholic acid in primary sclerosing cholangitis does not prevent colorectal neoplasia

BACKGROUND

Patients with primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD) have a high risk of developing colorectal cancer and dysplasia. Ursodeoxycholic acid (UDCA) has been suggested to have chemopreventive effects on the development of colorectal cancer and dysplasia but long-term data and larger trials are lacking.

AIM

To evaluate the effect of high dose (17-23 mg/kg/day) UDCA on colorectal neoplasia in a cohort of patients with PSC and IBD.

METHODS

From our previous 5-year randomised controlled trial of UDCA vs. placebo in PSC, we performed a follow-up of 98 patients with concomitant IBD from entry of the trial 1996-1997 until 2009 for development of colorectal cancer or dysplasia.

RESULTS

The total follow-up time was 760 person-years. Dysplasia/cancer-free survival was compared between placebo- (n = 50) and UDCA-treated (n = 48) patients. There was a similar frequency of dysplasia or cancer after 5 years between patients originally assigned to UDCA or placebo (13% vs. 16%) and no difference in dysplasia/cancer-free survival (P = 0.46, log rank test). At the end of 2009 no difference in cancer-free survival was detected, 30% of the placebo patients compared with 27% of UDCA patients had developed colorectal cancer or dysplasia.

CONCLUSIONS

Long-term high dose ursodeoxycholic acid does not prevent colorectal cancer or dysplasia in patients with primary sclerosing cholangitis-associated inflammatory bowel disease.

Sonography of the small intestine

In the last two decades, there has been substantial development in the diagnostic possibilities for examining the small intestine. Compared with computerized tomography, magnetic resonance imaging, capsule endoscopy and double-balloon endoscopy, ultrasonography has the advantage of being cheap, portable, flexible and user- and patient-friendly, while at the same time providing the clinician with image data of high temporal and spatial resolution. The method has limitations with penetration in obesity and with intestinal air impairing image quality. The flexibility ultrasonography offers the examiner also implies that a systematic approach during scanning is needed. This paper reviews the basic scanning techniques and new modalities such as contrast-enhanced ultrasound, elastography, strain rate imaging, hydrosonography, allergosonography, endoscopic sonography and nutritional imaging, and the literature on disease-specific findings in the small intestine. Some of these methods have shown clinical benefit, while others are under research and development to establish their role in the diagnostic repertoire. However, along with improved overall image quality of new ultrasound scanners, these methods have enabled more anatomical and physiological changes in the small intestine to be observed. Accordingly, ultrasound of the small intestine is an attractive clinical tool to study patients with a range of diseases.

High-dose ursodeoxycholic acid in primary sclerosing cholangitis: a 5-year multicenter, randomized, controlled study

BACKGROUND & AIMS

There is no medical treatment of proven benefit for primary sclerosing cholangitis. This study aimed at studying the effect of a higher dose of ursodeoxycholic acid than previously used on survival, symptoms, biochemistry, and quality of life in this disease.

METHODS

A randomized placebo-controlled study was performed in tertiary and secondary gastroenterology units. A total of 219 patients were randomized to 17 to 23 mg/kg body weight per day of ursodeoxycholic acid (n = 110) or placebo (n = 109) for 5 years. Follow-up data are available from 97 patients randomized to ursodeoxycholic acid and for 101 randomized to placebo. Quality of life was assessed by using the Medical Outcomes Study 36-item Short-Form Health Survey.

RESULTS

The combined end point "death or liver transplantation" occurred in 7 of 97 (7.2%) patients in the ursodeoxycholic acid group vs 11 of 101 (10.9%) patients in the placebo group (P = .368; 95% confidence interval, -12.2% to 4.7%). The occurrence of liver transplantation as a single end point showed a similar positive trend for ursodeoxycholic acid treatment (5/97 [5.2%] vs 8/101 [7.9%]; 95% confidence interval, -10.4% to 4.6%). Three ursodeoxycholic acid and 4 placebo patients died from cholangiocarcinoma, and 1 placebo patient died from liver failure. Alkaline phosphatase and alanine aminotransferase tended to decrease during the first 6 months. There were no differences between the 2 groups in symptoms or quality of life. Analyses of serum ursodeoxycholic acid concentration gave no evidence that noncompliance may have influenced the results.

CONCLUSIONS

This study found no statistically significant beneficial effect of a higher dose of ursodeoxycholic acid than previously used on survival or prevention of cholangiocarcinoma in primary sclerosing cholangitis.

Endosonography-guided endoscopic band ligation of Dieulafoy's malformation: a case report

Dieulafoy's vascular malformation may cause serious upper gastrointestinal hemorrhage. The mucosal lesion is usually small, and precise location of the lesion may therefore be difficult. We report a case of Dieulafoy's lesion successfully treated by endoscopic band ligation (EBL) where endoscopic ultrasonography (EUS), including Doppler examination, was applied for accurate diagnosis, guiding EBL and control of treatment.

Relationship between intestinal permeability and calprotectin concentration in gut lavage fluid

BACKGROUND

Calprotectin is released from neutrophils and monocytes, and increased calprotectin levels in stool may serve as a marker of intestinal inflammation. Intestinal permeability is increased in inflammatory bowel diseases, especially in Crohn disease. We studied the relationship between intestinal permeability and calprotectin concentration in intestinal lavage fluid in patients with known or suspected inflammatory bowel disease (IBD).

METHODS

Thirty-eight patients were examined; 17 had Crohn disease; 3, ulcerative colitis; and 18, irritable bowel syndrome. Intestinal lavage was performed by means of a nasojejunal tube positioned by gastroduodenoscopy. By means of a peristaltic pump 2 l isotonic polyethylene glycol solution (MW, 3350) containing 50 microCi 51Cr-labelled ethylenediaminetetraacetic acid (EDTA) were administered through the tube over a period of 40 min. The first clear fluid passed per rectum was collected and analysed for calprotectin levels with an enzyme-linked immunosorbent assay method. Urine was collected for 5 h and analysed for gamma radioactivity. 51Cr-EDTA excretion in urine was expressed as percentage of dose administered (that is, intestinal permeability).

RESULTS

Both intestinal permeability and calprotectin concentration were significantly higher in patients with IBD than in patients with functional conditions. In Crohn disease the values depended on disease activity but not on whether the disease was located in the small or in the large bowel. There was a highly significant correlation between calprotectin concentration in gut lavage fluid and intestinal permeability (r=0.79, P<0.0001).

CONCLUSION

The significant correlation between calprotectin concentration in gut lavage fluid and intestinal permeability supports the view that increased intestinal permeability in IBD might, at least in part, be a consequence of increased transepithelial migration of neutrophils.

Hydrosonography of the small intestine: comparison with radiologic barium study

BACKGROUND

Transabdominal ultrasonography of the small intestine is hampered by luminal gas. We have developed a new sonographic method (hydrosonography) that largely eliminates the gas problem and have compared this method with radiologic barium study.

METHODS

Fifty-six patients admitted for X-ray examination of the small bowel because of abdominal pain, diarrhoea, weight loss and/or known inflammatory bowel disease were examined. To remove luminal gas before performing transabdominal ultrasonography, 21 of polyethylene glycol solution was inserted through a nasojejunal tube by means of a peristaltic pump. Wall thickness, peristalsis, luminal narrowing, prestenotic dilatation, and extraintestinal complications were recorded.

RESULTS

On ultrasonography we were able to visualize the terminal part of the ileum in 98% of the patients. Perfect agreement between hydrosonography and barium studies was seen in 50 of 55 patients. However, 44 patients had normal findings on both examinations. The sensitivity and specificity of hydrosonography were 64% and 100%, respectively. The positive predictive value was 100%. For X-ray examination sensitivity and specificity were 91% and 100%, respectively. Four patients with minor mucosal abnormalities or pathologic findings in the upper part of the small intestine accounted for the relatively low overall sensitivity found for hydrosonography compared with roentgenography. However, important extraintestinal complications were disclosed by ultrasound.

CONCLUSIONS

Hydrosonography of the small bowel is a new, convenient, and reliable method for examining the lower part of the small intestine. However, it cannot replace barium studies in patients with mucosal abnormalities. especially in the upper part of the small bowel.