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Abstract
Abstract
We present the case of a 66–year–old patient suffering from metastatic kidney cancer who came to the emergency room complaining of dyspnea. 10 days prior to the event, the patient had received the last administration of chemotherapy which consisted of the combination of pembrolizumab (a monoclonal antibody) and axitinib (a tyrosine kinase inhibitor). The cardiological checks carried out up to that moment had not shown changes in the heart. In the emergency room ECG showed the presence of a sinus rhythm with a complete block of the right branch and no signs of ischemia were evident; blood chemistry tests showed an increase in troponin and BNP values. Echocardiography showed moderate left ventricular dysfunction. Therapy with diuretics, beta–blockers and Ras inhibitors was initiated which allowed for rapid resolution of symptoms. At a follow–up five days later the patient presented asymptomatic but with diffuse inversion of the T waves, a new elevation of troponin and more surprisingly the echo showed, in the presence of moderate left ventricular dysfunction, a mobile formation at the level of the apex of the left ventricle. Unfractionated heparin therapy was initiated since, on the basis of echocardiographic characteristics, the diagnosis appeared to be that of thrombosis and chemotherapy was suspended. In the following days the echo did not reveal any modification of the neoformation therefore in consideration of the characteristics (size and high degree of mobility) and of the oncological prognosis of more than one year we decided to initiate the patient to cardiac surgery for the removal operation. The histological analysis of the neoformation confirmed the thrombotic nature. Repeated echocardiography 15 days after surgery showed an almost complete recovery of the ejection fraction. To our knowledge, tyrosine kinase inhibitors can cause ventricular dysfunction (apoptosis) but, in general, it is not an acute event. Pembrolizumab has caused cases of acute myocarditis requiring discontinuation of therapy. As for the origin of the thrombosis the causes are not clear, it could be an effect of left ventricular dysfunction for myocarditis but it cannot be excluded that it is secondary to the use of one or both chemotherapy drugs.
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Sangiovanni A, Alimenti E, Gattai R, Filomia R, Parente E, Valenti L, Marzi L, Pellegatta G, Borgia G, Gambato M, Terreni N, Serio I, Belli L, Oliveri F, Maimone S, Brunacci M, D'Ambrosio R, Forzenigo LV, Russo FP, Rumi M, Barone M, Fracanzani AL, Raimondo G, Giannini EG, Brunetto MR, Villa E, Biganzoli E, Colombo M, Lampertico P. Undefined/non-malignant hepatic nodules are associated with early occurrence of HCC in DAA-treated patients with HCV-related cirrhosis. J Hepatol 2020; 73:593-602. [PMID: 32243959 DOI: 10.1016/j.jhep.2020.03.030] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIM An unexpected early increase in incidence, recurrence and clinical aggressiveness of hepatocellular carcinoma (HCC) has been reported (and refuted) in patients with HCV-related cirrhosis following direct-acting antiviral (DAA) treatment. To address this controversy, we performed a prospective multicenter study on consecutively enrolled cirrhotic patients, with or without a history of HCC, undergoing DAA therapy. PATIENTS AND METHODS A total of 1,161 HCC-free cirrhotics (group 1) and 124 cirrhotics who had received a curative treatment for an HCC (group 2) were enrolled. Clinical features, including presence of undefined/non-malignant liver nodules (UNMNs), were analyzed with respect to HCC incidence and recurrence. RESULTS During a median study time of 17 months in group 1 and 16 months in group 2, de novo HCC developed in 48 patients (yearly incidence 3.1/100 patient-years, 75% BCLC 0-A) and recurred in 40 (mean yearly incidence 29.9/100 patient-years, 83% BCLC 0-A). A peak of HCC instant incidence was observed at 4.2 months in group 1 patients with UNMNs, and at 7.7 months in group 2. By multivariable Cox regression models, UNMNs (hazard ratio [HR] 3.11; 95% CI 1.47-6.57: p = 0.003), ascites detected any time before enrolment (HR 3.04; 95% CI 1.23-7.51; p = 0.02), and alpha-fetoprotein log-value (HR 1.90; 95% CI 1.05-3.44; p = 0.03) were the variables independently associated with the incidence of de novo HCC, while history of alcohol abuse (HR 2.10; 95% CI 1.08-4.09; p = 0.03) and history of recurrence of HCC (HR 2.87; 95% CI 1.35-6.09; p = 0.006) were associated with HCC recurrence. CONCLUSION An early high incidence of both de novo HCC, in patients with UNMNs, and recurrent HCC was observed in DAA-treated patients; this was not accompanied by increased tumor aggressiveness. LAY SUMMARY This prospective study focuses on the risk of developing de novo or recurrent hepatocellular carcinoma (HCC) after direct-acting antiviral (DAA) treatment in patients with hepatitis C-related cirrhosis. We found that DAA treatment was associated with an early high HCC incidence in patients with undefined or non-malignant nodules, as well as in those with a history of complete response to HCC treatment. Whether this is related to the presence of clinically undetectable nests of cancer cells or to precancerous lesions that may progress to overt HCC upon DAA treatment remains unanswered. No evidence of increased clinical aggressiveness was reported in de novo or recurrent HCC.
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Affiliation(s)
- Angelo Sangiovanni
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico - Division of Gastroenterology and Hepatology - CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan, Italy.
| | - Eleonora Alimenti
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico - Division of Gastroenterology and Hepatology - CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan, Italy
| | - Riccardo Gattai
- Hepatology Unit and Laboratory of Molecular Genetics and Pathology of Hepatitis Viruses, University Hospital of Pisa, Pisa, Italy
| | - Roberto Filomia
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy
| | - Elisabetta Parente
- Gastroenterology Unit, Department of Emergency and Organ Transplantation (D.E.T.O.), University of Bari, Bari, Italy
| | - Luca Valenti
- Internal Medicine and Metabolic Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Luca Marzi
- Gastroenterology Unit, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Gaia Pellegatta
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Guglielmo Borgia
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples 'Federico II', Naples, Italy
| | - Martina Gambato
- Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy
| | | | - Ilaria Serio
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Luca Belli
- UOC Epatologia e Gastroenterologia, Ospedale Niguarda, Milan, Italy
| | - Filippo Oliveri
- Hepatology Unit and Laboratory of Molecular Genetics and Pathology of Hepatitis Viruses, University Hospital of Pisa, Pisa, Italy
| | - Sergio Maimone
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy
| | - Matteo Brunacci
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Roberta D'Ambrosio
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico - Division of Gastroenterology and Hepatology - CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan, Italy
| | | | - Francesco Paolo Russo
- Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Mariagrazia Rumi
- Division of Hepatology, Ospedale San Giuseppe, Università degli Studi di Milano, Milan, Italy
| | - Michele Barone
- Gastroenterology Unit, Department of Emergency and Organ Transplantation (D.E.T.O.), University of Bari, Bari, Italy
| | - Anna Ludovica Fracanzani
- Internal Medicine and Metabolic Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Giovanni Raimondo
- Division of Clinical and Molecular Hepatology, University Hospital of Messina, Messina, Italy
| | | | - Maurizia Rossana Brunetto
- Hepatology Unit and Laboratory of Molecular Genetics and Pathology of Hepatitis Viruses, University Hospital of Pisa, Pisa, Italy; Internal Medicine, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Erica Villa
- Gastroenterology Unit, Azienda Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy
| | - Elia Biganzoli
- Department of Clinical Sciences and Community Health & DSRC, University of Milan, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Massimo Colombo
- Center of Translational Research in Hepatology, Humanitas Hospital, Rozzano, Italy
| | - Pietro Lampertico
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico - Division of Gastroenterology and Hepatology - CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Crespi M, Demarzo MG, Brunacci M, Pellegatta G, Ferrando F, Ballestrero A, Grillo F, Savarino V, Giannini EG. Improvement in Waldenström's Macroglobulinemia after Successful Treatment of HCV with Direct-acting Antivirals. Ann Hepatol 2018; 17:1072-1077. [PMID: 30600285 DOI: 10.5604/01.3001.0012.7208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Chronic hepatitis C (HCV) virus infection may be associated with several non-hepatic manifestations, mainly driven by chronic immune stimulation, such as mixed cryoglobulinemia and Non-Hodgkin's Lymphoma. This association has been proved by several meta-analyses and some interventional studies demonstrating that antiviral treatment may be effective in inducing HCV-associated lymphoma regression. The recent advent of direct acting antivirals (DAAs) in the therapeutic armamentarium of HCV infection made possible treatment of patients with advanced liver disease. Here we report on a rare association of a cirrhotic patient with HCV and Waldenström's Macroglobulinemia with severe cryoglobulinemia, who had already failed an interferon-based antiviral regimen, whose haematologic disease was ameliorated by HCV eradication following treatment with sofosbuvir and simeprevir with ribavirin, and where successful treatment was accompanied also by consistent improvement in liver function and parameters of portal hypertension.
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Affiliation(s)
- Mattia Crespi
- Gastroenterology Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Maria Giulia Demarzo
- Gastroenterology Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Matteo Brunacci
- Gastroenterology Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Gaia Pellegatta
- Gastroenterology Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Fabio Ferrando
- Internal Medicine and Oncology Unit, Department of Internal Medicine, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Alberto Ballestrero
- Internal Medicine and Oncology Unit, Department of Internal Medicine, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Federica Grillo
- Pathology Unit, Department of Surgical Sciences, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Vincenzo Savarino
- Gastroenterology Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Edoardo G Giannini
- Gastroenterology Unit, Ospedale Policlinico San Martino, IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
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Carbone F, Bodini G, Brunacci M, Bonaventura A, Vecchiè A, Liberale L, Crespi M, Baldissarro I, Dallegri F, Savarino V, Montecucco F, Giannini EG. Reduction in TIMP-2 serum levels predicts remission of inflammatory bowel diseases. Eur J Clin Invest 2018; 48:e13002. [PMID: 30011062 DOI: 10.1111/eci.13002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 07/15/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Growing evidence indicates tissue inhibitors of matrix metalloproteinases (TIMPs) as potential players in inflammatory bowel disease (IBD), but, no prospective data are available in IBD remission/relapse. MATERIAL & METHODS In this prospective pilot study, a cohort of IBD patients (n = 32) was enrolled and treated with monoclonal anti-TNF-α antibodies. Patients were clinically followed up for a median period of 54 weeks. Serum circulating levels of C-reactive protein (CRP), TIMP-1 and -2, matrix metalloproteinase (MMP)-9 and -8, myeloperoxidase (MPO) and neutrophil elastase (NE) were assessed by ELISA at enrolment and at the end of the treatment. RESULTS The percentage (%) TIMP-2 reduction from baseline to end of treatment was independently associated with IBD remission at the end of treatment and follow-up as well. ROC curve analysis further confirmed the good prognostic accuracy of % TIMP-2 reduction over the treatment period. Conversely, no other change in inflammatory molecule concentrations was able to predict short- or long-term IBD remission. CONCLUSIONS This study indicates TIMP-2 reduction during IBD treatment with monoclonal anti-TNF-α antibodies as a potential prognostic parameter of short and long term remission. To understand if TIMP-2 is an innocent biomarker or an active pathophysiological factor in IBD remains to be clarified.
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Affiliation(s)
- Federico Carbone
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Giorgia Bodini
- Division of Gastroenterology Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Matteo Brunacci
- Division of Gastroenterology Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Aldo Bonaventura
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Alessandra Vecchiè
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Luca Liberale
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Mattia Crespi
- Division of Gastroenterology Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Isabella Baldissarro
- Division of Gastroenterology Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Franco Dallegri
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy.,Ospedale Policlinico San Martino, Genoa, Italy
| | - Vincenzo Savarino
- Division of Gastroenterology Department of Internal Medicine, University of Genoa, Genoa, Italy.,Ospedale Policlinico San Martino, Genoa, Italy
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy.,Ospedale Policlinico San Martino, Genoa, Italy.,Centre of Excellence for Biomedical Research (CEBR), University of Genoa, Genoa, Italy
| | - Edoardo G Giannini
- Division of Gastroenterology Department of Internal Medicine, University of Genoa, Genoa, Italy.,Ospedale Policlinico San Martino, Genoa, Italy
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Bodini G, Giannini EG, Savarino V, Del Nero L, Lo Pumo S, Brunacci M, De Bortoli N, Jain A, Tolone S, Savarino E. Infliximab trough levels and persistent vs transient antibodies measured early after induction predict long-term clinical remission in patients with inflammatory bowel disease. Dig Liver Dis 2018; 50:452-456. [PMID: 29274766 DOI: 10.1016/j.dld.2017.11.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 11/16/2017] [Accepted: 11/16/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND The use of therapeutic drug monitoring has been proposed as a useful tool in the management of patients with loss of response to biological therapy in patients with inflammatory bowel disease. AIMS To evaluate whether early, post-induction anti-tumor necrosis factor trough levels and the presence of different types of anti-drug antibodies may impact long-term clinical remission in patients with inflammatory bowel disease. METHODS We prospectively assessed anti-tumor necrosis factor trough levels and both persistent and transient anti-drug antibodies. The Harvey-Bradshaw Index and the partial Mayo score were evaluated at each visit or in case of relapse. RESULTS At week 14, median infliximab trough levels were significantly lower in patients who experienced loss of response at week 48 as compared to patients in stable remission (1.3mcg/mL [range 0-10.2mcg/mL] vs. 10.1mcg/mL[range 0-42.8mcg/mL], P<0.0004). ROC curve identified an infliximab trough levels of 6.2mcg/mL as the cut-off value with the highest accuracy (c-index=0.864) for loss of response at week 48. At week 14 we observed a correlation between anti-drug antibodies concentration and infliximab trough levels (rs=-0.513, P=0.04). CONCLUSIONS The results highlight the usefulness of assessing early biological TL in order to predict patients' long-term outcome.
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Affiliation(s)
- Giorgia Bodini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy.
| | - Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Vincenzo Savarino
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Lorenzo Del Nero
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Sara Lo Pumo
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Matteo Brunacci
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Nicola De Bortoli
- Gastroenterology Unit, Department of Internal Medicine, University of Pisa, Pisa, Italy
| | - Anjali Jain
- Department of Research and Development, Prometheus Laboratories Inc., San Diego, CA, USA
| | - Salvatore Tolone
- Department of Surgery, Second University of Naples, Naples, Italy
| | - Edoardo Savarino
- Gastroenterolgy Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
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Giannini EG, Bucci L, Garuti F, Brunacci M, Lenzi B, Valente M, Caturelli E, Cabibbo G, Piscaglia F, Virdone R, Felder M, Ciccarese F, Foschi FG, Sacco R, Svegliati Baroni G, Farinati F, Rapaccini GL, Olivani A, Gasbarrini A, Di Marco M, Morisco F, Zoli M, Masotto A, Borzio F, Benvegnù L, Marra F, Colecchia A, Nardone G, Bernardi M, Trevisani F. Patients with advanced hepatocellular carcinoma need a personalized management: A lesson from clinical practice. Hepatology 2018; 67:1784-1796. [PMID: 29159910 DOI: 10.1002/hep.29668] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 09/22/2017] [Accepted: 11/15/2017] [Indexed: 12/21/2022]
Abstract
UNLABELLED The Barcelona Clinic Liver Cancer (BCLC) advanced stage (BCLC C) of hepatocellular carcinoma (HCC) includes a heterogeneous population, where sorafenib alone is the recommended treatment. In this study, our aim was to assess treatment and overall survival (OS) of BCLC C patients subclassified according to clinical features (performance status [PS], macrovascular invasion [MVI], extrahepatic spread [EHS] or MVI + EHS) determining their allocation to this stage. From the Italian Liver Cancer database, we analyzed 835 consecutive BCLC C patients diagnosed between 2008 and 2014. Patients were subclassified as: PS1 alone (n = 385; 46.1%), PS2 alone (n = 146; 17.5%), MVI (n = 224; 26.8%), EHS (n = 51; 6.1%), and MVI + EHS (n = 29; 3.5%). MVI, EHS, and MVI + EHS patients had larger and multifocal/massive HCCs and higher alpha-fetoprotein (AFP) levels than PS1 and PS2 patients. Median OS significantly declined from PS1 (38.6 months) to PS2 (22.3 months), EHS (11.2 months), MVI (8.2 months), and MVI + EHS (3.1 months; P < 0.001). Among MVI patients, OS was longer in those with peripheral than with central (portal trunk) MVI (11.2 vs. 7.1 months; P = 0.005). The most frequent treatments were: curative approaches in PS1 (39.7%), supportive therapy in PS2 (41.8%), sorafenib in MVI (39.3%) and EHS (37.3%), and best supportive care in MVI + EHS patients (51.7%). Independent prognostic factors were: Model for End-stage Liver Disease score, Child-Pugh class, ascites, platelet count, albumin, tumor size, MVI, EHS, AFP levels, and treatment type. CONCLUSION BCLC C stage does not identify patients homogeneous enough to be allocated to a single stage. PS1 alone is not sufficient to include a patient into this stage. The remaining patients should be subclassified according to PS and tumor features, and new patient-tailored therapeutic indications are needed. (Hepatology 2018;67:1784-1796).
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Affiliation(s)
- Edoardo Giovanni Giannini
- Department of Internal Medicine, Gastroenterology Unit, San Martino Polyclinic, University of Genova, Genova, Italy
| | - Laura Bucci
- Department of Medical and Surgical Sciences, Semeiotica Medica Unit, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Francesca Garuti
- Department of Medical and Surgical Sciences, Semeiotica Medica Unit, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Matteo Brunacci
- Department of Internal Medicine, Gastroenterology Unit, San Martino Polyclinic, University of Genova, Genova, Italy
| | - Barbara Lenzi
- Department of Medical and Surgical Sciences, Semeiotica Medica Unit, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Matteo Valente
- Department of Medical and Surgical Sciences, Semeiotica Medica Unit, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Eugenio Caturelli
- Operative Unit of Gastroenterology, Belcolle Hospital, Viterbo, Italy
| | - Giuseppe Cabibbo
- Biomedical Department of Internal and Specialistic Medicine, Gastroenterology, Palermo, Italy
| | - Fabio Piscaglia
- Department of Medical and Surgical Sciences, Internal Medicine Unit, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Roberto Virdone
- Biomedical Department of Internal and Specialistic Medicine, Internal Medicin 2 Unit, Villa Sofia Hospital Agency Riuniti Hospitals-Cervello, Palermo, Italy
| | - Martina Felder
- Gastroenterology, Physiopathology and Digestive Endoscopy, Central Hospital of Bolzano, Bolzano, Italy
| | | | | | - Rodolfo Sacco
- Gastroenterology and Metabolic Diseases Unit, Hospital-University Agency of Pisa, Pisa, Italy
| | | | - Fabio Farinati
- Department of Surgical and Gastroenterological Sciences, Gastroenterology, University of Padova, Italy
| | | | - Andrea Olivani
- Department of Oncohematology and Internal Medicine, Infection diseases and Hepatology Unit, Parma, Italy
| | - Antonio Gasbarrini
- Internal Medicine and Gastroenterology Unit-Gemelli, Department of Internal Medicine, Rome, Italy
| | - Maria Di Marco
- Medicine Division, Bolognini Hospital Agency, Seriate, Italy
| | - Filomena Morisco
- Gastroenterology Unit, Department of Clinical and Sperimental Medicine, Naples, Italy
| | - Marco Zoli
- Department of Medical and Surgical Sciences, Zoli Internal Medicine, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Alberto Masotto
- Gastroenterology, Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Franco Borzio
- Department of Internal Medicine and Hepatology, Fatebenefratelli Hospital, Milan, Italy
| | - Luisa Benvegnù
- Department of Molecular Medicine, University of Padova, Padova, Italy
| | - Fabio Marra
- Internal Medicine and Hepatology, Department of Sperimental and Clinical Medicine, Florence, Italy
| | - Antonio Colecchia
- Department of Medical and Surgical Sciences, Gastroenterology Unit, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Gerardo Nardone
- Department of Clinical and Surgical Medicine-Federico II University, Naples, Italy
| | - Mauro Bernardi
- Department of Medical and Surgical Sciences, Semeiotica Medica Unit, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Franco Trevisani
- Department of Medical and Surgical Sciences, Semeiotica Medica Unit, Alma Mater Studiorum-University of Bologna, Bologna, Italy
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Savarino E, Zentilin P, Marabotto E, Pellegatta G, Coppo C, Brunacci M, Dulbecco P, Savarino V. Drugs for improving esophageal mucosa defense: where are we now and where are we going? Ann Gastroenterol 2017; 30:585-591. [PMID: 29118552 PMCID: PMC5670277 DOI: 10.20524/aog.2017.0187] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 07/24/2017] [Indexed: 12/12/2022] Open
Abstract
In the past, the attention of physiologists and doctors has been mainly focused on the key role of acid in the pathogenesis of gastroesophageal reflux disease (GERD), but increasing evidence that 20-40% of reflux patients respond not at all or only partially to proton pump inhibitors (PPIs) has underlined the concept that factors other than acid are implicated in its development and the elicitation of symptoms. Among these, impaired mucosal integrity, particularly in most patients with non-erosive reflux disease, has recently been reincluded and the reinforcement of defensive mechanisms and/or its protection has been reappointed as a renewed therapeutic target for the management of GERD patients. In this review we will summarize the existing knowledge of the old and novel compounds able to produce this therapeutic effect, including sucralfate, alginate-based drugs, and a new medical device consisting of hyaluronic acid and chondroitin sulfate dispersed in a bioadhesive carrier, together with the potential indications for their use. It is to be stressed, however, that, although these compounds may represent a real alternative to PPI therapy in GERD, the combination of mucosal protection with acid suppression may help manage many cases with a partial or unsatisfactory response to PPIs alone.
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Affiliation(s)
- Edoardo Savarino
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua (Edoardo Savarino), Italy
| | - Patrizia Zentilin
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa, Genoa (Patrizia Zentillin, Elisa Marabotto, Gaia Pellegatta, Claudia Coppo, Matteo Brunacci, Pietro Dulbecco, Vincenzo Savarino), Italy
| | - Elisa Marabotto
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa, Genoa (Patrizia Zentillin, Elisa Marabotto, Gaia Pellegatta, Claudia Coppo, Matteo Brunacci, Pietro Dulbecco, Vincenzo Savarino), Italy
| | - Gaia Pellegatta
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa, Genoa (Patrizia Zentillin, Elisa Marabotto, Gaia Pellegatta, Claudia Coppo, Matteo Brunacci, Pietro Dulbecco, Vincenzo Savarino), Italy
| | - Claudia Coppo
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa, Genoa (Patrizia Zentillin, Elisa Marabotto, Gaia Pellegatta, Claudia Coppo, Matteo Brunacci, Pietro Dulbecco, Vincenzo Savarino), Italy
| | - Matteo Brunacci
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa, Genoa (Patrizia Zentillin, Elisa Marabotto, Gaia Pellegatta, Claudia Coppo, Matteo Brunacci, Pietro Dulbecco, Vincenzo Savarino), Italy
| | - Pietro Dulbecco
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa, Genoa (Patrizia Zentillin, Elisa Marabotto, Gaia Pellegatta, Claudia Coppo, Matteo Brunacci, Pietro Dulbecco, Vincenzo Savarino), Italy
| | - Vincenzo Savarino
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa, Genoa (Patrizia Zentillin, Elisa Marabotto, Gaia Pellegatta, Claudia Coppo, Matteo Brunacci, Pietro Dulbecco, Vincenzo Savarino), Italy
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Savarino E, Marabotto E, Bodini G, Pellegatta G, Coppo C, Giambruno E, Brunacci M, Zentilin P, Savarino V. Epidemiology and natural history of gastroesophageal reflux disease. Minerva Gastroenterol (Torino) 2017; 63:175-183. [PMID: 28215067 DOI: 10.23736/s1121-421x.17.02383-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Gastroesophageal reflux disease (GERD) is highly prevalent in Western countries, particularly when considering its most classic symptom that is heartburn. This symptom is very frequent in the community and ranges from 10% to more than 30%, according to the various population-based studies. This disease is much more represented in Europe and USA than in Asiatic countries. It has been shown that GERD prevalence increases in parallel with the remarkable growth of obesity, as this condition is able to favor all the pathogenetic mechanisms leading to it. Current information regarding the phenotypic presentation of GERD shows that there are two main phenotypic manifestations, that are erosive reflux disease (ERD) and non-erosive reflux disease (NERD) and the latter includes the majority of patients (up to 70%). The major complication of GERD is the development of Barrett esophagus, a pre-malignant lesion potentially leading to esophageal adenocarcinoma. Data from medical literature on the natural history of this disease are scant and mainly retrospective, so the interpretation of them is very difficult. However, they seem to suggest that both NERD and mild esophagitis tend to remain as such overtime and the progression from NERD to ERD, from mild to severe ERD and from ERD to Barrett's esophagus may occur only in a small number of cases, ranging from 0% to 30%, 10-22% and 1-13%, respectively. Future studies should help us in elucidating better the real transition from one category to another and to do this, we have to exclude from the world of GERD all the functional conditions that nowadays can be easily recognized by means of impedance-pH monitoring.
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Affiliation(s)
- Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy -
| | - Elisa Marabotto
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Giorgia Bodini
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Gaia Pellegatta
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Claudia Coppo
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Elisa Giambruno
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Matteo Brunacci
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Patrizia Zentilin
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Vincenzo Savarino
- Division of Gastroenterology, Department of Internal Medicine, University of Genoa, Genoa, Italy
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Giannini EG, Moscatelli A, Brunacci M, Zentilin P, Savarino V. Prognostic role of mean platelet volume in patients with cirrhosis. Dig Liver Dis 2016; 48:409-13. [PMID: 26699823 DOI: 10.1016/j.dld.2015.10.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 10/13/2015] [Accepted: 10/19/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Studies carried out in patients with chronic hepatitis have shown that mean platelet volume (MPV) is associated with worse disease stage, although the role of MPV in patients with cirrhosis is less clear. AIM To evaluate the association between MPV values and clinical characteristics and stage of cirrhosis, and to assess its prognostic role. METHODS We studied 75 patients with cirrhosis and assessed the association between MPV values and cirrhosis characteristics, prognostic scores, and survival. The prognostic role of longitudinal variations of MPV was also assessed in 50 patients who had at least 12 months follow-up and who had MPV determination at 3-monhtly intervals. RESULTS Median MPV values were not statistically different according to aetiology of liver disease (P=0.485) and disease severity both taking into consideration the Child-Pugh classification (P=0.438) and the Model for End-stage Liver Disease score (P=0.978). Median MPV values were not significantly different in 23 Child-Pugh class C patients who died or survived (9.15fL versus 9.10fL, P=0.794) during a 12-month follow-up. Lastly, there was no significant modification of MPV over time at the various study time-points (3-month, 6-month, 9-month, 12-month) between patients who died and those who survived. CONCLUSIONS In patients with cirrhosis, MPV has no association with severity of disease and prognosis.
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Affiliation(s)
- Edoardo G Giannini
- Gastroenterology Unit, Department Internal Medicine, University of Genoa, IRCCS-Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy.
| | - Alessandro Moscatelli
- Gastroenterology Unit, Department Internal Medicine, University of Genoa, IRCCS-Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Matteo Brunacci
- Gastroenterology Unit, Department Internal Medicine, University of Genoa, IRCCS-Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Patrizia Zentilin
- Gastroenterology Unit, Department Internal Medicine, University of Genoa, IRCCS-Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Vincenzo Savarino
- Gastroenterology Unit, Department Internal Medicine, University of Genoa, IRCCS-Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
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Savarino E, Giacchino M, Brunacci M, Savarino V. Comment to "predictors of clinical response of acid suppression in Chinese patients with gastroesophageal reflux disease". Dig Liver Dis 2013; 45:868-9. [PMID: 23583546 DOI: 10.1016/j.dld.2013.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Accepted: 03/03/2013] [Indexed: 12/11/2022]
Affiliation(s)
- Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
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Savarino E, de Bortoli N, Brunacci M, Savarino V. Letter: symptom indexes in reflux monitoring - two are better than one. Aliment Pharmacol Ther 2013; 37:918. [PMID: 23551159 DOI: 10.1111/apt.12276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 02/18/2013] [Indexed: 12/08/2022]
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