Outcome of Ulcerative Colitis 20 Years after Diagnosis in a Prospective Population-based Inception Cohort from South-Eastern Norway, the IBSEN Study

BACKGROUND AND AIMS

The long-term course of ulcerative colitis [UC] is difficult to predict. Mortality, colectomy, cancer, and hospitalisation represent hard outcomes of disease. Moreover, knowledge on the risk of relapses and need for potent medication add important information about living with UC. We aimed to evaluate the course and prognosis of UC during the first 20 years after diagnosis, and to identify early prognostic risk factors.

METHODS

From 1990 to 1994, a population-based inception cohort of patients with inflammatory bowel disease was enrolled in South-Eastern Norway. A systematic follow-up [FU] was conducted at 1,5, 10, and 20 years after diagnosis. Clinical outcomes were recorded continuously, and possible relationships between early disease characteristics and outcomes were analysed using multiple regression analysis.

RESULTS

Among 519 UC patients, 119 died, 60 were lost to FU, and 340 were included in the FU cohort. The 20-year cumulative risk of colectomy was 13.0% (95% confidence interval [CI] [11.4-14.6]). Extensive colitis at diagnosis was independently associated with an increased risk of colectomy compared with proctitis (hazard ratio [HR] = 2].8, 95% CI [1.3-6.1]). In contrast, mucosal healing at 1-year FU was independently associated with reduced risk of colectomy [HR = 0.4, 95% CI [0.2-0.8]), and inversely associated with subsequent risk of relapse [adjusted HR = 0.5, 95% CI [0.3-0.7]).

CONCLUSIONS

The overall risk of colectomy in our cohort was lower than expected from previous studies, although considerable for patients with extensive colitis at diagnosis. Early mucosal healing was associated with better disease outcomes 20 years after diagnosis.

Patient-reported outcomes in palliative gastrointestinal stenting: a Norwegian multicenter study

BACKGROUND

The clinical effect of stent treatment has been evaluated by mainly physicians; only a limited number of prospective studies have used patient-reported outcomes for this purpose. The aim of this work was to study the clinical effect of self-expanding metal stents in treatment of malignant gastrointestinal obstructions, as evaluated by patient-reported outcomes, and compare the rating of the treatment effect by patients and physicians.

METHODS

Between November 2006 and April 2008, 273 patients treated with SEMS for malignant GI and biliary obstructions were recruited from nine Norwegian hospitals. Patients and physicians assessed symptoms independently at the time of treatment and after 2 weeks using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire supplemented with specific questions related to obstruction.

RESULTS

A total of 162 patients (99 males; median age = 72 years) completed both assessments and were included in the study. A significant improvement in the mean global health score was observed after 2 weeks (from 9 to 18 on a 0-100 scale, P < 0.03) for all stent locations. Both patients and physicians reported a significant reduction in all obstruction-related symptoms (>20 on the 0-100 scale, P < 0.006) after SEMS treatment. The physicians reported a larger mean improvement in symptoms than did the patients, mainly because they reported more severe symptoms before treatment.

CONCLUSION

SEMS treatment is effective in relieving symptoms of malignant GI and biliary obstruction, as reported by patients and physicians. The physicians, however, reported a larger reduction in obstructive symptoms than did the patients. A prospective assessment of patient-reported outcomes is important in evaluating SEMS treatment.

Do pancreatic duct stents cause or prevent pancreatic sepsis?

BACKGROUND

Pancreatic sepsis can occur after contrast injection into an obstructed or disrupted pancreatic duct. Whether stents cause or prevent pancreatic sepsis is unknown. Accordingly, the pancreatic duct bacteriology in patients with pancreatic duct stents was retrospectively reviewed and contrasted with biliary cultures taken from patients at the time of bile duct stent retrieval and/or exchange.

METHODS

Of 61 patients (29 men, 32 women; 72 stents; mean age 51 [16] years, range 14-88 years), 36 with pancreatic duct stents had pancreatic duct cultures obtained at the time of stent exchange and/or retrieval. The results of these cultures were compared with bile duct cultures taken from 36 patients at the time of biliary stent exchange/retrieval. Eleven of the 36 patients with pancreatic duct stents also had bile duct stents. Data collected included stent patency, clinical sepsis at initial stent placement or retrieval, administration of antibiotics before the procedure, indication for stent placement, stent duration, and culture results.

RESULTS

At stent retrieval and/or exchange, all 61 patients with pancreatic and/or biliary stents had contamination of the respective ducts with multiple enteric bacteria (mean 3.4 organisms in patients with pancreatic duct stents vs. 3.3 in those with bile duct stents). Clostridium perfringens was found in 17% and 0% of patients with, respectively, bile duct and pancreatic duct stents. Among the most common indications for pancreatic duct stent placement were stricture (28), sphincterotomy (9), leak (7), stones (3), and dilated pancreatic duct (1). Indications for a biliary stent included benign stricture (29), malignancy (6), stones (2), cholangitis (1), chronic pancreatitis (1), and dilated common bile duct (1). Pancreatic cultures were taken at a median of 85 days (interquartile range 60-126; range 13-273) and biliary cultures at a median of 87 days (interquartile range 45-149; range 19-927) after stent placement. Eleven patients, 6 with a bile duct stent, 4 with a pancreatic duct stent, and one with dual stents, developed pre-exchange/retrieval clinical sepsis; 3 had pancreatic sepsis. All had received antibiotics at initial placement. In the 11 patients with sepsis (12 stents), 8 stents were completely occluded at exchange/retrieval, 3 were partially occluded, and one was patent. In 50 patients (60 stents), no clinical sepsis developed; 7 stents were patent, 31 partially occluded, and 22 completely obstructed.

CONCLUSIONS

(1) Comparable to patients with biliary stents, all patients with pancreatic stents had contamination of the pancreatic ductal system by enteric flora. (2) In contrast to the 17% of patients with bile duct stents who had intraductal Clostridium perfringens, there were no instances of contamination with this organism in patients with pancreatic stent (p = 0.025), although, after adjusting for multiple comparisons, statistical significance was lost. (3) There was a tendency for stent occlusion to predispose to pancreatic sepsis, but occlusion by itself was insufficient (p = 0.106). (4) Further investigation is required to define the additional variables that are associated with the development of pancreatic sepsis.

Patients with functional dyspepsia responding to omeprazole have a characteristic gastro-oesophageal reflux pattern

BACKGROUND

The effect of acid secretion inhibitors in patients with functional dyspepsia (FD) is equivocal. One previous trial showed an effect in patients with a characteristic gastro-oesophageal reflux pattern. This double-blind trial compares the number of reflux episodes in responders and non-responders to omeprazole.

METHODS

Twenty-four patients (men/women, 11:13; mean age, 49 years) with FD were included; those with reflux as the main symptom were excluded. An upper endoscopy and a 24-h oesophageal pH measurement were performed before randomization to treatment with 10-20 mg omeprazole or placebo for 4 weeks. Patients who at questioning considered themselves to have achieved sufficient relief of dyspeptic symptoms after 4 weeks were characterized as responders.

RESULTS

The number of responders in the omeprazole and placebo groups was 8 of 14 (57%) and 2 of 10 (20%), respectively (P = 0.07). The mean number of reflux episodes at the 24-h oesophageal pH measurement in responders and non-responders to omeprazole was 57 and 25, respectively (P < 0.003). In the omeprazole group the number of responders was 0 of 5 (0%) in those with < 32 reflux episodes and 8 of 9 (89%) in those with > 32 reflux episodes (P < 0.003).

CONCLUSION

Patients with FD responding to omeprazole were characterized by many reflux episodes.

The symptomatic effect of cisapride in patients with irritable bowel syndrome and constipation

BACKGROUND

Cisapride improves symptoms in patients with idiopathic constipation. This trial compares the effect of cisapride with that of placebo in patients with irritable bowel syndrome (IBS) and constipation.

METHODS

Seventy patients were randomized to 12 weeks' treatment with 5 mg cisapride three times daily or placebo in a double-blind trial. The dose could be doubled after 4 weeks in patients without satisfactory improvement. The patients scored their symptoms on a 100-mm visual analogue scale (VAS) (0 = best, 100 = worst), and the investigators evaluated the symptomatic effect.

RESULTS

The dose was doubled in 17 and 23 patients in the cisapride and placebo groups, respectively, after 4 weeks. The patients' mean VAS score for global evaluation of IBS symptoms in the cisapride and placebo groups was 73 and 71 mm, respectively, at the start of treatment and 47 and 41 mm at the end. The difference between cisapride and placebo at the end was 6 mm in favour of placebo (95% confidence interval (CI), -6, 18) (NS). The investigators evaluated the effect as good or excellent in 39.2% and 58.8% in the cisapride and placebo groups, respectively. The difference in favour of placebo was 19.5% (95% CI, -5, 44) (NS). Nor were any statistically significant differences seen between cisapride and placebo in the other effect factors.

CONCLUSIONS

The trial seems to exclude a clinically significant effect of 15-30 mg cisapride daily in patients with IBS and constipation during a 12-week treatment period.

Are frequent short gastro-oesophageal reflux episodes the cause of symptoms in patients with non-ulcer dyspepsia responding to treatment with ranitidine?

BACKGROUND

Patients with non-ulcer dyspepsia (NUD) responding to treatment with H2-receptor antagonists have no clinically useful characteristics. This trial compares the gastro-oesophageal reflux pattern as measured by 24-h oesophageal pH monitoring in patients responding to ranitidine with that of non-responders.

METHODS

Thirty-one patients with NUD were randomized to 6 weeks' double-blind alternating treatment with 150 mg ranitidine twice daily or placebo and classified as responders or non-responders.

RESULTS

Pathologic gastro-oesophageal reflux was seen in 3 of the 13 responders and 4 of the 18 no-responders (NS). The responders had frequent short reflux episodes (< 1 min in duration). When 4 patients with > or = 5 reflux episodes longer than 5 min were excluded, the number of short reflux episodes (median) in responders and non-responders was 32 and 14, respectively. The difference is statistically significant (p = 0.025). There were no other differences between the groups.

CONCLUSIONS

In this study patients with NUD responding to ranitidine were characterized by frequent short reflux episodes in the absence of numerous long reflux episodes.

Mesalazine suppositories versus hydrocortisone foam in patients with distal ulcerative colitis. A comparison of the efficacy and practicality of two topical treatment regimens

BACKGROUND

Topical treatment is effective in patients with distal ulcerative colitis. This trial compares the efficacy, safety, and practicality of 4 weeks' treatment with 500 mg mesalazine suppositories with those of 178 mg hydrocortisone foam, both given twice daily.

METHODS

Seventy-nine patients with distal ulcerative colitis were stratified on the basis of the extent of the disease (proctitis and proctosigmoiditis) and randomized to one of the treatment groups. A disease activity index (DAI) based on symptoms and endoscopic findings was calculated. The patients evaluated the practicality of the treatment regimens, patients compliance was measured, and histologic findings recorded.

RESULTS

Of all the patients 22% and 38% were complete responders after 2 and 4 weeks, respectively. Median DAIs in the mesalazine and hydrocortisone groups before and after 2 and 4 weeks' treatment were 14, 6, and 4, and 13, 8, and 6, respectively. The difference between the treatment groups was statistically significant (p = 0.02) due to a better effect of mesalazine in patients with proctitis. Patients' evaluation of practicality and patient compliance were statistically significantly better in the mesalazine group.

CONCLUSIONS

Both treatment regimens are effective; mesalazine suppositories seem to be the preferred alternative.

Multiple lymphomatous polyposis of the gut

Multiple lymphomatous polyposis is very rare. We report two cases affecting duodenum, small intestine and colon/rectum, both with extensive disease, making radical surgery impossible and chemotherapy the treatment of choice. One patient died 23 days after initial treatment of myocardial infiltration, and the other is still alive 21 months after initial treatment.

[Sulindac-induced toxic epidermal necrolysis]

All nonsteroidal anti-inflammatory agents may have dermatological side effects, most of them harmless. However, serious adverse dermatological reactions have been described. The article presents a patient with probable sulindac-induced toxic epidermal necrolysis (TEN), and reviews the literature.