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Sorge A, Elli L, Rondonotti E, Pennazio M, Spada C, Cadoni S, Cannizzaro R, Calabrese C, de Franchis R, Girelli CM, Marmo R, Riccioni ME, Marmo C, Oliva S, Scarpulla G, Soncini M, Vecchi M, Tontini GE. Enteroscopy in diagnosis and treatment of small bowel bleeding: A Delphi expert consensus. Dig Liver Dis 2023; 55:29-39. [PMID: 36100515 DOI: 10.1016/j.dld.2022.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 07/29/2022] [Accepted: 08/14/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Enteroscopy plays an important role in the management of small bowel bleeding. However, current guidelines are not specifically designed for small bowel bleeding and recommendations from different international societies do not always align. Consequently, there is heterogeneity in the definitions of clinical entities, clinical practice policies, and adherence to guidelines among clinicians. This represents an obstacle to providing the best patient care and to obtain homogeneous data for clinical research. AIMS The aims of the study were to establish a consensus on the definitions of bleeding entities and on the role of enteroscopy in the management of small bowel bleeding using a Delphi process. METHODS A core group of eight experts in enteroscopy identified five main topics of small bowel bleeding management and drafted statements on each topic. An expert panel of nine gastroenterologists participated in three rounds of the Delphi process, together with the core group. RESULTS A total of 33 statements were approved after three rounds of Delphi voting. CONCLUSION This Delphi consensus proposes clear definitions and a unifying strategy to standardize the management of small bowel bleeding. Furthermore, it provides a useful guide in daily practice for both clinical and technical issues of enteroscopy.
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Affiliation(s)
- Andrea Sorge
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Luca Elli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Marco Pennazio
- University Division of Gastroenterology, City of Health and Science University Hospital, Turin, Italy
| | - Cristiano Spada
- Digestive Endoscopy Unit, Catholic University of Rome, Rome, Italy; Digestive Endoscopy Unit, Fondazione Poliambulanza, Brescia, Italy
| | - Sergio Cadoni
- Digestive Endoscopy Unit, Centro Traumatologico Ortopedico, Iglesias, Italy
| | - Renato Cannizzaro
- Experimental Oncological Gastroenterology Unit, Centro di Riferimento Oncologico di Aviano (CRO), Istituto Nazionale Tumori IRCCS, Aviano, Italy
| | - Carlo Calabrese
- University of Bologna Alma Mater - School of Medicine, Department of Medical and Surgical Sciences - Regional Referral Center for IBD, Bologna, Italy
| | | | | | | | - Maria Elena Riccioni
- Digestive Endoscopy Unit, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Clelia Marmo
- Digestive Endoscopy Unit, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Salvatore Oliva
- Gastroenterology and Paeditric Hepatology Unit, Università La Sapienza, Rome, Italy
| | | | - Marco Soncini
- Department of Internal Medicine, "A. Manzoni" Hospital, ASST Lecco, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Gian Eugenio Tontini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C. Reply to: 'Management of portal hypertension in patients treated with atezolizumab and bevacizumab for hepatocellular carcinoma'. J Hepatol 2022; 77:567-568. [PMID: 35526788 DOI: 10.1016/j.jhep.2022.04.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 12/04/2022]
Affiliation(s)
| | - Jaume Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Instituts d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and CIBERehd, University of Barcelona, Spain
| | | | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Cristina Ripoll
- Internal Medicine IV, Universitätsklinikum Jena, Friedrich Schiller University, Jena, Germany
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de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C. Corrigendum to 'Baveno VII - Renewing consensus in portal hypertension' [J Hepatol (2022) 959-974]. J Hepatol 2022; 77:271. [PMID: 35431106 DOI: 10.1016/j.jhep.2022.03.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Affiliation(s)
| | - Jaime Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Instituts d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and CIBERehd, University of Barcelona, Spain
| | | | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Cristina Ripoll
- Internal Medicine IV, Universitätsklinikum, Friedrich Schiller University, Jena, Germany
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de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C. Baveno VII - Renewing consensus in portal hypertension. J Hepatol 2022; 76:959-974. [PMID: 35120736 DOI: 10.1016/j.jhep.2021.12.022] [Citation(s) in RCA: 748] [Impact Index Per Article: 374.0] [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: 11/18/2021] [Revised: 12/10/2021] [Accepted: 12/17/2021] [Indexed: 02/06/2023]
Abstract
To expand on the work of previous meetings, a virtual Baveno VII workshop was organised for October 2021. Among patients with compensated cirrhosis or compensated advanced chronic liver disease (cACLD - defined at the Baveno VI conference), the presence or absence of clinically significant portal hypertension (CSPH) is associated with differing outcomes, including risk of death, and different diagnostic and therapeutic needs. Accordingly, the Baveno VII workshop was entitled "Personalized Care for Portal Hypertension". The main fields of discussion were the relevance and indications for measuring the hepatic venous pressure gradient as a gold standard, the use of non-invasive tools for the diagnosis of cACLD and CSPH, the impact of aetiological and non-aetiological therapies on the course of cirrhosis, the prevention of the first episode of decompensation, the management of an acute bleeding episode, the prevention of further decompensation, as well as the diagnosis and management of splanchnic vein thrombosis and other vascular disorders of the liver. For each of these 9 topics, a thorough review of the medical literature was performed, and a series of consensus statements/recommendations were discussed and agreed upon. A summary of the most important conclusions/recommendations derived from the workshop is reported here. The statements are classified as unchanged, changed, and new in relation to Baveno VI.
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Affiliation(s)
| | - Jaime Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Instituts d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and CIBERehd, University of Barcelona, Spain
| | | | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Cristina Ripoll
- Internal Medicine IV, Universitätsklinikum Jena, Friedrich Schiller University, Jena, Germany
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Rondonotti E, Spada C, Cadoni S, Cannizzaro R, Calabrese C, de Franchis R, Elli L, Girelli CM, Hassan C, Marmo R, Riccioni ME, Oliva S, Scarpulla G, Soncini M, Vecchi M, Pennazio M. Quality performance measures for small capsule endoscopy: Are the ESGE quality standards met? Endosc Int Open 2021; 9:E122-E129. [PMID: 33532548 PMCID: PMC7834698 DOI: 10.1055/a-1319-0742] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 10/19/2020] [Indexed: 02/07/2023] Open
Abstract
Background and study aims The European Society of Gastrointestinal Endoscopy (ESGE) recently issued a quality performance measures document for small bowel capsule endoscopy (SBCE). The aim of this nationwide survey was to explore SBCE practice with ESGE quality measures as a benchmark. Patients and methods A dedicated per-center semi-quantitative questionnaire based on ESGE performance measures for SBCE was created by a group of SBCE experts. One-hundred-eighty-one centers were invited to participate and were asked to calculate performance measures for SBCE performed in 2018. Data were compared with 10 ESGE quality standards for both key and minor performance measures. Results Ninety-one centers (50.3 %) participated in the data collection. Overall in the last 5 years (2014-2018), 26,615 SBCEs were performed, 5917 of which were done in 2018. Eighty percent or more of the participating centers reached the minimum standard established by the ESGE Small Bowel Working Group (ESBWG) for four performance measures (indications for SBCE, complete small bowel evaluation, diagnostic yield and retention rate). Conversely, compliance with six minimum standards established by ESBWG concerning adequate bowel preparation, patient selection, timing of SBCE in overt bleeding, appropriate reporting, reading protocols and referral to device-assisted enteroscopy was met by only 15.5 %, 10.9 %, 31.1 %, 67.7 %, 53.4 %, and 32.2 % of centers, respectively. Conclusions The present survey shows significant variability across SBCE centers; only four (4/10: 40 %) SBCE procedural minimum standards were met by a relevant proportion of the centers ( ≥ 80 %). Our data should help in identifying target areas for quality improvement programs in SBCE.
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Affiliation(s)
- Emanuele Rondonotti
- Unità Operativa Complessa di Gastroenterologia, Ospedale Valduce, Como, Italy
| | - Cristiano Spada
- Unità Operativa di Endoscopia Digestiva, Università Cattolica, Rome, Italy,Unità Operativa di Endoscopia Digestiva, Fondazione Poliambulanza, Brescia, Italy
| | - Sergio Cadoni
- Unità Operativa di Endoscopia Digestiva, Centro Traumatologico Ortopedico, Iglesias, Italy
| | - Renato Cannizzaro
- Struttura Operativa Complessa di Gastroenterologia Oncologica, Centro di Riferimento Oncologico di Aviano (CRO), Istituto Nazionale Tumori IRCCS, Aviano, Italy
| | - Carlo Calabrese
- Unità Operativa Malattia Infiammatorie Croniche Intestinali, Dipartimento di Medicina e Chirurgia (DIMEC), Ospedale S. Orsola-Malpighi Università di Bologna, Bologna, Italy
| | | | - Luca Elli
- Unità Operativa Complessa di Gastroenterologia ed Endoscopia-Centro per la Prevenzione e Diagnosi della Malattia Celiaca, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Carlo Maria Girelli
- Unità Di Gastroenterologia ed Endoscopia Digestiva, Ospedale di Busto Arsizio, Busto Arsizio, Italy
| | - Cesare Hassan
- Unità Operativa di Endoscopia Digestiva, Ospedale Nuovo Regina, Rome, Italy
| | - Riccardo Marmo
- Unità Operativa di Gastroenterologia, Ospedale Curto, Polla, Italy
| | - Maria Elena Riccioni
- Unità Operativa di Endoscopia Digestiva, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Salvatore Oliva
- Unità Operativa di Gastroenterologia e Epatologia Pediatrica, Università La Sapienza, Rome, Italy
| | - Giuseppe Scarpulla
- Unità Operativa di Gastroenterologia, Ospedale M. Raimondi, San Cataldo, Italy
| | - Marco Soncini
- Dipartimento di Medicina Interna, Ospedale Alessandro Manzoni, Lecco, Italy
| | - Maurizio Vecchi
- Dipartimento di Scienze Biomediche, Università degli Studi di Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Pennazio
- Divisione di Gastroenterologia U, Azienda Ospedaliero-Universitaria, Città della Salute e della Scienza, Torino, Italy
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Marmo R, Soncini M, de Franchis R. Patient's performance status should dictate transfusion strategy in nonvariceal acute upper gastrointestinal bleeding (NV-AUGIB): A prospective multicenter cohort study: Transfusion strategy in NV-AUGIB. Dig Liver Dis 2020; 52:1156-1163. [PMID: 32788141 DOI: 10.1016/j.dld.2020.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 02/29/2020] [Revised: 05/29/2020] [Accepted: 07/14/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Non-variceal acute UGI bleeding (NV-AUGIB) is a frequent indication for transfusion, but the best hemoglobin threshold and target values for transfusion in relation to the patients' performance status are unknown. OBJECTIVE To identify threshold and target hemoglobin levels for transfusion favoring survival of patients with NV-AUGIB stratified by ASA score. DESIGN Prospective cohort study. SETTING 50 hospitals of the Italian National Health Service. PARTICIPANTS 2758 consecutive patients with NV-AUGIB admitted to 50 Italian hospitals from January 1st, 2014 to December 31st, 2015. Five hemoglobin cut-off values were evaluated. RESULTS 30-days mortality: overall: 5.4%; ASA 1-2 patients: 2.5%; ASA 3-4 patients: 10.8%. Mortality was higher when hemoglobin at admission was ≤ 7 g/dL in ASA 1-2 patients, and when it was ≤ 8 g/dL in ASA 3-4 patients. The hemoglobin levels after transfusion favouring survival were ≥ 8 g/dL in ASA 1-2, p <0.0001 and 9-10 g/dL in ASA 3-4 patients; p = 0.0002. CONCLUSIONS In patients with NV-AUGIB the physical performance status should dictate the transfusion strategy. In ASA 1-2 patients, admission hemoglobin values ≤ 7 g/dL should prompt transfusion, aiming at a target value of 8-9 g/dL; the corresponding figures for ASA 3-4 patients are: admission hemoglobin level ≤ 8 g/dL and target value of 9-10 g/dL.
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Affiliation(s)
- Riccardo Marmo
- Gastroenterology Department, Presidio Ospedaliero Luigi Curto, ASL 3 Salerno, Via Luigi Curto , Polla (Salerno)
| | - Marco Soncini
- Medical Department, A. Manzoni Hospital, ASST Lecco, Via dell'Eremo, Lecco
| | - Roberto de Franchis
- Department of Biomedical and Clinical Sciences, "Luigi Sacco" Hospital, University of Milan, Milan, Italy.
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de Franchis R. Digestive and Liver Diseases and the COVID-19 Pandemic. Dig Liver Dis 2020; 52:799. [PMID: 32713475 PMCID: PMC7376346 DOI: 10.1016/j.dld.2020.07.006] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Affiliation(s)
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
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Shneider BL, de Ville de Goyet J, Leung DH, Srivastava A, Ling SC, Duché M, McKiernan P, Superina R, Squires RH, Bosch J, Groszmann R, Sarin SK, de Franchis R, Mazariegos GV. Primary prophylaxis of variceal bleeding in children and the role of MesoRex Bypass: Summary of the Baveno VI Pediatric Satellite Symposium. Hepatology 2016; 63:1368-80. [PMID: 26358549 DOI: 10.1002/hep.28153] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [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] [Received: 06/01/2015] [Revised: 09/01/2015] [Accepted: 09/05/2015] [Indexed: 12/17/2022]
Abstract
UNLABELLED Approaches to the management of portal hypertension and variceal hemorrhage in pediatrics remain controversial, in large part because they are not well informed by rigorous clinical studies. Fundamental biological and clinical differences preclude automatic application of approaches used for adults to children. On April 11-12, 2015, experts in the field convened at the first Baveno Pediatric Satellite Meeting to discuss and explore current available evidence regarding indications for MesoRex bypass (MRB) in extrahepatic portal vein obstruction and the role of primary prophylaxis of variceal hemorrhage in children. Consensus was reached regarding MRB. The vast majority of children with extrahepatic portal vein obstruction will experience complications that can be prevented by successful MRB surgery. Therefore, children with extrahepatic portal vein obstruction should be offered MRB for primary and secondary prophylaxis of variceal bleeding and other complications, if appropriate surgical expertise is available, if preoperative and intraoperative evaluation demonstrates favorable anatomy, and if appropriate multidisciplinary care is available for postoperative evaluation and management of shunt thrombosis or stenosis. In contrast, consensus was not achieved regarding primary prophylaxis of varices. Although variceal hemorrhage is a concerning complication of portal hypertension in children, the first bleed appears to be only rarely fatal and the associated morbidity has not been well characterized. CONCLUSION There are few pediatric data to indicate the efficacy and safety of pharmacologic or endoscopic therapies as primary prophylaxis or that prevention of a sentinel variceal bleed will ultimately improve survival; therefore, no recommendation for primary prophylaxis with endoscopic variceal ligation, sclerotherapy, or nonspecific beta-blockade in children was proposed.
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Affiliation(s)
- Benjamin L Shneider
- Texas Children's Hospital and the Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | | | - Daniel H Leung
- Texas Children's Hospital and the Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Anshu Srivastava
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Simon C Ling
- Hospital for Sick Children and the Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Mathieu Duché
- Hépatologie Pédiatrique and Centre de Référence National de l'Atrésie des Voies Biliaires, Radiologie Pédiatrique, Université Paris-Sud 11, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
| | | | | | | | - Jaime Bosch
- Hospital Clinic-IDIBAPS and CIBEREHD, Barcelona, Spain
| | | | - Shiv K Sarin
- Institute of Liver and Biliary Sciences, New Delhi, India
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Furfaro F, Bezzio C, Ardizzone S, Massari A, de Franchis R, Maconi G. Overview of biological therapy in ulcerative colitis: current and future directions. J Gastrointestin Liver Dis 2016. [PMID: 26114181 DOI: 10.15403/jgld.2014.1121.242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The treatment of ulcerative colitis (UC) has changed over the last decade. It is extremely important to optimize the therapies which are available nowadays and commonly used in daily clinical practice, as well as to stimulate the search for more powerful drugs for the induction and maintenance of sustained and durable remission, thus preventing further complications. Therefore, it is mandatory to identify the patients' prognostic variables associated with an aggressive clinical course and to test the most potent therapies accordingly. To date, the conventional therapeutic approach based on corticosteroids, salicylates (sulfasalazine, 5-aminosalicylic acid) or immunosuppressive agents is commonly used as a first step to induce and to maintain remission. However, in recent years, knowledge of new pathogenetic mechanisms of ulcerative colitis have allowed us to find new therapeutic targets leading to the development of new treatments that directly target proinflammatory mediators, such as TNF-alpha, cytokines, membrane migration agents, cellular therapies. The aim of this review is to provide the most significant data regarding the therapeutic role of drugs in UC and to give an overview of biological and experimental drugs that will become available in the near future. In particular, we will analyse the role of these drugs in the treatment of acute flare and maintenance of UC, as well as its importance in mucosal healing and in treating patients at a high risk of relapse.
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Affiliation(s)
- Federica Furfaro
- Department of Gastroenterology, Oncology-Surgery, L.Sacco University Hospital, Milan, Italy
| | - Cristina Bezzio
- Department of Gastroenterology, Oncology-Surgery, L.Sacco University Hospital, Milan, Italy
| | - Sandro Ardizzone
- Department of Gastroenterology, Oncology-Surgery, L.Sacco University Hospital, Milan, Italy
| | - Alessandro Massari
- Department of Gastroenterology, Oncology-Surgery, L.Sacco University Hospital, Milan, Italy
| | - Roberto de Franchis
- Department of Gastroenterology, Oncology-Surgery, L.Sacco University Hospital, Milan, Italy
| | - Giovanni Maconi
- Department of Gastroenterology, Oncology-Surgery, L.Sacco University Hospital, Milan, Italy.
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Furfaro F, Bezzio C, Ardizzone S, Massari A, de Franchis R, Maconi G. Overview of biological therapy in ulcerative colitis: current and future directions. J Gastrointestin Liver Dis 2016; 24:203-13. [PMID: 26114181 DOI: 10.15403/jgld.2014.1121.242.bezz] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The treatment of ulcerative colitis (UC) has changed over the last decade. It is extremely important to optimize the therapies which are available nowadays and commonly used in daily clinical practice, as well as to stimulate the search for more powerful drugs for the induction and maintenance of sustained and durable remission, thus preventing further complications. Therefore, it is mandatory to identify the patients' prognostic variables associated with an aggressive clinical course and to test the most potent therapies accordingly. To date, the conventional therapeutic approach based on corticosteroids, salicylates (sulfasalazine, 5-aminosalicylic acid) or immunosuppressive agents is commonly used as a first step to induce and to maintain remission. However, in recent years, knowledge of new pathogenetic mechanisms of ulcerative colitis have allowed us to find new therapeutic targets leading to the development of new treatments that directly target proinflammatory mediators, such as TNF-alpha, cytokines, membrane migration agents, cellular therapies. The aim of this review is to provide the most significant data regarding the therapeutic role of drugs in UC and to give an overview of biological and experimental drugs that will become available in the near future. In particular, we will analyse the role of these drugs in the treatment of acute flare and maintenance of UC, as well as its importance in mucosal healing and in treating patients at a high risk of relapse.
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Affiliation(s)
- Federica Furfaro
- Department of Gastroenterology, Oncology-Surgery, L.Sacco University Hospital, Milan, Italy
| | - Cristina Bezzio
- Department of Gastroenterology, Oncology-Surgery, L.Sacco University Hospital, Milan, Italy
| | - Sandro Ardizzone
- Department of Gastroenterology, Oncology-Surgery, L.Sacco University Hospital, Milan, Italy
| | - Alessandro Massari
- Department of Gastroenterology, Oncology-Surgery, L.Sacco University Hospital, Milan, Italy
| | - Roberto de Franchis
- Department of Gastroenterology, Oncology-Surgery, L.Sacco University Hospital, Milan, Italy
| | - Giovanni Maconi
- Department of Gastroenterology, Oncology-Surgery, L.Sacco University Hospital, Milan, Italy.
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Lampertico P, Invernizzi F, Viganò M, Loglio A, Mangia G, Facchetti F, Primignani M, Jovani M, Iavarone M, Fraquelli M, Casazza G, de Franchis R, Colombo M. The long-term benefits of nucleos(t)ide analogs in compensated HBV cirrhotic patients with no or small esophageal varices: A 12-year prospective cohort study. J Hepatol 2015; 63:1118-25. [PMID: 26100495 DOI: 10.1016/j.jhep.2015.06.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [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: 10/22/2014] [Revised: 05/14/2015] [Accepted: 06/08/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Esophageal varices (EV) are a marker of disease severity in compensated cirrhosis due to hepatitis B virus (HBV) which predicts also the risk of hepatocellular carcinoma (HCC), clinical decompensation and anticipated liver related death. The dynamics and prognostic significance of EV in patients under long-term HBV suppression by nucleos(t)ide analogs (NUC), are poorly known. METHODS A standardized protocol (Baveno) including 414 upper gastrointestinal (GI) endoscopies was applied to 107 HBeAg-negative compensated cirrhotic patients (93% Child-Pugh A) during a median of 12 (range 2 to 17) years of NUC therapy. Patients who initially started on lamivudine (LMV) and then developed resistance (LMV-R), were rescued by early administration of adefovir, or were switched to tenofovir. Surveillance included serum HBV DNA every three months and abdominal ultrasound every six months. RESULTS Twenty-seven patients had baseline F1 EV which regressed in 18, remained unchanged in eight and progressed in one patient; the 12-year cumulative incidence of EV regression was 83% (95% CI: 52-92%). De novo F1/F2 EV developed in 6/80 patients with a 12-year cumulative incidence of 10% (95% CI: 5-20%). Six of seven patients with de novo varices or progression of pre-existing varices had either a clinical breakthrough due to LMV-R and/or developed a HCC. No bleedings from ruptured EV occurred, 12 patients died (9 HCC) and 15 were transplanted (13 HCC): the 12-year cumulative incidence of HCC and overall survival was 33% (95% CI: 24-42%) and 76% (95% CI: 67-83%), respectively. CONCLUSIONS Long-term pharmacological suppression of HBV in HBeAg-seronegative patients with compensated cirrhosis leads to a significant regression of pre-existing EV accompanied by a negligible risk of developing de novo EV.
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Affiliation(s)
- Pietro Lampertico
- "A.M. and A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Federica Invernizzi
- "A.M. and A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Mauro Viganò
- Division of Hepatology, Ospedale San Giuseppe, Università degli Studi di Milano, Italy
| | - Alessandro Loglio
- "A.M. and A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Giampaolo Mangia
- "A.M. and A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Floriana Facchetti
- "A.M. and A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Massimo Primignani
- "A.M. and A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Manol Jovani
- "A.M. and A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Massimo Iavarone
- "A.M. and A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Mirella Fraquelli
- Division of Gastroenterology and Endoscopy, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Giovanni Casazza
- Department of Biomedical and Clinical Sciences, Ospedale Luigi Sacco, Università degli Studi di Milano, Milan, Italy
| | - Roberto de Franchis
- Division of Gastroenterology, Ospedale Luigi Sacco, Università degli Studi di Milano, Milan, Italy
| | - Massimo Colombo
- "A.M. and A. Migliavacca" Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy.
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Gralnek IM, Dumonceau JM, Kuipers EJ, Lanas A, Sanders DS, Kurien M, Rotondano G, Hucl T, Dinis-Ribeiro M, Marmo R, Racz I, Arezzo A, Hoffmann RT, Lesur G, de Franchis R, Aabakken L, Veitch A, Radaelli F, Salgueiro P, Cardoso R, Maia L, Zullo A, Cipolletta L, Hassan C. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47:a1-46. [PMID: 26417980 DOI: 10.1055/s-0034-1393172] [Citation(s) in RCA: 445] [Impact Index Per Article: 49.4] [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: 12/12/2022]
Abstract
This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). Main Recommendations MR1. ESGE recommends immediate assessment of hemodynamic status in patients who present with acute upper gastrointestinal hemorrhage (UGIH), with prompt intravascular volume replacement initially using crystalloid fluids if hemodynamic instability exists (strong recommendation, moderate quality evidence). MR2. ESGE recommends a restrictive red blood cell transfusion strategy that aims for a target hemoglobin between 7 g/dL and 9 g/dL. A higher target hemoglobin should be considered in patients with significant co-morbidity (e. g., ischemic cardiovascular disease) (strong recommendation, moderate quality evidence). MR3. ESGE recommends the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Outpatients determined to be at very low risk, based upon a GBS score of 0 - 1, do not require early endoscopy nor hospital admission. Discharged patients should be informed of the risk of recurrent bleeding and be advised to maintain contact with the discharging hospital (strong recommendation, moderate quality evidence). MR4. ESGE recommends initiating high dose intravenous proton pump inhibitors (PPI), intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour), in patients presenting with acute UGIH awaiting upper endoscopy. However, PPI infusion should not delay the performance of early endoscopy (strong recommendation, high quality evidence). MR5. ESGE does not recommend the routine use of nasogastric or orogastric aspiration/lavage in patients presenting with acute UGIH (strong recommendation, moderate quality evidence). MR6. ESGE recommends intravenous erythromycin (single dose, 250 mg given 30 - 120 minutes prior to upper gastrointestinal [GI] endoscopy) in patients with clinically severe or ongoing active UGIH. In selected patients, pre-endoscopic infusion of erythromycin significantly improves endoscopic visualization, reduces the need for second-look endoscopy, decreases the number of units of blood transfused, and reduces duration of hospital stay (strong recommendation, high quality evidence). MR7. Following hemodynamic resuscitation, ESGE recommends early (≤ 24 hours) upper GI endoscopy. Very early (< 12 hours) upper GI endoscopy may be considered in patients with high risk clinical features, namely: hemodynamic instability (tachycardia, hypotension) that persists despite ongoing attempts at volume resuscitation; in-hospital bloody emesis/nasogastric aspirate; or contraindication to the interruption of anticoagulation (strong recommendation, moderate quality evidence). MR8. ESGE recommends that peptic ulcers with spurting or oozing bleeding (Forrest classification Ia and Ib, respectively) or with a nonbleeding visible vessel (Forrest classification IIa) receive endoscopic hemostasis because these lesions are at high risk for persistent bleeding or rebleeding (strong recommendation, high quality evidence). MR9. ESGE recommends that peptic ulcers with an adherent clot (Forrest classification IIb) be considered for endoscopic clot removal. Once the clot is removed, any identified underlying active bleeding (Forrest classification Ia or Ib) or nonbleeding visible vessel (Forrest classification IIa) should receive endoscopic hemostasis (weak recommendation, moderate quality evidence). MR10. In patients with peptic ulcers having a flat pigmented spot (Forrest classification IIc) or clean base (Forrest classification III), ESGE does not recommend endoscopic hemostasis as these stigmata present a low risk of recurrent bleeding. In selected clinical settings, these patients may be discharged to home on standard PPI therapy, e. g., oral PPI once-daily (strong recommendation, moderate quality evidence). MR11. ESGE recommends that epinephrine injection therapy not be used as endoscopic monotherapy. If used, it should be combined with a second endoscopic hemostasis modality (strong recommendation, high quality evidence). MR12. ESGE recommends PPI therapy for patients who receive endoscopic hemostasis and for patients with adherent clot not receiving endoscopic hemostasis. PPI therapy should be high dose and administered as an intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour) for 72 hours post endoscopy (strong recommendation, high quality evidence). MR13. ESGE does not recommend routine second-look endoscopy as part of the management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). However, in patients with clinical evidence of rebleeding following successful initial endoscopic hemostasis, ESGE recommends repeat upper endoscopy with hemostasis if indicated. In the case of failure of this second attempt at hemostasis, transcatheter angiographic embolization (TAE) or surgery should be considered (strong recommendation, high quality evidence). MR14. In patients with NVUGIH secondary to peptic ulcer, ESGE recommends investigating for the presence of Helicobacter pylori in the acute setting with initiation of appropriate antibiotic therapy when H. pylori is detected. Re-testing for H. pylori should be performed in those patients with a negative test in the acute setting. Documentation of successful H. pylori eradication is recommended (strong recommendation, high quality evidence). MR15. In patients receiving low dose aspirin for secondary cardiovascular prophylaxis who develop peptic ulcer bleeding, ESGE recommends aspirin be resumed immediately following index endoscopy if the risk of rebleeding is low (e. g., FIIc, FIII). In patients with high risk peptic ulcer (FIa, FIb, FIIa, FIIb), early reintroduction of aspirin by day 3 after index endoscopy is recommended, provided that adequate hemostasis has been established (strong recommendation, moderate quality evidence).
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Affiliation(s)
- Ian M Gralnek
- Institute of Gastroenterology and Liver Diseases, Ha'Emek Medical Center, Afula, Israel
| | | | - Ernst J Kuipers
- Departments of Internal Medicine and Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Angel Lanas
- University of Zaragoza, Aragon Health Research Institute (IIS Aragon), CIBERehd, Spain
| | - David S Sanders
- Department of Gastroenterology, Sheffield Teaching Hospitals, United Kingdom
| | - Matthew Kurien
- Department of Gastroenterology, Sheffield Teaching Hospitals, United Kingdom
| | - Gianluca Rotondano
- Division of Gastroenterology and Digestive Endoscopy, Maresca Hospital, Torre del Greco, Italy
| | - Tomas Hucl
- Department of Gastroenterology and Hepatology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Mario Dinis-Ribeiro
- Department of Gastroenterology, IPO Porto, Portugal and CINTESIS, Porto Faculty of Medicine, Portgal
| | - Riccardo Marmo
- Division of Gastroenterology, Hospital Curto, Polla, Italy
| | - Istvan Racz
- First Department of Internal Medicine and Gastroenterology, Petz Aladar, Hospital, Gyor, Hungary
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Ralf-Thorsten Hoffmann
- Institute and Polyclinic for Diagnostic Radiology, University Hospital Dresden-TU, Dresden, Germany
| | - Gilles Lesur
- Department of Gastroenterology, Ambroise Paré Hospital, Boulogne, France
| | - Roberto de Franchis
- Department of Biomedical and Clinical Sciences, University of Milan, Gastroenterology Unit, Luigi Sacco University Hospital, Milan, Italy
| | - Lars Aabakken
- Department of Medical Gastroenterology, Rikshospitalet University Hospital, Oslo, Norway
| | - Andrew Veitch
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, United Kingdom
| | - Franco Radaelli
- Department of Gastroenterology, Valduce Hospital, Como, Italy
| | - Paulo Salgueiro
- Department of Gastroenterology, Centro Hospitalar do Porto, Portugal
| | - Ricardo Cardoso
- Department of Gastroenterology, Centro Hospitalar e Universitário de Coimbra, Portugal
| | - Luís Maia
- Department of Gastroenterology, Centro Hospitalar do Porto, Portugal
| | - Angelo Zullo
- Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Livio Cipolletta
- Gastroenterology and Endoscopy Department, Antonio Cardarelli Hospital, Naples, Italy
| | - Cesare Hassan
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
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Berzigotti A, Boyer TD, Castéra L, de Franchis R, Genescà J, Pinzani M. Reply to "Points to be considered when using transient elastography for diagnosis of portal hypertension according to the Baveno's VI consensus". J Hepatol 2015. [PMID: 26212027 DOI: 10.1016/j.jhep.2015.07.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Annalisa Berzigotti
- University Clinic of Visceral Surgery and Medicine, Inselspital Berne, Berne, Switzerland
| | - Thomas D Boyer
- Department of Medicine, Liver Research Institute, University of Arizona, College of Medicine, Tucson, AZ, USA
| | | | - Roberto de Franchis
- Department of Gastroenterology, Oncology-Surgery, L.Sacco University Hospital, Milan, Italy.
| | - Joan Genescà
- Liver Diseases Laboratory, Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Massimo Pinzani
- UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
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de Franchis R. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63:743-52. [PMID: 26047908 DOI: 10.1016/j.jhep.2015.05.022] [Citation(s) in RCA: 2037] [Impact Index Per Article: 226.3] [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: 04/29/2015] [Revised: 05/14/2015] [Accepted: 05/27/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Roberto de Franchis
- Department of Biomedical and Clinical Sciences, University of Milan, Gastroenterology Unit, Luigi Sacco University Hospital, Milan, Italy.
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Maconi G, Orlandini L, Asthana AK, Sciurti R, Furfaro F, Bezzio C, de Franchis R. The impact of symptoms, irritable bowel syndrome pattern and diagnostic investigations on the diagnostic delay of Crohn's disease: A prospective study. Dig Liver Dis 2015; 47:646-51. [PMID: 26004215 DOI: 10.1016/j.dld.2015.04.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [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: 12/17/2014] [Revised: 03/20/2015] [Accepted: 04/15/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND We investigated symptoms and tests performed prior to a formal diagnosis of Crohn's disease and the reasons for diagnostic delay. METHODS Consecutive patients recently diagnosed with Crohn's disease were enrolled between October 2012 and November 2013. Clinical data, symptoms including Rome III criteria at onset and at diagnosis, location and disease phenotype were recorded. Faecal calprotectin, radiological and endoscopic examinations performed prior to diagnosis were analysed. Diagnostic delay, stratified into tertiles and median time, was analysed using parametric and nonparametric tests. RESULTS 83 patients (49.4% males, median age 31 years) were enrolled. The median diagnostic delay was 8 (0-324) months. Twenty-six patients did not consult a general practitioner until diagnosis (31.3%), 18 presented to the emergency department (21.7%) and 8 directly to a gastroenterologist (9.6%). Diagnostic delay was not associated with specific symptoms. However, patients with bloating at presentation had a longer delay compared to those who did not (median, 6.1 vs. 16.8 months, respectively; p=0.016). Nineteen patients underwent incomplete ileocolonoscopies (22.9%) and 7 had no biopsies (8.4%), with a consequent diagnostic delay (median, 24 and 24 vs. 6 months, respectively; p=0.025 and p=0.008). CONCLUSION Diagnostic delay for Crohn's disease is significantly associated with incomplete ileocolonoscopies, but not with symptoms, except bloating at presentation.
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Affiliation(s)
- Giovanni Maconi
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences, L. Sacco University Hospital, Milan, Italy.
| | - Laura Orlandini
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences, L. Sacco University Hospital, Milan, Italy
| | - Anil K Asthana
- Department of Gastroenterology, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Roberta Sciurti
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences, L. Sacco University Hospital, Milan, Italy
| | - Federica Furfaro
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences, L. Sacco University Hospital, Milan, Italy
| | - Cristina Bezzio
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences, L. Sacco University Hospital, Milan, Italy
| | - Roberto de Franchis
- Gastroenterology Unit, Department of Biomedical and Clinical Sciences, L. Sacco University Hospital, Milan, Italy
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Bezzio C, Furfaro F, de Franchis R, Maconi G, Asthana AK, Ardizzone S. Ulcerative colitis: current pharmacotherapy and future directions. Expert Opin Pharmacother 2014; 15:1659-70. [DOI: 10.1517/14656566.2014.925445] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Forni D, Cleynen I, Ferrante M, Cassinotti A, Cagliani R, Ardizzone S, Vermeire S, Fichera M, Lombardini M, Maconi G, de Franchis R, Asselta R, Biasin M, Clerici M, Sironi M. ABO histo-blood group might modulate predisposition to Crohn's disease and affect disease behavior. J Crohns Colitis 2014; 8:489-94. [PMID: 24268527 DOI: 10.1016/j.crohns.2013.10.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [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] [Received: 08/21/2013] [Revised: 10/31/2013] [Accepted: 10/31/2013] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND AIMS ABO encodes a glycosyltranferase which determines the major human histo-blood group. The FUT2 fucosyltransferase allows expression of ABO antigens on the gastrointestinal mucosa and in bodily secretions (secretor phenotype). A nonsense allele in FUT2 represents a susceptibility variant for Crohn's disease, and both the secretor and ABO blood group status affect the composition of the gut microbiota. Thus, we evaluated if variants in ABO might represent good candidates as Crohn's disease susceptibility loci. METHODS We recruited two case-control cohorts, from Italy (n=1301) and Belgium (n=2331). Subjects were genotyped for one SNP in FUT2 and two variants in ABO. RESULTS No effect on Crohn's disease risk was detected for ABO variants, whereas an association was observed between the FUT2 polymorphism and Crohn's disease susceptibility in the Belgian sample, but not in the Italian cohort. The effect of histo-blood groups was evaluated using group O as the reference. Most non-O groups had odds ratios (ORs) higher than 1 in both cohorts, and combined analysis of the two samples indicated a predisposing effect for the A and B groups (OR=1.17, 95% CI: 1.02-1.32 and OR=1.33, 95% CI: 1.09-1.58, respectively). In Crohn's disease patients, the non-O blood group and the non-secretor status were associated with higher risk of developing a stricturing or penetrating disease. CONCLUSIONS ABO histo-blood group might confer susceptibility to Crohn's disease and modulate disease severity.
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Affiliation(s)
- Diego Forni
- Bioinformatics, Scientific Institute IRCCS E. Medea, 23842 Bosisio Parini, LC, Italy
| | - Isabelle Cleynen
- Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Marc Ferrante
- Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Andrea Cassinotti
- IBD Unit, Chair of Gastroenterology, Luigi Sacco University Hospital, 20157 Milan, Italy
| | - Rachele Cagliani
- Bioinformatics, Scientific Institute IRCCS E. Medea, 23842 Bosisio Parini, LC, Italy
| | - Sandro Ardizzone
- IBD Unit, Chair of Gastroenterology, Luigi Sacco University Hospital, 20157 Milan, Italy
| | - Severine Vermeire
- Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Maria Fichera
- IBD Unit, Chair of Gastroenterology, Luigi Sacco University Hospital, 20157 Milan, Italy
| | - Marta Lombardini
- IBD Unit, Chair of Gastroenterology, Luigi Sacco University Hospital, 20157 Milan, Italy
| | - Giovanni Maconi
- IBD Unit, Chair of Gastroenterology, Luigi Sacco University Hospital, 20157 Milan, Italy
| | - Roberto de Franchis
- IBD Unit, Chair of Gastroenterology, Luigi Sacco University Hospital, 20157 Milan, Italy
| | - Rosanna Asselta
- Dipartimento di Biotecnologie Mediche e Medicina Traslazionale, Università degli Studi di Milano, Milano, Italy
| | - Mara Biasin
- Chair of Immunology, DISC LITA Vialba, University of Milano, Milano, Italy
| | - Mario Clerici
- Chair of Immunology, Department of Physiopathology and Transplantation, University of Milan, 20090 Milano, Italy; Fondazione Don C. Gnocchi, IRCCS, 20148 Milano, Italy
| | - Manuela Sironi
- Bioinformatics, Scientific Institute IRCCS E. Medea, 23842 Bosisio Parini, LC, Italy.
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22
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Maconi G, Furfaro F, Sciurti R, Bezzio C, Ardizzone S, de Franchis R. Glucose intolerance and diabetes mellitus in ulcerative colitis: Pathogenetic and therapeutic implications. World J Gastroenterol 2014; 20:3507-3515. [PMID: 24707133 PMCID: PMC3974517 DOI: 10.3748/wjg.v20.i13.3507] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 01/26/2014] [Accepted: 03/06/2014] [Indexed: 02/06/2023] Open
Abstract
Diabetes mellitus is one of the most frequent co-morbidities of ulcerative colitis patients. The epidemiological association of these diseases suggested a genetic sharing and has challenged gene identification. Diabetes co-morbidity in ulcerative colitis has also relevant clinical and therapeutic implications, with potential clinical impact on the follow up and outcome of patients. These diseases share specific complications, such as neuropathy, hepatic steatosis, osteoporosis and venous thrombosis. It is still unknown whether the coexistence of these diseases may increase their occurrence. Diabetes and hyperglycaemia represent relevant risk factors for postoperative complications and pouch failure in ulcerative colitis. Medical treatment of ulcerative colitis in patients with diabetes mellitus may be particularly challenging. Corticosteroids are the treatment of choice of active ulcerative colitis. Their use may be associated with the onset of glucose intolerance and diabetes, with difficult control of glucose levels and with complications in diabetic patients. Epidemiologic and genetic evidences about diabetes co-morbidity in ulcerative colitis patients and shared complications and treatment of patients with these diseases have been discussed in the present review.
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Dell'Era A, Iannuzzi F, Fabris FM, Fontana P, Reati R, Grillo P, Aghemo A, de Franchis R, Primignani M. Impact of portal vein thrombosis on the efficacy of endoscopic variceal band ligation. Dig Liver Dis 2014; 46:152-6. [PMID: 24084343 DOI: 10.1016/j.dld.2013.08.138] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [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: 02/06/2013] [Revised: 08/11/2013] [Accepted: 08/20/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Influence of portal vein thrombosis on efficacy of endoscopic variceal banding in patients with cirrhosis or extrahepatic portal vein obstruction has never been evaluated. Aim of the study was to assess influence of thrombosis on rate and time to eradication in cirrhosis and extrahepatic portal vein obstruction undergoing banding, compared to cirrhotic patients without thrombosis. METHODS Retrospective analysis of 235 consecutive patients (192 with cirrhosis without thrombosis, 22 cirrhosis and thrombosis and 21 extrahepatic portal vein obstruction) who underwent banding. Banding was performed every 2-3 weeks until eradication; endoscopic follow-up was performed at 1, 3, 6 months, then annually. RESULTS Eradication was achieved in 233 patients. Median time to eradication in cirrhotic patients with portal vein thrombosis vs. cirrhotic patients without thrombosis was 50.9 days (12-440) vs. 43.4 days (13-489.4); log-rank: 0.04; patients with extrahepatic portal vein obstruction vs. cirrhotic patients without thrombosis 63.9 days (31-321.6) vs. 43.4 days (13.0-489.4); log-rank: 0.008. Thrombosis was shown to be the only risk factor for longer time to eradication. CONCLUSIONS Portal vein thrombosis per se appears to be the cause of a longer time to achieve eradication of varices but, once eradication is achieved, it does not influence their recurrence.
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Affiliation(s)
- Alessandra Dell'Era
- Department of Medical Sciences, Università degli Studi di Milano - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy; Gastroenterology 3 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy.
| | - Francesca Iannuzzi
- Department of Medical Sciences, Università degli Studi di Milano - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy; Gastroenterology 3 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Federica M Fabris
- Gastroenterology 3 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Paola Fontana
- Department of Medical Sciences, Università degli Studi di Milano - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy; Gastroenterology 3 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Raffaella Reati
- Department of Medical Sciences, Università degli Studi di Milano - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy; Gastroenterology 3 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Paolo Grillo
- Epidemiology Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Alessio Aghemo
- Gastroenterology 1 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Roberto de Franchis
- Department of Medical Sciences, Università degli Studi di Milano - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy; Gastroenterology 3 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Massimo Primignani
- Gastroenterology 3 Unit - IRCCS Fondazione Cà Granda Ospedale Policlinico di Milano, Milan, Italy
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de Franchis R, Dell’Era A. Pre-primary and Primary Prophylaxis of Variceal Hemorrhage. Variceal Hemorrhage 2014. [PMCID: PMC7121476 DOI: 10.1007/978-1-4939-0002-2_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Variceal hemorrhage is a life-threatening complication of portal hypertension. Thus, prevention of variceal formation (pre-primary prophylaxis) or at least prevention of variceal bleeding are important goals to improve life quality and—if possible—survival of patients with liver cirrhosis. Interruption of the underlying cause of liver disease is the most successful approach, which, however, often fails. For this situation interruption or modulation of different pathophysiological mechanisms leading to fibrosis, hyperdynamic circulation and portal hypertension have been shown effective in animal models. But few could be translated to humans. By contrast, different steps to prevent first bleeding from varices have proven successful in many clinical trials. These applied mainly drugs to lower portal pressure, such as nonselective β-blockers, or endoscopic obliteration of varices, while prophylactic shunt procedures are not advised.
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Affiliation(s)
| | - Alessandra Dell’Era
- Ospedale Universitario Luigi Sacco, Universitá degli Studi di Milano, UOC Gastroenterologia, Milano, Italy
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Cassinotti A, Sarzi-Puttini P, Fichera M, Shoenfeld Y, de Franchis R, Ardizzone S. Immunity, autoimmunity and inflammatory bowel disease. Autoimmun Rev 2014; 13:1-2. [DOI: 10.1016/j.autrev.2013.06.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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de Franchis R. Small bowel capsule endoscopy for management of Crohn's disease: where do we stand? Dig Liver Dis 2013; 45:556-7. [PMID: 23731842 DOI: 10.1016/j.dld.2013.03.022] [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: 03/19/2013] [Accepted: 03/29/2013] [Indexed: 12/11/2022]
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Rondonotti E, Marmo R, Petracchini M, de Franchis R, Pennazio M. The American Society for Gastrointestinal Endoscopy (ASGE) diagnostic algorithm for obscure gastrointestinal bleeding: eight burning questions from everyday clinical practice. Dig Liver Dis 2013; 45:179-85. [PMID: 22921043 DOI: 10.1016/j.dld.2012.07.012] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [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: 05/08/2012] [Revised: 07/03/2012] [Accepted: 07/15/2012] [Indexed: 12/11/2022]
Abstract
The diagnosis and management of patients with obscure gastrointestinal bleeding are often long and challenging processes. Over the last 10 years the introduction in clinical practice of new diagnostic and therapeutic procedures (i.e. Capsule Endoscopy, Computed Tomographic Enterography, Magnetic Resonance Enterography, and Device Assisted Enteroscopy) has revolutionized the diagnostic/therapeutic work-up of these patients. Based on evidence published in the last 10 years, international scientific societies have proposed new practice guidelines for the management of obscure gastrointestinal bleeding, which include these techniques. However, although these algorithms (the most recent ones are endorsed by the American Society for Gastrointestinal Endoscopy - ASGE) allow the management of the large majority of patients, some issues still remain unsolved. The present paper reports the results of the discussion, based on the literature published up to September 2011, among a panel of experts and gastroenterologists, working with Capsule Endoscopy and with Device Assisted Enteroscopy, attending the 6th annual meeting of the Italian Club for Capsule Endoscopy and Enteroscopy. Eight unresolved issues were selected: each of them is presented as a "Burning question" and the "Answer" is the strategy proposed to manage it, according to both the available evidence and the discussion among participants.
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Cagliani R, Pozzoli U, Forni D, Cassinotti A, Fumagalli M, Giani M, Fichera M, Lombardini M, Ardizzone S, Asselta R, de Franchis R, Riva S, Biasin M, Comi GP, Bresolin N, Clerici M, Sironi M. Crohn's disease loci are common targets of protozoa-driven selection. Mol Biol Evol 2013; 30:1077-87. [PMID: 23389767 DOI: 10.1093/molbev/mst020] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Previous studies indicated that a few risk variants for autoimmune diseases are subject to pathogen-driven selection. Nonetheless, the proportion of risk loci that has been targeted by pathogens and the type of infectious agent(s) that exerted the strongest pressure remain to be evaluated. We assessed whether different pathogens exerted a pressure on known Crohn's disease (CD) risk variants and demonstrate that these single-nucleotide polymorphisms (SNPs) are preferential targets of protozoa-driven selection (P = 0.008). In particular, 19% of SNPs associated with CD have been subject to protozoa-driven selective pressure. Analysis of P values from genome-wide association studies (GWASs) and meta-analyses indicated that protozoan-selected SNPs display significantly stronger association with CD compared with nonselected variants. This same behavior was not observed for GWASs of other autoimmune diseases. Thus, we integrated selection signatures and meta-analysis results to prioritize five genic SNPs for replication in an Italian cohort. Three SNPs were significantly associated with CD risk, and combination with meta-analysis results yielded P values < 4 × 10(-6). The bona fide risk alleles are located in ARHGEF2, an interactor of NOD2, NSF, a gene involved in autophagy, and HEBP1, encoding a possible mediator of inflammation. Pathway analysis indicated that ARHGEF2 and NSF participate in a molecular network, which also contains VAMP3 (previously associated to CD) and is centered around miR-31 (known to be disregulated in CD). Thus, we show that protozoa-driven selective pressure had a major role in shaping predisposition to CD. We next used this information for the identification of three bona fide novel susceptibility loci.
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Affiliation(s)
- Rachele Cagliani
- Bioinformatics Laboratory, Scientific Institute IRCCS E Medea, Bosisio Parini, LC, Italy
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Rondonotti E, Soncini M, Girelli CM, Russo A, Ballardini G, Bianchi G, Cantù P, Centenara L, Cesari P, Cortelezzi CC, Gozzini C, Lupinacci G, Maino M, Mandelli G, Mantovani N, Moneghini D, Morandi E, Putignano R, Schalling R, Tatarella M, Vitagliano P, Villa F, Zatelli S, Conte D, Masci E, de Franchis R. Can we improve the detection rate and interobserver agreement in capsule endoscopy? Dig Liver Dis 2012; 44:1006-11. [PMID: 22858420 DOI: 10.1016/j.dld.2012.06.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [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: 04/03/2012] [Revised: 05/15/2012] [Accepted: 06/20/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Data about strategies for improving the diagnostic ability of capsule endoscopy readers are lacking. AIM (1) To evaluate the detection rate and the interobserver agreement among readers with different experience; (2) to verify the impact of a specific training (hands-on training plus expert tutorial) on these parameters. METHODS 17 readers reviewed 12 videos twice; between the two readings they underwent the training. The identified small bowel findings were described by a simplified version of Structured Terminology and classifies as clinically significant/non-significant. Findings identified by the readers were compared with those identified by three experts (Reference Standard). RESULTS The Reference Standard identified 26 clinically significant findings. The mean detection rate of overall readers for significant findings was low (about 50%) and did not change after the training (46.2% and 46.4%, respectively). There was no difference in the detection rate among readers with different experience. The interobserver agreement with the Reference Standard in describing significant findings was moderate (k = 0.44; CI95%: 0.39-0.50) and did not change after the training (k = 0.44; CI95%: 0.38-0.49) or stratifying readers according to their experience. CONCLUSIONS Both the interobserver agreement and the detection rate of significant findings are low, regardless of the readers' experience. Our training did not significantly increase the performance of readers with different experience.
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Shneider BL, Bosch J, de Franchis R, Emre SH, Groszmann RJ, Ling SC, Lorenz JM, Squires RH, Superina RA, Thompson AE, Mazariegos GV. Portal hypertension in children: expert pediatric opinion on the report of the Baveno v Consensus Workshop on Methodology of Diagnosis and Therapy in Portal Hypertension. Pediatr Transplant 2012; 16:426-37. [PMID: 22409296 DOI: 10.1111/j.1399-3046.2012.01652.x] [Citation(s) in RCA: 132] [Impact Index Per Article: 11.0] [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: 12/13/2022]
Abstract
Complications of portal hypertension in children lead to significant morbidity and are a leading indication for consideration of liver transplantation. Approaches to the management of sequelae of portal hypertension are well described for adults and evidence-based approaches have been summarized in numerous meta-analyses and conferences. In contrast, there is a paucity of data to guide the management of complications of portal hypertension in children. An international panel of experts was convened on April 8, 2011 at The Children's Hospital of Pittsburgh of UPMC to review and adapt the recent report of the Baveno V Consensus Workshop on the Methodology of Diagnosis and Therapy in Portal Hypertension to the care of children. The opinions of that expert panel are reported.
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Maconi G, Bolzacchini E, Dell'Era A, Russo U, Ardizzone S, de Franchis R. Portal vein thrombosis in inflammatory bowel diseases: a single-center case series. J Crohns Colitis 2012; 6:362-7. [PMID: 22405175 DOI: 10.1016/j.crohns.2011.10.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [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: 08/11/2011] [Revised: 09/25/2011] [Accepted: 10/11/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND METHODS Portal vein thrombosis (PVT) has been reported as a complication of IBD in some case reports. We describe the presentation, diagnostic approaches, underlying risks factors and clinical outcome of 8 IBD patients with PVT. CASE-SERIES: The patients presented with partial PVT (4 patients) or portal cavernoma. Five patients had undergone surgery. In 2 patients portal biliopathy was diagnosed after detection of PVT. In 4 patients, the diagnosis of PVT was made while IBD was in remission. Five patients showed at least one risk factor for hypercoagulability: lupus anti-coagulant (one patient), increased von Willebrand factor (2 patients) or homocysteine levels (4 patients). Four patients received anticoagulant therapy for 6 months. None experienced other thrombotic events during a median of 5 years (range 2-8 years). CONCLUSION PVT is a potential complication of IBD, usually associated with acquired or inherited risks factors for hypercoagulability and with a benign outcome.
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Affiliation(s)
- Giovanni Maconi
- Gastrointestinal Unit, Department of Clinical Sciences, L.Sacco University Hospital, Milan, Italy.
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D'Ambrosio R, Aghemo A, Rumi MG, Primignani M, Dell'Era A, Lampertico P, Donato MF, De Nicola S, Prati GM, de Franchis R, Colombo M. The course of esophageal varices in patients with hepatitis C cirrhosis responding to interferon/ribavirin therapy. Antivir Ther 2012; 16:677-84. [PMID: 21817189 DOI: 10.3851/imp1807] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Gastrointestinal haemorrhage from ruptured esophageal varices (EV) is a significant cause of morbidity and mortality in patients with HCV-related cirrhosis. The risk of developing EV and bleeding is influenced by hepatitis severity, which can be attenuated by successful interferon (IFN) therapy. Our aim was to prospectively assess whether a successful IFN therapy modifies development and/or progression of EV in patients with HCV-related compensated cirrhosis. METHODS Child-Pugh A patients with either no or small (F1) EV underwent surveillance with repeated endoscopy during and after completion of IFN-based therapy. RESULTS A total of 127 patients (59 years, 79 males, 65 HCV-1/4 and 17 F1 EV) received weight-based ribavirin (RBV) combined with either IFN-α2b 3 MU three times per week (n=36), weekly pegylated (PEG)-IFN-α2b 1.5 μg/kg (n=68) or weekly PEG-IFN-α2a 180 μg (n=23). Patients were followed-up for 18-108 months after treatment completion with a median endoscopic follow-up of 68 months for the 62 patients with a sustained virological response (SVR) and 57 months for the 65 non-SVR patients (P=0.3). De novo EV developed in 10 (9.1%) patients including 2/57 SVR and 8/53 non-SVR (3.5% versus 15.1%; P=0.047), whereas EV progressed in size in 3 patients, including 1/5 SVR and 2/12 non-SVR (P=0.87). Two non-SVR patients bled from EV and one died. CONCLUSIONS A successful IFN therapy prevents or delays the de novo onset of EV in patients with compensated cirrhosis due to HCV, but does not abrogate the need for continued endoscopic surveillance.
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Affiliation(s)
- Roberta D'Ambrosio
- AM Migliavacca Center for Liver Disease, First Division of Gastroenterology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
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Spada C, Hassan C, Sturniolo GC, Marmo R, Riccioni ME, de Franchis R, Van Gossum A, Costamagna G. Literature review and recommendations for clinical application of Colon Capsule Endoscopy. Dig Liver Dis 2011; 43:251-8. [PMID: 21067981 DOI: 10.1016/j.dld.2010.10.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [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: 08/03/2010] [Revised: 09/16/2010] [Accepted: 10/01/2010] [Indexed: 12/11/2022]
Abstract
Colon Capsule Endoscopy represents a new diagnostic technology for colonic exploration. Despite the great enthusiasm around this new technique, only few studies are available in the literature, and reported results are still controversial and non-homogeneous. Current preparation protocols have led to discordant results. In January 2010, the first Italian Meeting on Colon Capsule Endoscopy was held. Aim of this Meeting was to critically evaluate the available results obtained by Colon Capsule Endoscopy in clinical studies, in order to identify the proper test indications, to propose a shared preparation protocol and Colon Capsule Endoscopy procedure. Studies published in literature were extensively reviewed and analysed during the Meeting. The available evidence served to propose recommendations for preparation protocols, proper test indications and Colon Capsule Endoscopy procedure. Possible perspectives were also critically analysed and are reported in this paper.
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Tontini GE, Rondonotti E, Saladino V, Saibeni S, de Franchis R, Vecchi M. Impact of gluten withdrawal on health-related quality of life in celiac subjects: an observational case-control study. Digestion 2011; 82:221-8. [PMID: 20588037 DOI: 10.1159/000265549] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [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: 09/08/2009] [Accepted: 12/03/2009] [Indexed: 02/04/2023]
Abstract
AIMS To evaluate health-related quality of life (HRQoL) in celiac disease (CD) patients at the time of diagnosis and during a gluten-free diet (GFD). PATIENTS AND METHODS We enrolled 43 adult CD patients (18 with a typical and 15 with an atypical clinical presentation, and 10 with dermatitis herpetiformis, DH) and 86 age- and sex-matched healthy controls. We administered the Short Form 36 Health Survey (SF-36) questionnaire at diagnosis and after 1, 12 and 24 months of a GFD. RESULTS At the time of diagnosis CD patients showed significantly lower SF-36 scores than controls; this figure was observed in women but not in men. At baseline, both typical and atypical CD patients had lower SF-36 scores than controls, while DH patients showed a SF-36 profile comparable to that of controls. During a GFD the SF-36 scores improved continuously in CD patients and in the female subgroup, becoming similar to those of matched controls at 1-year follow-up. After gluten withdrawal typical and atypical CD patients improved their SF-36 scores and reached values comparable to those of controls. CONCLUSIONS At diagnosis, CD patients perceived a poor HRQoL; this figure appears to be mostly associated with female gender. In all subgroups of CD patients with a low HRQoL at diagnosis, the GFD allowed progressive restoration of HRQoL perception.
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Rondonotti E, Soncini M, Girelli C, Villa F, Russo A, de Franchis R. Cost estimation of small bowel capsule endoscopy based on "real world" data: inpatient or outpatient procedure? Dig Liver Dis 2010; 42:798-802. [PMID: 20399716 DOI: 10.1016/j.dld.2010.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Revised: 02/02/2010] [Accepted: 03/09/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although capsule endoscopy is the cornerstone for the evaluation of the small bowel in patients with obscure GI bleeding data about costs are lacking. AIM To evaluate, from a third party payer point of view, whether performing capsule endoscopy as an outpatient instead of an inpatient procedure can reduce costs. MATERIALS AND METHODS The data source is a multicentre survey collecting data for 2921 patients; 1486 of them underwent capsule endoscopy for obscure GI bleeding or chronic unexplained iron-deficiency anaemia as inpatients (814 with positive, 211 with inconclusive and 461 with negative result). We estimated costs of inpatient procedures based on the diagnosis related groups (DRG) system, while those of outpatient procedures on reimbursement provided in five Italian regions. RESULTS We estimated that the cost for each inpatient undergoing capsule endoscopy is about € 1775.90. Assuming that all these patients had undergone the same procedure as outpatients, € 175.00-741.00 per patient (depending on the reimbursement and/or on diagnosis related group codes applied) would have been saved. CONCLUSIONS Our estimate suggests that, from the third party payer's perspective and using the diagnosis related group reimbursement system, shifting capsule endoscopy from inpatient to outpatient procedure, would be potentially cost saving at least for patients referred for obscure GI bleeding or chronic unexplained anaemia.
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Affiliation(s)
- Emanuele Rondonotti
- Congregazione Suore Infermiere dell'Addolorata, Ospedale Valduce, U.O.C., Gastroenterologia, Como (CO), Italy.
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de Franchis R. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2010; 53:762-8. [PMID: 20638742 DOI: 10.1016/j.jhep.2010.06.004] [Citation(s) in RCA: 977] [Impact Index Per Article: 69.8] [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: 06/09/2010] [Revised: 06/12/2010] [Accepted: 06/14/2010] [Indexed: 02/06/2023]
Affiliation(s)
- Roberto de Franchis
- Department of Medical Sciences, University of Milan, Head, Gastroenterology 3 Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico Foundation, Milan, Italy.
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Bruno S, Crosignani A, Facciotto C, Rossi S, Roffi L, Redaelli A, de Franchis R, Almasio PL, Maisonneuve P. Sustained virologic response prevents the development of esophageal varices in compensated, Child-Pugh class A hepatitis C virus-induced cirrhosis. A 12-year prospective follow-up study. Hepatology 2010; 51:2069-76. [PMID: 20196120 DOI: 10.1002/hep.23528] [Citation(s) in RCA: 155] [Impact Index Per Article: 11.1] [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: 12/12/2022]
Abstract
UNLABELLED The incidence of de novo development of esophageal varices (EV) in patients with compensated liver cirrhosis has been determined by few studies in the short term and never in the long term. The aims of the present study were to determine the incidence and the risk factors associated with the development of EV and to assess whether antiviral treatment and achievement of sustained virologic response (SVR) may prevent de novo EV development in patients with HCV-induced cirrhosis. We studied 218 patients with compensated EV-free, HCV-induced cirrhosis consecutively enrolled between 1989 and 1992 at three referral centers in Milan, Italy. Endoscopic surveillance was performed at 3-year intervals according to international guidelines. SVR was defined as undetectable serum HCV-RNA 24 weeks after treatment discontinuation. During a median follow-up of 11.4 years, 149/218 (68%) patients received antiviral treatment and 34 (22.8%) achieved SVR. None of the SVR patients developed EV compared with 22 (31.8%) of the 69 untreated subjects (P < 0.0001) and 45 (39.1%) of the 115 non-SVR patients (P < 0.0001). On multivariate analysis, HCV genotype 1b (hazard ratio [HR] 2.40; 95% confidence interval [CI] 1.17-4.90) and baseline model for end-stage liver disease (MELD) score (HR 1.20; 95% CI 1.07-1.35 for 1 point increase) were independent predictors of EV. CONCLUSION In the long term, the achievement of SVR prevents the development of EV in patients with compensated HCV-induced cirrhosis. Therefore, in these patients, endoscopic surveillance can be safely delayed or avoided. Genotype 1b infection and MELD score identify the subset of patients at higher risk of EV development who need tailored endoscopic surveillance.
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Affiliation(s)
- Savino Bruno
- Department of Internal Medicine, A.O. Fatebenefratelli e Oftalmico, Milan, Italy.
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Abstract
Since the introduction of small bowel capsule endoscopy, and more recently of esophageal capsule endoscopy, these diagnostic tools have become available for the evaluation of the consequences of portal hypertension in the esophagus, stomach, and small intestine. The main advantage of the esophageal and the small bowel capsule is the relatively less invasiveness that could potentially increase patients' adherence to endoscopic screening/surveillance programs. When esophageal capsule endoscopy was compared with traditional gastroscopy, it showed good sensitivity and specificity in recognizing the presence and the size of esophageal varices. However, the results are not consistent among studies, and more data are needed.
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Affiliation(s)
- Emanuele Rondonotti
- Università degli Studi di Milano, IRCCS Ca' Granda Ospedale Policlinico Foundation, Italy
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Saibeni S, Saladino V, Chantarangkul V, Villa F, Bruno S, Vecchi M, de Franchis R, Sei C, Tripodi A. Increased thrombin generation in inflammatory bowel diseases. Thromb Res 2010; 125:278-82. [DOI: 10.1016/j.thromres.2009.10.012] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Revised: 10/19/2009] [Accepted: 10/21/2009] [Indexed: 12/19/2022]
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Tripodi A, Primignani M, Chantarangkul V, Dell'Era A, Clerici M, de Franchis R, Colombo M, Mannucci PM. An imbalance of pro- vs anti-coagulation factors in plasma from patients with cirrhosis. Gastroenterology 2009; 137:2105-11. [PMID: 19706293 DOI: 10.1053/j.gastro.2009.08.045] [Citation(s) in RCA: 392] [Impact Index Per Article: 26.1] [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: 05/25/2009] [Revised: 07/09/2009] [Accepted: 08/12/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with cirrhosis have an increased tendency to develop thromboses despite the longer coagulation times of their plasma, compared with that of healthy individuals. We investigated whether plasma from cirrhotic patients has an imbalance of pro- vs anti-coagulation factors. METHODS We analyzed blood samples from 134 cirrhotic patients and 131 healthy subjects (controls) for levels of pro- and anti-coagulants and for thrombin generation in the presence or absence of thrombomodulin (the main physiologic activator of the protein C anticoagulant pathway). RESULTS The median ratio of thrombin generation (with/without thrombomodulin) was higher in patients (0.80; range, 0.51-1.06) than controls (0.66; range, 0.17-0.95), indicating that cirrhotic patients are resistant to the action of thrombomodulin. This resistance resulted in greater hypercoagulability of plasma from patients of Child-Pugh class C than of class A or B. The hypercoagulability of plasma from patients of Child-Pugh class C (0.86; range, 0.70-1.06) was slightly greater than that observed under the same conditions in patients with congenital protein C deficiency (0.76; range, 0.60-0.93). Levels of factor VIII, a potent pro-coagulant involved in thrombin generation, increased progressively with Child-Pugh score (from Child-Pugh class A to C). Levels of protein C, one of the most potent naturally occurring anti-coagulants, showed the opposite trend. CONCLUSIONS The hypercoagulability of plasma from patients with cirrhosis appears to result from increased levels of factor VIII and decreased levels of protein C-typical features of patients with cirrhosis. These findings might explain the risk for venous thromboembolism in patients with chronic liver disease.
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Affiliation(s)
- Armando Tripodi
- Department of Internal Medicine and Medical Specialties, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milano, Italy.
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Abstract
Esophagogastroduodenoscopy (EGD) with 3 to 6 biopsies in the descending duodenum is the gold standard for the diagnosis of celiac disease. At the time of the first diagnosis of celiac disease, an extensive evaluation of the small bowel is not recommended. However, video capsule endoscopy, because of its good sensitivity and specificity in recognizing the Endoscopic features of celiac disease, can be considered a valid alternative to EGD in patients unable or unwilling to undergo EGD with biopsies. Capsule endoscopy is also a possible option in selected cases with strong suspicion of celiac disease but negative first-line tests. In evaluating patients with refractory or complicated celiac disease, in whom a complete evaluation of the small bowel is mandatory (at least in refractory celiac disease type II patients) because of the possible presence of complications beyond the reach of conventional endoscopes, both capsule endoscopy and balloon-assisted enteroscopy have been found to be helpful. In these patients, capsule endoscopy offers several advantages: it is well tolerated, it allows inspection of the entire small bowel, and it is able to recognize subtle mucosal changes. However, in this setting, capsule endoscopy should ideally be coupled with imaging techniques that provide important information about the thickness of the wall of the intestine and about extraluminal abnormalities. Although deep enteroscopy (such as balloon enteroscopy) is expensive, time-consuming, and potentially risky in these frail patients, they may have a key role, because they make it possible to take tissue samples from deep in the small intestine.
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Affiliation(s)
- Emanuele Rondonotti
- Department of Medical Sciences, Gastroenterology 3 Unit, University of Milan, IRCCS Policlinico, Mangiagalli, Regina Elena Foundation, 20122 Milan, Italy.
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Romeo R, Del Ninno E, Rumi M, Russo A, Sangiovanni A, de Franchis R, Ronchi G, Colombo M. A 28-year study of the course of hepatitis Delta infection: a risk factor for cirrhosis and hepatocellular carcinoma. Gastroenterology 2009; 136:1629-38. [PMID: 19208358 DOI: 10.1053/j.gastro.2009.01.052] [Citation(s) in RCA: 213] [Impact Index Per Article: 14.2] [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: 07/29/2008] [Revised: 12/19/2008] [Accepted: 01/19/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Chronic infection with hepatitis Delta virus (HDV) is a risk factor for cirrhosis and hepatocellular carcinoma (HCC); predictors of disease outcome are, however, poorly defined. We tracked the course of HDV infection in 299 patients over a mean period of 233 months. METHODS We analyzed data from patients who had been HDV positive for at least 6 months (230 males; mean age, 30 years) admitted from 1978 to 2006 to Maggiore Hospital, Milan. HDV infection was defined by the presence of HDV antigen in liver tissue or serum HDV RNA in anti-HDV/hepatitis B surface antigen seropositive patients. At enrollment, 7 patients had acute hepatitis, 101 had mild-moderate chronic hepatitis, 76 had severe chronic hepatitis, and 104 had histologic or clinical cirrhosis. Ninety patients were treated with interferon, 62 with corticosteroids, and 12 with nucleoside analogues; 135 received no therapy. RESULTS Over a mean period of 233 months, 82 patients developed cirrhosis. Among the 186 total patients with cirrhosis, 46 developed HCC, 43 ascites, 44 jaundice, and 1 encephalopathy. Female sex, alcohol abuse, and HDV replication were associated with liver decompensation; HBV replication and interferon were associated with HCC development. By the end of the study, 186 patients were still alive, 63 had died, and 29 had received liver transplants. The main cause of death was liver failure (n = 37, 59%); HDV replication was the only independent predictor of mortality. CONCLUSIONS Persistent HDV replication leads to cirrhosis and HCC at annual rates of 4% and 2.8%, respectively, and is the only predictor of liver-related mortality.
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Affiliation(s)
- Raffaella Romeo
- A. M. Migliavacca Center, First Division of Gastroenterology, IRCCS Maggiore Hospital, University of Milan, Milan, Italy.
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Abstract
Current guidelines recommend screening all cirrhotic patients by endoscopy, to identify patients at risk of bleeding who should undergo prophylactic treatment. However, since the prevalence of varices in cirrhotic patients is variable, universal screening would imply a large number of unnecessary endoscopies and a heavy burden for endoscopy units. In addition, compliance to screening programs may be hampered by the perceived unpleasantness of endoscopy. Predicting the presence of oesophageal varices by non-invasive means might increase compliance and would permit to restrict the performance of endoscopy to those patients with a high probability of having varices. Over the years, several studies have addressed this issue by assessing the potential of biochemical, clinical and ultrasound parameters, transient elastography, CT scanning and video capsule endoscopy. The platelet count/spleen diameter ratio, CT scanning and video capsule endoscopy have shown promising performance characteristics, although none of them is equivalent to EGD. These methods are perceived by patients as preferable to endoscopy and thus might increase adherence to screening programs. Whether this will compensate for the lower sensitivity of these alternative techniques, and ultimately improve the outcomes if more patients undergo screening, is the crucial question that will have to be answered in the future.
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Affiliation(s)
- Roberto de Franchis
- Department of Medical Sciences, University of Milan, Fondazione Ospedale IRCCS Maggiore Policlinico, Mangiagalli and Regina Elena, Milan, Italy.
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Abstract
Until recently, diagnosis and management of small-bowel tumors were delayed by the difficulty of access to the small bowel and the poor diagnostic capabilities of the available diagnostic techniques. An array of new methods has recently been developed, increasing the possibility of detecting these tumors at an earlier stage. Capsule endoscopy (CE) appears to be an ideal tool to recognize the presence of neoplastic lesions along this organ, since it is non-invasive and enables the entire small bowel to be visualized. High-quality images of the small-bowel mucosa may be captured and small and flat lesions recognized, without exposure to radiation. Recent studies on a large population of patients undergoing CE have reported small-bowel tumor frequency only slightly above that reported in previous surgical series (range, 1.6%-2.4%) and have also confirmed that the main clinical indication to CE in patients with small-bowel tumors is obscure gastrointestinal (GI) bleeding. The majority of tumors identified by CE are malignant; many were unsuspected and not found by other methods. However, it remains difficult to identify pathology and tumor type based on the lesion’s endoscopic appearance. Despite its limitations, CE provides crucial information leading in most cases to changes in subsequent patient management. Whether the use of CE in combination with other new diagnostic (MRI or multidetector CT enterography) and therapeutic (Push-and-pull enteroscopy) techniques will lead to earlier diagnosis and treatment of these neoplasms, ultimately resulting in a survival advantage and in cost savings, remains to be determined through carefully-designed studies.
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46
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Mondelli MU, de Franchis R, Colombo M. Management of liver diseases 2008. Foreword. J Hepatol 2008; 48 Suppl 1:S1. [PMID: 18304677 DOI: 10.1016/j.jhep.2008.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
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47
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de Franchis R, Eisen GM, Laine L, Fernandez-Urien I, Herrerias JM, Brown RD, Fisher L, Vargas HE, Vargo J, Thompson J, Eliakim R. Esophageal capsule endoscopy for screening and surveillance of esophageal varices in patients with portal hypertension. Hepatology 2008; 47:1595-603. [PMID: 18435461 DOI: 10.1002/hep.22227] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.6] [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: 12/12/2022]
Abstract
UNLABELLED Bleeding from esophageal varices (EV) is a serious consequence of portal hypertension. Current guidelines recommend screening patients with cirrhosis with esophagogastroduodenoscopy (EGD) to detect varices. However, the unpleasantness and need for sedation of EGD may limit adherence to screening programs. Pilot studies have shown good performance of esophageal capsule endoscopy in detecting varices. This multicenter trial was designed to assess the diagnostic performance of capsule endoscopy in comparison with EGD. Patients undergoing EGD for screening or surveillance of EV underwent a capsule study previously. The study was designed as an equivalence study, assuming that a difference of <or=10% between capsule endoscopy and EGD in diagnosing EV would demonstrate equivalence. Two hundred eighty-eight patients were enrolled. Endoscopy was for screening in 195 patients and for surveillance of known EV in 93. Overall agreement for detecting EV between EGD and capsule endoscopy was 85.8%; the kappa score was 0.73. Capsule endoscopy had a sensitivity, specificity, positive predictive value, and negative predictive value of 84%, 88%, 92%, and 77%, respectively. The difference in diagnosing EV was 15.6% in favor of EGD. There was complete agreement on variceal grade in 227 of 288 cases (79%). In differentiating between medium/large varices requiring treatment and small/absent varices requiring surveillance, the sensitivity, specificity, positive predictive value, and negative predictive value for capsule endoscopy were 78%, 96%, 87%, and 92%, respectively. Overall agreement on treatment decisions based on EV size was substantial at 91% (kappa = 0.77). CONCLUSION We recommend that EGD be used to screen patients with cirrhosis for large EV. However, the minimal invasiveness, good tolerance, and good agreement of capsule endoscopy with EGD might increase adherence to screening programs. Whether this is the case needs to be determined.
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Affiliation(s)
- Roberto de Franchis
- Department of Medical Sciences, University of Milan, Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Ospedale Maggiore Policlinico, Mangiagalli and Regina Elena, Milan, Italy.
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48
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Bosch J, Thabut D, Albillos A, Carbonell N, Spicak J, Massard J, D'Amico G, Lebrec D, de Franchis R, Fabricius S, Cai Y, Bendtsen F. Recombinant factor VIIa for variceal bleeding in patients with advanced cirrhosis: A randomized, controlled trial. Hepatology 2008; 47:1604-14. [PMID: 18393319 DOI: 10.1002/hep.22216] [Citation(s) in RCA: 183] [Impact Index Per Article: 11.4] [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: 12/11/2022]
Abstract
UNLABELLED A beneficial effect of recombinant activated factor VII (rFVIIa) in Child-Pugh class B and C patients with cirrhosis who have variceal bleeding has been suggested. This randomized controlled trial assessed the efficacy and safety of rFVIIa in patients with advanced cirrhosis and active variceal bleeding. At 31 hospitals in an emergency setting, 256 patients (Child-Pugh > 8; Child-Pugh B = 26%, C = 74%) were randomized equally to: placebo; 600 microg/kg rFVIIa (200 + 4x 100 microg/kg); or 300 microg/kg rFVIIa (200 + 100 microg/kg). Dosing was intravenous at 0, 2, 8, 14, and 20 hours after endoscopy, in addition to standard vasoactive, prophylactic antibiotic, and endoscopic treatment. The primary composite endpoint consisted of failure to control 24-hour bleeding, or failure to prevent rebleeding or death at day 5. Secondary endpoints included adverse events and 42-day mortality. Baseline characteristics were comparable between groups. Administration of rFVIIa had no significant effect on the composite endpoint compared with placebo (P = 0.37). There was no significant difference in 5-day mortality between groups; however, 42-day mortality was significantly lower with 600 microg/kg rFVIIa compared with placebo (odds ratio 0.31, 95% confidence interval = 0.13-0.74), and bleeding-related deaths were reduced from 12% (placebo) to 2% (600 microg/kg). A marked heterogeneity in the failure rate in all treatment groups was observed across participating centers. Adverse events, including overall thromboembolic events, were comparable between groups. CONCLUSION Treatment with rFVIIa had no significant effect on the primary composite endpoint compared with placebo. Therefore, decision on the use of this hemostatic agent in acute variceal bleeding should be carefully considered, because results of this study do not support the routine use of rFVIIa in this setting. Adverse events were comparable across groups.
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Affiliation(s)
- Jaime Bosch
- Hepatic Hemodynamic Laboratory, Hospital Clinic and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), University of Barcelona, Spain.
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49
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Abstract
Capsule endoscopy has revoluzionized the study of the small bowel by providing a reliable method to evaluate, endoscopically, the entire small bowel. In the last six years several papers have been published exploring the possible role of this examination in different clinical conditions. At the present time capsule endoscopy is generally recommended as a third examination, after negative bidirectional endoscopy, in patients with obscure gastrointestinal bleeding. A growing body of evidence suggests also an important role for this examination in other clinical conditions such as Crohn's disease, celiac disease, small bowel polyposis syndromes or small bowel tumors. The main complication of this examination is the retention of the device at the site of a previously unknown small bowel stricture. However there are also some other open issues mainly due to technical limitations of this tool (which is not driven from remote control, is unable to take biopsies, to insufflate air, to suck fluids or debris and sometimes to correctly size and locate lesions). The recently developed double balloon enteroscope, owing to its capability to explore a large part of the small bowel and to take targeted biopsies, although being invasive and time consuming, can overcome some limitations of capsule endoscopy. At the present time, in the majority of clinical conditions (i.e. obscure GI bleeding), the winning strategy seems to be to couple these two techniques to explore the small bowel in a painless, safe and complete way (with capsule endoscopy) and to define and treat the lesions identified (with double balloon enteroscopy).
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Affiliation(s)
- Emanuele Rondonotti
- Universuta degli Studi di Milano, IRCCS Fondazione Policlinico, Mangiagalli, Regina Elena, Unita Operativa di Gastroenterologia 3, Via Pace 9, Milano 20122, Italy.
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50
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Rondonotti E, Villa F, Mulder CJJ, Jacobs MAJM, Franchis RD. Small bowel capsule endoscopy in 2007: indications, risks and limitations. World J Gastroenterol 2007; 13:6140-9. [PMID: 18069752 PMCID: PMC4171222 DOI: 10.3748/wjg.v13.i46.6140] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2007] [Revised: 09/25/2007] [Accepted: 10/26/2007] [Indexed: 02/06/2023] Open
Abstract
Capsule endoscopy has revoluzionized the study of the small bowel by providing a reliable method to evaluate, endoscopically, the entire small bowel. In the last six years several papers have been published exploring the possible role of this examination in different clinical conditions. At the present time capsule endoscopy is generally recommended as a third examination, after negative bidirectional endoscopy, in patients with obscure gastrointestinal bleeding. A growing body of evidence suggests also an important role for this examination in other clinical conditions such as Crohn's disease, celiac disease, small bowel polyposis syndromes or small bowel tumors. The main complication of this examination is the retention of the device at the site of a previously unknown small bowel stricture. However there are also some other open issues mainly due to technical limitations of this tool (which is not driven from remote control, is unable to take biopsies, to insufflate air, to suck fluids or debris and sometimes to correctly size and locate lesions). The recently developed double balloon enteroscope, owing to its capability to explore a large part of the small bowel and to take targeted biopsies, although being invasive and time consuming, can overcome some limitations of capsule endoscopy. At the present time, in the majority of clinical conditions (i.e. obscure GI bleeding), the winning strategy seems to be to couple these two techniques to explore the small bowel in a painless, safe and complete way (with capsule endoscopy) and to define and treat the lesions identified (with double balloon enteroscopy).
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