Health care costs of complex perianal fistula in Crohn's disease

AIM

To evaluate the use of health care resources and the associated costs of complex perianal Crohn's disease (CD) from the National Health System perspective.

METHODS

We conducted a multicenter, retrospective, observational study in which gastroenterologists from 11 hospitals in the Community of Madrid took part. Data was collected on the direct healthcare resources (pharmacological treatments, surgical procedures, laboratory/diagnostic tests, visits to specialists and emergency departments, and hospitalizations) consumed by 97 adult patients with complex perianal CD which was active at some point between January 1, 2005, and case history review.

RESULTS

We recorded 527 treatments: 73.1% pharmacological (32.3% antibiotic, 20.5% immunomodulator, 20.3% biological) and 26.9% surgical. Mean annual global cost was €8,289/patient, 75.3% (€6,242) of which was accounted for by pharmacological treatments (€13.44 antibiotics; €1,136 immunomodulators; €5,093 biological agents), 12.4% (€1,027) by hospitalizations and surgery, 7.7% (€640) by medical visits, 4.2% (€350) by laboratory/diagnostic tests, and 0.4% (€30) by emergency department visits.

CONCLUSIONS

Pharmacological therapies, and in particular biological agents, are the main cost driver in complex perianal CD; costs due to surgery and hospitalizations are much lower.

Intensification of infliximab therapy in Crohn's disease: efficacy and safety

INTRODUCTION

The response of Crohn's disease (CD) to infliximab is initially good, although a loss of efficacy is observed over time. Dose escalation has been recommended in such cases.

AIMS

To study the response to an intensified infliximab regimen in patients with CD; and to evaluate the adverse effects associated with intensification of therapy and identify predictors of loss of response.

METHODS

We performed a retrospective multicenter survey of all patients with CD who had been treated with at least the 3 induction doses of standard infliximab therapy, and for whom treatment had to be intensified due to loss of response. We analyzed the efficacy of the intensified regimen.

RESULTS

Thirty-three patients were included. After the first intensification dose, 79% of patients had a clinical response (33.5% complete response, 45.5% partial response). In the long term, 83%, 69%, 47%, and 29% of patients who had an initial response to the intensification maintained the response at 6, 12, 18, and 36 months, respectively. The loss of efficacy after escalation was 43% per patient-year of follow-up. One patient had an infusion reaction after 36 doses. One patient developed a herpes zoster infection.

CONCLUSIONS

A high proportion of patients whose dose of infliximab is increased due to loss of efficacy respond initially. However, nearly half lose the response after one year. The safety profile of an intensified infliximab regimen is good.

Refractory hepatic hydrothorax: successful treatment with octreotide

We report the case of a patient that developed hepatic hydrothorax as the first complication of liver cirrhosis. Due to the lack of response to diuretics, pleurodesis and TIPS, treatment with octreotide was started with resolution of hydrothorax. To the best of our knowledge, this is the third reported case of refractory hepatic hydrothorax with complete and sustained response to octreotide.

Higher proliferative capacity of T lymphocytes from patients with Crohn disease than from ulcerative colitis is disclosed by use of Herpesvirus saimiri-transformed T-cell lines

BACKGROUND

T lymphocytes play a crucial role in the pathogenesis of inflammatory bowel disease. Achieving stable T-cell lines, rather than continuous bleeding of patients, is desirable in order to dissect their implication in the disease.

METHODS

Long-lasting T-cell lines from patients with Crohn disease and ulcerative colitis and from healthy volunteers have been obtained by transformation of T lymphocytes using the lymphotropic Herpesvirus saimiri. Lines were subjected to phenotypic and functional analyses, and the results compared with freshly isolated peripheral blood mononuclear cells.

RESULTS

Fresh cells revealed only minor differences between patients and controls, with regard to phenotype and proliferative capacity. In contrast, the use of T-cell lines showed that cells from Crohn disease patients, but not ulcerative colitis patients, over-responded to several membrane or cytoplasmic stimuli when compared to control T-cell lines. Thus, higher responses were found when stimulated with alphaCD3 and IL2, alphaCD3 and alphaCD28, IL2 alone, phorbol esters (PMA) and alphaCD3 and, finally, PMA and alphaCD2 (P < 0.05 in all instances). Further, lines from patients with Crohn disease responded more vigorously to alphaCD3 and alphaCD28 or alphaCD3 and PMA when compared to ulcerative colitis (P < 0.05 in both instances).

CONCLUSIONS

The data obtained with these lines suggest that T cells from patients with Crohn disease differ in vivo in their proliferative capacity, as compared with those from ulcerative colitis patients, a finding that may reflect the clear Th-1 phenotype found in the former and absent in the latter.

Predictors of response to infliximab in patients with fistulizing Crohn's disease

OBJECTIVE

To evaluate the efficacy and toxicity of infliximab for the treatment of fistulizing Crohn's disease.

METHODS

Consecutive patients with fistulizing Crohn's disease receiving infliximab were prospectively enrolled. Partial response was defined as a reduction of 50% or more from base-line in the number of draining fistulae. Complete response was defined as the closure of all fistulae. The influence of different variables on the efficacy of infliximab was evaluated.

RESULTS

108 patients were included. The disease was inflammatory plus fistulizing in 18% and only fistulizing in 82%. After the third infusion of infliximab the response was partial in 26% and complete in 57%. Response (%) rates (partial/complete) depending on fistula location were: enterocutaneous (25/68%), perianal (35/60%), rectovaginal (36/64%), and enterovesical (20/40%). None of the studied variables (including concomitant immunosuppressive therapy) correlated with efficacy of infliximab in the multivariate analysis. Incidence of adverse effects (21%) depending on the dose of infliximab was: first dose (5.6%), second (7.4%), and third (11.1%).

CONCLUSIONS

Infliximab is an efficacious treatment for fistulizing Crohn's disease. Partial response was achieved in approximately one third of the patients, and complete response in more than half. No studied variable was predictive of response. Adverse effects were relatively infrequent and mild.

Autoimmune enteropathy in an adult with autoimmune multisystemic involvement

We describe the case of a 58-year-old woman with autoimmune enteropathy associated with thyroiditis, gastritis, transitory neutropenia, sicca syndrome and severe axonal polyneuropathy of autoimmune origin. Enterocyte autoantibodies were not detected. However, predisposition to autoimmune disease was indicated by the presence of high titres of anti-gastric parietal cell, anti-thyroglobulin, anti-thyroid peroxidase and anti-neutrophil antibodies. CD4+ and CD8+ lymphocytes were equally distributed in the lamina propria of the small intestine, but CD8+ cells were highly represented among intraepithelial lymphocytes.

Collagenous gastrobulbitis and collagenous colitis. Case report and review of the literature

A case is reported of collagenous gastrobulbitis on collagenous colitis in a 57-year-old woman with a 6-month history of watery diarrhea. Low serum levels of total proteins and albumin and increased fecal elimination of alpha1-antitrypsin were the only abnormal laboratory test results. Biopsy specimens from the colon, rectum, antrum, fundus, and duodenal bulb showed a thick subepithelial band composed of ultrastructurally normal collagen immunohistochemically negative for collagen IV and laminin. The diarrhea resolved with prednisone and responded to this treatment after a relapse 6 months later. One year later the patient developed severe alimentary intolerance and secondary weight loss. This symptom also responded to the same treatment. However, the collagen deposition did not disappear in the second biopsy samples of colonic and gastric mucosa. Only six cases have been previously reported with gastric and/or duodenal subepithelial collagenous deposition. Four were associated with collagenous colitis. One of these presented a subepithelial collagenous band in the terminal ileum. All these features suggest that this collagen deposition may affect the entire digestive tract with variable intensity, extension, and symptoms.

[Systemic amyloidosis associated with common variable hypogammaglobulinemia and intestinal lymphoid nodular hyperplasia]

Common variable hypogammaglobulinemia syndrome with lymphoid nodular hyperplasia of the intestine forms part of the so-called hypogammaglobulinemic enteropathies. It is characterized by decreased serum immunoglobulins, recurrent respiratory tract infections and chronic diarrhea. The development of systemic amyloidosis is infrequent, but it can be explained by the multiple infections in this setting. The case of a 47-years old woman with hypogammaglobulinemic enteropathy, who developed systemic amyloidosis is presented. It was manifested as a nephrotic syndrome. The previously published reports include 12 cases of common variable hypogammaglobulinemia with systemic amyloidosis. Half of them presented nephrotic syndrome as a manifestation of their amyloidosis. It is important to keep in mind this complication in these patients' follow-up in order to increase the doses of gammaglobulin. That is the way to compensate their additional losses because of the nephrotic syndrome that they usually develop.

[A comparative study of 2 technics of percutaneous endoscopic gastrostomy]

OBJECTIVE

To compare the two most frequently used methods of percutaneous endoscopic gastrostomy: Pull-string Ponsky-Gauderer type and Push-over-wire Sachs-Vine gastrostomy.

PATIENTS AND METHODS

Forty-four patients with oral feeding incapacity were prospectively randomized to one of the two methods of percutaneous endoscopic gastrostomy. In 22 patients the Ponsky-Gauderer type were used and in the other 22 the Sachs-Vine gastrostomy were employed. In every case the gastrostomy tube was replaced 4-5 months after its placement by a Flexiflo tube. The mean follow-up of the patients was 7.3 months (range: 4-18).

RESULTS

Gastrostomy was successful in every case. No differences were found between the two procedures in technical difficulties or complications during gastrostomy placement. Wound infection occurred in 6 patients (13%), 3 in each group, and in all cases it was cured with topic antibiotic treatment administered through the gastrostomy. Tube dislodgement was observed in 3 patients in the Ponsky-Gauderer group (soft internal with-holder). The only significant difference between the two procedures was found at the removal of the gastrostomy tube. In the Sachs-Vine type the removal of the tube was always endoscopically performed (due to the presence of a rigid internal with-holder), while the Ponsky-Gauderer type was always done by traction (soft internal with-holder). No related procedure mortality was found with any of the two techniques.

CONCLUSION

Both percutaneous endoscopic gastrotomy techniques are similar in efficacy, safety and morbidity and they prove to be a valid alternative to surgical gastrostomy in patients with oral feeding incapacity.

[A comparative randomized controlled study of the efficacy of interferon alfa-2b and interferon alfa-2a in the treatment of chronic hepatitis C]

Interferon (INF) is the treatment of choice in active chronic hepatitis C although the optimum therapeutic schedule remains undefined to date. One forty-eight patients with active chronic hepatitis C were included in a randomized controlled study to compare the therapeutic efficacy of 2 types of recombinant alpha IFN: alpha-2b IFN and alpha-2a IFN. Twelve patients were excluded from the study for different reasons. The groups were made up of 34 untreated patients (group I), 68 patients treated with 5 MU of alpha-2b IFN three times per week for 12 months (group II) and 32 patients with 6 MU of alpha-2a IFN three times per week for one year (group III). On finalization of the treatment 39 patients from group II (57%) and 20 (63%) from group III showed normal transaminases (p > 0.05) while this was not so in any patient from group I (p < 0.001). HCV infection of less than 5 years was significantly associated with complete biochemical response. During the post treatment follow up (16.2 +/- 11.1 months; range: 6-45 months) the transaminase levels reelevated in 26 (67%) responding patients from group II and in 12 (60%) patients from group III (p > 0.05). Therefore complete biochemical response was maintained in only 12 (19%) of the patients from group II and in 8 (25%) of the patients from group III (p > 0.05). Liver biopsy was carried out in the 3 post treatment months in 15 patients from group I, 29 from group II and 18 patients from group III with all the rebiopsied patients from groups II and III having demonstrated complete or partial response to IFN.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diagnostic value of the hepatic echo-histogram in chronic hepatopathy]

The aim of this study was to determine the histogram patterns and the diagnostic efficacy of liver echohistogram in chronic diffuse liver diseases. Abdominal ultrasound and liver echo-histogram were prospectively and blindly performed on 21 healthy controls, 24 patients with chronic hepatitis, 26 patients with liver cirrhosis, and 22 patients with fatty liver disease. Maximum liver echo intensity and echogenicity were decreased in chronic hepatitis. Increased anterior maximum liver echo intensity and echogenicity, decreased posterior maximum liver echo intensity and echogenicity, and reduced posterior/anterior maximum liver echogenicity ratio were found in fatty liver disease. The diagnostic efficacy indexes of abdominal ultrasound were enhanced by some echo-histogram data: anterior maximum echo intensity of the liver less than 20.52 decibels for chronic hepatitis and posterior/anterior maximum liver echogenicity ratio less than 0.231 for fatty liver disease. In liver cirrhosis, echohistogram showed a high dispersion of values and not enhanced the abdominal ultrasound diagnostic efficacy. In fatty liver disease, a positive correlation was found between percentage of hepatocytes with fatty change and anterior maximum echo intensity of the liver (rs = 0.47, p < 0.05), as well as between percentage of hepatocytes with fatty change and anterior maximum echogenicity of the liver (rs = 0.68, p < 0.01). These findings indicate that the liver echo-histogram improves the diagnostic efficacy of abdominal ultrasound in chronic hepatitis and fatty liver disease. We suggest that combined abdominal ultrasound and liver echo-histogram should be performed in the investigation of chronic diffuse liver diseases.

Rhabdomyolysis and cutaneous necrosis following intravenous vasopressin infusion

A continuous IV infusion of vasopressin was administrated to a patient with cirrhosis of the liver and acute gastrointestinal bleeding from esophageal varices. In the first 24 hours, the patient developed rhabdomyolysis and cutaneous necrosis. Stopping vasopressin infusion resulted in relief of these lesions. The rarity of these complications suggests an idiosyncratic reaction of susceptible individuals that may be related to previous vascular disease or a failure in baroreceptor regulation.

[Sixteen-year experience with gallbladder cancer. Review of 120 cases]

We reviewed retrospectively 120 patients with histologically diagnosed gallbladder carcinoma and collected during 16-years (1974-1989). Age and sex, annual distribution, predisposing factors, histological findings, clinical manifestations, complementary diagnostic methods, therapeutic measures and follow-up of patients were analyzed. Our results suggest the following conclusions: a) the annual incidence of gallbladder carcinoma remains unchanged; b) there is a close association with gallstones; c) the late diagnosis is due to unspecificity of clinical manifestations and low diagnostic effectivity of complementary methods; d) computed tomography and laparoscopy are the more effective complementary diagnostic methods in advanced gallbladder carcinoma; e) early gallbladder carcinoma is only diagnosed casually in cholecystectomy pieces; f) only the early carcinoma (grade I or II) is curable.