Clinical Course and Risk Factors for In-Hospital Mortality of 205 Patients with SARS-CoV-2 Pneumonia in Como, Lombardy Region, Italy

The aim of this study is to explore risk factors for in-hospital mortality and describe the effectiveness of different treatment strategies of 205 laboratory-confirmed cases infected with SARS-CoV-2 during the Lombardy outbreak. All patients received the best supportive care and specific interventions that included the main drugs being tested for repurposing to treat COVID-19, such as hydroxychloroquine, anticoagulation and antiviral drugs, steroids, and interleukin-6 pathway inhibitors. Clinical, laboratory, and treatment characteristics were analyzed with univariate and multivariate logistic regression methods to explore their impact on in-hospital mortality. Univariate analyses showed prognostic significance for age greater than 70 years, the presence of two or more relevant comorbidities, a P/F ratio less than 200 at presentation, elevated LDH (lactate dehydrogenase) and CRP (C-reactive protein) values, intermediate- or therapeutic-dose anticoagulation, hydroxychloroquine, early antiviral therapy with lopinavir/ritonavir, short courses of steroids, and tocilizumab therapy. Multivariable regression confirmed increasing odds of in-hospital death associated with age older than 70 years (OR 3.26) and a reduction in mortality for patients treated with anticoagulant (−0.37), antiviral lopinavir/ritonavir (−1.22), or steroid (−0.59) therapy. In contrast, hydroxychloroquine and tocilizumab have not been confirmed to have a significant effect in the treatment of SARS-CoV-2 pneumonia. Results from this real-life single-center experience are in agreement and confirm actual literature data on SARS-CoV-2 pneumonia in terms of both clinical risk factors for in-hospital mortality and the effectiveness of the different therapies proposed for the management of COVID19 disease.

Use of biosimilars in inflammatory bowel disease: a position update of the Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD)

The first infliximab biosimilar for the treatment of inflammatory bowel disease (IBD) was introduced in 2013, and today eight anti-TNF alpha biosimilars (three for infliximab and five for adalimumab) have been approved and licensed by the European Medicines Agency. Biosimilars present great potential in terms of cost saving and possible consequential reinvestment in the health care system. The increasing knowledge about the process of biosimilar development and use in IBD and the publication of many prospective clinical studies and real-life clinical experiences have progressively changed the point of view of IBD physicians. In the present position paper, the Italian Group for the Study of Inflammatory Bowel Disease present and discuss their updated statements and positions on this topic, with emphasis on the concepts of biosimilarity and extrapolation across indications, safety and immunogenicity, interchangeability and switching, automatic substitution, and, finally, patient education about biosimilars.

Haematemesis and acute dysphagia: oesophagogastroduodenoscopy or CT-which one first?

We present an uncommon case of a patient presenting at the emergency department for severe vomiting, persisting for at least 12 hours, without nausea or abdominal pain. She initially referred vomiting food eaten several hours earlier and eventually a single episode of haematemesis with emission of a small amount of red blood and clots. She also reported the occurrence of acute dysphagia for solid food. The patient underwent oesophagogastroduodenoscopy (OGD), which showed that the lumen was almost completely narrowed by a submucosal bluish bulging from midoesophagus (19 cm from the incisors) to the cardia (located at 35 cm from the incisors). She therefore underwent chest CT showing a 15 cm long intramural oesophageal haematoma. Although the combination of vomiting and haematemesis is usually associated with Mallory-Weiss syndrome, in which a prompt OGD has a key role in the patient management, when these symptoms are associated with acute dysphagia, a possible intramural haematoma might be suspected. In this case, chest CT should take precedence, because it allows a quick and complete diagnostic appraisal. However, in this setting, although OGD can directly show typical findings (bluish swelling mucosa with or without a superficial tears), it might increase the risk of oesophageal haematoma rupture and intraluminal bleeding.

The PROSIT Cohort of Infliximab Biosimilar in IBD: A Prolonged Follow-up on the Effectiveness and Safety Across Italy

BACKGROUND

We report a prospective, nationwide cohort evaluating the safety and effectiveness of CT-P13.

METHODS

A structured database was used to record serious adverse events (SAEs), clinical remission/response, inflammatory biomarkers (CRP and calprotectin), and endoscopic findings.

RESULTS

Eight hundred ten patients with inflammatory bowel disease (IBD) (452 Crohn's disease [CD]) were enrolled. Four hundred fifty-nine patients were naïve to anti-TNFα (group A), 196 had a previous exposure (group B), and the remaining 155 were switched to CT-P13 (group C). All patients were included in the safety evaluation with a mean follow-up of 345 ± 215 days and a total number of 6501 infusions. One hundred fifty-four SAEs were reported (19%), leading to cessation of the biosimilar in 103 subjects (12.7%). Infusion reactions were 71, leading to cessation of the biosimilar in 53 subjects (6.5%), being significantly more frequent in patients pre-exposed to anti-TNFα (P = 0.017). The efficacy of therapy was calculated in 754 IBD patients, with a mean follow-up of 329 ± 202 days. Forty-eight patients had a primary failure (6.4%), and 188 (25.6%) lost response during follow-up. Six hundred twenty-eight (364 CD) and 360 IBD patients (222 CD) completed the follow-up at 6 and 12 months, respectively. At 12 months, patients without loss of response were 71%, 64%. and 82% in groups A, B, and C, respectively (log rank P = 0.01). Clinical/endoscopic scores and inflammatory biomarkers dropped significantly in CD and UC patients (P = 0.01 and P < 0.0001) compared with baseline.

CONCLUSIONS

In this large prospective cohort, no further signals of difference in safety and effectiveness of CT-P13 in IBD has been observed.

Linked color imaging reduces the miss rate of neoplastic lesions in the right colon: a randomized tandem colonoscopy study

BACKGROUND

Linked color imaging (LCI) is a newly developed image-enhancing endoscopy technology that provides bright endoscopic images and increases color contrast. We investigated whether LCI improves the detection of neoplastic lesions in the right colon when compared with high definition white-light imaging (WLI).

METHODS

Consecutive patients undergoing colonoscopy were randomized (1:1) after cecal intubation into right colon inspection at first pass by LCI or by WLI. At the hepatic flexure, the scope was reintroduced to the cecum under LCI and a second right colon inspection was performed under WLI in previously LCI-scoped patients (LCI-WLI group) and vice versa (WLI-LCI group). Lesions detected on first- and second-pass examinations were used to calculate detection and miss rates, respectively. The primary outcome was the right colon adenoma miss rate.

RESULTS

Of the 600 patients enrolled, 142 had at least one adenoma in the right colon, with similar right colon adenoma detection rates (r-ADR) in the two groups (22.7 % in LCI-WLI and 24.7 % in WLI-LCI). At per-polyp analysis, double inspection of the right colon in the LCI-WLI and WLI-LCI groups resulted in an 11.8 % and 30.6 % adenoma miss rate, respectively (P < 0.001). No significant difference in miss rate was found for advanced adenomas or sessile serrated lesions. At per-patient analysis, at least one adenoma was identified in the second pass only (incremental ADR) in 2 of 300 patients (0.7 %) in the LCI - WLI group and in 13 of 300 patients (4.3 %) in the WLI - LCI group (P = 0.01).

CONCLUSIONS

LCI could reduce the miss rate of neoplastic lesions in the right colon.

Educational strategies for colonoscopy bowel prep overcome barriers against split-dosing: A randomized controlled trial

BACKGROUND

A split-dose (SD) regimen is crucial for colonoscopy quality. Compliance with SD for early morning colonoscopy is generally poor. The present study evaluated whether pre-colonoscopy counselling, in addition to a dedicated leaflet, might increase SD uptake.

METHODS

Consecutive 50-69-year-old patients undergoing screening colonoscopy before 10 a.m. were randomized to either receive written information only on bowel preparation (Written Group, WG) or written and oral instructions (Written and Oral Group, WaOG). The leaflet strongly encouraged SD adoption. The primary endpoint was the number of patients adopting SD in each group. The secondary endpoints were predictors of SD uptake, compliance with preparation schemes and cleansing adequacy.

RESULTS

A total of 286 patients (143 WG, 143 WaOG) were enrolled (mean age 59.6 ± 6.1 years, men 49.3%). SD was adopted by 114 and 125 patients in the WG and WaOG, respectively (79.7% versus 87.4%, p = 0.079). No significant differences were observed for the proportion of patients with full compliance with preparation scheme (97.9% versus 97.2%, p = 0.99) and of procedures with adequate bowel cleansing (95.6% versus 95.1%, p = 0.77). At multivariate analysis, a > 1 h travel time to the endoscopy service was inversely correlated with SD uptake (odds ratio (OR) 0.30, 95% confidence interval (CI) 0.09-0.98).

CONCLUSIONS

Our leaflet guaranteed satisfactory uptake of SD and excellent adherence to the preparation scheme for early morning colonoscopy. Its use might marginalize the need for additional oral instructions, particularly in open-access settings.

Accuracy of capsule colonoscopy and computed tomographic colonography in individuals with positive results from the fecal occult blood test

BACKGROUND & AIMS

Computed tomographic colonography (CTC) is a reliable option for screening subjects who are unable or unwilling to undergo optical colonoscopy (OC). A colon capsule (PillCam Colon2 [CC2]; GivenImaging Ltd., Yokneam, Israel) has shown promising results in detecting polyps larger than 6 mm. We compared the accuracy of CC2 and CTC in identifying individuals with at least 1 polyp greater than 6 mm and subjects' attitude toward the procedures.

METHODS

Fifty individuals (mean age, 59.2 ± 5.8 y; 58% male) with positive results from the immunochemical fecal occult blood test (iFOBT-positive) underwent CC2, CTC, and OC. The unblinded colonoscopy, integrating OC, CTC, and CC2 results, was used as the reference standard. In a per-patient analysis, the accuracy of CC2 and CTC were assessed for individuals with at least 1 polyp 6 mm or larger. Individuals were asked to choose which procedure they would be willing to repeat between CTC and CC2.

RESULTS

The combination of OC, CTC, and CC2 identified 16 cases with at least 1 polyp 6 mm or larger (reference standard). CTC identified the polyps with 88.2% sensitivity, 84.8% specificity, a 3.0 positive likelihood ratio, and a 0.07 negative likelihood ratio. CC2 identified the polyps with 88.2% sensitivity, 87.8% specificity, a 3.75 positive likelihood ratio, and a 0.06 negative likelihood ratio. Thirty-nine subjects (78%) said they preferred CC2 to CTC.

CONCLUSIONS

CC2 and CTC detect polyps 6 mm and larger with high levels of accuracy; these techniques are effective in selecting iFOBT-positive individuals who do not need to be referred for colonoscopy. CC2 seems to be better tolerated than CTC, and could be a reliable alternative to CTC for iFOBT-positive individuals who are unable or unwilling to undergo OC. ClinicalTrials.gov number: NCT01744509.

Hyoscine N-butylbromide for adenoma detection during colonoscopy: a randomized, double-blind, placebo-controlled study

BACKGROUND

Hyoscine N-butylbromide (HBB), commonly used during colonoscopy to facilitate cecal intubation, has been proposed to increase the adenoma detection rate (ADR).

AIMS

To evaluate whether HBB administration increases the adenoma detection rate and influences patients' tolerance.

METHODS

Consecutive colonoscopy outpatients were randomized after cecal intubation to receive either 20mg HBB or placebo i.v. The number, size, histology and location of polyps were recorded. The air retained in the abdomen was either indirectly estimated by ΔAC (difference in the abdominal circumference measured before and after colonoscopy) or directly evaluated by patients' perception (visual analogic scale, range 0-100).

RESULTS

402 patients (44% male; mean age 57.7±12.5years) received either HBB or placebo. No differences in ADR (31.7% vs. 28%, p=0.48), advanced-ADR (7.4% vs. 10.5%, p=0.35) were observed between HBB and placebo group, respectively. A significantly lower detection rate of flat/depressed lesions was observed in the HBB group (0.5% vs. 5.5%, p=0.003). The ΔAC and the bloating perception were comparable between the two groups (p=0.22 and p=0.48, respectively).

CONCLUSIONS

HBB administered before colonoscope withdrawal does not increase adenoma detection rate and seems to hamper the visualization of flat/depressed lesions. This finding raises concerns on the indiscriminate use of HBB during colonoscopy.

Resect and discard strategy in clinical practice: a prospective cohort study

BACKGROUND AND STUDY AIMS

Narrow-band imaging (NBI) has shown promising results in discriminating adenomatous from non-adenomatous colonic polyps. In patients with small polyps (< 10  mm), the application of NBI within a "resect and discard" strategy, might allow post-polypectomy surveillance intervals to be determined independently from histopathology. The aim of the present study was to assess the feasibility and safety of this approach in routine clinical practice.

PATIENTS AND METHODS

Consecutive colonoscopy outpatients with one or more polyps smaller than 10  mm were prospectively included. Each polyp was categorized by the endoscopist as adenoma or non-adenoma according to simplified NBI criteria, and future post-polypectomy surveillance interval was assigned accordingly. Following histopathology, post-polypectomy surveillance interval was subsequently re-assigned, and the accordance between endoscopy- and histology-directed surveillance strategies was calculated.

RESULTS

Among 942 colonoscopy patients, 286 (30.4 %) with only small polyps were included. In total, 511 small polyps were evaluated; 350 (68.5 %) were adenomas and 18 of these (5.1 %) had histologic features of advanced neoplasia. For the in vivo diagnosis of adenoma, NBI sensitivity, specificity, accuracy, and positive and negative likelihood ratios were 94.9 %, 65.8 %, 85.7 %, 2.80, and 0.08, respectively. The endoscopy-directed surveillance strategy was in accordance with the histology-directed strategy in 237 of 286 patients (82.9 %). In 9.8 % and 7.3 % patients, the endoscopy-directed approach would have resulted in early and delayed surveillance, respectively.

CONCLUSIONS

The resect and discard strategy seems to be a viable, safe, and cost-effective approach for the management of patients with small polyps. However, caution in the application of the strategy should be advocated for patients with polyps 6 - 9  mm in size and those with right-sided lesions, due to their malignant potential. The study was registered on Clinicaltrials.gov (NCT01462123).

Constipation in the elderly: management strategies

Constipation is a highly prevalent and bothersome disorder that negatively affects patients' social and professional lives and places a great economic burden on both patients and national health services. An accurate determination of the prevalence of constipation is difficult because of the various definitions used, but many epidemiological studies have shown that it affects up to 20% of the population at any one time. Although constipation is not a physiological consequence of normal aging, decreased mobility and other co-morbid medical conditions may contribute to its prevalence in older adults. Functional constipation is diagnosed when no secondary causes can be identified. Patients have some unusual beliefs about their bowel habits. Systematic attention to history, examination and investigation, especially in older people, can be highly effective in resolving problems and in enhancing quality of life. There is a considerable range of treatment modalities available for patients with constipation, but the clinical evidence supporting their use varies widely. However, if constipation is not managed proactively, patients can experience negative consequences, such as anorexia, nausea, bowel impaction or bowel perforation. The clinical benefits of various traditional pharmacological and non-pharmacological agents remain unclear. The first steps in the treatment of simple constipation include increasing intake of dietary fibre and the use of a fibre supplement. Patients with severe constipation or those unable to comply with the recommended intake of fibre may benefit from the addition of laxatives. More recently, newer agents (e.g. tegaserod and lubiprostone), have been approved for the treatment of patients with chronic constipation. Additional work is needed to determine what role, if any, these agents may play in the treatment of patients with chronic constipation. The purpose of this review is to identify evidence-based interventions for the prevention and management of constipation in the elderly.

Constipation in the elderly: management strategies

Constipation is a highly prevalent and bothersome disorder that negatively affects patients' social and professional lives and places a great economic burden on both patients and national health services. An accurate determination of the prevalence of constipation is difficult because of the various definitions used, but many epidemiological studies have shown that it affects up to 20% of the population at any one time. Although constipation is not a physiological consequence of normal aging, decreased mobility and other co-morbid medical conditions may contribute to its prevalence in older adults. Functional constipation is diagnosed when no secondary causes can be identified. Patients have some unusual beliefs about their bowel habits. Systematic attention to history, examination and investigation, especially in older people, can be highly effective in resolving problems and in enhancing quality of life. There is a considerable range of treatment modalities available for patients with constipation, but the clinical evidence supporting their use varies widely. However, if constipation is not managed proactively, patients can experience negative consequences, such as anorexia, nausea, bowel impaction or bowel perforation. The clinical benefits of various traditional pharmacological and non-pharmacological agents remain unclear. The first steps in the treatment of simple constipation include increasing intake of dietary fibre and the use of a fibre supplement. Patients with severe constipation or those unable to comply with the recommended intake of fibre may benefit from the addition of laxatives. More recently, newer agents (e.g. tegaserod and lubiprostone), have been approved for the treatment of patients with chronic constipation. Additional work is needed to determine what role, if any, these agents may play in the treatment of patients with chronic constipation. The purpose of this review is to identify evidence-based interventions for the prevention and management of constipation in the elderly.

High- versus low-dose proton pump inhibitors after endoscopic hemostasis in patients with peptic ulcer bleeding: a multicentre, randomized study

BACKGROUND

The most effective schedule of proton pump inhibitor (PPI) administration following endoscopic hemostasis of bleeding ulcers remains uncertain.

METHODS

Patients with actively bleeding ulcers and those with nonbleeding visible vessel or adherent clot were treated with epinephrine injection and/or thermal coagulation, and randomized to receive intravenous PPIs according to an intensive regimen (80 mg bolus followed by 8 mg/h as continuous infusion for 72 h) or a standard regimen (40 mg bolus daily followed by saline infusion for 72 h). After the infusion, all patients were given 20 mg PPI twice daily orally. The primary end point was the in-hospital rebleeding rate, as ascertained at the repeat endoscopy.

RESULTS

Bleeding recurred in 28 of 238 patients (11.8%) receiving the intensive regimen, and in 19 of 236 (8.1%) patients receiving the standard regimen (P= 0.18). Most rebleeding episodes occurred during the initial 72-h infusion: 18 (7.6%) and 19 events (8.1%) in the intensive and standard groups, respectively (P= 0.32). Mean units of blood transfused were 1.7 +/- 2.1 in the intensive and 1.5 +/- 2.1 in the standard regimen group (P= 0.34). The duration of hospital stay was <5 days for 88 (37.0%) and 111 patients (47.0%) in the intensive and standard groups (P= 0.03). There were fewer surgical interventions in the standard versus intensive regimen (1 vs 3). Five patients in each treatment group died.

CONCLUSIONS

Following endoscopic hemostasis of bleeding ulcers, standard-dose PPIs infusion was as effective as a high-dose regimen in reducing the risk of recurrent bleeding. (ClinicalTrials.gov number, NCT00374101).

Tumour necrosis factor alpha in segmental colitis associated with diverticula

The pathogenesis of segmental colitis associated with diverticula (SCAD) is unclear, but tumour necrosis factor alpha (TNF-alpha) has been shown to play a pivotal role in the pathogenesis of inflammatory bowel diseases. The aim of this study was to assess TNF-alpha levels in patients with SCAD. In a post hoc analysis of a prospective multicenter study, tissue samples from 13 patients diagnosed with SCAD were subjected to histological analyses. The severity of the inflammation was assessed by means of a histological score and histomorphometry (number of inflammatory cells/mm2). Immunohistochemical staining with an antibody against TNF-alpha was performed on all biopsies and the degree of staining expressed as the percentage of positive stromal cells/1000 counted (TNF-alpha score). Matched patients with irritable bowel syndrome (IBS) were used as controls. Over-expression of TNF-alpha was found in all SCAD patients (38.6 +/- 10.4%), and it was associated with a high histological score (2.5 +/- 0.5) and neutrophil cell count (16.3 +/- 3/mm2). These values were distinctly higher than those found in the IBS controls. Our data suggest that TNF-alpha activity is involved in SCAD pathogenesis, similarly to what occurs in Crohn's disease and ulcerative colitis.

Effectiveness of a continuous quality improvement program on colonoscopy practice

BACKGROUND AND STUDY AIM

Continuous quality improvement (CQI) is recommended by professional societies as part of every colonoscopy program, but little is known with regard to its effectiveness for colonoscopy outcomes. We prospectively assessed whether the implementation of a CQI program in routine clinical practice influences the quality performance of colonoscopy.

METHODS

In an open-access endoscopy unit at a secondary care center in Northern Italy, 6-monthly audit cycles were carried out over a 4-year period, to identify reasons for poor colonoscopy outcomes and institute appropriate changes to improve performance. The colonoscopy completion rate and the polyp detection rate as detected by endoscopists were considered to be key measures for improvement.

RESULTS

The initial crude colonoscopy completion rate was 84.6%, with a range for individual endoscopists 80.4%-94%. Four endoscopists had a completion rate lower than 90%. The overall polyp detection rate was 34%, with a wide variation among endoscopists (range 14%-42%). Poor patient tolerance and differences in colonoscopist expertise were the main determinants of lack of completion and variation in polyp detection rate. Changes to sedation practice, greater access to endoscopy sessions for the endoscopists with the lowest performance rates, and other organizational arrangements, were implemented to improve quality performance. The crude completion rates improved consistently, up to 93.1%, over the study period. This trend was confirmed even when adjusted completion rates were calculated. All endoscopists reached a crude completion rate of 90% or more and a polyp detection rate of over 20%. The introduction of CQI did not significantly change the overall incidence of procedure-related complications.

CONCLUSIONS

The effectiveness of colonoscopy can be improved by implementing a CQI program in routine colonoscopy practice.

Pregnancy before and after the diagnosis of inflammatory bowel diseases: retrospective case-control study

BACKGROUND AND AIM

Inflammatory bowel diseases (IBD) commonly affect women during the reproductive years. The aim of the present study was to evaluate the reproductive histories of patients with ulcerative colitis (UC) and Crohn's disease (CD) considering pregnancies occurring before and after the diagnosis.

METHOD

Case-control study evaluating IBD patients, interviewed by questionnaire about outcome of pregnancy and course of disease.

RESULTS

A total of 502 pregnancies from 199 patients in the prediagnosis group and 121 pregnancies from 90 patients in the post-diagnosis group were respectively compared with 996 and 204 pregnancies recorded in a control population. In prediagnosis pregnancies, CD was associated with increased risk of preterm delivery (odds ratio [OR] 4.62, 95% confidence interval [CI] 2.77-7.73; P < 0.001 vs controls and OR 3.52, 95% CI 1.75-7.07; P < 0.001 vs UC) and lower birthweight (P < 0.001 vs UC and controls). In post-diagnosis pregnancies, the rate of live births was lower, but not statistically significant in IBD (OR 0.22, 95% CI 0.04-1.25; P = 0.08) and the birthweight was significantly lower in CD than in UC (P < 0.03) and in controls (P < 0.02). In post-diagnosis pregnancies, a higher incidence of congenital abnormalities was found in IBD patients (5.5% vs 0.0%). The spontaneous abortion rate and therapeutic abortions were significantly higher in post than in prediagnosis pregnancies. Neither disease activity at conception nor treatment appeared to influence the outcome of pregnancy.

CONCLUSIONS

CD in the preclinical phase has some influence on pregnancy. In patients with IBD our data suggest that conception should not be discouraged. However, because of a modest increase in mild congenital abnormalities and abortions rates, pregnancy in IBD patients should be closely monitored.

Segmental colitis associated with diverticula: a 7-year follow-up study

BACKGROUND AND STUDY AIMS

We performed a long-term follow-up study of patients with segmental colitis associated with diverticula, in order to clarify the natural history of this disease.

PATIENTS AND METHODS

We identified 15 patients who were diagnosed as having segmental colitis associated with diverticula during 1997. We assessed these patients by means of periodic follow-up visits from 1997 to 2004.

RESULTS

Eight of the 15 patients had no clinical recurrence during follow-up. Five patients had sporadic recurrences that were clinically mild (on average, one in 5 years), which responded to topical therapy and often to self-medication. Only two patients were diagnosed during the follow-up period as having Crohn's disease; notably, these were the only patients who did not have hematochezia as the main symptom at onset.

CONCLUSION

The course of this disease appears to be substantially benign.

High-dose senna compared with conventional PEG-ES lavage as bowel preparation for elective colonoscopy: a prospective, randomized, investigator-blinded trial

OBJECTIVE

To compare the efficacy and patient acceptance of an oral high dose of senna to conventional polyethylene glycol-electrolyte lavage solution (PEG-ES) in adults undergoing elective colonoscopy.

METHODS

Consecutive outpatients referred for elective colonoscopy were prospectively randomly assigned to receive, the day before the procedure, either 24 tablets of 12 mg senna, divided into two doses at 1 p.m. and 9 p.m. (senna group, n=191), or standard 4-L PEG-ES (PEG-ES group, n=92). The overall quality of colon cleansing (primary outcome measure) and cleansing in the right colon were evaluated using the Aronchick scoring scale (1=excellent to 4=inadequate) by the investigator/endoscopist who was blinded to the treatment assignment. Patient acceptance and the safety of the preparation were assessed by a nurse, using a structured questionnaire covering compliance with the dosing, overall tolerance of the preparation (1=none or mild discomfort to 4=severely distressing), and adverse events.

RESULTS

The quality of colon cleansing, overall tolerance of the preparation, and compliance were significantly better with senna; overall cleansing was excellent or good in 90.6% of patients in the senna group and in 79.7% in the PEG-ES group (p= 0.003). The percentage of procedures rescheduled because of insufficient colon cleansing was 7.3% in the PEG-ES group and 2.6% in the senna group (p=0.035). Multivariate logistic regression modeling showed the PEG-ES preparation as negative independent predictor of unsuccessful bowel cleansing. The incidence of adverse reactions was similar in the two groups; patients who received senna experienced significantly less nausea and vomiting, but more abdominal pain.

CONCLUSIONS

An oral high dose of senna is a valid alternative to standard PEG-ES for outpatient colonoscopy preparation.

Gender and disease activity influence health-related quality of life in inflammatory bowel diseases

BACKGROUND/AIMS

Measurement of health related quality of life (HRQoL) is a new tool to evaluate patients with inflammatory bowel disease (IBD). The aims of this study were to verify reliability and responsiveness of a disease-specific questionnaire [Italian Questionnaire on Quality of Life (IQQoL)], and to assess the relationship between clinical and demographic variables and HRQoL in IBD patients.

METHODOLOGY

The IQQoL was submitted to all IBD patients consecutively seen at eight participating Hospitals, and re-administered at follow-up visits. The IQQoL covers intestinal and systemic symptoms, emotional and social function. The higher the score, the worse the HRQoL.

RESULTS

249 patients were enrolled, 106 with Crohn's disease (CD) and 143 with ulcerative colitis (UC). IQQoL was re-administered to 134 patients: 98 with unchanged, 17 with worsened and 19 with improved disease activity. The IQQoL was stable over time in patients with stable clinical conditions, and very responsive to change both in patients with improved and worsened disease activity. HRQoL was inversely correlated with disease activity, both in CD and UC. Perception of HRQoL was significantly worse in women than in men.

CONCLUSIONS

The IQQoL is a reliable and responsive instrument to assess HRQoL in IBD patients. Active disease is related to poor HRQoL perception. In CD, women, mainly if young, have a worse HRQoL perception than men.

Single bolus of midazolam versus bolus midazolam plus meperidine for colonoscopy: a prospective, randomized, double-blind trial

BACKGROUND

The aim of this study was to determine whether a single bolus of meperidine in addition to midazolam improves patient tolerance during colonoscopy.

METHODS

Consecutive patients undergoing outpatient colonoscopy were randomly assigned in double-blind fashion to receive a single rapid intravenous bolus of 5 mg of midazolam and placebo (Group A, n = 125) or 5 mg midazolam plus 50 mg meperidine (Group B, n = 128). Tolerance (4-point scale: 1 excellent, 4 unbearable), pain (4-point scale: 1 none, 4 severe) and willingness to undergo another colonoscopy were assessed 24 to 48 hours later in a telephone interview conducted by an independent observer blinded to the regimen of sedative medication.

RESULTS

Significantly more patients in Group A reported moderate or severe pain (28% vs. 9%; p < 0.001), poor or unbearable tolerance (18% vs. 6%; p < 0.01) and unwillingness to undergo colonoscopy again in the future (14% vs. 5%; p < 0.05). By multivariate analysis, randomization to the midazolam group and younger age were the only variables independently associated with the risk of reporting at least one of these outcomes. Recovery time, frequency of oxygen desaturation, and need for supplemental oxygen were not significantly different between the 2 groups.

CONCLUSIONS

The addition of a single bolus of meperidine to midazolam improves patient tolerance and lessens pain during colonoscopy without significantly increasing the frequency of side effects or prolonging recovery time.

Segmental colitis associated with diverticula: a prospective study. Gruppo di Studio per le Malattie Infiammatorie Intestinali (GSMII)

OBJECTIVE

Little is known about the clinical features and natural history of segmental colitis associated with diverticula. Our aim was to evaluate the incidence of segmental colitis associated with diverticula in patients undergoing colonoscopy, its clinical picture, and its outcome.

METHODS

This was a multicenter, prospective study. Patients with inflammatory bowel disease (IBD)-like lesions limited to colonic segments with diverticula were enrolled. Patients were treated with oral and topical 5-aminosalicylic (5-ASA) until remission was achieved; clinical and endoscopic follow-up was planned at 6 wk and 12 months.

RESULTS

A total of 5457 consecutive colonoscopies were recorded at five participating institutions; 20 patients (0.36%) met the endoscopic criteria for segmental colitis associated with diverticula. All had lesions in the left colon, and one also had lesions in the right colon. In six cases, a specific diagnosis was made thereafter. The remaining 14 patients (0.25% of colonoscopies; eight men; age range, 49-80 yr) were in clinical and endoscopic remission at the first follow-up visit. At onset, 13/14 had hematochezia, seven had diarrhea, and five had abdominal pain; only one had weight loss. No subject had fever. In all but one case, blood chemistries were normal. Five patients had had similar symptoms previously. Thirteen of 14 patients were in clinical and endoscopic remission at 12 months.

CONCLUSIONS

This endoscopic picture is not an exceptional finding. Hematochezia was the main clinical feature, and no relation with gender, age, or smoking habit was found. Blood chemistries were generally normal and the rectum was spared. The histological features were not diagnostic and most patients did not complain of any abdominal symptoms 12 months after enrollment.

Acute self-limiting jejunitis as the first manifestation of microscopic polyangiitis associated with Sjogren's disease: report of one case and review of the literature

We report a case of acute self-limiting ulcerative jejunitis of unknown aetiology in a 72-year-old female patient in which a subsequent diagnosis of microscopic polyangiitis and Sjogren's syndrome was made. All known causes of jejunal ulceration and inflammation were excluded. Previously reported cases of acute self-limiting jejunitis are reviewed and the possibility that acute jejunitis in this patient had been the first manifestation of systemic vasculitis is discussed.

Congenital short pancreas. Report of a new case observed during the course of a recurrent acute pancreatitis

A new case of congenital short pancreas (partial agenesis or hypoplasia of the dorsal pancreas) is reported. The patient was a 61-year-old caucasian man, referred for two episodes of non-severe acute biliary pancreatitis. Clinical and laboratory findings and the presence of ultrasound biliary sludge in the gallbladder supported the biliary origin of pancreatitis. Computerized tomography revealed a slightly enlarged and hypodense head of the gland but could not identify any pancreatic tissue in the region of the body and tail. Endoscopic retrograde pancreatography showed a short pancreas with a duct system in communication both with the accessory and main papilla. Laparoscopic cholecystectomy was performed and no further episodes of abdominal pain occurred. Short pancreas is a rare congenital abnormality consisting in the parenchyma and ductal system restricted to the head with some residual dorsal tapering and arborizing ducts communicating with the minor papilla. This anomaly can be an incidental finding and its association with episodes of recurrent pancreatitis needs to be proven.

Randomized study comparing omeprazole plus amoxycillin versus omeprazole plus clarithromycin for eradication of Helicobacter pylori

BACKGROUND

Dual therapy with omeprazole plus amoxycillin or with omeprazole plus clarithromycin has been proposed for eradication of Helicobacter pylori. The main problem is the great variability in the rate of eradication.

METHODS

A group of 287 consecutive patients with active peptic ulcers and H. pylori infections were admitted to a prospective, randomized, multicentre study, to be given omeprazole 20 mg b.d. plus either amoxycillin 1 g b.d. or clarithromycin 500 mg t.d.s. for 2 weeks. Cure was defined as the absence of H. pylori infection, 4-6 weeks after completing anti-microbial therapy, assessed by urease activity and histology of antral and body gastric biopsies.

RESULTS

The bacteria were eradicated in 68/143 patients (48%) treated with amoxycillin and omeprazole and 70/144 patients (49%) treated with clarithromycin and omeprazole (intention-to-treat analysis). The ulcers were healed in 118/127 patients (93%) treated with amoxycillin and in 115/123 (94%) of those treated with clarithromycin. Undesirable effects were rare with both treatments.

CONCLUSIONS

Combined treatment with omeprazole plus either amoxycillin or clarithromycin produced a high percentage of short-term healing of ulcers and was well tolerated, but is not useful as first-line anti-Helicobacter pylori treatment.

Pseudoxanthoma elasticum: a rare cause of gastrointestinal bleeding

Pseudoxanthoma elasticum (PXE) is a rare connective tissue disorder. The main clinical features of this condition are characteristic skin lesions, angioid streaks of the fundus oculi, and occlusive vascular disease. Gastric hemorrhage is a rare complication. A gastroscopic examination was performed on two patients with PXE who presented with upper gastrointestinal tract bleeding. The two patients had submucosal yellowish nodular lesions similar to the xanthoma-like skin lesions seen in the disease. We suggest that a diagnosis of PXE be considered for any patient with gastrointestinal hemorrhage, especially if routine clinical and endoscopic examination fail to reveal the cause, and if raised yellow plaque-like lesions are seen in the stomach by endoscopy.

First bleeding episode from oesophageal varices in cirrhotic patients: a prospective study of endoscopic predictive factors

Two hundred patients affected by liver cirrhosis and oesophageal varices were studied in 9 Gastrointestinal Units in Lombardy (Northern Italy) in order to assess factors possibly related to variceal bleeding. Only patients without any previous episode of gastrointestinal bleeding were included in the prospective evaluation. For each patient demographic data, aetiology of cirrhosis, various clinical and biochemical parameters able to group patients into the three Child-Pugh Classes, endoscopic items for calculation of Beppu's and of NIEC prognostic scores were recorded on computerized cards. Patients were regularly interviewed every three months for one year and underwent an upper gastrointestinal endoscopy at enrollment, after six months and in case of bleeding. Within the twelve-month follow-up period, 29 out of the 200 patients (14%) bled and 52 out of 200 died (26%). In 16 of the 52 patients who died (59% of bleeding patients) death was directly related to gastrointestinal bleeding. Bleeding from oesophageal varices was endoscopically proven in 19/29 patients, in another 9 bleeding was classified as from unknown source and in one patient a bleeding gastric ulcer was diagnosed. Univariate analysis of all the recorded clinical, biochemical and endoscopic parameters, performed by Chi-square method and Fisher exact test showed that the presence of RWM (p < 0.001) was the only factor significantly associated to variceal bleeding within one year. Relationship between size of varices and bleeding was very close to the statistical significance but did not achieve it (p = 0.058).

Biphasic annual periodicity in relapses of inflammatory bowel diseases. Gruppo di Studio per le Malattie Infiammatorie Intestinale

We evaluate the periodicity in relapses of ulcerative colitis and Crohn's disease in this multicenter prospective study. In 275 relapses among 184 patients with inflammatory bowel disease, a statistically significant biphasic annual periodicity, with peaks in the spring and autumn, was documented only for ulcerative colitis relapses (p = 0.006). This finding may be important in understanding relapse risk factors and in terms of prevention.

Biphasic diurnal periodicity in bleeding from peptic ulcer

OBJECTIVE

To evaluate if there was periodicity in the manifestations of gastrointestinal bleeding (hematemesis and melena).

METHOD

This is a multicenter prospective study carried out in the Endoscopy Units of eight hospitals. At the time of the emergency endoscopy, the following data were collected: age, sex, endoscopic diagnosis, solar hour of the first hematemesis (vomiting of bright red or tarry black material) and of the first melena (black or bloody soft stools), and any drugs taken during the week before the bleeding episode, regardless of the dose.

RESULTS

806 patients were studied. Bleeding was from peptic ulcer in 405 patients (50%), from esophageal varices in 197 (24%), and from other sources in the remainder. Analysis using single cosinor statistics showed a nonrandom distribution in bleeding from peptic ulcer, whether presenting first with hematemesis (p = 0.02) or melena (p = 0.03). There were two peaks at 6:45 AM and 6:45 PM for hematemesis and at 7:25 AM and 7:25 PM for melena, representing a biphasic diurnal (ultradian) rhythm.

CONCLUSIONS

This study shows that bleeding due to peptic ulcer has a biphasic diurnal periodicity. This has potential importance for the pathogenesis of bleeding, for the management of gastrointestinal hemorrhage and the administration of drugs known to cause peptic ulcer bleeding.

[Hepatic hematomas due to Menghini liver biopsy]

Hepatic hematomas, after liver biopsy, are collections of blood within the hepatic parenchyma and/or the hepatic capsula. The frequency of hematomas is reported to vary from 0% to 23% as a consequence of the patient selection and/or of the different diagnostic techniques (angiography, isotope techniques, ultrasound and CT scan).

AIM

To study prospectively, using the ultrasound scan, the incidence and the clinical significance of hematomas.

METHODS

115 liver punctures were prospectively studied; before and 24 hours after the procedure the patients were submitted to liver US scan and CBC, transaminase and bilirubin were also checked.

RESULTS

The procedure was unsuccessful in one patient and none had more than one needle pass; five patients had two biopsies in different sessions. The 24 hour post-biopsy liver US scan did not show any hepatic hematomas. No patient had a significant drop in hemoglobin or in red blood cells.

CONCLUSIONS

Hepatic hematomas after liver biopsy are uncommon and of little clinical significance.

Irritable bowel syndrome. Still far from a positive diagnosis

The diagnosis of irritable bowel syndrome requires the exclusion of any associated organic disease: a positive diagnosis would avoid expensive and potentially dangerous diagnostic procedures. A scoring system has been proposed for positive diagnosis where more than 44 points excluded organic digestive disease. The aim of this study was to determine the usefulness of this scoring system in a different setting. Patients (1257) consecutively referred to our medical division were admitted to the study and 270 of these, complaining of abdominal symptoms, were scored on the Kruis system method. The positive predictive value (53.8% for men and 81.5% for women) and the sensitivity (46.7% and 59.5%) did not appear to be adequate. The negative predictive value (91.6% and 87.3%) and the specificity (93.5 and 95.4%) gave higher results, but two cases of neoplasia and nine cases of other organic digestive diseases were not identified or suggested. We believe that this scoring system may be useful only as a first step in a diagnostic flow chart.