Predictive factors for an uncomplicated long-term course of Crohn's disease: a retrospective analysis

BACKGROUND

Predictive factors for a mild course of Crohn's disease (CD) may have therapeutic consequences, but as yet have not been identified.

AIMS

To identify baseline factors that predict mild CD and design a predictive scoring system.

METHODS

A retrospective, multicenter study of newly diagnosed CD patients allocated to mild CD (no therapy, mesalazine only, or mesalazine with a single initial short course of low-dose prednisone) or moderate CD (all other patients including resected patients).

RESULTS

162 patients (median follow-up 43 months) were analyzed: 47 mild CD and 115 moderate CD. For mild CD versus moderate CD, mean age at first diagnosis was higher (41.1 versus 33.9 years, p=0.02), mean C-reactive protein (CRP) concentration was lower (1.6 versus 3.6 mg/L, p<0.01), and perianal lesions were less frequent (0% versus 10.4%, p=0.02). The combined incidence of complications (stenosis, any type of fistula, extraintestinal complications or fever) was 21.3% in mild CD versus 35.7% in moderate CD (p=0.07). A scoring system based on age, CRP, endoscopic severity (adapted Rutgeert's score), perianal lesions and combined incidence of complications was developed which can predict a mild prognosis at the initial diagnosis, giving patients the chance of simplified therapy and accelerated step-up in the event of treatment failure.

CONCLUSIONS

Approximately a third of CD patients experience a mild disease course and require only basic therapy. A possible scoring system to predict mild CD which may avoid overtreatment and unnecessary risks for the patient and costs is suggested.

Clinical status, psychosocial impairments, medical treatment and health care costs for patients with inflammatory bowel disease (IBD) in Germany: an online IBD registry

BACKGROUND

The aim of this cross-sectional study was to establish an online inflammatory bowel disease (IBD) registry for a first picture of the situation of IBD outpatients' treatment in Germany.

METHODS

Between March 2006 and July 2007 IBD outpatients from 24 gastroenterological specialist practices and two hospitals in Germany were enrolled in an Internet-based registry to evaluate the outpatients' clinical status, psychological impairments, provided health care, as well as medical treatment and medication costs.

RESULTS

1032 IBD patients (ulcerative colitis/UC: 519; Crohn's disease/CD: 511; indeterminate colitis: 2) were enrolled in the study (age: 43 ± 14 years/M ± SD). Disease duration of all patients averaged 10 ± 8.5 years. In 519 UC-patients (49% male; 33% pancolitis), 66% were in remission as were 55% of CD patients (37 % male; 41 % active smokers). Associated with higher rates of disease activity (CDAI ≥ 150; CAI>4) were corticosteroids (CD, UC), topical medication (UC), relevant reported depressive symptoms (15%; 6-31%) and impairments in sexuality (21%; 9-42%). Relevant medication groups prescribed were oral aminosalicylates (UC: 70%; CD: 47%); immunosuppressive therapy - mostly azathioprine/6 MP (CD: 47%; UC: 26%), and Infliximab (CD: 8%; UC: 3%). Strongly associated with their clinical disease activity in UC as well as CD patients, 15% (6-31%) reported relevant depressive symptoms and 21% (9-42%) relevant impairments in sexuality.

CONCLUSIONS

The registry constitutes a large complemental database for the patient population in Germany. About one third of the IBD patients were not in clinical remission (CDAI ≥150/CAI >4) (CD: 45%; UC: 27%), although high rates of immunosuppressive drugs (CD: 47%; UC 26%) were administered. This study shows a large burden of active disease associated with an unexpectedly high (co)morbidity and high psychosocial impairments, indicating a reduced health state in IBD patients.

Efficacy and tolerability of a one-week triple therapy consisting of pantoprazole, clarithromycin and amoxycillin for cure of Helicobacter pylori infection in patients with duodenal ulcer

BACKGROUND

Previous studies have shown that one-week triple therapy consisting of omeprazole, clarithromycin and amoxycillin may cure Helicobacter pylori infection in the vast majority of patients. The present study was designed to test the hypothesis that a triple therapy with pantoprazole, clarithromycin and amoxycillin cures the infection in > or = 80% of duodenal ulcer patients infected with H. pylori.

METHODS

In an open two-centre study, 60 duodenal ulcer patients were treated with pantoprazole 40 mg b.d., clarithromycin 500 mg b.d. and amoxycillin 1 g b.d. for 1 week. During the second week patients received pantoprazole 40 mg once in the morning. We assessed H. pylori infection before treatment and 4 weeks after cessation of the study medication by a rapid urease test, histology after Warthin-Starry stain and a 13C-urea breath test.

RESULTS

Sixty patients (42 males, mean age 47.4 years) entered the trial. All patients were infected with H. pylori. One patient was withdrawn from the study because of allergy to penicillin and six patients were protocol violators. H. pylori infection was cured in 47 out of 53 patients who completed the trial according to the protocol (89%; 95% CI: 80-97%) and in 49 of 60 patients included in the trial (82%; 95% CI: 72-92%). Four weeks after the last administration of study drugs, 55 out of 60 ulcers had healed (92%). Twenty-nine patients reported 51 adverse events that were mostly mild to moderate.

CONCLUSIONS

One-week triple therapy consisting of pantoprazole, clarithromycin and amoxycillin is a simple and effective approach to the cure of H. pylori infection in patients with duodenal ulcer. In those patients who took the drugs as prescribed the H. pylori cure rate was 89%, with the lower 95% confidence limit being 80%.

Endoscopic and bioptic diagnosis of malignant non-Hodgkin's lymphoma of the stomach

Experience in the endoscopic and bioptic diagnosis of malignant non-Hodgkin's lymphomas of the stomach in 66 patients is reported all of which were B cell lymphomas originating in the mucosa associated lymphoid tissue (MALT) type. Two types of tumor could be differentiated by their appearance on endoscopy (two patients had both types). An exophytic type (n = 24) was easily recognized as malignancy on endoscopy and the diagnosis confirmed by endoscopic biopsy (mean of 1.2 endoscopic-bioptic examinations). It could be classified according to the Palmer classification; 50% were low-grade malignancies and 50% high-grade malignancies. Resection (n = 17) showed wall penetration beyond the muscularis propria in 70%. An infiltrative type (n = 44) was difficult to diagnose by means of endoscopy and biopsy (mean of 2.9 endoscopic-bioptic examinations); in one case a histological diagnosis could only be established on surgery. A classification system is suggested for this type (I--elevated, II--flat, III--cavitated). Most of these lymphomas were low-grade malignancies (77%), and limited to the mucosa and submucosa (79% of 34 resected cases). It is concluded that attention should be paid especially to the infiltrative type of gastric lymphoma which is difficult to diagnose and to differentiate from other gastric conditions such as ulcers and erosions, but which is most often found at an early stage and has a better prognosis. Complete tumor resection (R0) was achieved in 49 of 51 patients undergoing surgery (96%).(ABSTRACT TRUNCATED AT 250 WORDS)

How to run an endoscopy unit? Experience in the Federal Republic of Germany. Results of a survey of 31 centers

A survey of 31 German hospitals (14 university hospitals with a special gastrointestinal service, 13 key hospitals with specialized GI units, mainly university teaching hospitals, and 4 smaller hospitals without specialization) showed that a service providing the usual gastrointestinal endoscopic procedures is available in all university and key hospitals. In the university hospitals, an average of 4,765 procedures per year are performed, in the key hospitals with specialized GI units 5,558, and in the smaller hospitals without specialization 2,935. Such special methods as ERCP, PTC and operative endoscopy are usually restricted to special clinics. The number of doctors and nursing staff is adequate at university hospitals and in specialized key hospitals. Smaller hospitals without specialization need more nursing staff. All hospitals need more rooms. The supply of instruments is sufficient at university and key hospitals, but more instruments are needed in general non-specialized hospitals. German endoscopic units are relatively well equipped with X-ray machines, but further X-ray equipment is still needed to achieve less dependence on centralized radiological departments. There is a distinct need for more waiting and recovery rooms. At the present time, there is no optimal endoscopic unit in Germany. Better and appropriate outfitting of the units, and an optimized floor-plan encompassing endoscopy rooms, rooms for preparation and after-care are needed--which is not practical in the case of existing hospitals, but must be considered when planning new hospitals.

[Duodenal stenosis in coincidence with annular pancreas and cancer of the papilla]

We report on a case of annular pancreas complicated by the development of a carcinoma of the papilla causing secondary chronic obstructive pancreatitis. Eventually, a high-grade stenosis of the duodenum developed, leading to symptoms of gastric outlet obstruction. The stenosis was proved by endoscopic and radiologic diagnosis, but the exact anatomical condition was only revealed by an operation. Efficient diagnostic and therapeutic procedures in annular pancreas with its potential complications are discussed in detail.

[Malignant extrahepatic bile duct occlusion. Diagnosis and palliative treatment]

A diagnosis of malignant extrahepatic biliary obstruction was made in 123 cases by endoscopic retrograde cholangio-pancreaticography (ERCP) and (or) percutaneous transhepatic cholangiography (PTC). The diagnosis was confirmed by operation, biopsy or autopsy or further investigations and follow-up. The diagnosis was correct in 96% and false in only 4%. Clinical and biochemical findings were unreliable. Ultrasound investigations were accurate in 94% of cases with malignant obstruction low down. However, it was negative in cases with high obstruction in 19% due to the absence of dilatation of the intrahepatic biliary ducts. Consequently these cases could not be diagnosed without additional ERCP and PTC. ERCP and PTC also permit palliative treatment to be done. In 30% of all cases a palliative non-surgical treatment was performed such as endoscopic sphincterotomy with or without endoprosthesis or percutaneous transhepatic drainage.

Gastric polypectomy. Long-term results (survey of 23 centres in Germany)

In a survey of 23 endoscopy centres in the Federal Republic of Germany 6,182 cases are reported in which gastric polypectomies were performed. 1,177 patients were observed over a period of up to 7 years. Primary benign gastric polyps recurred in 6.1% most of them within 1 year after polypectomy, and genuinely recurrent polyps usually had a histological pattern identical to that of the ectomized polyps. In 32.5% new polyps occurred at different locations in the stomach, and most of them exhibited the same histological structure as the primary polyp. In 1.7% of primary benign solitary or multiple gastric polyps gastric carcinoma must be expected to develop. Follow-up examinations revealed only one carcinoma in 68 polyposis patients (= 1.5%), but in these cases, consideration must be given to a simultaneous carcinoma, which was observed in 8.5% at the first examination. In high-risk patients, endoscopic removal of protruded-type early gastric cancer and borderline lesion represents very satisfactory therapy. The recurrence rate of early gastric cancer was only 13.6% and of borderline lesion 9.7%. However, in cases of borderline lesions a cancer can be expected to develop in a further 8.6%. The consequences of this study are discussed.

[Long term results after endoscopic sphincterotomy]

A multicenter study of 25 centers covering 9041 endoscopic sphincterotomies showed that choledochal concrements still represent the main indication (83,9%). Circumscript papillary stenosis (10.64%) and papillary tumour(2.06%) are the next most frequent indications. Complications after endoscopic sphincterotomy may be expected in 7.55% of cases, somewhat more frequent after papillary stenoses than after choledochal concrements. The most frequent complication is haemorrhage, followed by pancreatitis, cholangitis in cases of choledochal concrements, and perforation. Mortality is around 1.12%. Late results after endoscopic sphincterotomy a satisfactory and concrement-free bile ducts are seen in 91.62%. Freedom of complaints or improvements of symptoms occur in 93.4%. Recurrent stones occur in 5.77%, restenoses were seen in 3.14%. Late results after endoscopic sphincterotomy ar worse in papillary stenosis than in choledocholithiasis. Mortality figures are twice as high and danger of perforation seems to be more frequent. Endoscopic sphincterotomy is done increasingly as an emergency measure.