Abstract: BACKGROUND: The aim of this study was to assess the morbidity of laparoscopic subtotal colectomy (STC) with or without anastomosis in patients with acute or severe colitis (SAC) complicating inflammatory bowel disease (IBD) who failed medical treatment. METHODS: Forty patients undergoing laparoscopic STC for SAC complicating IBD were identified and well-matched for age, gender, ASA score, and IBD severity at the time of colectomy (acute colitis vs steroid dependence only) with 48 patients undergoing open STC. RESULTS: There was no operative mortality. Mean (+/-SD) operative time was similar after laparoscopic and open STC (253 +/- 56 vs 231 +/- 75 min; NS). Two patients (5%) required conversion into laparotomy due to intensive adhesions (n = 1) and colonic fistula (n = 1). Overall morbidity and hospital stay was similar after laparoscopic STC and open STC (35% vs 56%) (9 +/- 3 vs 12 +/- 7 days) (P > .1) respectfully. After laparoscopic STC, 84% of the patients underwent restorative intestinal continuity (with either ileorectal or ileoanal anastomosis) through reoperative laparoscopy (n = 15) or elective incision at the site of previous stoma (n = 16). CONCLUSIONS: This case-matched study suggests that laparoscopic STC was as safe and effective as open STC for IBD patients with SAC. A laparoscopic STC allows restoration of intestinal continuity restoration (ie, ileal pouch anal or ileorectal anastomosis) through a laparoscopic approach or elective incision for the majority of the patients. For these reasons, laparoscopic approach represents the best approach for colitis-complicating IBD.
Abstract: BACKGROUND AND AIMS: The position of capsule endoscopy (CE) relative to push enteroscopy (PE) in the diagnostic algorithm of obscure gastrointestinal bleeding is unclear, as previous studies involved the use of both techniques in all patients. We therefore conducted a trial in which patients were randomized to undergo one or other exploration. METHODS: All consecutive patients referred for obscure gastrointestinal bleeding were randomized between CE and PE as the first-line exploration. The alternative method was only used if the first-line method revealed no definite bleeding source, or if required for clinical reasons during follow-up. RESULTS: CE and PE, used as the first-line exploration, identified a bleeding source in 20 of 40 patients and 9 of 38 patients, respectively (50% vs 24%; P = .02). CE missed lesions in 8% of patients, and all these lesions were located in sites accessible to standard endoscopy. PE missed lesions in 26% of patients. At the end of the 12-month follow-up period, the strategy based on CE as first-line exploration followed by PE if necessary only was similar to PE followed by CE in terms of diagnostic yield, clinical outcome, and therapeutic impact, but reduced the percentage of patients needing the alternative exploration (25% vs 79%; P < .001). CONCLUSIONS: CE has a higher diagnostic yield than PE in obscure gastrointestinal bleeding, and a strategy based on CE as first-line exploration avoids unnecessary explorations.
Abstract: AIM: To assess the characteristics and clinical course of nodular regenerative hyperplasia (NRH) in patients with inflammatory bowel disease treated with azathioprine, so as to estimate the frequency of this complication and search for risk factors. METHODS: Cases were identified through a systematic survey of patients followed at 11 centres. At one centre, the cumulative risk of NRH was estimated and a case-control study was undertaken to identify risk factors. RESULTS: 37 cases of NRH (30 male, 7 female) were identified between 1994 and 2005. The median dose of azathioprine was 2 mg/kg/d (range 1.5 to 3.0). The median time between the start of azathioprine and the diagnosis of NRH was 48 months (range 6 to 187). After a median follow up period of 16 months (range 1 to 138), 14 patients developed complications of portal hypertension. Using multivariate analysis, male sex and stricturing behaviour were the two risk factors associated with NRH in patients treated with azathioprine. The cumulative risk calculated from the database (one centre) was 0.5% at 5 years (95% confidence interval, 0.11 to 0.89) and 1.25% at 10 years (0.29 to 2.21). CONCLUSIONS: NRH is a rare but potentially severe complication of azathioprine in patients with inflammatory bowel disease. Clinicians should be aware of this complication, and should monitor liver function tests and platelet counts closely in their patients.
Abstract: ABSTRACT: BACKGROUND: Short-chain fructo-oligosaccharides (scFOS) are increasingly used in human diet for their prebiotic properties. We aimed at investigating the effects of scFOS ingestion on the colonic microflora and oro-fecal transit time in elderly healthy humans. METHODS: Stools composition, oro-fecal transit time, and clinical tolerance were evaluated in 12 healthy volunteers, aged 69+/-2 yrs, in three consecutive periods: basal period (2 weeks), scFOS (Actilight) ingestion period (8 g/d for 4 weeks) and follow-up period (4 weeks). Two-way ANOVA, with time and treatment as factors, was used to compare the main outcome measures between the three periods. RESULTS: Fecal bifidobacteria counts were significantly increased during the scFOS period (9.17 +/- 0.17 log cfu/g vs 8.52 +/- 0.26 log cfu/g during the basal period) and returned to their initial values at the end of follow-up (8.37 +/- 0.21 log cfu/g; P<0.05). Fecal cholesterol concentration increased during the scFOS period (8.18 +/- 2.37 mg/g dry matter vs 2.81 +/- 0.94 mg/g dry matter during the basal period) and returned to the baseline value at the end of follow-up (2.87 +/- 0.44 mg/g dry matter; P<0.05). Fecal pH tended to decrease during scFOS ingestion and follow-up periods compared to the basal period (P=0.06). Fecal bile acids, stool weight, water percentage, and oro-fecal transit time did not change throughout the study. Excess flatus and bloating were significantly more frequent during scFOS ingestion when compared to the basal period (P<0.05), but the intensity of these symptoms was very mild. CONCLUSIONS: Four-week 8 g/d scFOS ingestion is well tolerated and leads to a significant increase in fecal bifidobacteria in healthy elderly subjects. Whether the change in cholesterol metabolism found in our study could exert a beneficial action warrants further studies.
Abstract: Celiac disease (CD) is an enteropathy resulting from an abnormal immune response to gluten-derived peptides in genetically susceptible individuals. This immune response is initiated by intestinal transport of intact peptide 31-49 (p31-49) and 33-mer gliadin peptides through an unknown mechanism. We show that the transferrin receptor CD71 is responsible for apical to basal retrotranscytosis of gliadin peptides, a process during which p31-49 and 33-mer peptides are protected from degradation. In patients with active CD, CD71 is overexpressed in the intestinal epithelium and colocalizes with immunoglobulin (Ig) A. Intestinal transport of intact p31-49 and 33-mer peptides was blocked by polymeric and secretory IgA (SIgA) and by soluble CD71 receptors, pointing to a role of SIgA-gliadin complexes in this abnormal intestinal transport. This retrotranscytosis of SIgA-gliadin complexes may promote the entry of harmful gliadin peptides into the intestinal mucosa, thereby triggering an immune response and perpetuating intestinal inflammation. Our findings strongly implicate CD71 in the pathogenesis of CD.
Abstract: BACKGROUND & AIMS: Osteoporosis is common in patients with inflammatory bowel disease (IBD). Corticosteroids induce a rapid and important bone loss. Clinical trials have shown oral bisphosphonates to effectively prevent steroid-induced bone loss. However, patients with IBD have been excluded from most of these studies because of potential digestive adverse events. Clodronate is a non-amino-bisphosphonate available in intravenous form without expected digestive (as oral bisphosphonates) or proinflammatory (as amine bisphosphonates) side effects. Our aim was to assess the efficacy of intravenous clodronate in preventing steroid-induced bone loss. METHODS: A 12-month, double-blind, randomized, placebo-controlled trial was conducted in IBD patients beginning a steroid therapy. Sixty-seven patients (median disease duration, 38 mo; range, 1-240 mo) were randomized to receive one infusion per 3 months of either intravenous clodronate (900 mg, n = 33) or placebo. All the patients received calcium (1 g/day) and vitamin D (800 IU/day). The main outcome was the change in lumbar bone mineral density (BMD) between baseline and 1 year. Secondary outcomes included change in femoral neck BMD and adverse events. RESULTS: After 1 year, there was no change in BMD in the clodronate group, neither at the spine (-0.2%, not significant) nor at the femoral neck (2.3%, NS). In contrast, there was a significant decrease in lumbar spine (-2.0%, P = .0018) and femoral neck (-1.7%, P = .045) BMD in the placebo group. Tolerance to treatment was good. CONCLUSIONS: Intravenous clodronate is effective in the prevention of bone loss induced by steroids in patients with IBD.
Abstract: OBJECTIVES: The strongest environmental factors identified for ulcerative colitis (UC) are cigarette smoking and appendectomy. However, most studies have been performed using case-controls from hospital-based populations. The purpose of this study was to compare the history of previous appendectomy and smoking habits in a group of patients with UC and a control group, followed by gastroenterologists in private practice.METHODS: We performed a case control study in which 100 physicians recruited UC-patients and age and sex matched controls. Data were collected during a single visit. Based on a standardized questionnaire, UC patients and controls were divided into never, former or current smokers, and into subjects with or without a previous history of appendectomy.RESULTS: One hundred and ninety eight age- and sex-matched pairs of UC patients and controls were included. The prevalence of appendectomy in the UC-patients and control group was 12% and 46%, respectively. The pairwise-matched OR of ulcerative colitis for previous appendectomy was 0.10 (95% CI, 0.05-0.21) (P<0.0001). The OR for former and never smokers versus current smokers was 2.40 (95% CI 1.31-4.38) (P=0.004). In UC-patients, the OR of family history of UC compared with controls was 2.80 (95% CI, 1.01-7.77) (P=0.048).CONCLUSIONS: This case-control study confirmed a strong negative correlation between both appendectomy and tobacco smoking, and ulcerative colitis in patients followed-up by gastroenterological practitioners.
