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Abstract
PURPOSE OF REVIEW With the growing popularity and commercialization of probiotics, it is important to understand the implications of existing randomized controlled trials and their applicability in the clinical setting to treat luminal gastrointestinal diseases. RECENT FINDINGS Probiotics may be useful in the prevention of antibiotic-associated diarrhea, prevention of Clostridioides difficile infection and eradication of Helicobacter pylori. Some evidence supports the use of probiotics in the treatment of ulcerative colitis, prevention and treatment of pouchitis and irritable bowel syndrome. Caution has to be exercised in immunocompromised and critically ill individuals. New society guidelines do not encourage probiotic use in gastrointestinal disorders with the exception of premature infants to prevent necrotizing enterocolitis. SUMMARY Despite burgeoning body of literature and wide acceptance by the public, a thorough understanding of efficacy and safety of probiotics is lacking. Uniform dosage, standardized clinical end points, personalization based on host microbial profile and longer duration of follow-up on the research front may help in the future in appropriate positioning of probiotics in health and disease.
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Affiliation(s)
- Abbinaya Elangovan
- Department of Internal Medicine-Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Monika Fischer
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
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Wan XM, Wang ZL, Wang LY, Cai XT, Wan CM, Xie YM. Collagenous colitis in a child induced by chronic respiratory allergy: A case report. Medicine (Baltimore) 2020; 99:e21920. [PMID: 32871927 PMCID: PMC7458195 DOI: 10.1097/md.0000000000021920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Collagen colitis (CC) is a microscopic colitis diagnosed by mucosal biopsy and is extremely rare in children. PATIENT CONCERNS We reported a child with severe persistent diarrhea that could not be relieved with traditional diarrheal treatment. No abnormalities were found after multiple colonoscopies. DIAGNOSES A significant increase in total IgE levels was found in the patient's blood. He had a history of mild chronic allergic rhinitis and slightly intermittent wheezing. However, we found that the child had a hyperallergic reaction to multiple respiratory antigens and had mild pulmonary dysfunction. Finally, colonoscopy with biopsy identified the diagnosis of CC. INTERVENTION Considering that a respiratory allergic reaction was one of the causes of diarrhea, anti-allergic treatment was given to the child, and his severe diarrhea was soon relieved. Corticosteroid treatment was suggested to the patient, but his parents firmly refused steroid therapy. According to the patient's specific allergic reaction to mites, desensitization treatment was finally chosen for him. OUTCOMES After 1 year of desensitization for dust mites, the patient's respiratory symptoms improved, total IgE levels decreased, autoantibodies declined, and diarrhea did not reoccur. Colonoscopy with biopsy showed a significant improvement in pathology. CONCLUSION CC in children is rare, and childhood CC induced by a respiratory allergic reaction has not been previously reported. Therefore, this is a special case of CC in a patient who was cured with anti-allergy treatments and desensitization instead of steroid therapy.
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Affiliation(s)
- Xue-Meng Wan
- Department of Pediatrics, Sichuan University West China Second University Hospital, NO. 20, Section 3, Ren Min Nan Lu Road
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, P.R. China
| | - Zhi-Ling Wang
- Department of Pediatrics, Sichuan University West China Second University Hospital, NO. 20, Section 3, Ren Min Nan Lu Road
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, P.R. China
| | - Li-Yuan Wang
- Department of Pediatrics, Sichuan University West China Second University Hospital, NO. 20, Section 3, Ren Min Nan Lu Road
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, P.R. China
| | - Xiao-Tang Cai
- Department of Pediatrics, Sichuan University West China Second University Hospital, NO. 20, Section 3, Ren Min Nan Lu Road
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, P.R. China
| | - Chao-Min Wan
- Department of Pediatrics, Sichuan University West China Second University Hospital, NO. 20, Section 3, Ren Min Nan Lu Road
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, P.R. China
| | - Yong-Mei Xie
- Department of Pediatrics, Sichuan University West China Second University Hospital, NO. 20, Section 3, Ren Min Nan Lu Road
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, P.R. China
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Bergman D, Khalili H, Roelstraete B, Ludvigsson JF. Microscopic colitis and risk of cancer - a population-based cohort study. J Crohns Colitis 2020; 15:jjaa156. [PMID: 32710780 DOI: 10.1093/ecco-jcc/jjaa156] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS The association between microscopic colitis (MC) and cancer risk is unclear. Large, population-based studies are lacking. METHODS We conducted a nationwide cohort study of 11,758 patients with incident MC (diagnosed 1990-2016 in Sweden), 50,828 matched reference individuals and 11,614 siblings to MC patients. Data were obtained through Sweden´s pathology departments and from the Swedish Cancer Register. Adjusted hazard ratios (aHRs) were calculated using Cox proportional hazards models. RESULTS At the end of follow up (mean: 6.7 years), 1,239 (10.5%) of MC patients had received a cancer diagnosis, compared to 4,815 (9.5%) of reference individuals (aHR 1.08 (95%CI=1.02-1.16)). The risk of cancer was highest during the first year of follow up. The absolute excess risks for cancer at 5, 10 and 20 years after MC diagnosis were +1.0% (95%CI=0.4%-1.6%), +1.5% (0.4%-2.6%) and +3.7% (-2.3-9.6%), respectively, equivalent to one extra cancer event in every 55 individuals with MC followed for ten years.MC was associated with an increased risk of lymphoma (aHR 1.43, 1.06-1.92) and lung cancer (aHR 1.32, 1.04-1.68) but with decreased risks of colorectal (aHR 0.52, 0.40-0.66) and gastrointestinal cancers (aHR 0.72, 0.60-0.85). We found no association with breast or bladder cancer. Using siblings as reference group to minimize the impact of shared genetic and early environmental factors, patients with MC were still at an increased risk of cancer (HR=1.20; 95%CI=1.06-1.36). CONCLUSIONS This nationwide cohort study demonstrated an 8% increased risk of cancer in MC patients. The risk was highest during the first year of follow up.
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Affiliation(s)
- David Bergman
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Hamed Khalili
- Massachusetts General Hospital, Crohn's and Colitis Center and Harvard Medical School, Boston, MA
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Bjorn Roelstraete
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatrics, Orebro University Hospital, Orebro, Sweden
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, UK
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, USA
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Vedolizumab for the Induction of Remission in Treatment-refractory Microscopic Colitis in a Pediatric Patient. J Pediatr Gastroenterol Nutr 2020; 71:e47-e48. [PMID: 32304548 DOI: 10.1097/mpg.0000000000002739] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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55
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Beales IL. Successful use of beclometasone dipropionate for the treatment of microscopic colitis. United European Gastroenterol J 2020; 8:828-829. [PMID: 32448057 DOI: 10.1177/2050640620929244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ian Lp Beales
- Department of Gastroenterology, Norfolk and Norwich University Hospital, Norwich, UK
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56
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Khalili H, Burke KE, Roelstraete B, Sachs MC, Olén O, Ludvigsson JF. Microscopic Colitis and Risk of Inflammatory Bowel Disease in a Nationwide Cohort Study. Gastroenterology 2020; 158:1574-1583.e2. [PMID: 31926169 DOI: 10.1053/j.gastro.2019.12.028] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 12/11/2019] [Accepted: 12/28/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Microscopic colitis shares pathogenetic mechanisms with inflammatory bowel disease (IBD). We studied the association between microscopic colitis and risk of incident IBD using data from a nationwide cohort study. METHODS We conducted a prospective cohort study of all adults who received a diagnosis of microscopic colitis from 1990 through 2017 in Sweden and risk of incident IBD. Cases of microscopic colitis (n= 13,957) were identified through Systematized Nomenclature of Medicine codes from the ESPRESSO (Epidemiology Strengthened by histoPathology Reports in Sweden) study, which included gastrointestinal pathology reports from all of Sweden's 28 centers. Individuals with microscopic colitis were matched to 5 general population controls (n = 66,820) and to unaffected siblings (n =13,943). Cox regression was used to estimate adjusted hazard ratio (aHRs) and 95% confidence intervals (CIs). RESULTS Through December of 2017, we identified 323 incident cases of ulcerative colitis (UC) and 108 incident cases of Crohn's disease (CD) in patients with microscopic colitis compared with 94 UC and 42 CD cases in population comparators. Mean times from diagnosis of microscopic colitis to diagnosis of CD was 3.3 ± 3.2 years and to diagnosis of UC was 3.2 ± 3.5 years. In multivariable models, microscopic colitis was associated with an aHR of 12.6 (95% CI 8.8-18.1) for CD, 17.3 (95% CI 13.7-21.8) for UC, and 16.8 (95% CI 13.9-20.3) for IBD. The 10-year absolute excess risks of CD and UC were 0.9 (95% CI 0.7-1.1) and 2.6 (95% CI 2.2-2.9) percentage points, respectively. In sensitivity analyses, comparing patients with microscopic colitis with their unaffected siblings, the aHRs of CD and UC were 5.4 (95% CI 3.2-9.2) and 9.4 (95% CI 6.4-13.8), respectively. CONCLUSIONS In a population-based study in Sweden, we found a significant increase in risk of incident IBD among patients with microscopic colitis. Future studies should focus on potential mechanisms underlying these observed associations.
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Affiliation(s)
- Hamed Khalili
- Massachusetts General Hospital, Crohn's and Colitis Center and Harvard Medical School, Boston, Massachusetts; Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
| | - Kristin E Burke
- Massachusetts General Hospital, Crohn's and Colitis Center and Harvard Medical School, Boston, Massachusetts
| | - Bjorn Roelstraete
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Michael C Sachs
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Ola Olén
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Sachs' Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics, Orebro University Hospital, Orebro, Sweden; Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, United Kingdom; Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
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57
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Solberg F, Ohlsson B. Microscopic colitis and its associations with complications observed in classic inflammatory bowel disease: a systematic review. Scand J Gastroenterol 2020; 55:312-320. [PMID: 32182146 DOI: 10.1080/00365521.2020.1739325] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Objectives: Crohn's disease and ulcerative colitis are associated with an increased risk to develop anemia, cutaneous diseases, liver diseases, malignancy, osteoporosis, rheumatic diseases, thromboembolism and uveitis. The association between these diseases and microscopic colitis (MC) is not known. The aim of the present systematic review was to examine associations between MC and diseases observed in association with Crohn's disease and ulcerative colitis.Material and methods: According to the review protocol, original articles which described the prevalence of abovementioned diseases in relation to MC, were searched for in PubMed, Embase and Web of Science.Results: After exclusion of duplicates, 928 articles remained. Based on relevancy of their title, abstract or type of article, 16 articles were ordered in full text and after assessment, nine articles could be included in the review. A second research strategy with individual diseases rendered further two articles. Seven articles covered malignancy/neoplasia, where four showed no association with malignancy and three a reduced association compared with controls. Four articles covering rheumatic diseases showed an association between these diseases and MC. One study showed an association between MC and osteoporosis, whereas one did not. One study showed an association between MC and cutaneous diseases, whereas anemia, eye diseases and thromboembolism showed no associations.Conclusions: Due to short follow-up time in small studies, with selection bias due to exclusion of former or prevalent malignancy in an older population, no conclusions can be drawn concerning the true association between MC and malignancy. Rheumatic diseases seem to be associated with MC.
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Affiliation(s)
- Felix Solberg
- Department of Internal Medicine, Lund University, Skane University Hospital, Malmo, Sweden
| | - Bodil Ohlsson
- Department of Internal Medicine, Lund University, Skane University Hospital, Malmo, Sweden
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Münch A, Sanders DS, Molloy-Bland M, Hungin APS. Undiagnosed microscopic colitis: a hidden cause of chronic diarrhoea and a frequently missed treatment opportunity. Frontline Gastroenterol 2020; 11:228-234. [PMID: 32419914 PMCID: PMC7223274 DOI: 10.1136/flgastro-2019-101227] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/30/2019] [Accepted: 06/20/2019] [Indexed: 02/04/2023] Open
Abstract
Microscopic colitis (MC) is a treatable cause of chronic, non-bloody, watery diarrhoea, but physicians (particularly in primary care) are less familiar with MC than with other causes of chronic diarrhoea. The colon in patients with MC is usually macroscopically normal. MC can only be diagnosed by histological examination of colonic biopsies (subepithelial collagen band >10 µm (collagenous colitis) or >20 intraepithelial lymphocytes per 100 epithelial cells (lymphocytic colitis), both with lamina propria inflammation). The UK National Health Service exerts downward pressure to minimise colonoscopy referrals. Furthermore, biopsies are often not taken according to guidelines. These factors work against MC diagnosis. In this review, we note the high incidence of MC (comparable to ulcerative colitis and Crohn's disease) and its symptomatic overlap with irritable bowel syndrome. We also highlight problems with the recommendation by National Health Service/National Institute for Health and Care Excellence guidelines for inflammatory bowel diseases that colonoscopy referrals should be based on a faecal calprotectin level of ≥100 µg/g. Faecal calprotectin is <100 µg/g in over half of individuals with active MC, building into the system a propensity to misdiagnose MC as irritable bowel syndrome. This raises important questions-how many patients with MC have already been misdiagnosed, and how do we address this silent burden? Clarity is needed around pathways for MC management; MC is poorly acknowledged by the UK healthcare system and it is unlikely that best practices are being followed adequately. There is an opportunity to identify and treat patients with MC more effectively.
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Affiliation(s)
- Andreas Münch
- Division of Gastroenterology and Hepatology, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linköping University, Linköping, Sweden
| | - David S Sanders
- Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | | | - A Pali S Hungin
- The Institute of Health and Society, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
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59
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Larsson JK, Dabos KJ, Höglund P, Bohr J, Münch A, Giannakou A, Nemeth A, Wurm-Johansson G, Toth E, Plevris JN, Fineron P, Koulaouzidis A, Sjöberg K. Cancer Risk in Collagenous Colitis. J Clin Med 2019; 8:jcm8111942. [PMID: 31718057 PMCID: PMC6912303 DOI: 10.3390/jcm8111942] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/25/2019] [Accepted: 11/07/2019] [Indexed: 12/18/2022] Open
Abstract
Data on malignancy in patients with collagenous colitis (CC) is scarce. We aimed to determine the incidence of cancers in patients with CC. In a two-stages, observational study, data on cancers in patients diagnosed with CC during 2000-2015, were collected from two cohorts. The risk was calculated according to the age-standardized rate for the first cohort and according to the standardized incidence ratio for the second cohort. The first cohort comprised 738 patients (394 from Scotland and 344 from Sweden; mean age 71 ± 11 and 66 ± 13 years, respectively). The incidence rates for lung cancer (RR 3.9, p = 0.001), bladder cancer (RR 9.2, p = 0.019), and non-melanoma skin cancer (NMSC) (RR 15, p = 0.001) were increased. As the majority of NMSC cases (15/16) came from Sweden, a second Swedish cohort, comprising 1141 patients (863 women, mean age 65 years, range 20-95 years) was collected. There were 93 cancer cases (besides NMSC). The risk for colon cancer was decreased (SIR 0.23, p= 0.0087). The risk for cutaneous squamous cell carcinoma was instead markedly increased (SIR 3.27, p = 0.001).
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Affiliation(s)
- Johanna K. Larsson
- Department of Gastroenterology, Skåne University Hospital, 205 02 Malmö, Sweden;
| | - Konstantinos J. Dabos
- Centre for Liver & Digestive Disorders, the Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, Scotland, UK; (K.J.D.); (J.N.P.); (A.K.)
| | - Peter Höglund
- Department of Laboratory Medicine, Division of Clinical Chemistry and Pharmacology, SUS, Lund University, 221 85 Lund, Sweden;
| | - Johan Bohr
- Department of Medicine, Division of Gastroenterology, Örebro University Hospital, 702 81 Örebro, Sweden; School of Health and Medical Sciences, Örebro University, 701 85 Örebro, Sweden;
| | - Andreas Münch
- Division of Gastroenterology and Hepatology, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linköpings University, 581 83 Linköping, Sweden;
| | - Andry Giannakou
- Open University of Cyprus, Faculty of Economics and Management, 1678 Nicosia, Cyprus;
| | - Artur Nemeth
- Department of Medicine, Endoscopy Unit, Skåne University Hospital, 205 02 Malmö, Sweden; (A.N.); (G.W.-J.); (E.T.)
| | - Gabriele Wurm-Johansson
- Department of Medicine, Endoscopy Unit, Skåne University Hospital, 205 02 Malmö, Sweden; (A.N.); (G.W.-J.); (E.T.)
| | - Ervin Toth
- Department of Medicine, Endoscopy Unit, Skåne University Hospital, 205 02 Malmö, Sweden; (A.N.); (G.W.-J.); (E.T.)
| | - John N. Plevris
- Centre for Liver & Digestive Disorders, the Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, Scotland, UK; (K.J.D.); (J.N.P.); (A.K.)
| | - Paul Fineron
- Pathology Department, Western General Hospital, Edinburgh EH4 2XU , Scotland, UK;
| | - Anastasios Koulaouzidis
- Centre for Liver & Digestive Disorders, the Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, Scotland, UK; (K.J.D.); (J.N.P.); (A.K.)
| | - Klas Sjöberg
- Department of Gastroenterology, Skåne University Hospital, 205 02 Malmö, Sweden;
- Correspondence: ; Tel.: +464-033-6161
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Hughes MS, Molina GE, Chen ST, Zheng H, Deshpande V, Fadden R, Sullivan RJ, Dougan M. Budesonide treatment for microscopic colitis from immune checkpoint inhibitors. J Immunother Cancer 2019; 7:292. [PMID: 31699151 PMCID: PMC6839080 DOI: 10.1186/s40425-019-0756-0] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/20/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (CPIs) are effective against a variety of malignancies but can be limited by inflammatory toxicities such as enterocolitis. Enterocolitis is typically treated with systemically active glucocorticoids. Endoscopy can stratify patients by the severity of mucosal inflammation, including identifying patients with colitis in the absence of visible mucosal changes: microscopic colitis. Whether patients with CPI microscopic colitis could be managed differently from colitis with more severe mucosal involvement is unclear. The objective of this study was to describe outcomes in CPI microscopic colitis focusing on the response to first line treatment with budesonide. METHODS We evaluated data from a retrospective cohort from a single-center large academic hospital. The participants were all adult patients evaluated by endoscopy for suspected CPI enterocolitis between 3/2017 and 3/2019. The exposures were: Mayo Endoscopic Score (range 0-3). The subset was: oral budesonide, maximum dose 12 mg daily, administered minimum of 5 weeks. The main outcomes and measures were: Primary: time from first CPI exposure to first glucocorticoid use; use of systemic glucocorticoids; time from symptom onset to resolution; continuation of CPI therapy; number of additional CPI infusions received. Secondary: admissions for symptom control; novel irAE development; need for second-line immunosuppression; oncologic outcomes. RESULTS We identified 38 patients with biopsy confirmed CPI enterocolitis, 13 in the microscopic colitis cohort, and 25 in the non-microscopic colitis cohort. Budesonide use was higher in the microscopic colitis cohort (12/13 vs 3/25, p < 0.001), and systemic glucocorticoid use was higher in non-microscopic colitis (22/25 vs. 3/13, p < 0.001). Time from symptom onset to resolution did not differ. Microscopic colitis patients more frequently remained on CPI after developing (entero)colitis (76.9% vs 16.0%, p < 0.001). Microscopic colitis patients tolerating further CPI received, on average, 4.2 CPI infusions more than non-microscopic colitis patients tolerating CPI (5.8 vs 1.6, p = 0.03). Microscopic colitis was associated with increased time-to-treatment-failure (HR 0.30, 95% CI 0.14-0.66) and progression-free survival (HR 0.22, 95% CI 0.07-0.70). CONCLUSIONS Gastrointestinal mucosal inflammation without visible mucosal injury is a distinct, prevalent CPI enterocolitis subset that can be diagnosed by endoscopy. First-line budesonide appears effective in controlling "microscopic colitis" symptoms and prolonging immunotherapy duration. These findings present a compelling rationale for routine endoscopic evaluation of suspected CPI enterocolitis and suggest an alternative glucocorticoid-sparing treatment strategy for a subset of such patients.
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Affiliation(s)
- Michael S Hughes
- Harvard Medical School, Boston, MA, USA
- Present address: Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | | | - Steven T Chen
- Harvard Medical School, Boston, MA, USA
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Vikram Deshpande
- Harvard Medical School, Boston, MA, USA
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Riley Fadden
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Ryan J Sullivan
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Dougan
- Harvard Medical School, Boston, MA, USA.
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA.
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Crooks B, Limdi JK, McLaughlin J. How to manage chronic diarrhoea in the elderly? Frontline Gastroenterol 2019; 10:427-433. [PMID: 31656570 PMCID: PMC6788271 DOI: 10.1136/flgastro-2018-101097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/08/2019] [Accepted: 03/20/2019] [Indexed: 02/07/2023] Open
Affiliation(s)
- Benjamin Crooks
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
- Department of Gastroenterology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Jimmy K Limdi
- Section of IBD, Division of Gastroenterology, The Pennine Acute Hospitals NHS Trust, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - John McLaughlin
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
- Department of Gastroenterology, Salford Royal NHS Foundation Trust, Salford, UK
- Manchester Academic Health Science Centre, Manchester, UK
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Townsend T, Campbell F, O’Toole P, Probert C. Microscopic colitis: diagnosis and management. Frontline Gastroenterol 2019; 10:388-393. [PMID: 31656564 PMCID: PMC6788131 DOI: 10.1136/flgastro-2018-101040] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 11/15/2018] [Accepted: 11/18/2018] [Indexed: 02/04/2023] Open
Abstract
Microscopic colitis (MC) is a common cause of chronic, non-bloody, watery diarrhoea in older patients. The diagnosis depends on characteristic histological findings. Bile acid malabsorption and autoimmune conditions, including coeliac disease, are more frequently found in patients with MC, but colorectal neoplasia and mortality are not increased. Non-steroidal anti-inflammatory drugs, proton-pump inhibitors, selective serotonin reuptake inhibitors and smoking tobacco confer an increased risk of developing MC. Although a so-called benign disease, which rarely causes serious complications, it does have an impact on the quality of life. Several treatment options exist, but budesonide is the only treatment proven in randomised-controlled trials to be effective and safe for induction and maintenance of remission. This article provides a practical overview for the gastroenterologist looking after patients with MC.
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Affiliation(s)
- Tristan Townsend
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
| | - Fiona Campbell
- Department of Pathology, Royal Liverpool University Hospital, Liverpool, UK
| | - Paul O’Toole
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
| | - Chris Probert
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Jennings JJ, Charabaty A. Vedolizumab-Induced Remission in 3 Patients With Refractory Microscopic Colitis: A Tertiary Care Center Case Series. Inflamm Bowel Dis 2019; 25:e97. [PMID: 30889247 DOI: 10.1093/ibd/izz042] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Joseph J Jennings
- Department of Gastroenterology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Aline Charabaty
- Department of Gastroenterology, Johns Hopkins School of Medicine, Washington, DC, USA
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Rivière P, Münch A, Michetti P, Chande N, de Hertogh G, Schoeters P, Ferrante M, Vermeire S, Van Assche G. Vedolizumab in Refractory Microscopic Colitis: An International Case Series. J Crohns Colitis 2019; 13:337-340. [PMID: 30329034 DOI: 10.1093/ecco-jcc/jjy169] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Evidence for second-line therapy in patients with microscopic colitis [MC] failing budesonide is scarce, although anti-tumour necrosis factors [anti-TNFs], methotrexate and azathioprine have been reported to be effective in small cohort studies. Vedolizumab, a monoclonal antibody targeting α4β7-integrin, prevents homing of T-cells to the gut. We evaluated clinical remission with vedolizumab in budesonide-refractory MC patients. METHODS We solicited gastroenterologists in Europe and Canada for cases of MC treated with vedolizumab. Vedolizumab 300 mg IV was administered at weeks 0, 2 and 6, and then every 8 weeks. Clinical remission and histological remission were defined as less than three stools per day and normalization of histology, respectively, after induction treatment. RESULTS Eleven cases were retrieved (nine females, lymphocytic colitis [LC] n = 5, collagenous colitis [CC] n = 6). Median [interquartile range] disease duration at vedolizumab initiation was 51 [29-70] months. Nine of 11 patients had failed one immunosuppressant and ten of 11 at least one anti-TNF agent. After three infusions of vedolizumab, clinical remission was observed in 5/11 patients [two LC and three CC] of whom three remained well with maintenance therapy [median duration of 13 months]. Biopsies were obtained from 9/11 patients. Histological remission was observed in 3/4 patients with clinical remission [2/3 CC, 1/1 LC] and 0/5 patients without clinical improvement. CONCLUSION In a series of highly refractory MC patients, vedolizumab induced clinical remission in 5/11 subjects, of whom 75% showed normalized histology. Larger randomized trials are needed to assess the efficacy of vedolizumab in patients with MC.
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Affiliation(s)
- Pauline Rivière
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Herestraat, Leuven, Belgium
| | - Andreas Münch
- Division of Gastroenterology, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - Pierre Michetti
- Gastro-entérologie La Source-Beaulieu, Lausanne, Switzerland
| | - Nilesh Chande
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada
| | - Gert de Hertogh
- Department of Pathology, University Hospitals Leuven, KU Leuven, Herestraat, Leuven, Belgium
| | | | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Herestraat, Leuven, Belgium
| | - Séverine Vermeire
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Herestraat, Leuven, Belgium
| | - Gert Van Assche
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Herestraat, Leuven, Belgium
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Mosso E, Boano V, Grassini M, Battaglia E, Pellicano R. Microscopic colitis: a narrative review with clinical approach. MINERVA GASTROENTERO 2019; 65:53-62. [PMID: 30486642 DOI: 10.23736/s1121-421x.18.02539-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Microscopic colitis (MC) is diagnosed in presence of microscopic alterations of colonic mucosa, in patients without macroscopic lesions who referred for chronic diarrhea. The two types of MC are lymphocytic colitis (LC) and collagenous colitis (CC), but it is unclear whether these are the different expression of one unique disease or if they are distinct conditions. Today, although MC represents a consistent health problem, being responsible for a large part of gastroenterological consultations for diarrhea, it remains often underestimated. The detailed pathogenesis of MC has not been determined yet. Probably, it is the result of an interaction between individual, environmental and genetic factors. The most relevant risk factor for the development of MC is the use of certain drugs (such as non-steroidal anti-inflammatory drugs [NSAIDs], proton pump inhibitors [PPIs], selective serotonin reuptake inhibitors, beta-blockers, statins). Smoking is another relevant factor reported as associated with the development of MC. Diagnosis needs the execution of a colonoscopy in patients complaining about chronic diarrhea and abdominal pain. The crucial role is played by histology: MC is characterized by the presence of colonic mucosal lymphocytic infiltrate, with intraepithelial lymphocytes ≥20 per 100 enteric surface cells, in CC there is a typical subepithelial collagen layer, whose thickness is ≥10 μm. We carried out a review of the current literature to rule out what is new on epidemiology, diagnosis and therapy of MC.
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Affiliation(s)
- Elena Mosso
- Department of Gastroenterology, University of Turin, Turin, Italy
| | - Valentina Boano
- Department of Gastroenterology, University of Turin, Turin, Italy
| | - Mario Grassini
- Section of Physiopathology and Manometry, Unit of Gastroenterology and Endoscopy, Cardinal Massaja Hospital, Asti, Italy
| | - Edda Battaglia
- Section of Physiopathology and Manometry, Unit of Gastroenterology and Endoscopy, Cardinal Massaja Hospital, Asti, Italy
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Shor J, Churrango G, Hosseini N, Marshall C. Management of microscopic colitis: challenges and solutions. Clin Exp Gastroenterol 2019; 12:111-120. [PMID: 30881078 PMCID: PMC6398419 DOI: 10.2147/ceg.s165047] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Microscopic colitis (MC) is a chronic inflammatory bowel disease characterized by nonbloody diarrhea in the setting of normal appearing colonic mucosa. MC has two main subtypes based on histopathologic features, collagenous colitis and lymphocytic colitis. Management of both subtypes is the same, with treatment goal of reducing the number of bowel movements and improving consistency. First-line treatment involves counseling the patient about decreasing their risk factors, like discontinuing smoking and avoiding medications with suspected association such as NSAIDs, proton pump inhibitor, ranitidine, and sertraline. Starting loperamide for immediate symptomatic relief is used as an adjunct to therapy with glucocorticoids. Budesonide is considered first-line treatment for MC given its favorable side effect profile and good efficacy, though relapse rates are high. Systemic glucocorticoids should be reserved to patients unable to take budesonide. In glucocorticoid refractory disease, medications that have been tried include cholestyramine, bismuth salicylate, antibiotics, probiotics, aminosalicylates, immunomodulators, and anti-tumor necrosis factor-alpha inhibitors. More research is needed for the creation of a systematic stepwise approach for relapsing and refractory disease.
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Affiliation(s)
- Julia Shor
- Department of Gastroenterology, University of Massachusetts Medical School, Worcester, MA, USA,
| | - Gustavo Churrango
- Department of Gastroenterology, University of Massachusetts Medical School, Worcester, MA, USA,
| | - Nooshin Hosseini
- Department of Gastroenterology, Mount Sinai Hospital, New York, NY, USA
| | - Christopher Marshall
- Department of Gastroenterology, University of Massachusetts Medical School, Worcester, MA, USA,
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67
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Levy A, Borren NZ, Maxner B, Tan W, Bellavance D, Staller K, Chung D, Khalili H, Ananthakrishnan AN. Cancer risk in microscopic colitis: a retrospective cohort study. BMC Gastroenterol 2019; 19:1. [PMID: 30611218 PMCID: PMC6321729 DOI: 10.1186/s12876-018-0926-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 12/25/2018] [Indexed: 12/22/2022] Open
Abstract
Background The long-term natural history of microscopic colitis (MC) (collagenous colitis (CC), lymphocytic colitis (LC)), traditionally considered relapsing but non-progressive diseases, is poorly defined. Whether persistent histologic inflammation in such diseases is associated with an increased risk of colorectal neoplasia (CRN) or extracolonic cancers has not been robustly established. Methods This retrospective cohort included diagnosed with MC at a referral center. Rates of CRN and extracolonic cancer were compared to patients undergoing screening colonoscopy (n = 306) and to the United States population using data from the Surveillance, Epidemiology, and End-Results (SEER) program. Standardized incidence ratios (SIR) and 95% confidence intervals were calculated and multivariable regression models used to identify the effect of MC diagnosis and severity on cancer risk. Results Our study included 221 patients with microscopic colitis (112 CC, 109 LC) among whom 77% were women. Compared to the colonoscopy control population, MC was associated with similar odds of tubular adenoma (Odds ratio (OR) 1.07, 95% CI 0.69–1.66) or villous adenoma (OR 1.26, 95% CI 0.17–9.42). Compared to patients with a single episode of MC, those with 2 or more episodes had similar risk of colon cancer (OR 0.83, 95% CI 0.20–3.39) or tubular adenoma (OR 1.49 95% CI 0.83–2.67). We also identified no statistical increase in the rates of cancer in the MC population compared to US-SEER data. Conclusion Microscopic colitis was not associated with increased risk of CRN and extracolonic cancers when compared to controls undergoing colonoscopy or the US SEER population.
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Affiliation(s)
- Alexander Levy
- Division of Gastroenterology, Tufts Medical Center, Boston, MA, 02111, USA
| | - Nienke Z Borren
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Benjamin Maxner
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - William Tan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Danielle Bellavance
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, 02114, USA.,Harvard Medical School, Boston, MA, 02115, USA
| | - Daniel Chung
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, 02114, USA.,Harvard Medical School, Boston, MA, 02115, USA
| | - Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, 02114, USA.,Harvard Medical School, Boston, MA, 02115, USA
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, 02114, USA. .,Harvard Medical School, Boston, MA, 02115, USA.
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68
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Miehlke S, Aust D, Mihaly E, Armerding P, Böhm G, Bonderup O, Fernández-Bañares F, Kupcinskas J, Munck LK, Rehbehn KU, Nacak T, Greinwald R, Münch A, Bonderup O, Munck LK, Rannem T, Armerding P, Bläker M, Böhm G, Hoesl M, Kirsch C, Madisch A, Meier E, Miehlke S, Rehbehn KU, Kiss GG, Nagy F, Tulassay Z, Zsigmond F, Kupcinskas L, Bouma G, Pierik M, Fernández-Bañares F, Lucendo AJ, Bohr J, Hellström P, Lebrun B, Lindberg G, Münch A, Vigren L, Wielondek M, Krauss M, Dignass A, Kruis W. Efficacy and Safety of Budesonide, vs Mesalazine or Placebo, as Induction Therapy for Lymphocytic Colitis. Gastroenterology 2018; 155:1795-1804.e3. [PMID: 30195447 DOI: 10.1053/j.gastro.2018.08.042] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 08/07/2018] [Accepted: 08/23/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND & AIMS Lymphocytic colitis is a common cause of chronic, nonbloody diarrhea. However, the effects of treatment are unclear and randomized placebo-controlled trials were requested in a Cochrane review. We performed a randomized, placebo-controlled, multicenter study to evaluate budesonide and mesalazine as induction therapy for lymphocytic colitis. METHODS Patients with active lymphocytic colitis were randomly assigned to groups given budesonide 9 mg once daily (Budenofalk granules), mesalazine 3 g once daily (Salofalk granules), or placebo for 8 weeks in a double-blind, double-dummy design. The primary endpoint was clinical remission, defined as ≤21 stools (including ≤6 watery stools), in the 7 days before week 8. RESULTS The final analysis included 57 patients (19 per group). Most patients were female (72%) and the mean age was 59 years. The proportion of patients in clinical remission at week 8 was significantly higher in the budesonide group than in the placebo group (intention-to-treat analysis, 79% vs 42%; P = .01). The difference in proportions of patients in clinical remission at week 8 between the mesalazine (63%) and placebo groups was not significant (P = .09). The proportion of patients with histologic remission at week 8 was significantly higher in the budesonide group (68%) vs the mesalazine (26%; P = .02) or placebo (21%; P = .008) groups. The incidence of adverse events was 47.4% in the budesonide group, 68.4% in the mesalazine group, and 42.1% in the placebo group. CONCLUSIONS In a randomized multicenter study, we found oral budesonide 9 mg once daily to be effective and safe for induction of clinical and histologic remission in patients with lymphocytic colitis, compared with placebo. Oral mesalazine 3 g once daily was not significantly better than placebo. ClinicalTrials.gov no: NCT01209208.
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Affiliation(s)
- Stephan Miehlke
- Center for Digestive Diseases, Internal Medicine Center Eppendorf, Hamburg, Germany.
| | - Daniela Aust
- Institute for Pathology, University Hospital Carl Gustav Carus, TU Dresden, Germany
| | - Emese Mihaly
- 2nd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | | | - Günther Böhm
- Internal Medicine and Cardiology, Private Practice, Ludwigshafen am Rhein, Germany
| | - Ole Bonderup
- Diagnostic Center, Section of Gastroenterology, Regional Hospital Silkeborg, Silkeborg, Denmark
| | | | - Juozas Kupcinskas
- Department of Gastroenterology and Institute for Digestive Research, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Lars Kristian Munck
- Zealand University Hospital, Køge, and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | | | | | - Andreas Münch
- Department of Gastroenterology and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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69
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Moore M, Coleman HG, Allen PB, Loughrey MB. Microscopic colitis: a population-based case series over a 9-year period in Northern Ireland. Colorectal Dis 2018; 20:1020-1027. [PMID: 29742325 DOI: 10.1111/codi.14247] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 04/22/2018] [Indexed: 02/08/2023]
Abstract
AIM We report clinicopathological experience of microscopic colitis (MC) in a population-based case series in Northern Ireland over a 9-year period. METHOD The pathology laboratory information system within a large teaching centre serving two healthcare trusts was interrogated for cases coded between 2008 and 2016 as collagenous colitis (CC) or lymphocytic colitis (LC). Demographic, clinical and follow-up information was collected from healthcare records. RESULTS A total of 326 new diagnoses of MC were identified, an average annual incidence of 6.7 per 100 000 population. The average annual incidence of CC and LC was 5.0 and 1.7 per 100 000 population, respectively. For coding reasons it is likely that LC data are incomplete. Of 191 cases diagnosed by specialist gastrointestinal pathologists, 141 patients had CC and 50 patients had LC. Both CC and LC predominantly involved women aged 60-79. Some 15% demonstrated endoscopic abnormalities. Endoscopic sampling protocols varied widely: 30% of individuals with CC and 32% of those with LC had the right and left colon sampled separately, with histology concordant in 95% of cases. Of the 191 cases, only one case (of LC) was refractory to treatment; the rest exhibited a clinical response. Only 35 patients had follow-up endoscopy and biopsies, and three of each diagnosis showed persistent disease on histology. CONCLUSION Overall, CC and LC are benign conditions with similar demographics, clinical associations, management and outcomes. Separate sampling of the right and left colon is advised at colonoscopy if this diagnosis is being considered, but left colonic sampling, which can be performed at flexible sigmoidoscopy, will diagnose the vast majority of cases.
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Affiliation(s)
- M Moore
- Department of Cellular Pathology, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - H G Coleman
- Centre for Public Health, Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, UK
| | - P B Allen
- Division of Gastroenterology, South Eastern Health and Social Care Trust, Ulster Hospital, Dundonald, UK
| | - M B Loughrey
- Department of Cellular Pathology, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK.,Centre for Public Health, Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, UK
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70
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Krol R, van Oijen MGH. Editorial: proton pump inhibitors (PPIs) and microscopic colitis. Aliment Pharmacol Ther 2018; 48:880-881. [PMID: 30281829 DOI: 10.1111/apt.14953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Robin Krol
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, The Netherlands
| | - Martijn G H van Oijen
- Department of Medical Oncology, Amsterdam UMC, Cancer Center Amsterdam, Amsterdam, The Netherlands
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71
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Arasaradnam RP, Brown S, Forbes A, Fox MR, Hungin P, Kelman L, Major G, O'Connor M, Sanders DS, Sinha R, Smith SC, Thomas P, Walters JRF. Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, 3rd edition. Gut 2018; 67:1380-1399. [PMID: 29653941 PMCID: PMC6204957 DOI: 10.1136/gutjnl-2017-315909] [Citation(s) in RCA: 180] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 02/28/2018] [Accepted: 03/11/2018] [Indexed: 02/07/2023]
Abstract
Chronic diarrhoea is a common problem, hence clear guidance on investigations is required. This is an updated guideline from 2003 for the investigations of chronic diarrhoea commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). This document has undergone significant revision in content through input by 13 members of the Guideline Development Group (GDG) representing various institutions. The GRADE system was used to appraise the quality of evidence and grading of recommendations.
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Affiliation(s)
- Ramesh P Arasaradnam
- University Hospital Coventry, Coventry, UK
- Department of Applied Biological Sciences, University of Coventry, Coventry, UK
- Clinical Sciences Research Institute, University of Warwick, Warwick, UK
| | | | - Alastair Forbes
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Mark R Fox
- University of Zürich, Zürich, Switzerland
- Abdominal Centre, St Claraspital, Basel, Switzerland
| | - Pali Hungin
- School of Medicine, Pharmacy & Health, University of Durham, Durham, UK
| | | | - Giles Major
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | | | | | - Rakesh Sinha
- Department of Radiology, South Warwickshire Hospitals, Warwick, UK
| | - Stephen Charles Smith
- Department of Clinical Biochemistry, Midlands and NW Bowel Cancer Screening Hub, Rugby, UK
| | - Paul Thomas
- Department of Gastroenterology, Musgrave Park Hospital, Taunton, UK
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72
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Shaheen NJ, Fennerty MB, Bergman JJ. Less Is More: A Minimalist Approach to Endoscopy. Gastroenterology 2018; 154:1993-2003. [PMID: 29454789 DOI: 10.1053/j.gastro.2017.12.044] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/08/2017] [Accepted: 12/04/2017] [Indexed: 12/20/2022]
Abstract
A substantial literature documents inappropriate usage of gastrointestinal endoscopy in a variety of clinical settings. Overusage of endoscopy appears to be common, and 30% or more of procedures performed in some clinical settings have questionable indications. The potential reasons for overuse of endoscopy are multiple, and include cancer phobia, fear of medical malpractice litigation, profit motive, the investigation of "incidentalomas" found on other imaging, and underappreciation of the delayed harms of endoscopy, among other reasons. Clinical guidelines, which should limit overuse of endoscopy, may instead serve to promote it, if authors opt to be "conservative," recommending endoscopy in situations of unclear utility. Several strategies may decrease overuse of endoscopy, including careful attention to risk stratification when choosing patients to screen, adherence to guidelines for surveillance intervals for colonoscopy, the use of quality indicators to identify outliers in endoscopy utilization, and education on appropriate indications and the risks of overuse at the medical student, residency, and fellowship levels.
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Affiliation(s)
- Nicholas J Shaheen
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, North Carolina.
| | - M Brian Fennerty
- Division of Gastroenterology and Hepatology, Oregon Health and Sciences University, Portland, Oregon
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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73
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Miehlke S, Acosta MBD, Bouma G, Carpio D, Magro F, Moreels T, Probert C. Oral budesonide in gastrointestinal and liver disease: A practical guide for the clinician. J Gastroenterol Hepatol 2018; 33:1574-1581. [PMID: 29603368 DOI: 10.1111/jgh.14151] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 02/26/2018] [Accepted: 03/17/2018] [Indexed: 01/10/2023]
Abstract
Oral budesonide is a second-generation steroid that allows local, selective treatment of the gastrointestinal tract and the liver, minimizing systemic exposure. The results of randomized trials comparing budesonide versus placebo or active comparators have led to expert recommendations that budesonide be used to treat mild or moderate active ileocecal Crohn's disease, microscopic colitis (including both collagenous and lymphocytic colitis), ulcerative colitis, and non-cirrhotic autoimmune hepatitis. The mechanism of budesonide action obviates the need for dose tapering due to safety reasons after induction therapy. Where low-dose budesonide is used to maintain remission, usually in microscopic colitis, it does not appear to have adverse safety implications other than slight reductions in cortisol levels on rare occasions. As a gut-selective and liver-selective corticosteroid, budesonide offers an appealing alternative to conventional systemic glucocorticoids in diseases of these organs.
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Affiliation(s)
- Stephan Miehlke
- Center for Digestive Diseases, Internal Medicine Center Eppendorf, Hamburg, Germany
| | - Manuel Barreiro-de Acosta
- Intestinal Inflammatory Disease Unit, Department of Gastroenterology, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Gerd Bouma
- Department of Gastroenterology, Vrije University Medical Center, Amsterdam, The Netherlands
| | - Daniel Carpio
- Digestive System Service, University Hospital of Pontevedra Complex, Pontevedra, Spain
| | - Fernando Magro
- Department of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal
- MedInUP, Centre for Drug Discovery and Innovative Medicines, University of Porto, Porto, Portugal
| | - Tom Moreels
- Hepato-Gastroenterology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Chris Probert
- Department of Gastroenterology, Institute of Translational Medicine, Liverpool, UK
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74
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Cotter TG, Binder M, Loftus EV, Abboud R, McNally MA, Smyrk TC, Tremaine WJ, Sandborn WJ, Pardi DS. Development of a Microscopic Colitis Disease Activity Index: a prospective cohort study. Gut 2018; 67:441-446. [PMID: 27965284 DOI: 10.1136/gutjnl-2016-313051] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 11/07/2016] [Accepted: 11/23/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Microscopic colitis (MC) is a common cause of chronic diarrhoea, often with additional symptoms. No validated instruments exist to assess disease activity in MC, making it difficult to compare efficacy of treatments between clinical trials. We aimed to identify clinical features that independently predicted disease severity and create a Microscopic Colitis Disease Activity Index (MCDAI). DESIGN Patients with MC were prospectively administered a survey assessing their GI symptoms and the IBD Questionnaire (IBDQ). A single investigator also scored a physician global assessment (PGA) of disease severity on a 10-point scale. Multiple linear regression identified which symptoms best predicted the PGA. These symptoms were then combined in a weighted formula to create the MCDAI. The relationship between MCDAI and the IBDQ was investigated. RESULTS Of the 175 patients enrolled, 13 (7.4%) did not complete the survey. The remaining 162 had a median age of 66 years (range, 57-73) and 74% were female. Several clinical features were independently associated with PGA (number of unformed stools daily, presence of nocturnal stools, abdominal pain, weight loss, faecal urgency and faecal incontinence). These parameters were combined to create the MCDAI, which strongly predicted the PGA (R2=0.80). A 1-unit decrease in disease activity (ΔMCDAI) was associated with a 9-unit increase in quality of life (ΔIBDQ). CONCLUSIONS The MCDAI strongly predicted the PGA and correlated with a validated measure of quality of life. Several symptoms in addition to diarrhoea are associated with disease severity in MC.
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Affiliation(s)
- Thomas G Cotter
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Moritz Binder
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Edward V Loftus
- Divisions of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Rami Abboud
- Divisions of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Meredythe A McNally
- Divisions of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas C Smyrk
- Department of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - William J Tremaine
- Divisions of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - William J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, California, USA
| | - Darrell S Pardi
- Divisions of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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75
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Högger L, Vavricka S. [Microscopic Colitis]. PRAXIS 2018; 107:1195-1199. [PMID: 30376775 DOI: 10.1024/1661-8157/a003099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Microscopic colitis (MC) is still an underestimated cause of chronic, non-bloody watery diarrhea. It is typically manifested in elderly patients with a female predominance. The incidence of microscopic colitis has been increasing. The aetiology and pathophysiology remain unclear. Conditions associated with it include autoimmune diseases. There may be a genetic predisposition, as familial cases have been described. As implicated by the name microscopic colitis, the diagnosis is found by histological examination. There are mainly two subtypes, the lymphocytic colitis (LC) and the collagenous colitis (CC). Even if the condition's long-term course is benign, a chronic recurrent course of the symptoms is frequent. Due to the symptoms, there is an impairment of patient's health-related quality of life. A correct diagnosis and therapy is therefore mandatory. The aim of this paper is to create awareness for microscopic colitis.
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MESH Headings
- Adult
- Aged
- Biopsy
- Chronic Disease
- Colitis, Collagenous/diagnosis
- Colitis, Collagenous/etiology
- Colitis, Collagenous/pathology
- Colitis, Lymphocytic/diagnosis
- Colitis, Lymphocytic/etiology
- Colitis, Lymphocytic/pathology
- Colitis, Microscopic/diagnosis
- Colitis, Microscopic/etiology
- Colitis, Microscopic/pathology
- Diagnosis, Differential
- Diarrhea/etiology
- Diarrhea/pathology
- Female
- Humans
- Intestinal Mucosa/pathology
- Male
- Middle Aged
- Quality of Life
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Affiliation(s)
- Lisa Högger
- 1 Klinik für Allgemein-, Viszeral- und Gefässchirurgie, Kantonsspital Baden
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76
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Gomaa MS, Elsawaby AS, Awad EA, Abdel Rahman MG. Microscopic colitis in Egyptian population: study of some contributing factors and role of chromogranin A as a diagnostic marker. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2017. [DOI: 10.4103/ejim.ejim_36_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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77
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Piper MS, Saad RJ. Diabetes Mellitus and the Colon. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2017; 15:460-474. [PMID: 29063998 PMCID: PMC6049816 DOI: 10.1007/s11938-017-0151-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OPINION STATEMENT Diabetes mellitus (DM) can affect the structure and function of the colon promoting commonly encountered lower gastrointestinal symptoms such as constipation, diarrhea, abdominal distention, bloating, and abdominal pain. Specific colonic disorders for which adults with DM are at greater risk include chronic constipation, enteropathic diarrhea, colorectal cancer (CRC), inflammatory bowel disease, microscopic colitis, and Clostridium difficile colitis. Smooth muscle structure and function, density of the interstitial cells of Cajal, and the health and function of the autonomic and enteric nerves of the colon are all potential affected by DM. These effects can in turn lead to alterations in colon motility, visceral sensation, immune function, endothelial function, and the colonic microbiome. The evaluation and treatment for slow transit constipation as well as pelvic floor dysfunction should be considered when constipation symptoms are refractory to initial treatment measures. DM-related medications and small bowel conditions such as celiac disease and small intestinal bowel overgrowth should be considered and excluded before a diagnosis of enteropathic diarrhea is made. Given the higher risk of CRC, adults with DM should be appropriately screened and may require a longer bowel preparation to ensure an adequate evaluation.
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Affiliation(s)
- Marc S Piper
- Providence-Park Hospital, Michigan State University College of Human Medicine, Lansing, MI, USA
| | - Richard J Saad
- Michigan Medicine at the University of Michigan, 3912 Taubman Center, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA.
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78
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Cotter TG, Kamboj AK, Hicks SB, Tremaine WJ, Loftus EV, Pardi DS. Case report: Pentoxifylline treatment in microscopic colitis. Medicine (Baltimore) 2017; 96:e8355. [PMID: 29145246 PMCID: PMC5704791 DOI: 10.1097/md.0000000000008355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Microscopic colitis is a common cause of diarrhea. Pentoxifylline, a xanthine derivative with anti-tumor necrosis factor-alpha properties, is prescribed for intermittent claudication and other disorders. Our goal was to evaluate the outcomes of patients with microscopic colitis treated with pentoxifylline. PATIENT CONCERNS Nine patients with microscopic colitis (8 collagenous colitis and 1 lymphocytic colitis) seen at Mayo Clinic, Rochester, between January 1, 1997 and November 30, 2016, were included. The median age was 56.9 years (range 51.6-60.2), 8 were female (89%), and the median disease duration was 64.8 months (range 60-109). The indications for treatment were budesonide refractoriness in 7 patients, budesonide dependence in 1 patient, and budesonide intolerance in 1 patient. DIAGNOSES A histological diagnosis of microscopic colitis was confirmed in all patients. INTERVENTIONS Pentoxifylline 400 mg three times a day was used for a median of 3 months (range 2.5-8.3). OUTCOMES Complete response occurred in 1 patient (11%) and partial response in 3 patients (33%). The patient who achieved complete response was treated with pentoxifylline due to budesonide intolerance, and completed 43 months of successful maintenance therapy. There were no adverse effects reported. LESSONS The majority of budesonide-experienced patients with active microscopic colitis did not respond to pentoxifylline. However, it was well-tolerated, with 1 patient achieving long-term remission and one-third of the cohort having a partial response. Larger controlled studies are required to evaluate the efficacy of pentoxifylline and predictors of response in microscopic colitis. In particular, patients who are not budesonide-refractory may be more likely to respond.
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Affiliation(s)
| | | | | | | | - Edward V. Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Darrell S. Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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79
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Titos-García A, Aranda-Narváez JM, Romacho-López L, González-Sánchez AJ, Cabrera-Serna I, Santoyo-Santoyo J. Nonoperative management of perforated acute diverticulitis with extraluminal air: results and risk factors of failure. Int J Colorectal Dis 2017; 32:1503-1507. [PMID: 28717840 DOI: 10.1007/s00384-017-2852-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2017] [Indexed: 02/04/2023]
Abstract
AIM The aim of this study was to analyze the results of nonoperative management of patients with perforated acute diverticulitis with extraluminal air and to identify risk factors that may lead to failure and necessity of surgery. METHODS Methods included observational retrospective cohort study of patients between 2010 and 2015 with diagnosis of diverticulitis with extraluminal air and with nonoperative management initial. Patient demographics, clinical, and analytical data were collected, as were data related with computed tomography. Univariate and multivariate analyses with Wald forward stepwise logistic regression were performed to analyze results and to identify risk factors potentially responsible of failure of nonoperative management. RESULTS Nonoperative management was established in 83.12% of patients diagnosed with perforated diverticulitis (64 of 77) with an overall success rate of 84.37%, a mean hospital stay of 11.98 ± 7.44 days and only one mortality (1.6%). Patients with pericolic air presented a greater chance of success (90.2%) than patients with distant air (61.5%). American Society of Anesthesiologists (ASA) grade III-IV (OR, 5.49; 95% CI, 1.04-29.07) and the distant location of air (OR, 4.81; 95% CI, 1.03-22.38) were the only two factors identified in the multivariate analysis as risk factors for a poor nonoperative treatment outcome. Overall recurrence after conservative approach was 20.4%; however, recurrence rate of patients with distant air was twice than that of patients with pericolic air (37.5 vs 17.39%). Only 14.8% of successfully treated patients required surgery after the first episode. CONCLUSION Nonoperative management of perforated diverticulitis is safe and efficient. Special follow-up must be assumed in patients ASA III-IV and with distant air in CT.
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Affiliation(s)
- Alberto Titos-García
- Trauma and Emergency Surgery Unit. General, Digestive and Transplantation Surgery Department, University Regional Hospital, Carlos Haya Av., 29010, Málaga, Spain.
| | - Jose M Aranda-Narváez
- Trauma and Emergency Surgery Unit. General, Digestive and Transplantation Surgery Department, University Regional Hospital, Carlos Haya Av., 29010, Málaga, Spain
| | - Laura Romacho-López
- Trauma and Emergency Surgery Unit. General, Digestive and Transplantation Surgery Department, University Regional Hospital, Carlos Haya Av., 29010, Málaga, Spain
| | - Antonio J González-Sánchez
- Trauma and Emergency Surgery Unit. General, Digestive and Transplantation Surgery Department, University Regional Hospital, Carlos Haya Av., 29010, Málaga, Spain
| | - Isaac Cabrera-Serna
- Trauma and Emergency Surgery Unit. General, Digestive and Transplantation Surgery Department, University Regional Hospital, Carlos Haya Av., 29010, Málaga, Spain
| | - Julio Santoyo-Santoyo
- Trauma and Emergency Surgery Unit. General, Digestive and Transplantation Surgery Department, University Regional Hospital, Carlos Haya Av., 29010, Málaga, Spain
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80
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Tolba MF, El-Serafi AT, Omar HA. Caffeic acid phenethyl ester protects against glucocorticoid-induced osteoporosis in vivo: Impact on oxidative stress and RANKL/OPG signals. Toxicol Appl Pharmacol 2017; 324:26-35. [PMID: 28363435 DOI: 10.1016/j.taap.2017.03.021] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 03/19/2017] [Accepted: 03/23/2017] [Indexed: 12/11/2022]
Abstract
Glucocorticoid-induced osteoporosis (GIO) is one of the most common causes of secondary osteoporosis. Given that glucocorticoids are considered as a main component of the treatment protocols for a variety of inflammation and immune-mediated diseases besides its use as adjuvant to several chemotherapeutic agents, it is crucial to find ways to overcome this critical adverse effect. Caffeic acid phenethyl ester (CAPE), which is a natural compound derived from honeybee propolis displayed promising antiosteoporotic effects against mechanical bone injury in various studies. The current work aimed at investigating the potential protective effect of CAPE against GIO in vivo with emphasis on the modulation of oxidative status and receptor activator of NF-kB ligand (RANKL)/osteoprotegrin (OPG) signaling. The results showed that CAPE opposed dexamethasone (DEX)-mediated alterations in bone histology and tartarate-resistant acid phosphatase (TRAP) activity. In addition, CAPE restored oxidative balance, Runt-related transcription factor 2 (RunX2) expression and reduced caspase-3 activity in femur tissues. Co-administration of CAPE with DEX normalized RANKL/OPG ratio and Akt activation indicating a reduction in DEX-osteoclastogenesis. In conclusion, concurrent treatment of CAPE with DEX exhibited promising effects in the protection against DEX-induced osteoporosis through opposing osteoclastogenesis and protecting osteoblasts. The potent antioxidant activity of CAPE is, at least in part, involved in its anti-apoptotic effects and modulation of RunX2 and RANKL/OPG signals. The use of CAPE-enriched propolis formulas is strongly recommended for patients on chronic glucocorticoid therapy to help in the attenuation of GIO.
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Affiliation(s)
- Mai F Tolba
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Ain Shams University, Cairo 11566, Egypt; Chapman University, Irvine 92618, CA, USA
| | - Ahmed T El-Serafi
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah 27272, United Arab Emirates; Department of Medical Biochemistry, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Hany A Omar
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah 27272, United Arab Emirates; Department of Pharmacology, Faculty of Pharmacy, Beni-Suef University, Beni-Suef 62514, Egypt.
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81
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Abstract
PURPOSE OF REVIEW Microscopic colitis is a common cause of chronic watery diarrhea, particularly in the elderly. The accompanying symptoms, which include abdominal pain and fatigue, can markedly impair patients' quality of life. Diagnosis is based upon characteristic histologic findings of the colonic mucosa. This review focuses on the current approach to evaluation and management of patients with microscopic colitis. RECENT FINDINGS Although the incidence of microscopic colitis has been increasing over time, recent epidemiological studies show stabilization at 21.0-24.7 cases per 100,000 person-years. Recent research has further expanded our knowledge of the underlying pathophysiology and emphasized the entity of drug-induced microscopic colitis and the association with celiac disease. Two recent randomized studies have confirmed the effectiveness of oral budesonide for both induction and maintenance treatment of microscopic colitis and is now endorsed by the American Gastroenterological Association as first-line treatment. The incidence of microscopic colitis has stabilized at just over 20 cases per 100,000 person-years. Celiac disease and drug-induced microscopic colitis should be considered in all patients diagnosed with microscopic colitis. There are a number of treatments available for patients with microscopic colitis; however, budesonide is the only option well studied in controlled trials and is effective for both induction and maintenance treatment.
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82
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Camilleri M, Sellin JH, Barrett KE. Pathophysiology, Evaluation, and Management of Chronic Watery Diarrhea. Gastroenterology 2017; 152:515-532.e2. [PMID: 27773805 PMCID: PMC5285476 DOI: 10.1053/j.gastro.2016.10.014] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 09/21/2016] [Accepted: 10/11/2016] [Indexed: 02/08/2023]
Abstract
Chronic watery diarrhea poses a diagnostic and therapeutic challenge and is often a disabling condition for patients. Although acute diarrhea is likely to be caused by infection, the causes of chronic diarrhea (>4 weeks in duration) are more elusive. We review the pathophysiology, diagnosis, and treatment of chronic diarrhea. Drawing on recent insights into the molecular mechanisms of intestinal epithelial transport and barrier function, we discuss how diarrhea can result from a decrease in luminal solute absorption, an increase in secretion, or both, as well as derangements in barrier properties. We also describe the various extraepithelial factors that activate diarrheal mechanisms. Finally, clinical evaluation and tests used in the assessment of patients presenting with chronic diarrhea are reviewed, and an algorithm guiding therapeutic decisions and pharmacotherapy is presented.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Joseph H. Sellin
- Division of Gastroenterology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Kim E. Barrett
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, CA
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83
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Salter TG, Williams MD. Antidepressant-Associated Microscopic Colitis: A Case Report and Literature Review. PSYCHOSOMATICS 2017; 58:307-312. [PMID: 28347506 DOI: 10.1016/j.psym.2017.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 01/18/2017] [Accepted: 01/18/2017] [Indexed: 01/27/2023]
Affiliation(s)
- Thomas G Salter
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN.
| | - Mark D Williams
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
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84
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Budesonide-Related Iatrogenic Cushing's Syndrome in Microscopic Colitis. ACG Case Rep J 2017; 4:e5. [PMID: 28138449 PMCID: PMC5244872 DOI: 10.14309/crj.2017.5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 06/09/2016] [Indexed: 12/22/2022] Open
Abstract
Budesonide is the treatment of choice for microscopic colitis because of its excellent risk to benefit ratio. It is a potent, well-absorbed corticosteroid, but because of a high rate of first-pass metabolism in the liver, its systemic bioavailability is low. It has fewer corticosteroid-related adverse effects than prednisone, and adrenal suppression is considered to be rare. We present a middle-aged woman with lymphocytic colitis whose symptoms responded to budesonide but developed budesonide-related iatrogenic Cushing’s syndrome. Withdrawal of budesonide led to restoration of normal pituitary-adrenal responsiveness but at the price of recurrent diarrhea due to re-emergence of lymphocytic colitis.
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85
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Pseudomembranous Collagenous Colitis: A Case of Not-so-Microscopic Colitis. ACG Case Rep J 2016; 3:e187. [PMID: 28119938 PMCID: PMC5226204 DOI: 10.14309/crj.2016.160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 09/02/2016] [Indexed: 02/07/2023] Open
Abstract
We present a 72-year-old male who developed progressive, watery diarrhea despite anti-motility agents. On colonoscopy, the mucosa was inflamed and covered with an exudate. Stool studies for Clostridium difficile and Escherichia coli were negative. Biopsies revealed pseudomembranous collagenous colitis, a rare form of microscopic colitis. His symptoms improved dramatically with budesonide therapy.
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86
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Guagnozzi D, Landolfi S, Vicario M. Towards a new paradigm of microscopic colitis: Incomplete and variant forms. World J Gastroenterol 2016; 22:8459-8471. [PMID: 27784958 PMCID: PMC5064027 DOI: 10.3748/wjg.v22.i38.8459] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 08/20/2016] [Accepted: 09/08/2016] [Indexed: 02/06/2023] Open
Abstract
Microscopic colitis (MC) is a chronic inflammatory bowel disease that has emerged in the last three decades as a leading cause of chronic watery diarrhoea. MC classically includes two main subtypes: lymphocytic colitis (LC) and collagenous colitis (CC). Other types of histopathological changes in the colonic mucosa have been described in patients with chronic diarrhoea, without fulfilling the conventional histopathological criteria for MC diagnosis. Whereas those unclassified alterations remained orphan for a long time, the use of the term incomplete MC (MCi) is nowadays universally accepted. However, it is still unresolved whether CC, LC and MCi should be considered as one clinical entity or if they represent three related conditions. In contrast to classical MC, the real epidemiological impact of MCi remains unknown, because only few epidemiological studies and case reports have been described. MCi presents clinical characteristics indistinguishable from complete MC with a good response to budesonide and cholestiramine. Although a number of medical treatments have been assayed in MC patients, currently, there is no causal treatment approach for MC and MCi, and only empirical strategies have been performed. Further studies are needed in order to identify their etiopathogenic mechanisms, and to better classify and treat MC.
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87
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Law EH, Badowski M, Hung YT, Weems K, Sanchez A, Lee TA. Association Between Proton Pump Inhibitors and Microscopic Colitis. Ann Pharmacother 2016; 51:253-263. [PMID: 27733667 DOI: 10.1177/1060028016673859] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective: Microscopic colitis (MC) is a chronic inflammatory disease of the colon that is characterized by chronic, watery, nonbloody diarrhea. Concern regarding a potential association between proton-pump inhibitors (PPIs) and MC has recently emerged. We sought to systematically review and summarize the evidence for the potential association between PPIs and MC. Data Sources: We systematically searched EMBASE, MEDLINE, Cochrane Database of Systematic Reviews, International Pharmaceutical Abstracts, and Google Scholar using the terms proton-pump inhibitors (omeprazole, lansoprazole, dexlansoprazole, rabeprazole, pantoprazole, or esomeprazole), microscopic colitis, collagenous colitis, and lymphocytic colitis. Study Selection: Full-text, English-language reports of case reports/series, observational studies, experimental studies, and systematic reviews/meta-analyses published between January 2000 to August 2016 were included. Bibliographies from pertinent publications were reviewed for additional references. Outcome was defined as the development of biopsy-confirmed MC. Data Extraction/Synthesis: A total of 19 publications were identified: 5 case control studies and 14 case reports/series (encompassing a total of 32 cases). All studies were limited by small sample sizes. Risk of MC by dose or specific PPI agent was not investigated in any of the studies. A review of the current body of evidence reveals a possible association between PPIs and MC. Conclusions: There is a need for large observational studies of high quality to examine the differential effect of specific PPIs and whether the magnitude of association is dose dependent. Given their widespread use, clinicians should routinely question whether patients are receiving unnecessary treatment with PPIs and discontinue therapy where appropriate.
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Affiliation(s)
- Ernest H. Law
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Melissa Badowski
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Yu-Ting Hung
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Kimberly Weems
- School of Public Health, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Angelica Sanchez
- School of Public Health, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Todd A. Lee
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
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88
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Diagnosis and treatment of microscopic colitis. Clin J Gastroenterol 2016; 9:169-74. [DOI: 10.1007/s12328-016-0656-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 05/20/2016] [Indexed: 02/07/2023]
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