Sténose iléale

Effectiveness comparison between ustekinumab and infliximab for Crohn's disease complicated with intestinal stenosis: a multicenter real-world study

BACKGROUND

The efficacy of ustekinumab (UST) and infliximab (IFX) in Crohn's disease (CD) patients with intestinal stenosis remains uncertain.

OBJECTIVE

This study aims to compare the efficacy of UST and IFX in the treatment of CD patients with intestinal stenosis.

DESIGN

This was a retrospective and multicenter cohort study.

METHODS

In this retrospective study, we included CD patients treated with IFX or UST at five centers. We assessed the clinical response rate at weeks 12 and 24, steroid-free clinical remission rate at weeks 24 and 52 for overall patients and those with stenosis, and objective examination (intestinal ultrasound and/or endoscopy) response rate at week 52 for stenosis patients.

RESULTS

A total of 211 CD patients (106 IFX and 105 UST) were included, with 119 (56 IFX and 63 UST) having intestinal stenosis. In the overall patient population, there were no significant differences in clinical response rate and steroid-free clinical remission rate at weeks 12, 24, and 52 between the IFX and UST groups. In patients with stenosis, the steroid-free clinical remission rate at week 52 was significantly lower in the IFX group compared to the UST group (51.79% IFX vs 69.84% UST, p = 0.044). The objective examination response rate did not significantly differ between the IFX and UST groups at week 52 (66.67% IFX vs 76.19% UST, p = 0.690). In the UST group, steroid-free clinical remission rate was higher in bio-naïve patients than bio-experienced patients at week 24 (75.00% bio-naïve vs 55.38% bio-experienced, p = 0.043).

CONCLUSION

UST may be considered a more advantageous treatment option for those CD patients with intestinal stenosis, as it has better steroid-free clinical remission rates compared to IFX.

Effectiveness of contrast-enhanced ultrasound for characterisation of intestinal inflammation in Crohn's disease: a comparison with surgical histopathology analysis

BACKGROUND

Differentiation between predominantly inflammatory versus fibrous-predominant lesions is particularly important in order to decide the optimal therapy in patients with refractory symptoms in Crohn's disease (CD).

OBJECTIVE

The purpose of this investigation was to evaluate the accuracy of several US parameters, especially of contrast-enhanced US, for evaluation of mural inflammation in CD, with histopathology as the reference.

MATERIALS AND METHODS

Preoperative ultrasound examination, including contrast-enhanced ultrasound (CEUS) was performed in 25 consecutive patients with Crohn's disease undergoing elective bowel resection. Ultrasound variables, such as wall thickness, transmural complications, colour Doppler grade, quantitative analysis of the enhancement and the presence and severity of strictures, were prospectively evaluated and compared with the histopathology results. Histopathology grading of acute inflammation using the acute inflammatory score and the degree of fibrostenosis was performed in each segment and the results were compared with all the US variables as well as with a previously defined ultrasound score system for inflammatory and fibrostenotic changes.

RESULTS

28 segments were analysed. In pathology analysis there were 12 predominantly inflammatory segments, 9 predominantly fibrostenotic and 7 compound lesions. When the pathology score was dichotomised into two groups (inflammatory and fibrostenotic) the number of stenoses correctly classified by US was 23 out 28, with a substantial agreement (kappa=0.632). There was a good correlation between the sonographic and pathology scores, both inflammation (Spearman's, r=0.53) and fibrostenosis (Spearman's, r=0.50). Transmural complications, colour Doppler grade and percentage of increase in contrast enhancement were significantly associated with the pathology inflammatory score (p=0.018, p=0.036 and p=0.005, respectively). There was a significantly negative association between the colour Doppler grade and the pathologic fibrostenotic score.

CONCLUSIONS

Ultrasound, including CEUS, can be a useful tool for distinguishing inflammatory from fibrostenotic lesions in CD. This information can be useful in the management of CD.

Which magnetic resonance imaging findings accurately evaluate inflammation in small bowel Crohn's disease? A retrospective comparison with surgical pathologic analysis

BACKGROUND

The aim was to evaluate the value of magnetic resonance imaging (MRI) findings in Crohn's disease (CD) in correlation with pathological inflammatory score using surgical pathology analysis as a reference method.

METHODS

CD patients who were to undergo bowel resection surgery underwent MR enterography before surgery. The CD pathological inflammatory score of the surgical specimens was classified into three grades: mild or nonactive CD, moderately active CD, and severely active CD; fibrosis was also classified into three grades: mild, moderate, and severe. Mural and extramural MRI findings were correlated with pathological inflammatory and fibrosis grades.

RESULTS

Fifty-three consecutive patients were included retrospectively. The mean delay between MRI and surgery was 24 days (range 1-90, median 14). The CD pathological inflammatory score was graded as follows: grade 0 (11 patients, 21%), grade 1 (15 patients, 28%), and grade 2 (27 patients, 51%). MRI findings significantly associated with pathological inflammatory grading were wall thickness (P < 0.0001), degree of wall enhancement on delayed phase (P < 0.0001), pattern of enhancement on both parenchymatous (P = 0.02), and delayed phase, (P = 0.008), T2 relative hypersignal wall (P < 0.0001), blurred wall enhancement (P = 0.018), comb sign (P = 0.004), fistula (P < 0.0001), and abscess (P = 0.049). The inflammation score correlated with the fibrosis score (r = 0.63, P = 0.0001).

CONCLUSIONS

Our study identified MRI findings significantly associated with surgical pathological inflammation. These lesions are considered potentially reversible and may be efficiently treated medically. We also showed that fibrosis was closely and positively related to inflammation.

Infliximab treatment for symptomatic Crohn's disease strictures

BACKGROUND

Some reports have suggested that infliximab may induce obstructive symptoms and, although there is no firm evidence, it is usually contra-indicated in-patients with Crohn's disease (CD) and strictures.

AIMS

To evaluate the effect of infliximab on symptomatic strictures of the small intestine in CD and to identify predictive factors of clinical response.

METHODS

This retrospective study included symptomatic patients treated with infliximab after conventional treatment had failed. The short-term (week 8) and long-term results were classified according to predefined criteria as complete, partial response, or failure.

RESULTS

Before infliximab, 18 patients had complete obstruction or intermittent chronic abdominal pain. Fourteen patients were treated by corticosteroids and 13 received immunosuppressive drugs. At week 8, complete, partial response and failure were observed in 10, 7 and 1 patients, respectively. Fourteen patients continued maintenance infliximab treatment after week 8. During the most recent evaluation (median follow-up: 18 months), 8 patients were on maintenance infliximab treatment; only eight were still on prednisone; there were five complete responses, 10 partial responses and three failures. Initiating prednisone or increasing its dosage was the only factor associated with a short-term complete response.

CONCLUSIONS

Infliximab may be effective in patients with symptomatic strictures from CD, and should be tested before considering surgery.