Natural History of Perianal Fistulising Lesions in Patients With Elderly-onset Crohn's Disease: A Population-based Study

INTRODUCTION

Most studies of elderly-onset Crohn's disease [CD; diagnosed in patients aged 60 or over] have described a mild course. However, data on the natural history of perianal fistulising CD [pfCD] in this population are scarce. In a population-based cohort study, we described the prevalence, natural history, and treatment of pfCD in patients with elderly-onset CD vs patients with paediatric-onset CD.

METHOD

All patients diagnosed with CD at or after the age of 60 between 1988 and 2006, were included [n = 372]. Logistic regression, Cox models, and a nested case-control method were used to identify factors associated with pfCD.

RESULTS

A total of 34 elderly patients [9% of the 372] had pfCD at diagnosis. After a median follow-up of 6 years (interquartile range [IQR]: 3; 10), 59 patients [16%] had pfCD; the same prevalence [16%] was observed in paediatric-onset patients. At last follow-up, anal incontinence was more frequent in elderly patients with pfCD than in elderly patients without pfCD [22% vs 4%, respectively; p < 10-4]. Rectal CD at diagnosis was associated with pfCD: hazard ratio (95% confidence interval [CI] = 2.8 [1.6-5.0]). Although 37% of the patients received immunosuppressants and 17% received anti-tumour necrosis factor agents, 24% [14 out of 59] had a definitive stoma at last follow-up.

CONCLUSION

During the first 6 years of disease, the prevalence of pfCD was similar in elderly and paediatric patients. Rectal involvement was associated with the appearance of pfCD in elderly-onset patients. Around a quarter of patients with elderly-onset CD will have a stoma. Our results suggest that treatment with biologics should be evaluated in these patients.

Dramatic Increase in Incidence of Ulcerative Colitis and Crohn's Disease (1988-2011): A Population-Based Study of French Adolescents

OBJECTIVES

Few data are available to describe the changes in incidence of pediatric-onset inflammatory bowel disease (IBD). The aim of this study was to describe changes in incidence and phenotypic presentation of pediatric-onset IBD in northern France during a 24-year period.

METHODS

Pediatric-onset IBD (<17 years) was issued from a population-based IBD study in France between 1988 and 2011. Age groups and digestive location were defined according to the Paris classification.

RESULTS

1,350 incident cases were recorded (8.3% of all IBD) including 990 Crohn's disease (CD), 326 ulcerative colitis (UC) and 34 IBD unclassified (IBDU). Median age at diagnosis was similar in CD (14.4 years (Q1=11.8-Q3=16.0)) and UC (14.0 years (11.0-16.0)) and did not change over time. There were significantly more males with CD (females/males=0.82) than UC (females/males=1.25) (P=0.0042). Median time between onset of symptoms and IBD diagnosis was consistently 3 months (1-6). Mean incidence was 4.4/10⁵ for IBD overall (3.2 for CD, 1.1 for UC and 0.1 for IBDU). From 1988-1990 to 2009-2011, a dramatic increase in incidences of both CD and UC were observed in adolescents (10-16 years): for CD from 4.2 to 9.5/10⁵ (+126%; P<0.001) and for UC, from 1.6 to 4.1/10⁵ (+156%; P<0.001). No modification in age or location at diagnosis was observed in either CD or UC.

CONCLUSIONS

In this population-based study, CD and UC incidences increased dramatically in adolescents across a 24-year span, suggesting that one or more strong environmental factors may predispose this population to IBD.

Extra-intestinal Manifestations at Diagnosis in Paediatric- and Elderly-onset Ulcerative Colitis are Associated With a More Severe Disease Outcome: A Population-based Study

BACKGROUND AND AIMS

Data on extra-intestinal manifestations [EIM] and their impact on the disease course of ulcerative colitis [UC] in population-based cohorts are scarce, particularly in paediatric- and elderly-onset UC patients. The aims of this population-based study were to assess: 1] the occurrence of EIM in paediatric- and elderly-onset UC; 2] the factors associated with EIM; and 3] their impact on long-term disease outcome.

METHODS

Paediatric-onset [< 17 years at diagnosis] and elderly-onset UC patients [> 60 years at diagnosis] from a French prospective population-based registry [EPIMAD] were included. Data on EIM and other clinical factors at diagnosis and at maximal follow-up were collected.

RESULTS

In all, 158 paediatric- and 470 elderly-onset patients were included [median age at diagnosis 14.5 and 68.8 years, median follow-up 11.2 and 6.2 years, respectively]. EIM occurred in 8.9% of childhood- and 3% of elderly-onset patients at diagnosis and in 16.7% and 2.2% of individuals during follow-up [p < 0.01], respectively. The most frequent EIM was joint involvement [15.8% of paediatric onset and 2.6% of elderly-onset]. Presence of EIM at diagnosis was associated with more severe disease course [need for immunosuppressants or biologic therapy or colectomy] in both paediatric- and elderly-onset UC (hazard ratio [HR] = 2.0, 95% confidence interval [CI]: 1.0-4.2; and HR = 2.8, 0.9-7.9, respectively). Extensive colitis was another independent risk factor in both age groups.

CONCLUSIONS

Elderly-onset UC patients had lower risk of EIM either at diagnosis or during follow-up than paediatric-onset individuals. EIM at diagnosis predicted more severe disease outcome, including need for immunosuppressive or biologic therapy or surgery, in both paediatric- and elderly-onset UC.

Endoscopic ultrasound-guided needle-based confocal laser endomicroscopy in solid pancreatic masses

BACKGROUND AND STUDY AIMS

The differential diagnosis of solid pancreatic masses by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is currently suboptimal in centers that are not equipped with rapid on-site evaluation. Needle-based confocal laser endomicroscopy (nCLE) enables real-time in vivo microscopic imaging during endoscopy. This study aimed to describe nCLE interpretation criteria for the characterization of pancreatic masses, with histopathological correlation, and to perform the first validation of these criteria.

PATIENTS AND METHODS

A total of 40 patients were evaluated by EUS-FNA combined with nCLE for the diagnosis of pancreatic masses. Final diagnosis was based on EUS-FNA histology and follow-up at 1 year. Five unblinded examiners defined nCLE criteria for adenocarcinoma, chronic pancreatitis, and neuroendocrine tumor (NET) using a set of video sequences from 14 patients with confirmed pathology (Step 1). These criteria were retrospectively validated by four independent, blinded examiners using sequences from 32 patients (Step 2).

RESULTS

nCLE criteria were described for adenocarcinoma (dark cell aggregates, irregular vessels with leakages of fluorescein), chronic pancreatitis (residual regular glandular pancreatic structures), and NET (black cell aggregates surrounded by vessels and fibrotic areas). These criteria correlated with the histological features of the corresponding lesions. In the validation review, a conclusive nCLE result was obtained in 75 % of cases (96 % correct). Statistical evaluation provided promising results, with high specificity, and negative and positive predictive values for all types of pancreatic masses.

CONCLUSION

Considering the low negative predictive value of EUS-FNA, nCLE could help to rule out malignancy after a previous inconclusive EUS-FNA. Larger studies are required to confirm these findings and to establish the role of nCLE in the diagnosis of pancreatic masses.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT01563133).

A novel approach to the diagnosis of pancreatic serous cystadenoma: needle-based confocal laser endomicroscopy

BACKGROUND AND STUDY AIMS

The differential diagnosis of solitary pancreatic cystic lesions is frequently difficult. Needle-based confocal laser endomicroscopy (nCLE) performed during endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a new technology enabling real-time imaging of the internal structure of such cysts. The aim of this pilot study was to identify and validate new diagnostic criteria on nCLE for pancreatic cystic lesions.

PATIENTS AND METHODS

A total of 31 patients with a solitary pancreatic cystic lesion of unknown diagnosis were prospectively included at three centers. EUS-FNA was combined with nCLE. The final diagnosis was based on either a stringent gold standard (surgical specimen and/or positive cytopathology) or a committee consensus. Six nonblinded investigators reviewed nCLE sequences from patients with the most stringent final diagnosis, and identified a single feature that was only present in serous cystadenoma (SCA). The findings were correlated with the pathology of archived specimens. After a training session, four blinded independent observers reviewed a separate independent video set, and the yield and interobserver agreement for the criterion were assessed.

RESULTS

A superficial vascular network pattern visualized on nCLE was identified as the criterion. It corresponded on pathological specimen to a dense and subepithelial capillary vascularization only seen in SCA. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of this sign for the diagnosis of SCA were 87 %, 69 %, 100 %, 100 %, and 82 %, respectively. Interobserver agreement was substantial (κ = 0.77).

CONCLUSION

This new nCLE criterion seems highly specific for the diagnosis of SCA. The visualization of this criterion could have a direct impact on the management of patients by avoiding unnecessary surgery or follow-up.Clinicaltrials.gov NCT01563133.

Effectiveness of telaprevir or boceprevir in treatment-experienced patients with HCV genotype 1 infection and cirrhosis

BACKGROUND & AIMS

We investigated the effectiveness of the protease inhibitors peginterferon and ribavirin in treatment-experienced patients with hepatitis C virus (HCV) genotype 1 infection and cirrhosis.

METHODS

In the Compassionate Use of Protease Inhibitors in Viral C Cirrhosis study, 511 patients with HCV genotype 1 infection and compensated cirrhosis who did not respond to a prior course of peginterferon and ribavirin (44.3% relapsers or patients with viral breakthrough, 44.8% partial responders, and 8.0% null responders) were given either telaprevir (n = 299) or boceprevir (n = 212) for 48 weeks. We assessed percentages of patients with sustained viral responses 12 weeks after therapy and safety. This observational study did not allow for direct comparison of the 2 regimens.

RESULTS

Among patients given telaprevir, 74.2% of relapsers, 40.0% of partial responders, and 19.4% of null responders achieved SVR12. Among those given boceprevir, 53.9% of relapsers, 38.3% of partial responders, and none of the null responders achieved SVR12. In multivariate analysis, factors associated with SVR12 included prior response to treatment response, no lead-in phase, HCV subtype 1b (vs 1a), and baseline platelet count greater than 100,000/mm(3). Severe adverse events occurred in 49.9% of cases, including liver decompensation, severe infections in 10.4%, and death in 2.2%. In multivariate analysis, baseline serum albumin level less than 35 g/L and baseline platelet counts of 100,000/mm(3) or less predicted severe side effects or death.

CONCLUSIONS

Relatively high percentages of real-life, treatment-experienced patients with HCV genotype 1 infection and cirrhosis respond to the combination of peginterferon and ribavirin with telaprevir or boceprevir. However, side effects are frequent and often severe. Baseline levels of albumin and platelet counts can be used to guide treatment decisions. ClinicalTrials.gov number: NCT01514890.

Factors of accuracy of transient elastography (fibroscan) for the diagnosis of liver fibrosis in chronic hepatitis C

The purpose of this study was to assess the influence of success rate and interquartile range on the accuracy of transient elastography for the diagnostic of fibrosis in hepatitis C virus infection. Two-hundred fifty-four consecutive patients had liver stiffness measurements and liver biopsy of at least 15 mm. Discordances of at least two stages between transient elastography and histological assessment were observed in 28 cases (11%). Factors of discordance were assessed by comparing the 28 misclassified cases with the 226 others. In multivariate analysis, fibrosis stage (F0-F2 versus F3-F4) and the ratio interquartile range/median value of liver stiffness measurement (IQR/M) were associated with discordances (P <or= 0.05). The most significantly discriminant cutoff value was 0.21. For IQR/M < 0.21 versus IQR/M >or= 0.21, discordances of at least two stages of fibrosis were respectively observed in 10 of 135 cases (7.4%) versus 18 of 119 cases (15.1%) (P <or= 0.05). In patients with IQR/M >or= 0.21 versus IQR/M < 0.21, for the diagnosis of liver fibrosis F >or= 2, F >or= 3, F = 4, areas under the receiver operating characteristic curve (AUROCs) were 0.80 (95% confidence interval [CI], 0.73-0.89) versus 0.81 (95% CI, 0.70-0.90), (P = NS); 0.80 (95% CI, 0.72-0.88) versus 0.89 (95% CI, 0.83-0.95) (P = 0.04); and 0.86 (95% CI, 0.77-0.94) versus 0.95 (95% CI, 0.92-0.99) (P = NS). No association was found between success rate and discordance.

CONCLUSION

IQR/M is a factor of overestimation of liver fibrosis, and the most discriminant cutoff value is 0.21. Success rate is not a factor of accuracy for the diagnosis of hepatic fibrosis.

Routine practice HCV infection screening with saliva samples: multicentric study in an intravenous drug user population

OBJECTIVE

The purpose of this randomized multicentric study was to evaluate the diagnostic contribution of screening for HCV infection on saliva samples in day-to-day practice in the intravenous drug-user (IVDU) population.

METHODS

Between January and May 2004, 274 presumably HCV-negative IVDU were screened for HCV infection in 15 centers in France (median age 29 years). After centralized randomization, screening tests were performed on blood samples (arm A) or saliva samples (arm B). Screening tests were performed in 78 subjects (28%) had never been screened before and in 196 subjects (72%) who had had a negative HCV screening test on average 12 months prior to the beginning of the study. In the event of a positive saliva test for anti-HCV Ab, a serum test for anti-HCV Ab was performed. In the event of a positive serum test for anti-HCV Ab, PCR was performed on serum to measure HCV-RNA.

RESULTS

Fourteen individuals were positive for HCV RNA (7 in each arm). Six of these cases had not been detected before. In eight cases, the median time between the last negative screening test and study inclusion was 11 months (range 6-94 months).

CONCLUSIONS

Viremia tests were positive in 5% percent of the target population, although one-third of the individuals in arm A (blood samples) were not tested. The saliva test may be a useful alternative in the event of refusal of a blood test or when poor venous conditions compromise venous puncture. A confirmatory blood test still remains difficult to obtain in nearly half of patients.

[Incidence and risk factors of HCV infection in a cohort of intravenous drug users in the North and East of France]

BACKGROUND

In order to evaluate the incidence and risk factors of infection by hepatitis C virus (HCV) among intravenous drug users we conducted a prospective cohort study of HCV and HIV negative IVDU in the North and East of France.

METHODS

Two hundred and thirty-one IVDU who had injected drug at least once in their lifetime and were negative for anti-HCV and anti-HIV were followed-up every three months over a 12-month period. Serum anti-HCV and anti-HIV antibodies were tested at inclusion in the study and at the end of the follow-up. Data on injection practices and behaviours were collected at inclusion and at each visit, and a test for anti-HCV antibodies was performed on a saliva sample. When this proved positive, an ELISA test for serum anti-HCV antibodies was carried out.

RESULTS

Of the 231 participants included, 165 (71.4%) underwent a final HCV and HIV serum test. The incidence was nil for HIV infection and 9% (95% CI: 4.6-13.4) person-years for HCV infection. Among IVDU who injected at least once during the last 6 months HCV infection incidence was 11% (95% CI: 4.7-17.1) person-years. The multivariate analysis carried out on the inclusion data found female sex alone to be an independent predictive factor of HCV seroconversion. In a Cox proportional hazard multivariate analysis that took into account time-dependent exposures and covariates, we found that syringe and cotton sharing were, after adjusting for other covariates, the only independent predictive factors of HCV seroconversion: hazard ratio: 6.3 [corrected] (95% CI: 1.1-35.4; [corrected] p<0.05) and 16.4 (95% CI: 1.4-190.6; [corrected] p<0.05), respectively.

CONCLUSION

The transmission of the HCV virus persists among French IVDU despite an ongoing national harm reduction program. Injecting material and cotton sharing are the two major determinants of transmission in this cohort.

Acute hepatitis C during the third trimester of pregnancy

A pregnant woman presented at 32 weeks of amenorrhea with jaundice secondary to acute hepatitis C. Spontaneous delivery took place 3 days later. The infant's serum tested negative for C viral RNA 6 months after delivery. Treatment with high doses of interferon-alpha for a period of 4 weeks was begun 4 days after delivery. Although a virological response was noted at the end of the treatment, the hepatitis relapsed and progressed toward chronicity. Case reports of acute hepatitis C during pregnancy are very rare, as the methods used for the follow-up of pregnant women render the diagnosis of asymptomatic forms difficult. In one case, the acute hepatitis C was severe. The occurrence of acute hepatitis C during pregnancy seems to increase the risk of premature delivery, but not that of vertical transmission. Given the frequency of side effects, it seems preferable not to begin interferon treatment until after delivery.

Maladie de Crohn au cours du traitement de l’hépatite chronique C par interféron et ribavirine

Digestive side effects associated with interferon and ribavirin in the treatment of chronic hepatitis C seem to be non specific. So far, inflammatory bowel diseases have only been rarely described in this context. We report two cases of Crohn's disease which occurred a few months after interferon and ribavirin treatment for chronic hepatitis C. The first case was a 43 year old man treated for 7 months with a interferon and ribavirin combination for chronic hepatitis C who experienced colitis related to Crohn's disease, with the occurrence of articular and cutaneous manifestations. The second case was a 43 year old women treated for 8 months with a pegylated interferon and ribavirin combination for chronic hepatitis C who developed Crohn's disease with right ileo-colic topography and severe evolution requiring an ileo-coecal resection because of the failure of medical treatment. The alpha interferon used for its antiviral action against hepatitis C virus, has complex immuno-modulation effects which could reveal latent Crohn's disease.

Incidence and risk factors of HCV and HIV infections in a cohort of intravenous drug users in the North and East of France

In order to evaluate the incidence and risk factors of infection by hepatitis C virus (HCV) among injecting drug users (IDUs), we conducted a prospective cohort study of HCV- and human immunodeficiency virus (HIV)-negative IDUs in the North and East of France. A total of 231 HCV and HIV IDUs who had injected drugs at least once in their lifetime were followed up every 3 months over a 12-month period. Serum anti-HCV and anti-HIV were tested at inclusion in the study and at the end of the follow-up. Data on injecting practices were collected at inclusion and at each visit. Of the 231 participants included, 165 (71.4%) underwent a final HCV and HIV serum test. The incidence was nil for HIV infection and 9/100 person-years (95% CI 4.6-13.4) for HCV infection. In a multivariable analysis, we found that syringe and cotton sharing were the only independent predictive factors of HCV seroconversion.

[Feasibility of prosthesis insertion by laparotomy as palliative treatment for malignant duodenal stenosis]

The authors report a preliminary series assessing the feasibility of duodenal stenting using a surgical approach. The study included 16 patients with a malignant duodenal outlet obstruction for whom a biliaryobstruction necessitated a laparotomyor following an endoscopic stenting failure. The stent was efficient in 15 patients with a complete relieve of obstruction. These patients could have oral intake at the end of the first postoperative week. No stent obstruction occurred. The duodenal stenting by laparotomy could be a good alternative to palliative gastroenteral anasotomosis.

[An inter-laboratory study of anti-HCV antibody detection in saliva samples]

AIM

The purpose of this study was to evaluate the efficacy of anti-hepatitis C virus (HCV) antibody detection in the saliva samples of 108 drug users in an inter-laboratory study.

METHODS

Between January and June 2001, 108 subjects in Lille, Metz and Lens received a test to detect anti-HCV antibodies in their saliva. Two consecutive saliva samples were taken in each subject (Salivette system, Sarstedt). An HCV serology (Axsym HCV 3.0, Abbott) was also performed and serum HCV RNA detection by Amplicor HCV 2.0 (Roche) was performed when HCV serology was positive. Sixty three patients had a negative HCV serology, 45 had a positive HCV serology, and 31 of these had positive HCV RNA as well. Tests for the detection of the anti HCV antibody in saliva samples were performed as a blind study in both the Lille and the Thionville laboratories.

RESULTS

The sensitivity of saliva anti-HCV antibody tests was respectively 71% (32/45) and 78% (35/45) in Lille and Thionville. In the event of positive HCV viremia, the sensitivity was respectively 90% (28/31) and 93% (29/31). The specificity was respectively 97% (61/63) and 98.5% (62/63). Results from the two laboratories agreed for 101 saliva tests while discrepancies were found in 7 (Kappa Concordance Coefficient: 0.85).

CONCLUSIONS

This study confirms, in a large, unselected population sample, that anti-HCV antibody detection tests in saliva allow the detection of 90% of viremic HCV-antibody-positive patients with excellent specificity. The simplicity and reproductibility of this technique makes it a precious tool for epidemiological studies.

[Rapid progress of cirrhosis in hepatitis C: the role of age at the time of viral contamination]

OBJECTIVE

The aim of this study was to assess predictive factors for the progression to liver cirrhosis in hepatitis C.

METHODS

One hundred thirty six patients (79 men; 57 women; mean age 39 years) with transfusion or intravenous drug use-associated hepatitis C virus (HCV) infection were studied. Sex, cause of infection, duration of contamination, and genotype were studied as predictive factors of progression to liver cirrhosis.

RESULTS

One hundred twenty three patients presented with chronic hepatitis without cirrhosis and 13 had cirrhosis. At the time of liver biopsy, rates of cirrhosis were: 0% before 40 years, 10% between 40 and 60 years, and 47% after 60 years. (p < 0.05). Rates of cirrhosis according to the age at the time of contamination were as follows: 3% before 30 years; 16% between 30 and 50 years; 46% after 50 years even though duration of the disease was comparable in the three groups. In multivariate analysis, two independent factors were associated with liver cirrhosis: age at contamination and duration of infection.

CONCLUSION

Duration of infection and especially age at contamination seem better correlated with the probability of cirrhosis than the route of transmission or the genotype 1b. The results of this study suggest that progression to cirrhosis is slower in cases of contamination before 30 years of age than later on. Age at the time of contamination is an important predictive factor of progression to cirrhosis.

The MxA protein levels in whole blood lysates of patients with various viral infections

Interferon alpha (IFNalpha), a type I interferon, can be considered as a viral infection marker because this cytokine is induced during many viral infections. However, it is quite difficult to detect IFNalpha in sera. Investigations are interested in various intra-cellular IFNalpha-induced proteins as viral infection markers. However the activity of these enzymes increased not only in response to type I IFNs but also to type II IFN. MxA protein can be detected in the cytoplasm of IFNalpha/beta-treated cells, whereas other cytokines, including IFNgamma, are poor inducers. Using an immunochemiluminescent assay, we studied MxA protein in whole blood of 34 patients with various viral infections. The whole blood was drawn into sterile vacuum tubes containing heparin or EDTA. MxA values were relatively similar in heparin-treated samples and EDTA-treated samples, with differences not exceeding 1 ng/ml. The levels of MxA protein were compared in whole blood obtained by using two different lysis procedures. A correlation was found between the MxA levels obtained by using procedure I and procedure II, but higher amounts of MxA protein were found with procedure II. The second procedure is rapid and more convenient than the other and it is carried out in one step which reduce technical problems. High levels of MxA protein were found in peripheral blood cells of patients with acute viral infections (Rotavirus, Adenovirus, RSV, CMV), but MxA protein was not elevated in bacterial infections. The MxA levels were also studied in peripheral blood of 32 HCV positive patients. MxA protein was not found in most of IFNalpha-untreated patients, even those with high viral load. In contrast, high levels of MxA protein were found in IFNalpha-treated patients. MxA quantitation can be considered as a specific marker of acute viral infections, and could be useful in the management of treatment with IFNalpha.

[Results of laparoscopic cholecystectomy for acute cholecystitis in elderly patients]

OBJECTIVES

The aim of this retrospective study was to evaluate the feasibility and the morbidity of laparoscopic cholecystectomy for acute cholecystitis in elderly patients.

METHODS

Among 891 consecutive patients who underwent cholecystectomy, 151 had acute cholecystitis. Fifty three patients of > or = 70 years of age (group 1) were compared to 98 younger patients (group 2). Analysis was made in "intention to treat" so directly open cholecystectomies during the same period were also included.

RESULTS

Elderly patients had a lower success rate of laparoscopic treatment (52.8% versus 70.4%; p < 0.05). This difference was due to higher rate of directly open cholecystectomy in the elderly (17% versus 2%). There was no difference between both groups in conversion rate to laparotomy (30.2% versus 26.5%). Surgical morbidity was 7.5% in group 1 and 4% in group 2 (NS). General complications were more frequent in the elderly (p < 0.05). Five patients in group 1 (9.4%) died of general complications of which 3 were operated on directly by open cholecystectomy. There was no mortality in group 2.

CONCLUSION

Acute cholecystitis in the elderly remains a severe disease in which laparoscopic treatment is only possible in about fifty percent.

Efficacy and tolerance of mesalazine suppositories vs. hydrocortisone foam in proctitis

BACKGROUND

Topical treatments with steroids or mesalazine are the most effective treatments for idiopathic proctitis.

AIM

To compare the efficacy and tolerance of mesalazine suppositories vs. hydrocortisone acetate foam in the treatment of acute proctitis.

PATIENTS AND METHODS

242 patients with active idiopathic proctitis were randomized to receive once daily either one Pentasa suppository (mesalazine 1 g) or 100 mg hydrocortisone (Colofoam) for 14-21 days (until remission). Disease activity and tolerance of the treatments were assessed using a daily questionnaire, by physician assessment, and endoscopy score.

RESULTS

Both treatments induced a significant reduction in disease activity. Mesalazine suppositories were significantly more effective than hydrocortisone on rectal blood loss (P = 0.002) and mucus (P = 0.02) parameters, and on the degree of the decrease in endoscopy score (P = 0.02). No significant difference was observed between treatments concerning histology or tolerance.

CONCLUSION

Mesalazine suppositories were as well-tolerated as hydrocortisone foam, but were more effective for some parameters of disease activity.

[Sensorimotor polyneuropathy in a flare-up of Crohn disease]

A 22-year-old man developed an axonal sensorimotor polyneuropathy and an episode of pyloroduodenal stenosis at the same time. Rectal biopsy established the diagnosis of Crohn's disease. The etiologic investigations were negative. The neurological and gastrointestinal troubles improved and followed a parallel course. Without vitamin deficiency or metronidazole treatment, peripheral polyneuropathy is a rare event in Crohn's disease. An autoimmune cause is suspected.

[Hepatocellular carcinoma in asymptomatic primary biliary cirrhosis]

Hepatocellular carcinoma is an uncommon complication of primary biliary cirrhosis. Hepatocellular carcinoma occurs generally in the end stage of the disease. We report a case of asymptomatic primary biliary cirrhosis complicated by a hepatocellular carcinoma in a 66 year-old man.

[Adenocarcinoma of the appendix. A propos of a case complicated by double local and parietal recurrence]

Adenocarcinoma of the appendix is rarely encountered and is usually discovered fortuitously at pathology examination of the surgical specimen. Six years after surgery for degenerative villous tumor of the appendix, local and parietal recurrence led to surgery in our patient. We present here the indications for complementary hemicolectomy and management of parietal scars resulting from the initial appendectomy.

Specific antibody response to oligomannosidic epitopes in Crohn's disease

Elevated antibody levels against the yeast Saccharomyces cerevisiae have been reported in sera from patients with Crohn's disease and not with ulcerative colitis. The aim of the study was to identify the nature of the epitopes supporting this antibody response. Whole cells from different S. cerevisiae strains were selected in immunofluorescence assay for their ability to differentiate the antibody responses of patients with Crohn's disease and ulcerative colitis. Their cell wall phosphopeptidomannans were then tested as antigen in enzyme-linked immunosorbent assay (ELISA) against sera from 42 patients with Crohn's disease, 20 patients with ulcerative colitis, and 34 healthy controls. Graded chemical degradations were performed on the most reactive strain phosphopeptidomannan. The discriminating epitope was determined through gas-liquid chromatography-mass spectrometry. The greatest discrimination among patients with Crohn's disease, ulcerative colitis, and controls was obtained with Su1, a S. cerevisiae strain used in brewing of beer. ELISA directed against phosphopeptidomannan of this strain was 64% sensitive and 77% specific for discriminating Crohn's disease versus ulcerative colitis and 71% sensitive and 89% specific for Crohn's disease versus controls. Periodate oxidation and selective degradation demonstrated that the most important polysaccharide epitope was shared by both the acid-stable and the alkali-labile domains of the phosphopeptidomannan. The determination of oligomannose sequences of S. cerevisiae Su1 phosphopeptidomannans suggested that a mannotetraose, Man (1 --> 3)Man(1 --> 2)Man(1 --> 2)Man, supported the serological response seen in Crohn's disease. Further identification of the immunogen eliciting this antibody response as a marker of the disease may help to understand its etiology.

[Lymphomas of the colon complicating hemorrhagic rectocolitis]

Colonic lymphoma is a rare complication of ulcerative colitis. We report two cases of B cell colonic lymphoma occurring in two patients who had a left-sided ulcerative colitis for 7 and 24 years respectively. The diagnosis was made during surgery in one case and at colonoscopy in the other. Complete remission was achieved after surgery and chemotherapy with a 8-year and 15-month follow-up respectively.

[Prevalence of hepatitis C, B and D markers and histopathological aspects in a group of intravenous drug addicts]

OBJECTIVES

The aim of this study was to assess the prevalence of infection by HCV, HBV, HDV and HIV and their biological and histopathological patterns in 104 intravenous drug users.

METHODS AND RESULTS

Seventy-five patients (72%) had anti-HCV antibodies. Transmission was rapid because 33% of those who had been drug users for 6 months or less had anti-HCV antibodies. The contamination rate was very high because 90% of those who had been drug users for 2 years or less had anti-HCV antibodies. Thirty-four (33%) had an HBV marker, and 6 were HBs Ag carriers. None of the patients had anti-HDV antibodies. Only one patient had anti-HIV antibodies. Twenty-five anti-HCV antibody positive drug users underwent liver biopsy. Seven (28%) had normal ALAT levels and 18 (72%) had permanently or intermittently elevated ALAT levels. The mean histological activity on the Knodell index was 4.1 (range: 1-8).

CONCLUSIONS

This study indicates that contamination by HCV is almost inevitable after 2 years of intravenous drug use. The low prevalence of HBV, HDV, and HIV infection might be explained by a low endemic state of these viruses in our area.

Alpha-chain disease: analysis of alpha-chain protein and secretory component in jejunal fluid

BACKGROUND

It is unclear why different forms of alpha-chain disease protein appear in intestinal fluid. This was studied in a 23-year-old Mauritanian man in whom alpha-chain disease was diagnosed localized to the duodenum and jejunum, nasopharynx, and bone marrow.

METHODS

The duodenal infiltrate was studied by immunohistochemistry. Forms of alpha chain-containing proteins in serum and jejunal fluid were analyzed by ultracentrifugation and radioimmunoassays.

RESULTS

The infiltrating cells contained alpha-1 chain but no light chains, and approximately 66% showed variable expression of J chain. Serum contained a large fraction of monomeric alpha-chain disease protein, whereas both monomeric and heavier forms appeared in jejunal fluid. Some of the latter were bound to secretory component, and the fluid contained virtually no free component.

CONCLUSIONS

Linkage of polymeric alpha-chain disease protein to secretory component depends on balanced synthesis of alpha chains and J chain in the proliferating B cells, giving rise to polymers with binding site for secretory component expressed as an epithelial receptor. Insufficient receptor-mediated transport capacity (either relative and/or because of intestinal crypt reduction) results in passive external transfer of polymers without bound secretory component along with leakage of serum-derived or locally produced monomeric alpha-chain disease protein, the latter presumably originating from immunocytes with little or no J-chain synthesis.

Favorable cytogenetic abnormalities in secondary leukemia

The authors report on five patients with secondary leukemia (SL) and one of the "specific" chromosomal rearrangements usually encountered in de novo acute nonlymphoblastic leukemia: inv(16), t(15;17), t(8;21), and t(9;11). They were characterized by solid tumor as the primary malignancy in four of five cases, absence of preleukemic phase in all cases, and myelodysplastic features in one of five cases only. All patients achieved complete remission (CR) with aggressive chemotherapy. Only two relapsed, but follow-up is still limited in the three remaining cases. Cytogenetic analysis is important in all younger patients with SL, especially if unusual features (such as absence of preleukemic phase or myelodysplastic features) are found. Aggressive chemotherapy appears to be indicated in those patients if a "specific" rearrangement is found.