Follow-up evaluation and management of anemia in inflammatory bowel disease: A study by the Italian Group for Inflammatory Bowel Diseases (IG-IBD)

BACKGROUND

The RIDART I study found a 13.6% prevalence of anemia in Italian patients with inflammatory bowel disease (IBD); most cases were due to iron-deficiency anemia (IDA).

AIMS

To evaluate changes in hemoglobin concentration during a 24-week follow-up of anemic patients with IBD.

METHODS

Follow-up laboratory and clinical data were obtained from RIDART I study patients with anemia. Factors affecting hemoglobin concentration, the impact of anemia on fatigue and quality of life (QoL), and its relationship with treatment, disease activity and disease complications were investigated.

RESULTS

Hemoglobin was 108 g/L at baseline, increased to 121 g/L at follow-up week 12 (p < 0.001) and then stabilized until week 24, but most patients remained anemic, with IDA, throughout the study. Hemoglobin improvement was greater in patients receiving either oral or parenteral iron supplementation. Following hemoglobin normalization, anemia relapse rate during follow-up was 30%. Oral iron did not cause disease reactivation. Lower follow-up hemoglobin was associated with a higher probability of having active disease, clinical complications, increased fatigue and reduced QoL.

CONCLUSIONS

In anemic patients with IBD, anemia represents a long-lasting problem, in most cases persisting for up to 24 weeks, with high relapse rate and a negative impact on fatigue and QoL.

Something new in the management of acute pancreatitis: brief review of recent guidelines and practical tips

Improvement in diagnostic and therapeutic techniques has led to revision of past guidelines on the management of acute pancreatitis (AP), still not uniformly applied on the territory, partly due to the different distribution of resources to the various centers, partly due to the lack of unequivocal conduct in the approach itself. We had tried to outline most important changes emerged from the revision of recent and authoritative guidelines, focusing on what we believe are still critical points and identifying attitudes more equally shared than others. Based also on the experience of our small center, which however manages numerous cases of AP and their complications, we finally proposed a simple decision algorithm, which does not claim to be a codified recommendation, but only a small and concrete suggestion.

Prevalence, Pathogenesis and Management of Anemia in Inflammatory Bowel Disease: An IG-IBD Multicenter, Prospective, and Observational Study

BACKGROUND

Anemia is a common extraintestinal manifestation of inflammatory bowel disease (IBD), with a 6% to 74% prevalence and a negative impact on patient survival and quality of life, although the prevalence is apparently declining due to improved disease treatment. We aimed to investigate the prevalence, pathogenesis, and clinical correlates of anemia in Italian patients with IBD.

METHODS

A multicenter, prospective, observational study, involving 28 Italian gastroenterology centers, was conducted to investigate the epidemiology and consequences of IBD-associated anemia. Clinical and laboratory data of anemic patients were obtained at study enrolment.

RESULTS

Anemia was diagnosed in 737 of 5416 adult IBD outpatients (prevalence 13.6%); females were more commonly affected than males (odds ratio, 1.5; 95% confidence interval [CI], 1.2-1.7) and had more severe anemia. In the majority of cases, anemia was due to iron deficiency (62.5% of cases; 95% CI, 58.3%-66.6%), either isolated or in association with inflammation and/or vitamin deficiencies; anemia of inflammation accounted for only 8.3% of cases. More severe anemia was associated with increasing fatigue and worse quality of life. Only 68.9% of anemic patients with iron deficiency (95% CI, 63.4%-73.8%) and 34.6% of those with vitamin deficiencies (95% CI, 26.2%-44.2%) were properly treated with supplementation therapy.

CONCLUSIONS

In Italy, the prevalence of IBD-associated anemia is lower than previously reported. Anemia of IBD is most commonly due to iron deficiency and contributes to fatigue and poor quality of life, but remains untreated in a large proportion of patients with iron and/or vitamin deficiencies. This study is registered at clinicaltrials.gov as NCT02872376.

A multicenter survey on endoscopic retrograde cholangiopancreatography during the COVID-19 pandemic in northern and central Italy

Background and study aims  COVID-19 has dramatically impacted endoscopy practice because upper endoscopy procedures can be aerosol-generating. Most elective procedures have been rescheduled. Endoscopic retrograde cholangiopancreatography (ERCP) is frequently performed in emergency or urgent settings in which rescheduling is not possible. We evaluated the impact of the COVID-19 pandemic on ERCP in Italy during the SARS-CoV-2 lockdown, in areas with high incidence of COVID-19. Patients and methods  We performed a retrospective survey of centers performing ERCP in high COVID-19 prevalence areas in Italy to collect information regarding clinical data from patients undergoing ERCP, staff, case-volume and organization of endoscopy units from March 8, 2020 to April 30, 2020. Results  We collected data from 31 centers and 804 patients. All centers adopted a triage and/or screening protocol for SARS-CoV-2 and performed follow-up of patients 2 weeks after the procedure. ERCP case-volume was reduced by 44.1 % compared to the respective 2019 timeframe. Of the 804 patients undergoing ERCP, 22 (2.7 %) were positive for COVID-19. Adverse events occurred at a similar rate to previously published data. Of the patients, endoscopists, and nurses, 1.6 %, 11.7 %, and 4.9 %, respectively, tested positive for SARS-CoV-2 at follow up. Only 38.7 % of centers had access to a negative-pressure room for ERCP. Conclusion  The case-volume reduction for ERCP during lockdown was lower than for other gastrointestinal endoscopy procedures. No definitive conclusions can be drawn about the percentage of SARS-CoV-2-positive patients and healthcare workers observed after ERCP. Appropriate triage and screening of patients and adherence to society recommendations are paramount.

Groove pancreatitis: a case report with a brief review of this diagnostic challenge

Groove Pancreatitis is an uncommon and still under-recognized form of recurrent or chronic pancreatitis that involves the space between the pancreatic head, the duodenum and the common bile duct, the so called groove area. Its importance is that it can mimic pancreatic carcinoma, it may coexist with it or even masks it and should be considered in the differential diagnosis of pancreatic masses or duodenal stenosis. Groove Pancreatitis represents a diagnostic challenge because, from a clinical point of view, its manifestations and complications can be numerous and different from each other. Despite modern imaging techniques, even in the most specialized centers, many untrained radiologists and gastroenterologists may encounter difficulty to make the proper diagnosis. In this work, we have described a case Groove Pancreatitis manifesting as flare up of previously diagnosed chronic pancreatitis and we have tried to make a brief revision of literature concerning diagnosis and treatment of the disease.

Something new in management of acute pancreatitis: brief review of recent guidelines and practical tips

Improvement in diagnostic and therapeutic techniques has led to revision of past guidelines on the management of Acute Pancreatitis (AP), still not uniformely applied on the territory, partly due to the different distribution of resources to the various centers, partly due to the lack of unequivocal conduct in the approach itself. We had tried to outline most important changes emerged from the revision of recent and authoritative guidelines, focusing on what we believe are still critical points and identifying attitudes more equally shared than others. Based also on the experience of our small center, which however manages numerous cases of AP and their complications, we finally proposed a simple decision algorithm, which does not claim to be a codified recommendation, but only a small and concrete suggestion.

Management of Helicobacter pylori in Piedmont, Italy

Helicobacter pylori (H. pylori) is a Gram-negative bacterium, usually acquired during childhood, whose natural habitat is the gastric lumen. H. pylori is accepted as the most important cause of gastritis and peptic ulcer in humans. Nevertheless, its important role in the pathogenesis of gastric cancer as well as in several extra-gastroduodenal diseases has been confirmed. The aim of this work is to discuss, for the first time in a single article, all publications concerning H. pylori infection arising from Piedmont region, Italy, where in 1893 Giulio Bizzozero was the first who observed and described spiral organisms in the stomach of animal models. A systematic review of all publications on the management of H. pylori in adults in Piedmont, based on a PubMed and a Scopus research from 1965 to 2017 was performed. The discussed aspects are the epidemiology, the study on gastric and extragastric diseases related to H. pylori, the diagnostic methods, the treatment of H. pylori infection, and the possibility of reinfection. In conclusions, with almost 70 publications, Piedmont has proudly maintained the tradition of the father of the H. pylori.

Appropriateness of colonoscopy in a digestive endoscopy unit: a prospective study using ASGE guidelines

RATIONALE, AIMS AND OBJECTIVES

Appropriate indications for colonoscopy (C) are essential for a rational use of resources. The aim of this study is to evaluate the appropriateness of indication for C according to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines and to evaluate whether appropriate use was correlated with the diagnostic yield of C.

METHODS

We analysed 677 consecutive C performed over an 11-month period in a digestive endoscopy unit with an open access system.

RESULTS

The rate of 'generally indicated' C was 77% and 'generally not indicated' C was 18%. The rate of indication not listed in the ASGE guidelines was 5%. The percentage of generally not indicated C requested by gastroenterologists for outpatients was lower than that requested by primary care surgeons or doctors (9.5%, 29%, 25.3%, respectively). In 38 (7.3%) and in 111 (21.3%) of 520 patients with appropriate C, cancer and polyps larger than 5 mm were found, respectively. Twenty polyps greater than 5 mm were detected in 15 cases (12%) of 122 inappropriate C, with only one case of intramucosal carcinoma; four (12%) polyps measuring over 5 mm were found in C not listed in ASGE guidelines. No advanced stage cancer was detected in the inappropriate group and in C not listed in ASGE guidelines.

CONCLUSIONS

Our results showed the high rate of inappropriate procedures, according to ASGE guidelines, requested by surgeons, internists and primary care doctors for both outpatients and inpatients. The proportion of not indicated endoscopic procedures requested by gastroenterologists must be reduced through more carefully application of ASGE guidelines. Endoscopic findings were more stringent in appropriate C.

Type III intestinal metaplasia, Helicobacter pylori infection and gastric carcinoma risk index in an Italian series of 1750 patients

BACKGROUND/AIMS

To evaluate the utility of 2 biopsies of antrum and gastric body on routine endoscopy for the assessment of type III intestinal metaplasia (IM-3) and Helicobacter pylori (Hp), 1750 patients (pts) (895 males; 855 females) were considered from June'98 to June'00.

METHODOLOGY

Specimens were graded 0 to 3 for atrophy, IM-3 and Hp. 610 pts treated previously with antibiotics or not eligible for biopsy were excluded from initial 2360 pts.

RESULTS

IM-3 was found in 118 pts (6.7%), 100 pts (5.7%) only in the antrum. 10 of 355 pts (2.8%) with normal endoscopy and 47 of 702 (6.6%) with non-erosive endoscopic gastritis resulted IM-3 positive in the antrum. 709 pts (40.5%) were positive for Hp in antrum and/or corpus. The presence of Hp and IM-3 in the antrum was not correlated (p=0.99; Spearman test). A positive correlation (p=0.000) between duodenal ulcer and Hp was found when antral Hp positivity was taken into account. The gastric carcinoma risk index (GCRI) was found in 358 pts (20.4%); in this group 131 pts (36.6%) were Hp positive, 81 pts (22.65%) had IM-3 only in the antrum, 184 pts (51.4%) had atrophy.

CONCLUSIONS

The incidence of IM-3 is low (6.7%) in routine endoscopy. Normal endoscopy doesn't exclude the presence of IM-3. Biopsy is necessary to discover IM-3 in the antrum in 5.3% of pts with normal or aspecific endoscopic gastritis. Application of the GCRI might be useful for identifying a group of patients carrying a higher risk for gastric carcinoma.

Effect of Helicobacter pylori eradication on bulbitis and duodenal gastric metaplasia

BACKGROUND/AIMS

Duodenal gastric metaplasia seems to be linked to infection by Helicobacter pylori, to the extent of acid secretion and to bulbitis. An investigation was made of the relationship between bulbitis and duodenal gastric metaplasia, or whether bulbitis can arise along with duodenal gastric metaplasia after Helicobacter pylori eradication in an average of six years.

METHODOLOGY

We compared 22 patients with duodenal ulcers [male/female 16/6; (mean age+/-SD) 55+/-12 years] Helicobacter pylori-negative after eradication, with 23 Helicobacter pylori-positive patients free from active duodenal ulcers [male/female 17/6; (mean age+/-SD) 59+/-12 years].

RESULTS

The bulbitis score was found to be lower in the Helicobacter pylori-negative than in the Helicobacter pylori-positive group (p=0.02). The duodenal gastric metaplasia score in the Helicobacter pylori-negative was higher than in the Helicobacter pylori-positive group (p=0.001). We failed to find any relationship between the presence of bulbitis and duodenal gastric metaplasia. We found a non-significant inverse correlation between the presence of duodenal gastric metaplasia and chronic body gastritis (p=0.07).

CONCLUSIONS

Bulbitis and duodenal gastric metaplasia may depend on different causal factors not related to Helicobacter pylori infection. The extension of duodenal gastric metaplasia with time following recovery from peptic ulcer disease may represent a mucosal protection factor against acid.

Helicobacter pylori antibodies (CagA and VacA) detection. The link between cancer and infection

BACKGROUND

Infection with different genotypes of virulent Helicobacter pylori (Hp) strain, CagA and/or VacA positive, can play a role in the development of atrophic gastritis, duodenal ulcer (DU), and gastric carcinomas (GC). This study was undertaken to investigate if patients with GC with Hp negative histological Giemsa staining had a past infection by virulent strains of Hp CagA and/or VacA positive.

METHODS

Twenty GC, (average age +/- SD) 68.14+/-9.8 years old, Hp negative to histological take part to the study. Two-control group were included: 19 Hp infected patients with DU eradicated 10 years before, 58+/-18.2 yrs. Hp negative status was determined every year with histology and follow-up after therapy was 120+/-32 months; range 96-144 months. Twenty asymptomatic children, 7+/-4.47 yrs, with Hp negative faecal test. The immunoblot assay was used to detect serum antibodies against CagA and VacA.

RESULTS

Prevalence of CagA and VacA seropositivity was 90 and 95% in GC, 84 and 84% in DU Hp negative, 25 and 5% in children Hp negative, respectively. CagA and VacA antibody positivity was not significantly different between GC and patients with DU eradicated 10 years before. A true significant positivity was found against children (''t''-Student test; p<0.0001). Statistical difference was found in age between groups p<0.03.

CONCLUSIONS

Patients with GC, although Hp negative at present, could be infected by Hp before the appearance of the disease as confirmed by CagA and VacA seropositivity. These data may reinforce the idea to consider Hp as a direct carcinogenetic agent of GC.

Gastric atrophy and intestinal metaplasia changes 8 years after Helicobacter pylori eradication. A blind, randomised study

BACKGROUND

Chronic atrophic gastritis and intestinal metaplasia are regarded as predisposing factors for gastric cancer associated with Helicobacter pylori infection, and their severity appears to influence gastric cancer risk. Our purpose was to determine the outcome of chronic gastritis after H. pylori eradication in a long-term follow-up.

METHODS

Fifty-four consecutive patients with duodenal ulcer and H. pylori infection were enrolled in the study. Endoscopic examination with antral and corporal biopsy was done at baseline and yearly after conventional eradication therapy (omeprazole 40 mg b.i.d., amoxocyllin 1 g b.i.d and clarithromycin 500 mg b.i.d.). Gastritis, atrophy, and metaplasia were graded according to the updated Sydney System.

RESULTS

Twenty-four patients were successfully treated; infection persisted in 14 and 16 dropped out (during the first 5 years of follow-up). Inflammation and mean neutrophil activity significantly decreased in patients in whom H. pylori was eradicated. Glandular atrophy improved in 2 and disappeared in 5/17 patients, whereas intestinal metaplasia improved in 3 and disappeared in 2/12. In the patients in whom H. pylori persisted, inflammatory infiltrate, atrophy and intestinal metaplasia had not significantly decreased during follow-up. In contrast, glandular atrophy worsened in 2 and developed in 5/7 patients. Similarly, intestinal metaplasia did not improve when present and developed in 5/13 cases.

CONCLUSIONS

In a long-term follow-up, H. pylori eradication does not affect glandular atrophy, but it seems to prevent the development of precancerous lesions such as intestinal metaplasia.

Diagnostic use of endoscopic mucosal resection in ''borderline'' gastric lesions unresolved with standard biopsies

BACKGROUND

Endoscopic mucosal resection (EMR) of gastric superficial malignancies less than 20 mm in size and flat or slightly elevated without ulceration can be a definitive treatment, but its role in lesions of uncertain etiology or in which standard biopsies specimens fail to determine diagnosis is uncertain. EMR was performed in 7 patients previously diagnosed as having low grade dysplasia (Category 3 of Vienna classification) by standard biopsies on polypoid or flat gastric lesions.

METHODS

After day spraying with 0.2% indigo carmine and injection of 20 ml saline with adrenaline 1/20000, EMR of flat or sessile polyps (size between 5 to 15 mm) was performed by the Cap and Suction technique (Inoue).

RESULTS

In 3 patients a previous diagnosis of low grade dysplasia was changed into high grade dysplasia, in 1 patient adenocarcinoma was found at EMR histology. In 3 patients EMR confirmed diagnosis made with routine endoscopy biopsies and finally in 2 patients dysplasia was down-graded into intestinal metaplasia.

CONCLUSIONS

EMR may be considered in diagnostic gastric lesions with low grade dysplasia at standard biopsies (Category 3 of Vienna Classification of gastrointestinal neoplasia).

Gastric carcinoma risk index, type III intestinal metaplasia and Helicobacter pylori status on antrum and body biopsies in a prospective general population study

BACKGROUND

To evaluate the utility of 2 biopsies of antrum and gastric body on routinary endoscopy for the assessment of type III intestinal metaplasia (IM-3) and Helicobacter pylori (Hp) status, 1750 patients (pts) (895 males and 855 females, mean age 60.2) were considered from June 1998 to June 2000.

METHODS

Specimens were graded 0 to 3 for atrophy, IM-3 and Hp status. 620 pts treated previously with antibiotics or not eligible for biopsy were excluded from initial 2360 pts.

RESULTS

IM-3 (score >0), was found in 118 pts (6.7%), 86 pts (4.9%) only in the antrum. Ten of 355 pts (2.8%) with normal endoscopy findings and 47 of 702 (6.6%) with non erosive endoscopic gastritis resulted IM-3 positive in the antrum. 709 pts (40.5%) were found positive for Hp in antrum or/and corpus. The presence of Hp and IM-3 in the antrum was not correlated (p=0.99; spearman test). A positive correlation (p=0.000) between duodenal ulcer and Hp was found when antral Hp positivity was taken into account. Gastric carcinoma risk index (GCRI) was found in 358 pts (20.4%); in this group 131 pts (36.6%) were Hp positive, 82 pts (23%) have IM-3, 184 pts (51.4%) have atrophy.

CONCLUSIONS

The incidence of IM-3 is low (6.7%) in routinary endoscopy. Normal endoscopy does not exclude the presence of IM-3. The biopsy is necessary to discover IM-3 in the antrum in 5.3% of pts with normal or aspecific endoscopic gastritis. Application of the GCRI might be useful to identify a group of patients carrying a higher risk for gastric carcinoma.

Helicobacter pylori-positive duodenal ulcer: a long-term double-blind randomized study in patients healed with H2-receptor antagonists

BACKGROUND

The NIH Consensus Conference in 1994 (1) concluded that all patients with peptic ulcer disease should be tested and treated for Helicobacter pylori and that further evaluation was needed for patients in remission.

MATERIALS AND METHODS

We evaluated in a double blind randomization 30 patients whose duodenal ulcers had been healed with H2-receptor antagonists and who remained in remission on maintenance therapy. After ulcer healing and the presence of H. pylori had been confirmed, these patients were randomized to receive eradication therapy or placebo and were followed for a mean period of 23 months.

RESULTS

Almost all patients receiving placebo had ulcer recurrence, whereas the patients treated with antibiotics demonstrate a low recurrence rate.

CONCLUSION

These data suggest, for the first time to our knowledge, the importance of treating with antibiotics duodenal ulcer patients whose disease is in remission.

[Helicobacter pylori in patients undergoing periodic hemodialysis]

Forty-nine haemodialyzed patients have been submitted consecutively, under informed consent, to endoscopy with multiple antral gastric mucosa biopsies for Helicobacter pylori (HP) identification, performed by urease, microscopic and cultural tests, as well as histologic examination. Patients have been considered HP negative when negative for all tests; positivity for HP has been correlated with gastritis histologically evaluated according to Whitehead; at endoscopy, blood samples for HP specific IgG, IgA, IgM have been collected; patient's life style concerning smoke, alcohol and drugs as FANS has been investigated as well. HP prevalence in our haemodialyzed patients is 38.8 per cent, similar to general population submitted to endoscopy; a statistically significant correlation between HP and gastritis and specific IgG, but no correlation between HP and age, dialysis duration, IgA, IgM, smoking, alcohol or drugs consumption has been found.