Long-term evolution and predictive factors of mild inflammatory bowel disease

BACKGROUND

Crohn's disease (CD) and ulcerative colitis (UC) are potentially progressive diseases. Few data are available on the prevalence and the factors associated with mild inflammatory bowel diseases (IBD).

AIM

Our aim was to assess the natural history of mild CD and mild UC and to identify predictive factors of mild evolution over the long term.

METHODS

Retrospective study of IBD patients registered in the database of the university hospital CHU of Liège, Belgium. Mild CD was defined as an inflammatory luminal disease (no stricture, abdominal or perianal fistulae) requiring no immunomodulator (IM), anti-TNF and no surgery. Mild UC was defined as no requirement for IM, anti-TNF and no colectomy.

RESULTS

Four hundred and seventy-three CD and 189 UC were included (median follow-up: 13 and 11 years respectively). At 1 year, 147 patients had mild CD. At 5 years and the maximum follow-up, 56% and 13% patients still had mild CD, respectively. At 1 year, 142 patients had mild UC. At 5 years and the maximum follow-up, 72% and 44% still had a mild UC, respectively. Factors associated with long-term mild CD and UC were older age at diagnosis and absence of corticosteroids in the first year. In UC proctitis location was associated with mild UC.

CONCLUSIONS

In this cohort, 90% of CD patients and 3/4 of UC with mild disease at 1 year lost their mild disease status over time. An old age at diagnosis was predictive of the persistence of a mild CD and UC.

Persisting signs of disease activity at Magnetic Resonance Enterocolonography predict clinical relapse and disease progression in quiescent Crohn's disease

INTRODUCTION

Deep remission including clinical remission and tissue healing has been advocated as the therapeutic target in Crohn's disease. Yet, the definition of deep remission remains unclear. The aim of this study was to assess the persisting lesions at magnetic resonance enterocolonography (MREC) in clinically quiescent Crohn's disease as well as their relapse predictive value.

METHODS

we performed a prospective monocentre cohort study. We included patients with clinical remission. At baseline, these patients had blood tests, the measurement of fecal calprotectin and underwent a MREC. They were then followed up clinically for a minimum of 1 year. A relapse was defined by a HBI > 4 with an increase of at least 3 points. Correlations between clinical, demographic, biological parameters and MREC signs were assessed as well as the time-to-relapse predictive value of the studied variables.

RESULTS

Twenty seven patients were recruited. Fourteen out of 27 had persisting disease activity at MREC. MREC signs only partly correlated with biomarkers. Ten out of 27 patients relapsed over a median follow up of 25 months. In univariate analysis, relative contrast enhancement of the most affected segment (HR: 2.56; P = 0.046), ulcers (HR: 12.5; P = 0.039), fistulas (HR: 14.1; P = 0.009) and target sign (HR: 3.63; P = 0.049) were associated with relapse. In multivariate analysis, fistula was the only one.

CONCLUSIONS

Half of the patients with clinically quiescent Crohn's disease had persisting signs of disease activity at MREC. These signs predicted time-to-relapse.

[FROM EVIDENCE-BASED MEDICINE TO PERSONALIZED MEDICINE IN CROHN'S DISEASE]

The therapeutic armamentarium in Crohn's disease includes mesalazine, steroids (including topical drugs), anti-metabolites (purines, methotrexate), anti-TNFα antibodies and, more recently, selective inhibitors of lymphocytes homing (vedolizumab). The efficacy of these drugs has been shown in pivotal phase 3 placebo-controlled trials and meta-analyses. However, the use of these drugs in routine practice still remains ill-defined. Those are rather the cohort studies, natural history data and therapeutic strategy trials that help the clinician to determine, for each individual patient, the treatment leading to an optimal benefit/risk profile, aiming at moving from evidence-based medicine towards personalized medicine.

Depth of remission in Crohn's disease patients seen in a referral centre : associated factors and impact on disease outcome

INTRODUCTION

Our goals were to assess the prevalence of biological and tissue remission in routine practice in Crohn's disease, and to evaluate the correlation between biological or tissue remission and clinical or demographic characteristics as well as their impact on disease outcome.

METHODS

We performed a retrospective monocenter study. Biological remission was defined by a CRP < 5 mg/I. Tissue remission was defined by the absence of ulcer at endoscopy and/or absence of signs of acute inflammation at MRI. Association with demographic, clinical and laboratory markers was studied by logistic regression models and rates of relapses, hospitalizations and surgeries were compared using the logrank test.

RESULTS

Among the 263 patients included, 147 were in clinical remission; 102/147 (69%) were in biological remission. Fifty-six patients also had morphological evaluation: 37 (66%) were in tissue remission. Biological remission was associated with older age, higher hemoglobin and lower BMI. Tissue remission was associated with older age, lower platelets count, absence of previous surgery, and the use of immunosuppressant. Time-to-relapse was significantly longer in patients with biological remission and in patients with tissue remission as compared to patients without biological or tissue remission.

CONCLUSIONS

Among the patients in clinical remission seen as outpatients, two thirds were either in biological and/or tissue remission. Biological and/or tissue remission was associated with a better outcome than clinical remission alone.

Does co-treatment with immunosuppressors improve outcome in patients with Crohn's disease treated with adalimumab?

BACKGROUND

There is clear benefit from combination therapy with infliximab and immunosuppressive drugs (IS), but few data are available for adalimumab (ADA).

AIM

To assess the efficacy of ADA monotherapy and ADA+IS for induction and maintenance therapy in Crohn's disease.

METHODS

Retrospective study of patients with Crohn's disease treated with ADA in Oxford, UK or Liège, Belgium. Treatment periods were divided into 6-month semesters. A combination therapy semester was defined as ADA+IS for at least 3 months; successful induction meant clinical response; a semester with flare as ADA dose escalation, starting steroids, perianal complication, or surgery; and ADA failure as ADA withdrawal for secondary loss of response or intolerance. Semesters with and without flares were compared through univariate and multivariate analysis.

RESULTS

Successful induction was achieved in 171/207 (83%) patients, with no significant difference between ADA+IS and ADA monotherapy (85% vs. 82%, P = 0.50). Five hundred and sixty-two semesters in 181 patients were included for maintenance analysis. ADA+IS was not associated with fewer semesters with flare (34% vs. 35%, P = 0.96), or with ADA failure (6% vs. 8%, P = 0.43). Nevertheless, combination therapy in the first semester was associated with a lower risk of ADA failure (5% vs. 10%, P = 0.04, OR = 0.48) and combination therapy beyond 6 months was associated with fewer semesters with flares (14% vs. 36%, P = 0.02, OR = 0.31).

CONCLUSIONS

There may be a benefit from adalimumab+immunosuppressive drugs combination therapy during the first semester of initiating adalimumab, with a slight decrease in adalimumab failure and lower need for adalimumab dosage escalation.

[Genetics and environment in chronic inflammatory bowel diseases]

Inflammatory bowel diseases are both environmental and genetic illnesses. More than one hundred genes or loci involved in the regulation of innate or acquired immune response as well as intestinal mucosa homeostasis have been identified. Environmental studies have been less numerous up to now and only smoking and appendectomy have been validated, as protector for ulcerative colitis, while smoking is clearly associated with an increased risk and more severe forms of Crohn's disease. An important role is also currently suspected for the intestinal flora and the dysbiosis described in inflammatory bowel disease could contribute to the triggering or the persistence of the inflammation. New therapeutic strategies are currently studied, particularly aiming at targeting immune, inflammatory or homeostatic pathways corresponding to the predisposing gene variants.

[Fifteen years of use of anti-TNF antibodies in moderate to severe Crohn's disease: how to make the best of this experience]

After fifteen years of use, the anti-TNF antibodies have become the corner stone of the treatment of moderate and severe Crohn's disease. The skill acquired over the years through experimental trials and clinical experience leads to increased therapeutic efficacy and minimized risks. These antibodies are introduced increasingly earlier in Crohn's disease as well as in a broader range of patients, aiming at changing the natural history of the diseases by avoiding the development of intestinal tissue damage and complications.

Evolution and predictive factors of relapse in ulcerative colitis patients treated with mesalazine after a first course of corticosteroids

INTRODUCTION

Mesalazine remains the first line treatment for the induction and the maintenance of remission in mild to moderate ulcerative colitis (UC). Its efficacy as a maintenance treatment after a first flare treated with corticosteroids has not been specifically studied. The aims of our work were to study a cohort of UC patients treated with mesalazine after a course of oral systemic corticosteroids and to identify predictive factors of relapse and of colectomy.

MATERIAL AND METHOD

We studied retrospectively a cohort of 143 UC patients, who never received immunosuppressive drugs, and treated for the first time with oral corticosteroids for a flare. Among patients responding to corticosteroids, we studied the group treated by mesalazine after the flare.

RESULTS

Fifty% (n=52) achieved a complete clinical remission with steroid weaning. In this group, 67% (n=35) received oral mesalazine. Seventy-five % of patients treated by mesalazine relapsed (median 29 months, range: 1-156). Fourteen % required a colectomy (median 11 months, range: 1-24). Kaplan Meier curve showed a relapse rate and a colectomy rate over one year of 26% and 11% respectively. In multivariate analysis, male gender and short duration of disease were predictive factors of the time-to-relapse. No factor was predictive of time-to-colectomy.

CONCLUSION

Maintenance efficacy of mesalazine over one year after a first course of corticosteroids for a disease flare is reasonably high. The longer-term relapse rate becomes higher in male patients with a short disease duration. An immunosuppressive treatment could be discussed in case of further relapse despite improved medication-adherence. Medication-adherence should first be assessed and promoted. An immunosuppressive treatment could be discussed in case of further relapse despite improved medication-adherence.

Hepatitis C of genotype 2: the role of medical invasive exams

BACKGROUND AND AIM

Hepatitis C virus genotype 2 is the third in order of frequency in Belgium. The aim of this study was to better define the genotype 2 carriers' epidemiology characteristics.

METHODS

In a database comprising 1726 viremic hepatitis C virus patient from the south part of Belgium, the files of 98 genotype 2 carriers were reviewed.

RESULTS

There was a strong association between genotype 2 and the mode of transmission. The rate of contamination by invasive medical exams was very high (23%), and statistically different from the one of the others genotypes. Eligibility for antiviral therapies and the rate of sustained viral response were high.

CONCLUSION

HCV genotype 2 was highly associated with transmission by invasive medical exams.

Anti-tumor necrosis factor nonresponders in Crohn's disease: therapeutic strategies

Anti-TNF antibodies have revolutionized the treatment of Crohn's disease. In pivotal trials, however, the frequencies of primary and secondary nonresponders appeared rather high with, by the end of 1 year of scheduled treatment, only one fifth of the patients initially treated still in sustained remission. Other studies and monocentric experiences have indicated that these seemingly disappointing results were partly due to suboptimal selection of the patients and absence of treatment optimization. Optimal selection of the patient includes proving active intestinal lesions and systemic inflammation as well as excluding stricturing or infectious complications. Treatment optimization includes potential immunosuppressive co-treatment and dose or administration interval adjustment of the anti-TNF. When a failure is confirmed with an anti-TNF despite such optimization, second- or third-line anti-TNFs have proved useful. Beyond that, a transient steroid course and surgical procedures still represent rescue option, waiting for new promising biologics in development.

[Adenocarcinoma of the small intestines complicating coeliac disease in an adult: case report]

Coeliac disease is an auto-immune disease due to gluten intolerance. One per cent of the European population is concerned. This small bowel adenocarcinoma is rare and concerns less than 5% of the digestive neoplasias. However the frequency of this rare cancer is higher in presence of coeliac disease. We are reporting the case of a 67-years-old woman whose coeliac disease has been complicated 5 years thereafter by a jejunal adenocarcinoma. The latter was found during an etiology search for iron deficiency anemia.

[Biologic therapies in chronic inflammatory bowel diseases]

Crohn's disease and ulcerative colitis are chronic inflammatory bowel diseases which can be difficult to control with conventional therapies. Thanks to a better knowledge of their physiopathology, new therapies aimed at specific targets of the inflammatory cascade were developed. Three monoclonal anti-TNF antibodies were produced. Infliximab and adalimumab, currently widely used, can induce sustained remission in Crohn's disease. Infliximab is also efficacious in UC. Certolizumab pegol provides good short term results; its long term efficacy, however, remains to be assessed by further clinical trials. Therapies targeting leucocyte trafficking (anti-integrine) have also been provided and are associated with good clinical responses in Crohn's disease. Natalizumab (anti-alpha4) is responsible for significant side effects and is no longer in use in gasrtoenterology in Europe whereas MLN02 (anti-alpha417) has a good profile in terms of efficacy and safety. Monoclonal anti bodies targeting other cytokines are under development, mainly ustekinumab which inhibits IL12 and IL23. Ustekinumab generates favourable clinical responses in Crohn's disease. The development of biologic therapies in inflammatory bowel disease has dramatically altered the course and management of these disorders.

[Monoclonal antibodies therapies for colorectal cancer: cétuximab, panitumumab and bevacizumab]

Colorectal cancer is the third most common form of cancer in Europe, Its prognosis is poor, since median survival time for metastatic patients is about 20 months. Progresses in molecular biology have lead to significant improvement in the management of metastatic colorectal cancer with targeted therapies. The monoclonal antibodies anti-EGFR and anti-VEGFR improve the overall and the progression-free survival. The anti-EGFR antibodies (cétuximab and panitumumab) have been marketed in Belgium, as monotherapy or in association with chemotherapy (FOLFIRI) for third line use in patients with wild type K-ras. The anti-VEGFR bevacizumab is the standard first line treatment in metastatic colorectal cancer with irinotecan based chemotherapy. For the future, the place of monoclonal antibodies therapies in adjuvant or in first line settings and the value of combining targeted therapies have to be further defined.

[Treatment of (unresectable) hepatocellular carcinoma at an intermediate or advanced stage]

Hepatocellular carcinoma is the main primitive tumor of the liver. It occurs in the setting of liver cirrhosis in more than 90% of the cases in developing countries. The prognosis depends on the size, number and extension of the tumor as well as on the severity of the underlying liver disease. The Barcelona Clinic Classification takes into account these different parameters and helps the clinician in the therapeutic decision. Some patients (around 25%) are amenable to therapy with a curative intent (liver transplantation, resection, destruction by radiofrequency). In patients with hepatocellular carcinoma at an intermediate stage, lipiodolized chemoembolization gives a survival advantage in comparison with placebo. No conventional regimen of chemotherapy has a proven survival benefit. In patients with a hepatocellular carcinoma at an advanced stage, sorafenib, an oral multi-targeted kinase inhibitor, is the first compound to demonstrate a significant effect on survival free of disease progression in a selected group of patients. Its toxicity profile is particularly favourable. Combination of surgical and medical therapies should be properly evaluated in clinical trials in the near future.

[Colorectal cancer screening: an absolute necessity and a concrete reality in the French community]

Colorectal cancer is a real problem of public health. Screening is an absolute necessity. An ambitious program of screening is launched in the French Community. Faecal occult blood test will be proposed to average risk patients in the general population. A total colonoscopy will be performed if FOBT is positive. First step colonoscopy will be proposed to high or very high risk patients. General practitioners are in the core of the multi-disciplinary program.

[Genomics of inflammatory bowel diseases: basis for a new molecular classification and new therapeutic strategies of these diseases]

Inflammatory Bowel Disease, Crohn's disease and ulcerative colitis, are complex, multifactorial, polygenic diseases. Huge progresses in the knowledge of human genome and genotyping techniques have allowed the identifications of dozens of genes and loci associated with these diseases. These discoveries set the path for a new molecular classification of these diseases and let us see new therapeutic possibilities. The present paper highlights, in the setting of the Synthèse CHU 2009 meeting, the contributions of the team of the CHU and university of Liège in this field.

Are we giving biologics too much time? When should we stop treatment?

The optimal duration of biological treatment, particularly anti-TNF, in inflammatory bowel disease (IBD) is a very important question both for patients and physicians. There is no published evidence to clearly and definitely answer this question. However data on natural history of IBD, long term safety of biologics, immunosuppressors (IS) cessation and some preliminary studies on biologics cessation may help us to discuss this topic. The decision to stop a biological treatment is currently based on a compromise between the benefits and risks associated with the prolongation of this treatment. IBD, more particularly CD, are characterized by the development of complications and the need for recurrent hospitalizations and surgeries in approximately 2/3 of cases. In these patients potentially in need of biological treatments, it is probable that, as it has been demonstrated for IS, the longer a stable remission has be achieved under treatment, the lower the risk of relapse is after treatment cessation. Further prospective studies should now aim at disclosing patient characteristics associated with a low risk of relapse to implement this strategy.

[Hepatitis E: a Third World's hepatitis found in Belgium]

Hepatitis E virus is the second cause of acute viral hepatitis of oral-fecal origin in the world. This virus has a vast distribution throughout the world and manifests itself either in epidemic or endemic-sporadic form in many developing countries. Usually, the cases of HEV infection in industrialized countries are observed after a history of travel in an endemic area. However, an increasing number of cases have been attributed to a HEV zoonotic form transmitted by swine. HEV infection can lead to deadly fulminant hepatic failure in 1-4% in the common population, but the mortality incidence reaches 20% in case of third trimester pregnant women infection. The diagnosis of HEV infection can be made using serological tests but today, RT-PCR is considered as the gold standard test. Unfortunately, this technique is not widely available in Belgium yet. There is no treatment for HEV infection, only prophylactic measures as hygiene and sewage treatment can stop epidemics. Recently, a new vaccine, still in research phase, has showed promising outcomes.

[Eosinophilic esophagitis in adults: report of a case]

Eosinophilic esophagitis is a chronic inflammatory disease. The most typical symptoms are recurrent dysphagia and episodes of food impactions. This pathology is quite frequently associated with atopy. We report the case of a 39-year-old patient, suffering from allergic asthma, admitted to hospital for an episode of food impaction. Clinical, endoscopic and histological findings lead to the diagnosis of eosinophilic esophagitis. From data of the litterature, we discuss the diagnosis, the pathogeny and the treatment of this pathology.

The role of the Toll receptor pathway in susceptibility to inflammatory bowel diseases

The intestinal flora has long been thought to play a role either in initiating or in exacerbating the inflammatory bowel diseases (IBD). Host defenses, such as those mediated by the Toll-like receptors (TLR), are critical to the host/pathogen interaction and have been implicated in IBD pathophysiology. To explore the association of genetic variation in TLR pathways with susceptibility to IBD, we performed a replication study and pooled analyses of the putative IBD risk alleles in NFKB1 and TLR4, and we performed a haplotype-based screen for association to IBD in the TLR genes and a selection of their adaptor and signaling molecules. Our genotyping of 1539 cases of IBD and pooled analysis of 4805 cases of IBD validates the published association of a TLR4 allele with risk of IBD (odds ratio (OR): 1.30, 95% confidence interval (CI): 1.15-1.48; P=0.00017) and Crohn's disease (OR: 1.33, 95% CI: 1.16-1.54; P=0.000035) but not ulcerative colitis. We also describe novel suggestive evidence that TIRAP (OR: 1.16, 95% CI: 1.04-1.30; P=0.007) has a modest effect on risk of IBD. Our analysis, therefore, offers additional evidence that the TLR4 pathway - in this case, TLR4 and its signaling molecule TIRAP - plays a role in susceptibility to IBD.

[Therapeutic update in gastroenterology]

During the last decade, advances in molecular biology and biotechnology allowed, the development of biological treatments aimed at more precise targets. New algorithms in inflammatory bowel diseases, chronic hepatitis C and digestive oncology are examples of the marked progress achieved by these therapies.

[The FibroScan: a new non invasive method of liver fibrosis evaluation]

The FibroScan is a device allowing a non invasive diagnosis and quantification of liver fibrosis. The procedure is based on transient elastography and allows to record liver stiffness by measuring the velocity of shear wave across liver parenchyma. The elasticity is directly correlated to velocity of the wave. In chronic hepatitis C, there is a good correlation between liver elasticity and stage of fibrosis. The FibroScan has also been studied in other chronic liver diseases, such as hepatitis B, primary biliary cirrhosis, sclerosing cholangitis, auto-immune hepatitis, alcohol, steatosis, hemachromatosis with reproductible results. In a cirrhotic patient, it also allows to assess the severity of cirrhosis and to evaluate the risk of complication. It is a painless procedure, with a good acceptability by the patients. Therefore, the FibroScan can be regularly performed, allowing the follow up of fibrosis evolution over time.

[Innovative therapies in inflammatory bowel disease at the CHU]

Inflammatory bowel diseases (IBD), Crohn's disease and ulcerative colitis are frequent illnesses in western countries. They have a dramatic impact on the health-related quality of life. The new biological treatments developed for these diseases are potentially very effective, but are also expensive and may have significant side effects. In the present paper, the authors describe new biological therapies used during the past 10 years at the CHU. More than 20 therapeutic protocols were implemented. These protocols have given the patients the opportunity to gain very rapid access to new efficient therapies, to benefit from promising techniques for the evaluation of their pathology and to be submitted to a close follow-up that frequently called their treatment into question in the light of the most innovative options.

[Screening for colorectal cancer]

Colorectal cancer is the second leading cause of death in Northern countries and need a national screening program to reduce mortality and improve quality of life. Screening has to be cost-effective and acceptable for patients. Many screening tools, invasive or not, are existing and often debated: FOBT, sigmoidoscopy and complete colonoscopy. New tools are in development and have to be evaluated in current practice: virtual colonoscopy, new endoscopic technologies, DNA on faeces or proteomics with markers in serum.

Determinants of gastro-protective drugs co-prescription during treatment with nonselective NSAIDs: a prospective survey of 2197 patients recruited in primary care

OBJECTIVE

Our goal was to identify the magnitude of gastro-protective drugs (GPDs) co-prescription and the profile of patients who received GPD co-prescription, during nonsteroidal anti-inflammatory drugs (NSAIDs) treatment in a "real life setting" of primary care practice.

METHODS

A pragmatic prospective 6-month survey of 2197 new takers of nonselective NSAIDs, selected and followed by general practitioners (GPs) on the bias of their usual standards of care.

RESULTS

Forty-seven percent of our survey population used at least one GPD during the 6-month follow-up. No difference was identified between piroxicam, diclofenac, ibuprofen, meloxicam and nimesulid for the GPD co-prescription. Besides the presence of gastro-intestinal (GI) symptoms, previous use of GPD, previous occurrence of GI disorders and increase in age are the most prominent predictive factors of GPD use during NSAID treatment. When adjusted for other risk factors, co-prescription of GPD was significantly increased in patients aged 55 years and above (odds ratio (OR): 1.29, 95% confidence interval (CI): 1.01-1.64) with no further increase in the co-prescription in older subjects.

CONCLUSION

Patients above 55 years with previous history of GI symptoms or GPD use are more likely to benefit from cytoprotective medications.

Adjuvant hyperthermic intraperitoneal peroperative chemotherapy (HIPEC) associated with curative surgery for locally advanced gastric carcinoma. An initial experience

AIM OF THE STUDY

After macroscopic radical (R0) surgery for advanced gastric carcinoma, 40 to 50% of the tumors recur in the abdomen as locoregional or peritoneal disease. We initiated a protocol in which patients with suspicion of macroscopic serosal, lymphatic or peritoneal invasion, treated with R0 resection, underwent adjuvant HIPEC.

METHODS

Between June 1998 and January 2003, 16 patients with locally advanced adenocarcinoma of the stomach were included in the study. Surgery consisted of a total gastrectomy with a D2 lymphadenectomy. Splenectomy (n = 1), splenopancreatectomy (n = 4), transverse colectomy (n = 3), left hepatectomy (n = 1), localized peritonectomy (n = 3) were associated to obtain a R0 resection. HIPEC protocol consisted of heated (42.5 degrees C) intraperitoneal mitomycin C (15 mg/m2) for a planned duration of 90 minutes.

RESULTS

HIPEC median duration was limited to 73(20-90) min because of central hyperthermia recognition in half of the cases. One patient died in the postoperative period of sepsis secondary to a duodenal fistula. Postoperative morbidity included pancreatic fistula (n = 2), pulmonary oedema (n = 1), pulmonary embolus (n = 1) and transient renal failure (n = 1). UICC staging was IB (n = 2), II (n = 2), IIIA (n = 5), IIIB (n = 1), IV (n = 6). Nine of the 16 patients are alive without recurrence with a median follow-up of 52 months. Four patients developed a recurrence, intraperitoneal (n = 2), systemic (n = 1), or combined (n = 1). Two patients were lost to follow-up.

CONCLUSIONS

Aggressive surgical therapy and HIPEC might represent the standard of care in a selected population with locoregional disease and for whom a R0 resection can be achieved. This protocol was associated in this study with a 75% 5-year survival with a low peritoneal recurrence rate and an acceptable morbidity.

[Acute colitis in Wegener's disease: a case report]

We report the case of a 52 year old man who was hospitalized within a context of a persistent deterioration of his general condition. He was suspected of having a chronic inflammatory colitis. A pulmonary radiography revealed the presence of voluminous bilateral excavated masses with hydro-aerical levels. After having refuted among others a suspicion of tuberculosis, the results of a thoracic percutaneous transpleural lung aspiration by needle under tomodensitometric control steered our diagnosis towards a vascularitis of the Wegener disease type. A treatment with corticotherapy in large doses completed with cyclophosphamid allowed for clinical, biological and radiological improvement. Wegener's granulomatosis usually starts in an insidious manner with febrile episodes and an impairment of the general condition associated with inflammatory biological signs, as observed in our patient. After these warning symptoms, come ORL and/or pulmonary and/or renal impairment, which represent the classical triad of diffused GW. However a certain number of particularities unusual for that diagnosis characterized our patient and prompted the discussion of this case.

Evolution of the prevalence and characteristics of anemia in inflammatory bowel diseases between 1993 and 2003

INTRODUCTION

Anemia has been considered as an overlooked complication of inflammatory bowel disease. Studies dating back to the 80ties and the 90ties have shown 30% of anemia among inflammatory bowel disease (IBD) patients. More recently, the broader use of immunosuppressive drug and infliximab allowing better mucosal healing as well as a more aggressive treatment of anemia, including the use of safer form of IV iron, may have influenced the prevalence of anemia among IBD patients. Our aim was to asses the prevalence and characteristics of anemia among two cohorts of IBD patients at 10 years interval and to look for associated clinical or demographic factors.

METHODS

Using the IBD patients register of one senior gastroenterologist, we identified IBD patients he had consecutively seen and who had blood test at the outpatient clinic during the years 1993 and 2003. Demographic and clinical characteristics, treatment for Crohn's disease, blood test results and treatment of anemia were recorded and compared between these two cohorts. Anemia was defined as an hemoglobin level lower than the normal value of the laboratory of our hospital.

RESULTS

80 and 90 patients were identified in 1993 and 2003, respectively. There was no significant difference between the two cohorts, according to age, gender, disease type, duration or location. There were 27/80 (33.8%) and 15/90 (16.7%) anemic patients in 1993 and 2003, respectively (P = 0.013). The prevalence of severe anemia (hemoglobin level < 10.5 g/100 ml) was similar in the two cohorts (6.3% and 5.6%). Characteristics of the anemia were similar in the two cohorts with a majority of iron deficiency anemia and inflammatory anemia. Ferritin and CRP levels were not significantly different in the two cohorts. The only significant difference was a more frequent use of immunosuppressive treatment and infliximab in 2003 than in 1993 (33.3% vs. 13.8% ; P = 0.0038, RR: 0.41, 0.22-0.77)

CONCLUSIONS

Prevalence of mild to moderate anemia has significantly decreased in our population over the last 10 years. The only difference detected between the two cohorts was the increased use of immunosuppressive drug (mainly azathioprine).

Diagnosis of small bowel malabsorption syndromes in adults

Patients with malabsorption represent a small proportion of presentations with chronic diarrhea. In spite of some progress, the last twenty years were not very innovating in malabsorption investigations. Supporting history may direct investigations toward either the small bowel or pancreas. Serological testing for celiac disease will determine most cases without invasive investigation, but individuals suspected to have small bowel malabsorption, despite negative celiac serology, should have endoscopic distal duodenal biopsies taken to exclude other rare forms of small bowel enteropathy. This strategy has largely supplanted many older tests of small bowel function.

[Chronic anemia in inflammatory bowel diseases: review]

Chronic anemia has been considered as an overlooked complication of inflammatory bowel disease (IBD). However it deserves full attention since even mild to moderate anemia has significant impact on quality of life. During the past decade relevant progress has been made in the understanding and treatment of this pathology. In our review, we focus on frequency, mechanisms, diagnosis and treatment of anemia in IBD.

[Food intolerance and allergy in the irritable bowel syndrome]

Irritable Bowel Syndrome (IBS) is a complex and heterogeneous entity that concerns about 1/4 of adults and would be responsible for 50% of gastro-enterology medical consultations. IBS etiopathogenesis and physiopathology are not yet fully known. Implications of food intolerance and allergy in this syndrome remain controversial. In this review we recall numerous mechanisms of allergy or food intolerance generating IBS, as well as clinical entities mimicking an IBS. We present a series of diagnostic tests and potential treatments. We finally propose a management strategy for these patients.

Altered expression of type I insulin-like growth factor receptor in Crohn's disease

The fibrotic and antiapoptotic effects of insulin-like growth factors (IGF) are mediated by type I IGF receptor (IGF-1R). IGFs could play a role in intestinal stricturing and in the maintenance of inflammation in Crohn's disease (CD). We aimed to describe IGF-1R expression in CD intestinal lesions, to compare it to other intestinal inflammatory diseases and to correlate it with fibrosis and apoptosis. IGF-1R expression and apoptosis (active caspase-3) were studied by immunohistochemistry. Surgical intestinal specimens [17 CD, nine controls, six diverticulitis and four ulcerative colitis (UC)] were used. IGF-1R was expressed transmurally mainly by inflammatory cells (IC) and smooth muscle cells, both in diseased intestine and controls. IGF-1R positive IC were increased in the mucosa and the submucosa of CD (P < 0.007), and in involved areas compared to uninvolved areas (P = 0.03). In UC, the number of IGF-1R positive IC was only increased in the mucosa, and was not different from controls in the submucosa. In diverticulitis, the number of IGF-1R positive IC did not differ from controls. In CD submucosa, IGF-1R expression in IC was inversely correlated with apoptosis in uninvolved areas (P = 0.01). Expression of IGF-1R in submucosal fibroblast-like cells, subserosal adipocytes and hypertrophic nervous plexi was specific for CD. We have shown a transmural altered expression of IGF-1R in CD. This may suggest a role for IGF-1R in the maintenance of chronic inflammation and stricture formation in CD.

A patient who survived total colonic ulcerative colitis surinfected by cytomegalovirus complicated by toxic megacolon and disseminated intravascular coagulation

The authors report the case of a patient aged 60-year-old who survived ulcerative colitis complicated by toxic megacolon and disseminated intravascular coagulation. This patient was not known for this ulcerative colitis and was first hospitalised for a suspicion of diverticulitis. The admission symptoms were fever, abdominal pain and bloody diarrhoea. The evolution was defavorable under antibiotics and sulfasalazine. The patient was readmitted 5 days after he left hospital, and the diagnosis of UC was based on colon biopsy made during the first hospitalisation. A treatment with methylprednisolone was started and the patient worsened day by day with apparition of toxic megacolon and disseminated intravascular coagulation. Subtotal colectomy was performed for degradation of general status and coagulation factors. Pathological findings confirmed ulcerative colitis with toxic megacolon. Cytomegalovirus inclusions were demonstrated on the colonic specimen and confirmed by PCR. In this report the authors discuss the etiology of toxic megacolon and disseminated intravascular coagulation in ulcerative colitis surinfected by cytomegalovirus. Mortality of these pathologies is high necessitating rapid diagnosis of cytomegalovirus infection by sigmoid biopsy. Management requires immunosupression interruption and ganciclovir therapy, or surgery in unsuccessful medical treatment.

Profile of soluble cytokine receptors in Crohn's disease

INTRODUCTION

Soluble cytokine receptors (sCRs) modulate the in vivo activity of cytokines. Deficient sCR production could participate in the pathogenesis and course of Crohn's disease (CD). The aim of the study was to examine the profile of sCRs in CD patients and their modulation by infliximab and corticosteroids.

METHODS

We prospectively examined active CD patients (aCD) treated with either infliximab (n = 21) or corticosteroids (n = 9), CD patients in clinical remission (rCD, n = 20), ulcerative colitis patients (UC, n = 24), and healthy subjects (HS, n = 15). Cultures of colonic biopsies were also examined from CD inflamed (n = 8), CD non-inflamed (n = 7), and healthy mucosa (n = 8). Levels of tumour necrosis factor alpha (TNF-alpha), soluble TNF receptor I (sTNFRI), soluble TNF receptor II (sTNFRII), interleukin 1beta (IL-1beta), soluble IL-1 receptor I (sIL-1RI), soluble IL-1 receptor II (sIL-1RII), IL-6, soluble IL-6 receptor (sIL-6R), and sgp130 were measured using ELISA.

RESULTS

Higher levels of sTNFRI (p<0.05, p<0.01), sTNFRII (p<0.01, p<0.01), sIL-1RI (p<0.05, NS), IL-6 (p<0.01, p<0.01), and sIL-6R (p<0.05, NS) were observed in aCD compared with rCD and HS. Interestingly, sIL-1RII (p<0.05, p<0.01) and sgp130 (p<0.01, p<0.01) were profoundly decreased in aCD compared with rCD and HS, and were negatively correlated with CRP. Deficient production of sIL-1RII was specific to CD (not observed in ulcerative colitis), and was further confirmed at the mucosal level. Infliximab decreased sTNFRII at one and four weeks (p<0.05) and enhanced sIL-6R levels at one week (p<0.05). Corticosteroids increased sIL-1RII levels at one week (p<0.05).

CONCLUSION

CD is associated with dysregulated production of sCRs. Deficiency in sIL-1RII and sgp130 may be essential to CD pathogenesis. Their replacement through the use of fusion proteins could represent future alternative therapeutic strategies for CD.

Increased expression of receptor activator of NF-kappaB ligand (RANKL), its receptor RANK and its decoy receptor osteoprotegerin in the colon of Crohn's disease patients

Crohn's disease (CD) is associated with low bone mass due to chronic inflammation and other factors. Receptor activator of NF-kappaB ligand (RANKL), its receptor RANK and its decoy receptor osteoprotegerin (OPG) are potentially involved in this process as they regulate osteoclastogenesis and are influenced by pro-inflammatory cytokines. The aim of this study was to determine the levels of soluble RANKL (sRANKL), RANK and OPG expression both in the serum and in the colon of CD patients. Levels of sRANKL and OPG were assessed in the serum and the supernatants of cultured colonic biopsies in patients with CD and controls by ELISA. RANK expression was explored by immunostaining and immunofluorescence of fixed colonic samples. OPG and sRANKL levels were higher in the serum of CD patients as compared to age- and sex-matched controls. Levels of sRANKL and OPG were significantly enhanced in cultured colonic biopsies from CD, and OPG levels correlated with histological inflammation, and pro- and anti-inflammatory cytokine levels. No significant correlation was found for sRANKL. RANK+ cells were increased in the colon of CD, particularly in inflamed areas. These cells were positive for CD68 or S100 protein. We conclude that serum and local levels of sRANKL and OPG are increased in CD. Moreover, RANK is expressed in the colonic mucosa by subpopulations of activated macrophages or dendritic cells at higher levels in CD compared to normal colon.

[Endoscopic mucosa resection for superficial esophageal carcinoma: an alternative to radical surgery?]

Radical surgery is the standard of care for resectable esophagus cancers, with mortality less than 5% in heavily trained surgical teams. Nevertheless, the morbidity of surgery is quite high due to the procedure and due to the poor status of these patients. Endoscopic mucosal resection seems effective for the resection of superficial malignant lesions of esophagus with an acceptable morbidity profile. A correct staging has to confirm the superficial character of the lesion and exclude deeper infiltration into the digestive wall or nodal involvement. This technique might be an acceptable alternative to surgery or superficial lesions, particularly for patients at high risk for aggressive surgical procedure.

Development of adenocarcinoma in chronic fistula in Crohn's disease

The authors report the case of a 55 yr-old woman suffering from Crohn's disease since 31 years with stricture and fistulas developed in the ileocolic junction and anorectal portion. Long-standing anorectal fistulas and stricture led to adenocarcinoma and finally fistulisation in the vagina. Diagnosis was made by perineal examination with biopsies under general anaesthesia. Treatment was first posterior pelvectomy with resection of the anterior wall of vagina. Secondarily, radiochemotherapy was administrated. The authors discuss the incidence and risk factors of carcinoma in Crohn's disease with chronic fistulas.

A naturalistic study of the determinants of health related quality of life improvement in osteoarthritic patients treated with non-specific non-steroidal anti-inflammatory drugs

OBJECTIVES

To capture changes in the quality of life (QoL) occurring in patients with osteoarthritis (OA) during treatment with non-specific non-steroidal anti-inflammatory drugs (NSAIDs) and to identify factors that predict such changes.

METHODS

A naturalistic, prospective follow up of 783 patients with OA in whom primary care physicians decided to start treatment with non-selective NSAIDs. Short Form-36 (SF-36) and the Western Ontario and McMaster Universities OA index (WOMAC) were assessed at baseline and after 3 months. Baseline results were compared with QoL values in 4800 subjects randomly selected from the general population. Multiple regression analysis was performed to identify determinants of QoL at baseline and measures influencing changes in SF-36 or WOMAC during follow up.

RESULTS

All QoL dimensions were significantly (p<0.01) decreased in patients with OA compared with controls. Significant improvement (p<0.05) in four dimensions of the SF-36 (vitality, role emotional, role physical, bodily pain) and in all components of the WOMAC was seen between baseline and month 3. Older age, female sex, longer duration of OA, and a higher number of comorbidities were the major determinants of a poor QoL at baseline. Maximal benefit from non-specific NSAIDs was seen in patients with the most severe impairment in QoL and the shortest duration of OA.

CONCLUSION

OA negatively impacts all dimensions of the QoL. Non-specific NSAIDs improve the QoL in patients with OA treated in a "real life setting". The profile of patients receiving maximal benefit from such treatment may be of interest for health providers, enabling them to decide who should preferentially be given cytoprotective treatments or coxibs.

Rapid improvement of bone metabolism after infliximab treatment in Crohn's disease

BACKGROUND

Crohn's disease is associated with low bone mineral density and altered bone metabolism.

AIM

To assess the evolution of bone metabolism in Crohn's disease patients treated with infliximab.

METHODS

We studied 71 Crohn's disease patients treated for the first time with infliximab for refractory Crohn's disease. Biochemical markers of bone formation (type-I procollagen N-terminal propeptide, bone-specific alkaline phosphatase, osteocalcin) and of bone resorption (C-telopeptide of type-I collagen) were measured in the serum before and 8 weeks after infliximab therapy and compared with values in a matched healthy control group.

RESULTS

Eight weeks after treatment with infliximab, a normalization of bone markers was observed with a median increase in formation markers of 14-51% according to marker and a lower but significant decrease in resorption marker (median 11%). A clinically relevant increase in bone formation markers was present in 30-61% of patients according to the marker. A clinically relevant decrease in C-telopeptide of type-I collagen was present in 38% of patients. No association was found with any tested demographic or clinical parameter.

CONCLUSION

Infliximab therapy in Crohn's disease may rapidly influence bone metabolism by acting either on bone formation or bone resorption. This improvement seems to be independent of clinical response to infliximab.

Medical treatment of chronic anal fissure. where do we stand on reversible chemical sphincterotomy?

Anal fissure is a common problem which can evolve to chronicity. Chronic anal fissure is thought to be an ischemic ulceration related to sphincter hypertonia. Lateral internal sphincterotomy, the most common treatment for chronic anal fissure, may cause permanent injury to anal sphincter leading to fecal incontinence. To avoid such side effect were developed medications producing a temporary or reversible sphincterotomy reducing the sphincter pressure only until the fissure has healed: nitrates, calcium channel antagonists and botulinum toxin. Authors aimed to summary the state of research on such treatments (efficacy, side effects, recurrence risk) and to clarify the role of these different medical options in the current treatment of chronic anal fissure.

[Video-capsule endoscopy for small bowel investigation]

Capsule endoscopy is a new technique of exploration which enables to visualize the entire small bowel. Occult or unexplained digestive bleeding currently constitutes on major indication of this technique. The aim of this study is to report the results obtained among 15 patients investigated by capsule endoscopy and to discuss the place of this new technique in the small bowel exploration.

Association between polymorphism in IgG Fc receptor IIIa coding gene and biological response to infliximab in Crohn's disease

AIM

To test the hypothesis of an association between polymorphism in FCGR3A (the gene coding for FcgammaRIIIa, which is expressed on macrophages and natural killer cells, is involved in antibody-dependent cell-mediated cytotoxicity and has recently been associated with a positive response to rituximab, a recombinant immunoglobulin G1 antibody used in non-Hodgkin's lymphomas) and response to infliximab in Crohn's disease.

METHODS

FCGR3A-158 polymorphism was determined using an allele-specific polymerase chain reaction assay in 200 Crohn's disease patients who had received infliximab for either refractory luminal (n = 142) or fistulizing (n = 58) Crohn's disease. Clinical and biological responses (according to C-reactive protein levels) were assessed in 200 and 145 patients, respectively.

RESULTS

There were 82.9% clinical responders in V/V patients vs. 72.7% in V/F and F/F patients (N.S.). Globally, the decrease in C-reactive protein was significantly higher in V/V patients than in F carriers (P = 0.0078). A biological response was observed in 100% of V/V patients, compared with 69.8% of F carriers (P = 0.0002; relative risk, 1.43; 95% confidence interval, 1.27-1.61). In the sub-group of patients with elevated C-reactive protein before treatment, the multivariate analysis selected the use of immunosuppressive drugs and FCGR3A genotype as independent factors influencing the clinical response to infliximab (P = 0.003).

CONCLUSION

Crohn's disease patients with FCGR3A-158 V/V genotype have a better biological and, possibly, clinical response to infliximab.

Tioguanine in patients with Crohn's disease intolerant or resistant to azathioprine/mercaptopurine

BACKGROUND

Tioguanine (TG) is an antimetabolite which may be regarded as an alternative to azathioprine (AZA)/mercaptopurine (MP) in patients with inflammatory bowel diseases.

AIMS

: To evaluate the tolerance and efficacy of TG in patients with Crohn's disease, intolerant or resistant to AZA/MP.

METHODS

An open prospective study was made on Crohn's disease patients treated with TG. Intolerance to AZA/MP was defined as a reaction occurring within 1 month after introduction of AZA/MP, including pancreatitis, abdominal pain, fever, arthralgia, myalgia, cutaneous rash, fatigue, alopecia, hepatitis and digestive intolerance. Resistance to AZA/MP was defined as the persistence of activity after at least 3 months of AZA/MP therapy.

RESULTS

Forty-nine Crohn's disease patients (36 women, 13 men; intolerance: n = 39; resistance: n= 10) were treated with TG (20 mg/day). Clinical pancreatitis did not recur under TG. Five patients (10%) had to stop TG due to intolerant reactions observed 13-21 days after TG was started. No haematological side-effects were observed under TG. The probability of clinical remission without corticosteroids or infliximab at 6 and 12 months was 46% and 79%, respectively, in the 40 patients with active disease at baseline. The probability of clinical relapse during maintenance TG therapy at 6 and 12 months was 29% and 53%, respectively, in the 28 patients in remission at baseline or who had achieved remission on TG.

CONCLUSIONS

TG is a possible alternative treatment in Crohn's disease patients, intolerant (especially for pancreatitis) or resistant to AZA/MP.

Treatment of acute diarrhoea: update of guidelines based on a critical interuniversity assessment of medications and current practices

Further to a thorough analysis of the problem of acute diarrhoea and the therapeutic options, recommendations were defined following a multidisciplinary approach. These guidelines take into account the reality of frequent self-medication. They further differ as a function of age (children, primarily treated by ORS and for whom self-medication is not advised versus adults who can self-medicate), symptoms (uncomplicated diarrhoea versus dysentery) and location where the diarrhoea is contracted (at home or when travelling).

[Primary and secondary prevention of colorectal cancer]

Colorectal cancer is really a public health problem. The authors review the literature about the environmental factors leading to colorectal cancer. Chemoprevention of colorectal cancer is also discussed, particularly by aspirin and non steroidal anti-inflammatory drugs. Development of specific cyclooxygenase-2 inhibitors constitutes a promising research's field. Secondary prevention by coloscopy and polypectomy must lead to a lower rate of colorectal cancer disease and improvement of mortality.

Early development of stricturing or penetrating pattern in Crohn's disease is influenced by disease location, number of flares, and smoking but not by NOD2/CARD15 genotype

BACKGROUND

Crohn's disease is a heterogeneous entity. Disease behaviour, characterised as stricturing, penetrating, or non-stricturing non-penetrating, is a clinically important phenotype as it is associated with complications and need for surgery. It has recently been showed that the behaviour of Crohn's disease changes over the course of the disease.

AIM

To assess the association between rapid development of a penetrating or stricturing pattern of Crohn's disease and demographic and clinical characteristics as well as NOD2/CARD15 genotype.

PATIENTS AND METHODS

A total of 163 patients with a firm diagnosis of Crohn's disease and who had non-penetrating non-stricturing disease at diagnosis were studied. Various demographic and clinical characteristics as well as antisaccharomyces cerevisiae antibody status and NOD2/CARD15 genotype were documented in these patients. These characteristics were compared in subgroups of patients according to evolution of disease behaviour five years after diagnosis.

RESULTS

Five years after diagnosis there were 110 (67.5%) patients with non- structuring non-penetrating disease, 18 (11%) with stricturing disease, and 35 (21.5%) with penetrating disease. In multivariate analysis, only disease location and number of flares per year were significantly discriminant between the three subgroups (p=0.0009 and 0.0001, respectively). Ileal location of the disease was associated with a stricturing pattern while a high number of flares was associated with a penetrating pattern. Active smoking was also associated with a penetrating pattern compared with a non-stricturing non-penetrating pattern only.

CONCLUSIONS

Early development of stricturing or penetrating behaviour in Crohn's disease is influenced by disease location, clinical activity of the disease, and smoking habit, but not by NOD2/CARD15 genotype.