[Inflammatory bowel disease during pregnancy]

The prevalence of inflammatory bowel disease (IBD) increased in the last decades. Thus, the number of pregnant women with the condition is also increasing. Given that active disease itself is the main risk factor for complications during pregnancy, it is necessary to achieve a complete remission before planning a pregnancy. Also, pregnant women with IBD must be monitored noninvasively and be treated proactively, including escalated therapies, if needed, to prevent potential flares during pregnancy. Patients can undergo vaginal delivery in most forms of IBD. However, cesarean delivery is still preferable in women with a history of ileal pouch-anal anastomoses (IPAA) or active perianal disease.

Primary sclerosing cholangitis and inflammatory bowel disease: Intestine-liver interrelation

The association between inflammatory bowel disease (IBD) and primary sclerosing cholangitis should be considered a distinct clinical entity. This association involves genetic abnormalities, epidemiological factors (more common in men, with no a geographical pattern) and, commonly, subclinical inflammation, predominance of the right colon (endoscopic and histological), backwash ileitis and rectal sparing. Furthermore, there is an increased risk of colorectal cancer and cholangiocarcinoma. The aim of this review is to show how IBD influences the progression of this entity, transplantation requirements and recurrence. We also discuss the current evidence on the use of biological therapy in this group of patients.

[Update on celiac disease]

The prevalence of Celiac disease in the general population is approximately 1% and remains undiagnosed in a significant proportion of individuals. Its clinical presentation includes the classical malabsorption syndrome, unspecific and extra-intestinal manifestations, and silent celiac disease. The serologic diagnosis has an elevated sensitivity and specificity and, at least in adult population, it must be confirmed by biopsy in every case. Diagnosis in subjects already on gluten free diet includes HLA typing and gluten challenge with posterior serologic and histologic evaluation. The core of the treatment is the gluten free diet, which must be supervised by an expert nutritionist. Monitoring must be performed with serology beginning at 3-6 months, and with histology two years after the diagnosis, unless the clinical response is poor. Poor disease control is associated with complications such as lymphoma and small bowel adenocarcinoma. In the future, it is likely that new pharmacologic therapies will be available for the management of celiac disease.

[Distal intestinal obstruction syndrome: report of two cases with cystic fibrosis]

Distal Intestinal Obstruction Syndrome (DIOS) has a 16% incidence among patients with Cystic Fibrosis (CF). It is characterized by an intestinal obstruction secondary to fecal impaction in distal ileum or cecum. We report two adult patients with DIOS. A female with CF and subjected to lung transplantation at the age of 13 years old. Five years later, she consulted for an intestinal obstruction. She was treated conservatively with a good clinical evolution. She had a new episode of DIOS eight months later that was also treated conservatively. A 31 year-old mole, subjected to bilateral lung transplantation nine years before, that was admitted to the hospital for a bronchiolitis. Three days after admission he started with an intestinal obstruction that was diagnosed as a DIOS. He was managed conservatively with a good clinical response.

[Thiopurine S-methyltransferase gene polymorphism in Chilean blood donors]

BACKGROUND

Thiopurine S-methyltransferase (TPMT) is a cytosolic enzyme that catalyzes the S-methylation of 6-mercaptopurine and azathioprine. Low-activity phenotypes are correlated with polymorphism in the TPMT gene. Patients with low or undetectable TMPT activity could develop severe myelosuppression when they are treated with standard doses of thiopurine drugs. Since ethnic differences in the TPMT gen polymorphism have been demonstrated worldwide, its assessment in the Chilean population is worthwhile.

AIM

To investigate the TMPT gene polymorphism in a Chilean blood donor individuals.

SUBJECTS AND METHODS

The frequency of four allelic variants of the TPMT gene, *2 (G238C), *3A (G460A and A719G), *3B (G460A) and *3C (A719G) were analyzed in 210 Chilean blood donors, using polymerase chain reaction (PCR), restriction fragment length polymorphism (RFLP) and allele-specific PCR-based assays.

RESULTS

TPMT variants associated to low enzymatic activity, were detected in 16 subjects (8%), who had a heterozygous genotype (*3A in 12; *3C in three and *2 in one subject). No TPMT*3B allelic variant was found. The normal allele (wild-type) was found in 92% of studied individuals.

CONCLUSIONS

The allele TPMT*3A, is the most prevalent in this group of Chilean blood donors, as in Caucasian populations.

[Small bowel transplantation: Report of a single case]

Small bowel transplantation is associated with a patient survival at one and five years, of 80% and 63%, respectively. We report a 36 year-old female with short bowel syndrome, subjected to the first small bowel transplantation performed in Chile. A cadaveric gran was used. Immunosuppression was achieved by means of alemtuzumab, tacrolimus, sirolimus, micofenolate mofetil and steroids. Serial endoscopies and biopsies were performed during seven months after transplantation. The most important late complications were a drug induced renal failure, infections caused by opportunistic agents and a gastrointestinal bleeding probably induced by drugs. After 29 months of follow up, the patient is ambulatory, on oral diet only and with no evidence of graft rejection.

[Small intestinal bacterial overgrowth in patients with functional gastrointestinal diseases]

BACKGROUND

Recent studies have described a high percentage of small intestinal bacterial overgrowth (SIBO) in patients with irritable bowel syndrome (IBS). However, the prevalence of SIBO has not been well established in other functional disorders.

AIM

To evaluate the prevalence of SIBO in patients with different functional gastrointestinal disorders (FGID).

MATERIAL AND METHODS

Patients with FGID completed a self-administered questionnaire providing information to diagnose functional disorders on the basis of Rome II criteria. SIBO was assessed using a standardized lactulose breath test. A basal value of breath hydrogen (H2) >20 ppm and/or two lectures of HZ values >20 ppm during the first 60 minutes were considered suggestive of SIBO.

RESULTS

We studied 367 patients with a mean age of 50 years (87% females). Of these, 225 had IBS (45 constipation predominant, 121 diarrhea predominant and 59 alternating type), 33 had functional constipation, 83 had functional bloating and 26 had functional diarrhea. SIBO was found in 76% of patients with IBS, 73% of those with functional constipation, 69% of those with functional diarrhea and 68% of those with functional bloating.

CONCLUSIONS

This study confirms a high percentage of SIBO in patients with IBS and other FGID. The eradication of SIBO should be considered as a therapeutic tool in these patients.

[Rectal barostat in irritable bowel syndrome]

BACKGROUND

Many patients with irritable bowel syndrome (IBS) have lowered sensory thresholds to rectal distention when compared to control subjects, a phenomenon called visceral hypersensitivity.

AIM

To investigate the usefulness of a rectal barostat as a diagnostic tool in IBS and if there are differences in visceral hypersensitivity in different groups of IBS patients.

PATIENTS AND METHODS

Ten healthy subjects and 19 IBS patients, defined using Rome II criteria (12 with constipation, three with diarrhea and four alternating between diarrhea and constipation), were studied. Sequential isobaric rectal distentions, from 2 mmHg up to a maximal pressure of 52 mmHg or when the patients reported pain, were carried out. Visceral hypersensitivity was defined as a pain threshold under 38 mmHg.

RESULTS

Only 26% of IBS patients had visceral hypersensitivity (16% and 43% of patients with IBS and constipation and IBS and diarrhea or alternating symptoms, respectively, p =NS). Pain threshold in controls, patients with IBS and constipation and patients with IBS and diarrhea or alternating symptoms was 43.8+/-6.6, 45.3+/-9.2 and 40.8+/-9.2 mmHg, respectively (p =NS).

CONCLUSIONS

Our results do not support the usefulness of the electronic rectal barostat as a diagnostic method to diagnose IBS.

[Inflammatory bowel disease: experience of two Chilean centers]

BACKGROUND

The incidence of Inflammatory Bowel Disease (IBD) has increased, particularly in the developed world, and probably also in Chile.

AIM

To report our experience with a large group of patients from two medical centers, Hospital Clinico de la Universidad de Chile (HCUCH) and Clinica Las Condes (CLC) and to characterize the clinical features of IBD in Chile.

PATIENTS AND METHODS

Retrospective review of 238 patients with IBD (age range 14-78 years, 143 women) treated at HCUCH and CLC between January 1990 and August 2002.

RESULTS

One hundred eighty one patients had ulcerative colitis (UC) and 57 had Crohn's disease (CD), with an UC/CD ratio of 3.2/1. Forty eight percent of patients were aged between 20 and 39 years old and 69% were diagnosed after 1995. Patients from HCUCH had more severe disease, more complications and needed surgery more often.

CONCLUSIONS

Clinical features of Chilean patients with IBD are similar to those of other countries. UC is more common than EC. There is a higher proportion of women with the disease. The severity of the disease was higher among HCUCH.

Sobrecrecimiento bacteriano intestinal: An update

Small intestinal bacterial overgrowth (SIBO) is characterized by nutrient malabsorption, associated with an excessive number of bacteria in the proximal small intestine. Unfortunately, the diagnosis of bacterial overgrowth presents several difficulties and limitations, and as yet there is not a widespread agreement on the best diagnostic test. SIBO occurs when there are alterations in intestinal anatomy, gastrointestinal motility, or a lack of gastric acid secretion. The true association between SIBO and irritable bowel syndrome and celiac disease remains uncertain. The treatment usually consists in the eradication of bacterial overgrowth with repeated courses of antimicrobials, nutritional support and when it is possible, the correction of underlying predisposing conditions.

[Mesenteric vein thrombosis: clinical manifestations, treatment and outcome]

BACKGROUND

Mesenteric vein thrombosis (MVT) is uncommon and accounts for 5-10% of all mesenteric ischemic events. In 80% of cases, an etiologic factor is found. The clinical presentation varies and the diagnosis is made based on imaging studies. The treatment involves anticoagulation alone or in combination with surgery.

AIM

To describe the clinical characteristics of patients with MVT.

PATIENTS AND METHODS

Retrospective and prospective review of all cases with MVT, treated between 1995-2001. The clinical presentation, imaging studies, treatment and outcome were evaluated.

RESULTS

29 cases of MVT were reviewed (14 females, age 56 +/- 15 years). Twenty two patients (76%) had recognizable risk factors. The main symptoms were abdominal pain (86%) and vomiting (55%). The diagnosis of acute mesenteric ischemia was suspected on admission only in 6 patients (21%). Thirteen patients underwent transabdominal color Doppler ultrasonography and the diagnosis was confirmed for 11 of these (85%). Twenty out of 24 patients (85%) studied with computed tomography, had positive signs of MVT. Twenty one patients (72%) received anticoagulation, 10 of whom also underwent surgery. Four patients (14%) received surgical treatment alone. Four patients were not treated. Seven patients (24%) died.

CONCLUSIONS

MVT is difficult to identify. It is necessary to have a high degree of suspicion in patients who have risk factors. The diagnosis is made with imaging studies. The treatment consists of early anticoagulation and surgical intervention when indicated.