["Probiotic medicine" and certainty of the evidence.]

These are excellent times for probiotic medicine. We have discovered more than 150,000 genomes of the microbiome, which can be aggregated into 4,930 species. However, the dream of microbiome-based medicine requires a new approach - an ecological and evolutionary understanding of host-microbe interactions, rather than a qualitative analysis of species. Yet researchers still disagree on what constitutes a healthy microbiome or how to define an altered one. There is still uncertainty as to which properties of the microbiome will represent the most informative biomarkers in clinical and epidemiological studies. And little is known about how the microbiomes of different regions of the body, such as the mouth, intestines or skin, interact. It is time to re-establish the foundations for the certainty of evidence in myocrobiome-based medicine. We believe robust new pillars are needed: starting clinical trials whenever possible; extending the role of N-of-1 trials; ending the "one probiotic for every disease" principle; reduce the number of outcomes of each research; search for the replicability of the results (the best test for the validity of an intervention with probiotics is not statistical significance but the replication of the result). Again, we would like to urge probiotic medicine researchers not to publish in "pirate" journals.

[Probiotics for the antibiotics associated diarrhea and for Clostridium difficile infection.]

The term probiotic refers to live microorganisms that survive passage through the gastrointestinal tract and have beneficial effects on the host. Many strains of probiotic microorganisms have been shown to inhibit growth and metabolic activity as well as the adhesion to intestinal cells of enteropathogenic bacteria, to modulate the gut microbiota and to have immunostimulatory or regulatory properties. The use of probiotic microorganisms for the prevention and the treatment of Antibiotic Associated Diarrhea is an obvious measure and perhaps the most usual application of probiotics. This overview summarizes the most commonly used probiotic microorganisms for DAA and IBD.

[Side effects of antibiotic: diarrhea and Clostridium difficile infection.]

Antibiotics are some of the most frequently prescribed medications worldwide, but antibiotic therapy may disturb the colonization resistance of gut microbiota to pathogenic bacteria, resulting in a range of symptoms that include, most notably, diarrhea that occurs between 7% and 33% of adults and 66 and 80% in pediatric patients (median of 22%) who take antibiotics. The diverse class of antibiotics may damage the metabolic homeostasis and can alter the level of intestinal metabolites including amino acids, bile acids, glucose, short chain fatty acids through alteration in abundance of metabolically active bacteria. Clostridium difficile is the main cause of antibiotics associated diarrhea: 3rd generation Cephalosporin, Clyndamicin, 2nd and 4th generation Cephalosporines, Sulfamethoxazole-trimethoprim, Quinolones, Penicillin combination show the strongest association with diarrhea.

[Revival of evidence-based medicine in gastroenterology.]

The evidence-based medicine (EBM) in gastroenterology is born with the XIII International Congress of Gastroenterology, the world congress of Gastroenterology, held in Rome in 1988. A clinical epidemiology manual was placed in the congress bag for each participant. The book contained an approach to biostatistics, interpretation of epidemiological data, clinical trials, meta-analysis and decision analysis. In the pocket appeared for the first time a floppy disk that offered softwares for the analysis of Student's and χ2, for randomization and for meta-analysis. In the following years the clinical epidemiology courses of Torgiano were born, now arriving at the 18th edition. The dedicated EBGH.it portal was also born. The reflections of recent years have suggested 8 theses for the renaissance of EBM in gastroenterology. 1. The patient must return to the center of the EBM. 2. There is an urgent need for more efficient production and implementation of evidences. 3. Researchers in gastroenterology should start studies only in relevant clinical fields where are not yet sufficient answers. 4. The EBM must move towards the evidence on the different effects of an intervention. 5. The relevance of the P-value should be reconsidered. 6. Precision medicine is growing. But EBM can not wait. 7. The best validity test is not the significance but the reproducibility of the data. 8. Data from the real world (real world evidence) can help increase the validity of clinical results.

[First part: the intestinal microbiota]

The human gastrointestinal tract contains a large number of commensal (non pathogenic) and pathogenic microbial species that have co-evolved with the human genome and differ in composition and function based on their location, as well as age, sex, race/ethnicity, and diet of their host and we can in fact consider the human body as a mix of human and bacterial cells. It is now evident that the large intestine is much more than an organ for waste material and absorption of water, salts and drugs, and indeed has a very important impact on human health, for a major part related to the specific composition of the complex microbial community in the colon. In man, the large gut receives material from the ileum which has already been digested and the contents are then mixed and retained for 6-12 hours in the caecum and right colon. Thus, the large intestine is an open system, with nutrients flowing in the caecum, and bacteria, their metabolic products, and undigested foodstuffs being excreted as faeces. The anaerobic brakdown of carbohydrate and protein by bacteria is known conventionally as fermentation. In man the major end products are the short-chain fatty acids (SCFA) acetate, propionate, butirate, the gases H2 and CO2, ammonia, amines, phenols and energy, which the bacteria use for growth and the maintenance of cellular function. The microbiota is also an important factor in the development of the immune response. The interaction between the gastrointestinal tract and resident microbiota is well balanced in healthy individuals, but its breakdown can lead to intestinal and extraintestinal disease.

[Evidence-based medicine vs personalized medicine.]

Evidence-based medicine (EBM) and personalized medicine (PM) are driven by two diverse modes of reasoning about «evidence making». EBM has been criticized since his quality mark has been misappropriated by vested interests, the benefits statistically significant may be marginal in clinical practice, rigid rules and technology may produce care that is management driven rather than patient centered. On the contrary PM (or "precision medicine") refers to the tailoring of medical treatment to the specific characteristics of each patient involving the ability to classify individuals into subpopulations that are uniquely susceptible to a specific treatment, sparing expense and side effects and is derived from doubts on the results of subgroup analyses and on non responders in clinical trials typical of EBM. While both paradigms are epistemically sound they cannot, and should not, be hybridized into a unique model. Rather they ought to represent two compatible, but alternative ways of informing the Clinical practice. The clinicians may expect to see their responsibility increasing as they will deal with diverse, but equally compelling ways of reasoning and deciding about which intervention will qualify as the «best one» in each individual case.

[Probiotics]

On the basis of the currently available literature, which includes well-designed clinical trials, systematic reviews and meta-analyses, certain effects can be ascribed to probiotics as a general class. It is accepted that sufficient evidence has accumulated to support the concept of benefits of certain probiotics; it is reasonable to expect that evidence gained from a defined class of live microbes might be appropriate for certain, but not all, health outcomes. Moreover there is a need for clear communication to consumers and health-care providers of the activity of differentiate probiotic products.

Ménétrier's disease diagnosed by enteroclysis CT: a case report and review of the literature

This study reports a case of Ménétrier's disease (MD) in an adult who presented with epigastric pain and peripheric edema. We focused in particular on the imaging and diagnostic aspects of the presenting case as well as clinical, histologic, and therapeutic aspects. Computed tomography (CT) enteroclysis is a new imaging technique which combines enteroclysis and spiral multislice CT. To the best of our knowledge this is the first report on a MD in an adult patient diagnosed by CT Enteroclysis.

Is microencapsulation the future of probiotic preparations? The increased efficacy of gastro-protected probiotics

In a recent publication we assessed the kinetics of intestinal colonization by microencapsulated probiotic bacteria in comparison with the same strains given in an uncoated form. It's well known, in fact, that microencapsulation of probiotics with specific materials is able to confer a significant resistance to gastric juice, thus protecting the cells during the gastric and duodenal transit and enhancing the probiotic efficacy of any supplementation. In any case, this was the first study reporting the fecal amounts of probiotics administered in a coated, protected form compared with traditional, uncoated ones. Here we discuss additional in vitro data of resistance of the same bacteria to gastric juice, human bile and pancreatic secretion and correlate them with the results of in vivo gut colonization.

Oral beclomethasone dipropionate as an alternative to systemic steroids in mild to moderate ulcerative colitis not responding to aminosalicylates

BACKGROUND

Aminosalicylates (5-ASA) are first-line treatment for mild-moderate ulcerative colitis (UC). Systemic corticosteroids (CS) are considered for patients in whom 5-ASA has been unsuccessful, but their use is limited by adverse effects. Beclomethasone dipropionate (BDP), a topically acting steroid with low systemic bioavailability, has a more favorable safety profile, but its role in clinical practice is not yet well established.

AIM

The aim of the present study is to assess whether oral BDP can be an alternative treatment to systemic CS for patients with mild-moderate UC not responding to first-line therapy with 5-ASA.

METHODS

From 2003 to 2006, all consecutive patients with mild-moderate UC unresponsive to oral and topical 5-ASA (+/-topical CS) administered for at least 3 weeks received an 8-week course of oral BDP (10 mg/day for 4 weeks and 5 mg/day for an additional 4 weeks). Co-primary end-points were: (1) clinical remission within 8 weeks, without need of systemic CS; (2) steroid-free remission for 12 months.

RESULTS

Sixty-four patients were included. In this study, within 8 weeks, 48/64 patients (75%) entered remission without systemic CS, while 16/64 (25%) failed to enter remission. Within 12 months, 37/64 patients (58%) had prolonged steroid-free remission, while 11/64 (17%) relapsed. During 1 year, 75% of patients receiving oral BDP could avoid systemic CS.

CONCLUSIONS

Oral BDP can avoid the use of systemic CS in the vast majority of patients with mild-moderate UC not responding to 5-ASA and could be considered as a second-line treatment for these patients.

Predicting mortality in non-variceal upper gastrointestinal bleeders: validation of the Italian PNED Score and Prospective Comparison with the Rockall Score

OBJECTIVES

We sought (i) to validate a new prediction rule of mortality (Progetto Nazionale Emorragia Digestiva (PNED) score) on an independent population with non-variceal upper gastrointestinal bleeding (UGIB) and (ii) to compare the accuracy of the Italian PNED score vs. the Rockall score in predicting the risk of death.

METHODS

We conducted prospective validation of analysis of consecutive patients with UGIB at 21 hospitals from 2007 to 2008. Outcome measure was 30-day mortality. All the variables used to calculate the Rockall score as well as those identified in the Italian predictive model were considered. Calibration of the model was tested using the chi2 goodness-of-fit and performance characteristics with receiver operating characteristic (ROC) analysis. The area under the ROC curve (AUC) was used to quantify the diagnostic accuracy of the two predictive models.

RESULTS

Over a 16-month period, data on 1,360 patients were entered in a national database and analyzed. Peptic ulcer bleeding was recorded in 60.7% of cases. One or more comorbidities were present in 66% of patients. Endoscopic treatment was delivered in all high-risk patients followed by high-dose intravenous proton pump inhibitor in 95% of them. Sixty-six patients died (mortality 4.85%; 3.54-5.75). The PNED score showed a high discriminant capability and was significantly superior to the Rockall score in predicting the risk of death (AUC 0.81 (0.72-0.90) vs. 0.66 (0.60-0.72), P<0.000). Positive likelihood ratio for mortality in patients with a PNED risk score >8 was 16.05.

CONCLUSIONS

The Italian 10-point score for the prediction of death was successfully validated in this independent population of patients with non-variceal gastrointestinal bleeding. The PNED score is accurate and superior to the Rockall score. Further external validation at the international level is needed.

Current level of consensus on probiotic science--report of an expert meeting--London, 23 November 2009

The present paper summarizes the consensus views of a group of 9 European clinicians and scientists on the current state of scientific knowledge on probiotics, covering those areas where there is substantial evidence for beneficial effects and those where the evidence base is poor or inconsistent. There was general agreement that probiotic effects were species and often strain specific. The experts agreed that some probiotics were effective in reducing the incidence and duration of rotavirus diarrhoea in infants, antibiotic-associated diarrhoea in adults and, for certain probiotics, Clostridium difficile infections. Some probiotics are associated with symptomatic improvements in irritable bowel syndrome and alleviation of digestive discomfort. Probiotics can reduce the frequency and severity of necrotizing enterocolitis in premature infants and have been shown to regulate intestinal immunity. Several other clinical effects of probiotics, including their role in inflammatory bowel disease, atopic dermatitis, respiratory or genito-urinary infections or H.pylori adjuvant treatment were thought promising but inconsistent.

Long-term prevention of post-operative recurrence in Crohn's disease cannot be affected by mesalazine

BACKGROUND

Prevention of post-operative recurrence has a central role in the management of Crohn's Disease (CD). Many drugs have been evaluated in prospective randomised controlled trials (RCTs) but the results are disappointing. Mesalazine, the drug more extensively investigated, has been shown to be effective for preventing recurrence in the short-term; however, the overall benefit is small and no data are available on the long-term effectiveness.

AIM

To compare the long-term occurrence of post-operative recurrence in patients who received regular prophylactic treatment with mesalazine with patients who did not receive prophylaxis after the first radical resection for ileo-caecal CD.

PATIENTS AND METHODS

The records of 216 patients with ileo-caecal CD at their first resection were reviewed: 146 patients (67.6%) received post-operative prophylaxis with mesalazine while 70 patients (32.4%) received no prophylaxis. Allocation of patients in the two groups was determined by patients' preferences and by different policies in the post-operative prophylactic approach. The mean follow-up after surgery was 153.7 months (range 12-544). The co-primary endpoints were post-operative clinical and surgical recurrence.

STATISTICAL ANALYSIS

Kaplan-Meier survival method, Chi-square, Student t-test.

RESULTS

The two groups were comparable with regard to gender, age at surgery, smoking habits, pattern of CD (perforating/not perforating), and disease duration before surgery. One year after surgery, a small, not statistically significant, risk reduction in clinical recurrence was observed in mesalazine treated group (-7.6%; 95% CI -18.0% to 2.8%). Within 10 years after surgery, the cumulative probability of clinical recurrence and surgical recurrence were similar in the two groups (Log Rank test p=0.9 and p=0.1 respectively).

CONCLUSION

Mesalazine prophylaxis is not effective for preventing the long-term post-operative recurrence in ileo-caecal Crohn's disease.

Chemoprevention in gastrointestinal adenocarcinoma: for few but not for all?

Despite the general progress of the last two decades in oncogenesis mechanism comprehension, in screening and surveillance programs, in technological support to diagnosis and in treatment protocols, the long-term survival of gastrointestinal (GI) cancer patients is not substantially changed. Therefore chemoprevention strategies still appear as a possible alternative to screening and surveillance programs in reducing the incidence and the mortality for GI cancer, at an acceptable cost/effectiveness ratio. The present review is focused on three GI cancers: esophageal adenocarcinoma, gastric cancer and colorectal cancer and their respective precarcinogenic lesions. The authors examine, for each neoplasia, the available chemopreventive agents, their mechanism of action in preventing cancer, the potential targets in the cell growth process, the cost/effectiveness ratio and, whenever present in literature, a comparison with other cancer prevention strategies. The authors conclude that, at present, with the available agents, chemoprevention is not indicated for all patients at low or moderate risk for GI cancer, and should not be considered as a substitute for endoscopic surveillance. In high-risk patients only, both chemoprevention and surveillance could be used. In future more specific agents and combined therapies should be tested in specific group of patients identified by their genomic susceptibility to develop cancer and responsiveness to therapy.

Colectomy rate in acute severe ulcerative colitis in the infliximab era

BACKGROUND

Severe ulcerative colitis is a potentially life-threatening condition. Due to advances in medical therapy, the mortality rate has dropped to <2% over the past 30 years, but the colectomy rate reaches 30%. Recently, infliximab has been shown to be effective as rescue therapy but little is known about long-term benefits.

AIM

To evaluate short-and long-term colectomy rates for severe ulcerative colitis in the era of biological treatment and to identify predictive factors of long-term colectomy.

PATIENTS AND METHODS

From 2001 to 2006 all in-patients with severe ulcerative colitis, according to Truelove and Witts criteria, were retrospectively reviewed. All patients had received intravenous steroid treatment; infliximab (5 mg/kg at 0, 2 and 6 weeks) was used as rescue therapy in steroid-refractory patients; colectomy was performed in patients who deteriorated whilst on steroid treatment or failed to respond to infliximab.

RESULTS

Of the 314 ulcerative colitis patients hospitalized during the study period, 52 (16.5%) met the criteria of severe ulcerative colitis. After median 7 days (range 4-15) on intravenous steroids, 37/52 (71%) patients showed a clinical response, while 15/52 (29%) were steroid-refractory. Of these, four underwent urgent colectomy and 11 received infliximab. A clinical response was observed in all infliximab-treated patients. In the long-term, another six patients underwent elective colectomy. The overall colectomy rate, following the acute attack, was 19%; the cumulative probability of a course without colectomy was 90%, 86%, 84%, 81%, after 6, 12, 18 and 24 months, respectively. No deaths occurred. The long-term colectomy risk was comparable in patients treated with infliximab and in steroid-responsive patients (18% vs. 11% respectively; OR 1.9; 95% CI 0.26-14.5). No predictive factors of colectomy, in the long-term, were identified.

CONCLUSIONS

Surgery continues to play an important role in acute severe ulcerative colitis. Infliximab can avoid urgent colectomy in steroid-refractory patients but the risk of elective colectomy, in the long-term, is not modified.

Predictive factors of mortality from nonvariceal upper gastrointestinal hemorrhage: a multicenter study

OBJECTIVES

From an Italian Registry of patients with upper gastrointestinal hemorrhage (UGIH), we assessed the clinical outcomes and explored the roles of clinical, endoscopic, and therapeutic factors on 30-day mortality in a real life setting.

METHODS

Prospective analysis of consecutive patients endoscoped for UGIH at 23 community and tertiary care institutions from 2003 to 2004. Covariates and outcomes were defined a priori and 30-day follow-up obtained. Logistic regression analysis identified predictors of mortality.

RESULTS

One thousand and twenty patients were included. A total of 46 patients died for an overall 4.5% mortality rate. In all, 85% of deaths were associated with one or more major comorbidity. Sixteen of 46 patients (35%) died within the first 24 h of the onset of bleeding. Of these, eight had been categorized as ASA class 1 or 2 and none of them was operated upon, despite a failure of endoscopic intention to treatment in four. Regression analysis showed advanced age, presence of severe comorbidity, low hemoglobin levels at presentation, and worsening health status as the only independent predictors of 30-day mortality (P < 0.001). The acute use of a PPI exerted a protective effect (OR 0.23, 95% CI 0.09-0.73). Recurrent bleeding was low (3.2%). Rebleeders accounted for only 11% of the total patients deceased (OR 3.27, 95% CI 1.5-11.2).

CONCLUSIONS

These results indicate that 30-day mortality for nonvariceal bleeding is low. Deaths occurred predominantly in elderly patients with severe comorbidities or those with failure of endoscopic intention to treatment.

Early versus late surgery for ileo-caecal Crohn's disease

BACKGROUND

Surgical resection is almost inevitable in Crohn's disease. Surgery is usually performed for refractory or complicated disease: no studies appear to have been carried out, so far, to evaluate the potential benefits of performing surgery early in the course of the disease.

AIM

To compare the long-term course of Crohn's disease following ileo-caecal resection performed at the time of diagnosis (early surgery) or during the course of the disease (late surgery). Patients and methods Overall 207 patients with ileo-caecal Crohn's disease at their first resection were reviewed: 83 patients underwent surgery at the time of diagnosis (early surgery), while 124 underwent surgery 54.2 months (range 1-438) after diagnosis (late surgery). The mean follow-up after surgery was 147 months (range 12-534). The primary endpoint was clinical recurrence, defined as need for corticosteroids for symptomatic disease in the presence of endoscopic and/or radiologic recurrence. Secondary endpoints were need for immunosuppressants and surgical recurrence.

STATISTICAL ANALYSIS

Kaplan-Meier survival method and Cox proportional hazards regression model.

RESULTS

Within 10 years after surgery, the cumulative probability of clinical recurrence was significantly lower in the early surgery group (Log Rank test P = 0.01). A trend was observed regarding the need for immunosuppressants (P = 0.05). No difference was observed regarding surgical recurrence. At multivariate analysis, early surgery was the only independent variable associated with a reduced risk of clinical recurrence (Hazard ratio, HR = 0.57; 95% CI 0.35 to 0.92, P = 0.02), but not with need for immunosuppressants and surgical recurrence (HR = 0.51; 95% CI 0.20 to 1.30, P = 0.15; HR = 0.66; 95% CI 0.33 to 1.35, P = 0.25, respectively).

CONCLUSION

Early surgery prolongs clinical remission compared to surgery performed during the course of the disease, but the natural history of disease is not modified.

Meta-analysis: the use of non-steroidal anti-inflammatory drugs and pancreatic cancer risk for different exposure categories

BACKGROUND

A better understanding of predictors of risk for pancreatic ductal adenocarcinoma (PDAC) could inform preventive efforts against this lethal cancer. While aspirin (ASA) and non-steroidal anti-inflammatory drugs (NSAIDS) might protect against several gastrointestinal cancers, their role in the development of PDAC remains unclear.

AIM

To conduct a systematic review and meta-analysis on the relation between ASA/NSAIDs exposure and the risk of PDAC. Methods We searched Pubmed, Embase, Scopus, Cochrane database of systematic reviews and reference lists of identified papers and included observational (cohort or case-control) studies and randomized controlled trials examining exposure to ASA and/or NSAIDs and the incidence or mortality of PDAC. We defined three categories (low, intermediate, high), based on exposure duration and dose.

RESULTS

Eight studies fulfilled our inclusion criteria (four cohort, three case controls, and one randomized controlled trial studies) enrolling 6301 patients between 1971-2004; all but one study took place in the US. The pooled OR were 0.99 (0.83-1.19), 1.11 (0.84-1.47) and 1.09 (0.67-1.75) in the low, intermediate and high exposure groups respectively, with considerable heterogeneity (I(2) ranging 60-86%). Sensitivity analysis by ASA use only, study design or sex did not reveal additional important information.

CONCLUSIONS

This study did not show an association between ASA/NSAIDs and PDAC. The large baseline exposure in controls in North-America may have obscured an association. There is need for additional studies, especially in Europe, to clarify this issue.

Long-term outcome of Crohn's disease following corticosteroid-induced remission

INTRODUCTION

Corticosteroids are the gold standard in the treatment of moderate to severe Crohn's disease but are often associated with severe and potentially dangerous side effects. Despite an initial clinical response many patients become steroid dependent or require further steroid courses in the long term. The aim of the present study was to assess the probability of the need for further steroid treatment in Crohn's disease patients following steroid-induced remission and to establish if clinical variables can predict further steroid needs. PATIENTS AND All

METHODS

patients at their first steroid course and with corticosteroid-induced remission, defined as a Crohn's Disease Activity Index (CDAI) <150, 4 wk after steroid weaning, were studied and observed at follow-up for 12 months. The main outcome was clinical relapse requiring further steroid treatment. Statistical analysis was performed using the Kaplan-Meier method and multivariable Cox proportional hazard regression model taking into consideration gender, age at diagnosis, disease location and behavior, smoking habits, CDAI score before steroid treatment, and C reactive protein values at steroid weaning, as covariates.

RESULTS

A total of 77 patients with steroid-induced remission were included. One-year follow-up was available in 75 of the 77 patients (97.4%). During follow-up 49 of 75 patients (65.3%) maintained remission or presented mild relapse not requiring steroids while 26 of 75 patients (34.6%) had moderate to severe relapse requiring further steroid treatment. The cumulative probability of a course free from steroids was 93.3%, 82.6%, 78.6%, and 66.6% at 3, 6, 9, and 12 months, respectively. At multivariate analysis, increased C reactive protein at steroid weaning and penetrating complications were independent risk factors for further steroid requirement (OR 5.57, 95% CI 1.20-25.91, P= 0.001 and OR 4.20, 95% CI 1.76-10.04, P= 0.005, respectively).

CONCLUSION

Despite an initial clinical response and successful steroid tapering, 35% of patients required further steroid treatment within 1 yr. An increased C reactive protein value, at steroid weaning, despite clinical remission, and penetrating complications may predict further steroid requirement in already steroid responsive patients.

Probiotics: from research to consumer

Intestinal microflora has metabolic, trophic and protective functions, and can be modified in pathological conditions and by the exogenous administration of probiotics. Probiotics are defined as living microorganisms which resist gastric, bile, and pancreatic secretions, attach to epithelial cells and colonize the human intestine. In the last twenty years research has been focused on the identification of the role of planktonic flora and adhesive bacteria in health and disease, and on the requisite of bacterial strains to become probiotic product which can be marketed. Probiotics can be commercialized either as nutritional supplements, pharmaceuticals or foods, but the marketing as a pharmaceutical product requires significant time, complex and costly research, and the demonstration of a well-defined therapeutic target. This review examines the sequential steps of research which, from the identification of a possible probiotic strain, lead to its production and marketing, summarizing the whole process existing behind its development, through its growth in laboratory, the studies performed to test its resistance to human secretions and stability, microencapsulation technologies, and safety tests.

Mucosal features and granulocyte-monocyte-apheresis in steroid-dependent/refractory ulcerative colitis

BACKGROUND

Mucosa-infiltrated granulocyte neutrophils are an early characteristic of inflammation and the main histological feature of active ulcerative colitis. Mucosal healing has recently been indicated as an important tool in the evaluation of response to treatment. While several studies have stressed the efficacy of granulocyte-monocyte-apheresis in inducing clinical remission in active ulcerative colitis, few data are available on mucosal features.

AIM

Aim of this study was to assess the effects of granulocyte-monocyte-apheresis on clinical and mucosal features in patients with ulcerative colitis, dependent upon or refractory to steroids.

MATERIAL AND METHODS

From April 2004 to April 2005, 12 patients (5 females, 7 males, mean age 49 years, range 33-71 years), with mild-moderate ulcerative colitis (six left colitis, six pancolitis) dependent/refractory upon steroids were enrolled. Each patient was treated for a 5-week period with five cycles of granulocyte-monocyte-apheresis. Patients were evaluated at baseline and 1 week after the last apheresis by means of Global Physician Assessment, quality of life features, laboratory tests (erythrocyte sedimentation rate, CRP, full blood count, faecal calprotectine), endoscopy and histology.

RESULTS

At week 6 of follow-up, complete mucosal healing was observed in 3 out of 12 patients, partial mucosal healing in 8 patients and no change in 1 patient. Clinical response was complete in 8 out of 12 patients.

CONCLUSIONS

These data suggest that granulocyte-monocyte-apheresis induces an improvement both in clinical and mucosal lesions in steroid-dependent/refractory ulcerative colitis. Of note, the reduction in granulocyte infiltration and the improvement in mucosal lesions are accompanied by a reduction in faecal calprotectine.

Management of diverticular disease: is there room for rifaximin?

Treatment of symptomatic diverticular disease of the colon is aimed at the relief of symptoms and the prevention of major complications. The efficacy of fiber supplementation and of anticholinergic and spasmolytic agents remains controversial. Antibiotics are commonly used in the treatment of inflammatory complications of diverticular disease. Data from open labelled and randomized controlled trials do suggest the efficacy of rifaximin in obtaining symptomatic relief in patients with diverticular disease. Approximately 30% therapeutic gain compared to fiber supplementation only can be expected after one year of intermittent treatment with rifaximin. Considering the safety and tolerability of rifaximin, this drug can be recommended for patients with symptomatic uncomplicated diverticular disease.

Evolution of clinical behaviour in Crohn's disease: predictive factors of penetrating complications

BACKGROUND AND AIMS

Crohn's disease is a heterogeneous entity. The Vienna Classification defines three different clinical patterns: 'non-stricturing, non-penetrating', 'stricturing' and 'penetrating'. Aim of this study was to assess the change in clinical behaviour over time and to evaluate whether an evolution towards penetrating complications can be predicted.

METHODS

A total of 139 patients with non-penetrating behaviour at the time of diagnosis were included. The mean follow-up was 4.84 years (range 1-23.2 years). The clinical behaviour, according to the Vienna Criteria, was assessed at the diagnosis and at the end of follow up. Statistical analysis was performed by means of the Kaplan-Meier method and standard logistic regression analysis.

RESULTS

The cumulative probability of a change in clinical behaviour was 22, 38 and 63% at 3, 6 and 12 years, respectively, and the cumulative probability of developing penetrating complications was 22, 33 and 55% at 3, 6 and 12 years, respectively. Young age at diagnosis (<40 years) and a stricturing behaviour are independent risk factors of developing major penetrating complications (internal fistula, mass or abscess): OR=6.0, 95% CI 1.1-30.5; OR=4.0, 95% CI 1.5-10.9, respectively, but not perianal disease.

CONCLUSIONS

The behavioural classification of Crohn's disease is a dynamic model in which each status should be considered as not fixed but evolutive. Perianal disease should be considered a distinct pattern of penetrating behaviour.

Timing of cholecystectomy for acute calculous cholecystitis: a meta-analysis

OBJECTIVES

To compare early with delayed cholecystectomy for the treatment of acute lithiasic cholecystitis: a meta-analysis of prospective randomized trials.

METHODS

Pertinent studies were selected from the Medline, Embase, Cancerlit, HealthSTAR and Cochrane Library Databases, references from published articles, and reviews. Twelve prospective randomized trials (9 addressing open cholecystectomy and 3 laparoscopic cholecystectomy) were selected. Conventional meta-analysis according to the DerSimonian and Laird method was used for the pooling of the results. The rate difference (RD) (95% CI) and the number needed to treat (NNT) were used as a measure of the therapeutic effect.

RESULTS

Cumulative operative and perioperative mortality and morbidity were 0.9% and 17.8%, respectively, for open cholecystectomy and 0% and 13.1%, respectively, for laparoscopic cholecystectomy. The pooled RD for operative complications in early surgery was 1.37% (95% CI =-3.78% to 6.53%; p= 0.2) for open cholecystectomy and 3.11% (95% CI =-15.10% to 8.87%; p= 0.6) for laparoscopic cholecystectomy. In laparoscopic cholecystectomy the cumulative conversion rate to open cholecystectomy was 21.5%. The pooled RD for conversion rate in early laparoscopic cholecystectomy was -7.99% (95% CI =-18.46% to 2.47%; p= 0.1; NNT = 13). Total hospital stay (mean +/- SD) was significantly shorter in the early surgery group (9.6 +/- 2.5 days vs 17.8 +/- 5.8 days; p < 0.0001). More than 20% of patients referred to delayed surgery fail to respond to conservative management or suffer recurrent cholecystitis in the interval period.

CONCLUSIONS

Early operation (open or laparoscopic) does not carry a higher risk of mortality and morbidity compared to delayed operation and should be the preferred surgical approach for patients with acute lithiasic cholecystitis.

Magnetic Resonance enteroclysis imaging in Crohn's disease

PURPOSE

To assess the role of magnetic resonance enteroclysis (MRE) in patients with Crohn's disease, in order to identify involved segments, define the extension and evaluate transmural alterations.

MATERIALS AND METHODS

Eighteen patients with known Crohn's disease were studied with MR (1.5 T), with breath-hold T2-weighted TSE, T2-weighted TSE SPIR and 3D T1-weighted sequences before and after gadolinium injection (0.2 mmol/kg) in the coronal and axial planes. The small bowel was distended by the administration of 2 l of methylcellulose through a nasojejunal tube and drug induced hypotony. Typical patterns of Crohn's disease, such as mucosal abnormalities, parietal thickening and narrowing of the bowel, prestenotic dilation, fibrofatty proliferation and enlarged lymph nodes were analysed on radiological and MRE images. MRE was performed within 30 days from conventional radiological studies (conventional enteroclysis and small bowel follow-through).

RESULTS

Good distension of the bowel wall was obtained in all cases. MRE assessed the presence of parietal thickening and narrowing of the bowel wall (14/18 cases) and the presence of prestenotic dilatation (12/18 cases). Vascular enhancement (14/18 cases), transmural abnormalities (8/18 cases), fibrofatty proliferation (3/18 cases), abscess formation (2/18 cases) and enlarged mesenteric lymph nodes (6/18 cases) were also observed. MRE missed small fistulas which were visible in radiological studies in two patients.

CONCLUSIONS

MRE appears to be a promising technique in patients with Crohn's disease. Due to limited spatial resolution MRE could be a useful adjunct to radiological studies and in following up selected groups of patients with prior known disease.

Infliximab for severe recurrent Crohn's disease presenting with massive gastrointestinal hemorrhage

Severe gastrointestinal hemorrhage is an uncommon complication of Crohn's disease. Most bleeding episodes originate from colonic ulcers or ulcerated areas. The management of severe gastrointestinal bleeding in Crohn's disease is a therapeutic challenge. Several approaches including surgical resection, specific medical therapy of Crohn's disease, endoscopic treatment, or angiographic intervention have been attempted, but recurrence of bleeding is high. Monoclonal anti TNFalpha antibodies (infliximab) can induce relatively rapid mucosal healing. We report two cases of severe recurrent Crohn's disease presenting with massive lower gastrointestinal bleeding in which infliximab induced rapid mucosal healing and prevented recurrent bleeding.

Long-term liver histology improvement in patients with chronic hepatitis C and sustained response to interferon

A retrospective multicentre survey was conducted to evaluate, in patients with chronic hepatitis C, the long-term liver histological changes induced by interferon (IFN). A total of 112 patients (mean age 46.4 years) were studied. All patients had received a 6-12-month IFN-alpha course (6-18 MU/week) and had successively undergone clinical, biochemical and virological follow-up for at least 36 months (range: 36-76). In each patient, two liver biopsies had been performed: 1-6 months before treatment and, 12-76 months after its completion. In 87 patients with biochemical and virological sustained response persisting for 12 months after therapy, post-treatment liver necroinflammation and fibrosis mean(+/-SD) scores (Knodell index) were significantly lower than pretreatment scores (2.9 +/- 2.2 vs 6.8 +/- 2.9 and 0.8 +/- 1.0 vs 1.2 +/- 1.1, respectively; P < 0.01). In 25 patients who relapsed within 1 year, necroinflammation and fibrosis post-treatment mean scores were similar to pretreatment scores (7.4 +/- 3.2 vs 6.9 +/- 3.1 and 1.8 +/- 1.3 vs 1.6 +/- 1.2, respectively; P > 0.05). On an individual basis, necroinflammation decreased in 87% of sustained responders but only in 36% of relapsers (P < 0.001), whereas fibrosis decreased in 44% of sustained responders but only in 14% of relapsers (P < 0.001). In sustained responders with biopsies performed 12-23 months (n=34), 24-35 months (n=26) or more than 36 months (n=27) after treatment, a progressive decrease of mean necroinflammatory score was observed (-2.6 +/- 2.1, -4.1 +/- 3.4 and -5.2 +/- 3.7 points, respectively; P < 0.01). A similar pattern was observed in fibrosis score (-0.3 +/- 0.6, -0.3 +/- 0.7 and -0.7 +/- 0.9 points, respectively; P < 0.05). Hence, among chronic hepatitis C patients treated with IFN, those with a 12-month sustained response, unlike those who relapse, have a long-term progressive reduction and, in some cases, a complete regression of liver histological damage.

An ontological approach to evidence-based medicine and meta-analysis

The "evidence-based medicine" (EBM) paradigm is centered on the concept of "best evidence" and clinical studies based on this approach are more likely to be considered by physicians in their practice. In this paper we describe an ontology representing the concepts involved in evidence-based medicine and meta-analysis and show how an ontological approach can be applied both for revisiting EBM conceptual foundations and for allowing a more effective knowledge-based information retrieval in literature.

Effects of guar gum, ispaghula and microcrystalline cellulose on abdominal symptoms, gastric emptying, orocaecal transit time and gas production in healthy volunteers

BACKGROUND

Dietary fibres are carbohydrates that resist hydrolysis by human intestinal enzymes but are fermented by colonic microflora. Soluble dietary fibres are fermented by anaerobic bacteria with production of gases, short chain fatty acids and other metabolic products believed to cause symptoms such as bloating, abdominal distension, flatulence. Insoluble fibres are only partially fermented, serving almost exclusively as bulking agents that result in shorter transit time and increased faecal mass.

AIMS

To evaluate effect of a supplementation of a single 5 g dose of dietary fibre to a solid meal on gastric emptying, orocaecal transit time, gas production and symptom genesis, in healthy volunteers. Three different dietary fibres were tested, two soluble (guar gum and ispaghula] and one insoluble (microcrystalline cellulose).

PATIENTS AND METHODS

After a 24-hour low fibre diet, 10 healthy subjects had a standard meal consisting of white bread and one 70 g egg the yolk of which was mixed with 100 mg of 13C octanoic acid and fried. Breath samples were collected for 13CO2 measurements with a mass spectrophotometer and excretion curve (Tlag, T1/2) evaluation. Further breath samples were collected and analysed with a gas chromatograph for the evaluation of H2 and CH4 production and orocaecal transit time. Each evaluation was repeated adding to standard meal, diluted in 300 ml tap water, respectively: a single 5 g dose of microcrystalline cellulose, guar gum or ispaghula. Subjects were asked to report all symptoms experienced from time of meal ingestion over 24 hours, evaluating the intensity.

RESULTS

Dietary fibres did not significantly change gastric emptying (Tlag, T1/2) and orocaecal transit time of standard meal. Subjects experienced more symptoms when meals were supplemented with guar gum (p=0.009 vs standard meal) and ispaghula (p=0.048 vs standard meal). There was a poor, but significant, correlation between gas production and symptoms (r=0. 38, p=0. 01).

CONCLUSIONS

Addition of different dietary fibres to a solid meal did not influence gastric emptying and orocaecal transit time. Microcrystalline cellulose caused fewer symptoms than guar gum and ispaghula probably due to the insoluble nature and the dimensions of the particles of this micronised cellulose.

Budesonide in the treatment of Crohn's disease: a meta-analysis

AIM

To perform a meta-analysis to assess the effectiveness and safety of oral budesonide for inducing remission in active Crohn's disease and for preventing relapse in Crohn's disease with medically- or surgically-induced remission.

METHODS

All randomized, double-blind controlled trials involving oral budesonide therapy in Crohn's disease were retrieved from a Medline search, reviews articles or their bibliographies. Of 83 articles retrieved, 12 met the inclusion criteria. Data extraction was performed by three independent observers and scoring disagreements were resolved by consensus.

RESULTS

Six trials tested budesonide in active disease and six in quiescent disease. Budesonide was less effective than conventional corticosteroids for inducing remission of active Crohn's disease (pooled rate difference, RD -8.5%; 95% CI: -16.4 to -0.7%; P=0.02), but corticosteroid-related adverse events were reduced (RD -22.4%; 95% CI: -32 to -12.8%; P < 0.001). In quiescent Crohn's disease, budesonide was as effective as placebo for preventing relapse in medically induced remission (RD -0.8%; 95% CI: -9.9 to 8.3%; P=0.42) and endoscopic recurrence in surgically induced remission (RD -3.5%; 95% CI: -16.9 to 9.8%; P=0.30). In the long term treatment, budesonide had an occurrence rate of corticosteroid-related adverse effects similar to placebo (RD 5.3%; 95% CI: -3.9 to 14.5%; P=0.30).

CONCLUSIONS

Budesonide is significantly less effective than conventional corticosteroids for inducing remission in active Crohn's disease, but the risk of corticosteroid-related adverse effects is significantly reduced. Budesonide is not effective in preventing relapse of Crohn's disease after medically- or surgically-induced remission.

[Lansoprazole: an analysis of the clinical trials in the 3 years of 1997-1999]

Aim of this overview was to evaluate the main clinical trials with lansoprazole published from 1997 to 1999 in English-language journals, regarding gastroesophageal reflux disease, peptic ulcer, NSAID-induced ulcer, and ZES. Results of clinical trials for therapy and prevention of lesions/symptoms have been evaluated separately. In direct comparisons, lansoprazole alone (not combined with antibiotics) proves to be equieffective to other PPI and more effective than H2-RA in both therapy and prevention of GERD, peptic ulcer (a part from anti-Hp regimens) and NSAID-induced ulcer. Among Hp-eradicating regimens in patients with peptic ulcer or functional dyspepsia, lansoprazole-based triple therapy is equal in efficacy to other PPI-based or RBC-based triple therapies and, in any case, significantly better than dual therapies. The in vitro anti-Hp activity of lansoprazole, more marked than with other PPI, does not seem to effort clinical advantages. Safety of lansoprazole is largely satisfactory and no different from other PPI and H2-RA.

Prevention of non-steroidal anti-inflammatory drug-induced gastrointestinal mucosal injury: risk factors for serious complications

BACKGROUND

1-2% of all patients under non-steroidal anti-inflammatory drug therapy are exposed to serious upper gastrointestinal complications. The policy of prevention of non-steroidal anti-inflammatory drug-induced gastrointestinal mucosal injury by using misoprostol or suppressing acid secretion is still a matter of debate.

AIMS

To discuss the effectiveness of prophylaxis of a gastrointestinal complication during non-steroidal anti-inflammatory drug treatment, according to the number and relevance of risk factors.

PATIENTS

A total of 8.843 patients with rheumatoid arthritis, admitted to the widest prospective multicentre mega-trial, on 6-month complication prevention of non-steroidal anti-inflammatory drug-induced ulcers.

METHODS

The results are presented in terms of the number of patients to be treated (number needed to treat) in order to prevent one serious upper gastrointestinal complication, and corrected for the number of patients, that receiving the prophylaxis therapy, would lead to one additional withdrawal (number needed to harm).

RESULTS

The base-line risk for a complication strongly depended on the number and relevance of risk factors: history of peptic ulcer disease, of gastrointestinal bleeding, of cardiovascular disease, and age. In the general study population, the relative risk reduction of gastrointestinal complications with misoprostol was 40%: thus the number needed to treat to prevent 1 event was 250 in the experimental period (6 months) or 125 when normalized at one-year treatment (1 year number needed to treat]. When considering the prophylaxis gain in intermediate (risk 1-2%) or high risk subjects (patients with a probability of an event over 2%, for the presence of 1 important risk factor or multiple factors), the 1-year number needed to treat rapidly drops from about 100 to about 17. The number needed to harm for one withdrawal was 18. The number needed to treat corrected for withdrawals in order to avoid major complications rises from 125 to 132 in the general population of non-steroidal anti-inflammatory drug users; from 102 to 105 in subjects at intermediate risk, such as patients with history of cardiovascular disease; in the groups at high risk, from 26 to 27 (patients with history of peptic ulcer disease), and from 16 to 17 (patients with history of peptic ulcer disease, cardiovascular disease and aged over 65 years).

CONCLUSIONS

Patients at intermediate and high risk for complications from non-steroidal anti-inflammatory drug-induced ulcers should be considered for prophylaxis. In this group of patients, misoprostol prevention of severe complications is effective, and its clinical relevance similar to that of other preventive measures in medical practice.

Acute ischaemic colitis following intravenous cocaine use

Intestinal ischaemia is an uncommon complication of recreational cocaine abuse. We report the case of a 36-year-old male who underwent emergency surgery for acute abdomen. At laparotomy, the transverse colon appeared markedly oedematous, dilated and with subserosal haemorrhage. Segmental resection was performed and microscopic examination of the resected specimen showed focal necrosis of the mucosa with a patchy polymorphonuclear and mononuclear infiltrate. The submucosa was markedly thickened due to oedema; focal haemorrhage was observed and blood vessels were dilated but showed no structural abnormalities or thrombosis. These findings were consistent with ischaemic colitis. No risk factors for intestinal ischaemia were present but the patient stated that he had injected cocaine i.v. the day before the onset of symptoms. He was not a cocaine abuser but occasionally sniffed, smoked or injected cocaine. Cocaine use should be considered in the aetiological diagnosis of intestinal ischaemia in young patients.

DNA/protein flow cytometry as a predictive marker of malignancy in dysplasia-free Barrett's esophagus: thirteen-year follow-up study on a cohort of patients

Intestinal metaplasia identifies Barrett's esophagus (BE) and is associated with an increased risk for esophageal adenocarcinoma. Dysplasia occurs as an intermediate step. However, progression from metaplasia to neoplasia without the demonstration of dysplasia has been described. The role of dual-parameter flow cytometry (FC) as a predictor of neoplastic risk in dysplasia-free cases was evaluated. DNA/protein FC and histology were performed on 362 samples from 30 dysplasia-free BE patients, followed up since 1985 once every 1-2 years. Nine cases were aneuploid, five of which (group IV) were frankly aneuploid; in the other four cases (group III), aneuploidy was detectable by dual-parameter analysis only. Twenty-one patients were diploid. Twelve (group II) also had an abnormally high G1-phase protein content compared to group I (nine patients), which were diploid with a low-moderate protein content. In three patients of group IV an adenocarcinoma in situ was diagnosed, after 5, 6, and 10 years, respectively. In two patients of group III, a low- and a high-grade dysplasia were observed at 3 and 6 years follow-up, respectively. One patient of group I first acquired a high protein content, then an aneuploid DNA content, and then progressed to adenocarcinoma (12 years). None of the still diploid patients (17 cases) have progressed to dysplasia or cancer compared with 6 of 13 presently aneuploid patients (P < 0.01). In conclusion, DNA/protein FC is a marker of increased malignant potential and thus may be used to detect patients at higher risk in dysplasia-free BE and assist in understanding the various stages of malignant transformation in long-term follow-up studies.

Omeprazole 20 or 40 mg daily for healing gastroduodenal ulcers in patients receiving non-steroidal anti-inflammatory drugs

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are strongly associated with gastroduodenal ulcers, and the management of patients with NSAID-associated ulcers represents a common clinical dilemma.

AIM

To assess NSAID-associated ulcer healing during treatment with either standard (20 mg) or high dosage (40 mg) omeprazole.

METHODS

One hundred and sixty-nine patients chronically ingesting diclofenac, ketoprofen, indomethacin or naproxen for osteoarthritis or rheumatoid arthritis, who had abdominal pain and an endoscopically proven gastroduodenal ulcer, were evaluated in a randomized, double-blind, dose regimen trial with omeprazole 20 mg o.m. (n = 81) or omeprazole 40 mg o.m. (n = 88). Ulcer healing was assessed endoscopically at 4 and 8 weeks in the case of unhealed ulcers. Patients continued their usual daily dose of anti-inflammatory medication throughout the study period.

RESULTS

One hundred and fifty-six patients completed the study (77 patients taking 20 mg omeprazole and 79 patients taking 40 mg omeprazole); 12 patients were lost during follow-up and one patient reported an adverse event. Cumulative ulcer intention-to-treat healing rates at 8 weeks were 88% (95% confidence interval (CI) = 79-95%) for the 20 mg omeprazole group and 96.2% (95% CI = 89-99%) for the 40 mg group, and 97.1% (95% CI = 90-100%) for the 20 mg omeprazole group and 98.6% (95% CI = 93-100%) for the 40 mg group by per protocol analysis. There were no statistically significant differences between the two groups. Symptom relief did not differ significantly between the two treatment groups.

CONCLUSION

Both standard and high doses of omeprazole are equally safe and effective regimens for the treatment of NSAID-induced gastroduodenal ulcers when anti-inflammatory treatment is not discontinued.

Correlation of various Crohn's disease activity indexes in subgroups of patients with primarily inflammatory or fibrostenosing clinical characteristics

Several activity indexes, including clinical variables, laboratory variables or both, have been proposed to assess the activity and severity of Crohn's disease (CD). Although activity indexes are commonly used in clinical trials, doubts exist as to whether it is correct to group together and quantify under the same numerical expression the very heterogeneous clinical manifestations of CD. The aim of our study was to try to establish a correlation between clinical and laboratory activity indexes of CD in subgroups of patients with primarily inflammatory or primarily fibrostenosing clinical characteristics. At least two activity indexes were calculated among 232 outpatient examinations in 61 CD patients. Indexes were classified as clinical, laboratory, or both. A close correlation was observed when indexes calculated on clinical variables were compared or when those that include only or prevalently laboratory parameters were compared. Conversely, the correlation between clinical and laboratory indexes tended to be poor. Taking into consideration the subgroups of patients, the correlation between clinical and laboratory indexes was high in primarily inflammatory disease but low in the primarily fibrostenosing form. The clinical activity of CD does not always reflect the quantity of inflammation measured by laboratory parameters. This is particularly true in primarily fibrostenosing disease. Different clinical patterns of CD should always be considered in the attempt to quantify with an activity index the activity and severity of disease.

[Dietary fiber in internal medicine]

The suggestion that dietary fibre is of particular importance in our diet is a relatively recent concept. Much of the initial emphasis for increased dietary fibre began with the pioneering work of Burkitt and Trowell in the 1960s who observed that traditional African populations consumed diets high in plant fibre and that these populations experienced very low incidences of non-communicable diseases including cardio-vascular disease, diabetes mellitus and non-infectious bowel diseases, including cancer. Although it is difficult to predict from the chemical structure how dietary fibres will behave physiologically, generally dietary fibre sources can be grouped into two major types: (a) soluble, viscous, fermentable and (b) insoluble, non-viscous, slowly fermentable. As detailed below, these sources of fibres appear to have quite different physiological effects.

Effects of sulglycotide on inflammation and epithelial cell turnover in active Helicobacter pylori+ chronic gastritis. A pilot study

The effects of Sulglycotide were evaluated in a pilot study of active H. pylori+ atrophic gastritis. Ten informed patients (mean age 51 +/- 13 years) entered a double-blind study. Five received Sulglycotide 400 mg three times a day for one year, the other 5, placebo. At 0, 30, 90, 270, and 360 days of treatment, patients underwent endoscopic examinations with multiple biopsies. Morphometric studies (number of inflammatory cells and percent gland volume), morphologic studies (according to the Sydney system), and flow cytofluorimetry were performed in all cases. Compared to findings in the placebo group, patients treated with Sulglycotide showed a reduced number of inflammatory cells and an increase in gland volume 120 days after treatment. While the difference was not statistically significant, the trend was confirmed by the morphologic patterns. Flow cytofluorimetry revealed an increase in the percentage of cells in the G2 phase (full maturation) and a parallel drop in the S phase (premitotic synthesis) in the Sulglycotide group only in the first three months. These data would appear to indicate an acceleration of gastric epithelial cell maturation and a decrease in the inflammatory infiltrate under the effect of Sulglycotide.

Severe ulcerative colitis, dural sinus thrombosis, and the lupus anticoagulant

Thromboembolic disease is a well-recognized but very uncommon complication of inflammatory bowel disease. The mechanisms of the increased risk of thrombosis are not well understood: although several coagulation abnormalities have been described in inflammatory bowel disease patients, it is not clear whether they actually contribute to hypercoagulation or whether they are nonspecific markers of inflammation. Antiphospholipid antibodies (anticardiolipin antibodies and/or lupus anticoagulant) have recently been associated with an increased risk of thrombosis, particularly cerebrovascular disease in young patients. We report the case of a 33-yr-old female with severe ulcerative colitis at first attack who developed thrombosis of the superior and inferior longitudinal dural sinuses. No risk factors for thrombosis or coagulation abnormalities were observed; however, lupus anticoagulant was detected in the serum. The patient was successfully treated with osmotic agents, prophylactic anticonvulsant, and antiplatelet therapy, combined with i.v. steroids. After 6 months, the colitis is in remission, and the neurological recovery is good even if not yet complete.

Oral cromolyn sodium in comparison with elimination diet in the irritable bowel syndrome, diarrheic type. Multicenter study of 428 patients

BACKGROUND

In a significant number of patients affected by the irritable bowel syndrome, an adverse reaction to food is proposed to be a causative factor. A diet that eliminates the offending foods is the obvious treatment for such adverse reactions. Compliance with a dietetic regimen is often poor and sometimes not completely free from risks.

METHODS

Since the diarrheic type of irritable bowel syndrome seems mainly affected by food intolerance, and previous observations suggested that oral cromolyn sodium is effective in such patients, a multicenter therapeutic trial in the diarrheic type of irritable bowel syndrome was carried out in 346 of 409 patients with this disease, to evaluate the effects of oral cromolyn sodium and compare its efficacy with that of an elimination diet.

RESULTS

Symptoms related to the irritable bowel syndrome improved in 60% of patients treated with elimination diet and in 67% of those treated with oral cromolyn sodium (1500 mg/day) for 1 month. Moreover, in both groups clinical results were significantly better in the patients positive to the skin prick test than in the negative ones.

CONCLUSIONS

These results confirm the high prevalence of adverse reactions to foods in diarrheic irritable bowel syndrome and the usefulness of cromolyn sodium treatment in these patients.

Efficacy of rifaximin in the treatment of symptomatic diverticular disease of the colon. A multicentre double-blind placebo-controlled trial

BACKGROUND AND AIMS

In a recent open trial we have shown the efficacy of long term intermittent administration of a poorly absorbable antibiotic (rifaximin) in obtaining symptomatic relief in uncomplicated diverticular disease of the colon. The aim of this double-blind placebo-controlled trial was to test our previous observations.

METHODS

One hundred and sixty-eight outpatients with symptomatic uncomplicated diverticular disease were treated with fibre supplementation (glucomannan 2 g/day) plus rifaximin 400 mg b.d. for 7 days every month (84 patients), or with glucomannan 2 g/day plus placebo two tablets b.d. for 7 days every month (84 patients). Clinical evaluation was performed at admission and at three-month intervals for 12 months.

RESULTS

After 12 months, 68.9% of the patients treated with rifaximin were symptom-free or mildly symptomatic, compared to 39.5% in the placebo group (P = 0.001). Symptoms such as bloating and abdominal pain or discomfort were primarily affected by antibiotic treatment when compared with placebo (P < 0.001).

CONCLUSION

Rifaximin appears to be of some advantage in obtaining symptomatic relief in diverticular disease of the colon when compared with fibre supplementation alone.