Aliment Pharmacol Ther 2011; 33: 902–910

Aim.The aim of this study was to assess the role of fecal calprotectin (FC) in diagnosis of complicated colonic diverticular disease (DD) and to compare it with uncomplicated colonic DD and matched controls.Methods.We studied 57 consecutive patients with a new endoscopic diagnosis of colonic diverticulosis (45 with asymptomatic uncomplicated DD, and 12 with acute diverticulitis) and 25 healthy controls.The level of FC was measured in every case by a semiquantitative test with three categories of results: type 1 (under 15 μg/g), type 2 (15-60 μg/g), and type 3 (more than 60 μg/g).The results were correlated with the degree of histological inflammation of colonic mucosa that was assessed by the degree of lymphocytic cell density.Results.We found higher FC values in acute uncomplicated diverticulitis (p<0.05)than in asymptomatic uncomplicated DD and in healthy controls.There were no differences between uncomplicated colonic DD and healthy controls.FC values increase according to the increase of lymphocytic cell density, showing a statistically significant correlation (p<0.05).Patients with acute diverticulitis were treated with antibiotics for 10 days; in these patients, reassessment of FC after three months revealed a significant decrease comparing with the initial level.Conclusions.FC may be useful to detect colonic inflammation in DD and in distinguishing acute diverticulitis from uncomplicated colonic DD and healthy controls.Also, FC may be useful for follow-up after treatment.

Background. Seasonal variations in onset of symptoms have been reported in ulcerative colitis but not in Crohn's disease.Aim. To investigate whether our inflammatory bowel diseases patients presented seasonal variations in onset of symptoms.Patients and methods. Patients with a diagnosis of inflammatory bowel diseases established between 1995 and May 2004, and consecutively observed from June 2003 to May 2004, were included in the study. Onset of symptoms (year, season and month) was recorded. Expected onsets with a uniform distribution during the year were calculated and compared to observed onsets. Statistical analysis: chi-square test, odds ratio (95% confidence interval).Results. Overall 425 inflammatory bowel diseases patients were enrolled. Onset of symptoms (year and season) was established in 353/425 patients (83%; 150 Crohn's disease; 203 ulcerative colitis). Onset of symptoms in inflammatory bowel diseases patients as a whole occurred more frequently in spring-summer compared to autumn-winter (odds ratio 1.39; 95% confidence interval 1.03-1.87-, p < 0.03). This variation was observed in Crohn's disease (odds ratio 1.59; 95% confidence interval 1.00-2.51 : p < 0.05) and a similar trend, although not significant, was observed in ulcerative colitis (odds ratio 1.27; 95% confidence interval 0.86-1.88; p = 0.27).Conclusions. These data indicate that onset of Crohn's disease symptoms occurred more frequently during spring-summer. A similar trend was observed in ulcerative colitis. Environmental factors, such as associated infections, smoking, use of drugs and seasonal changes in immune function may be responsible for triggering the clinical onset of inflammatory bowel diseases. (c) 2005 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

Bazuro, Giuseppe Emilio MD; Amadei, Emanuela MD; Luchetti, Roberto MD; Ciaco, Antonio MD; Castrucci, Marco MD; Broglia, Laura MD; Capurso, Lucio MD Author Information

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.

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.

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.

Recent clinical trials question the benefit of prophylaxis for stress-related gastric hemorrhage(SRH) for patients admitted to intensive care units(ICU).Moreover, some prophylactic agents may increase the incidence of nosocomial pneumonia.Nevertheless, some authors advocate continued use of seemingly low-cost prophylactic agents in the ICU.Our aim was to determine the cost-effectiveness of sucralfatc and cimetidine prophylaxis for SRH in patients admitted to an ICU.Methods: Estimates of SRH incidence, efficacy of prophylaxis and incidence of nosocomial pneumonia were based on data from published studies.Cost data were based on cost of medications and cost of treating SRH and pneumonia at our institution.The marginal cost-effectiveness of prophylaxis was calculated separately for sucralfate and cimetidinc and expressed as cost per bleed averted.An incremental cost-effectiveness analysis was employed to compare the two agents.Sensitivity analyses of the effect of the major clinical outcomes on the cost per bleed averted were performed.Results: At the base-case assumptions of 6% risk of developing SRH and 50% risk-reduction due to prophylaxis, the cost of sucralfate was $1,144 per bleed averted.However, it has recently been reported that the risk of SRH for the majority of patients admitted to an ICU is only 0.1%.For this population of low risk patients, the cost per bleed averted was $103,725.Conversely, cost savings as a resuh of sucralfate prophylaxis may be realized in populations with 33% risk of SRH.Including nosocomial pneumonia in the analysis significantly increased the cost per bleed averted.Each case of nosocomial pneumonia increased the cost per bleed averted by $10,062.The effect of pneumonia on the cost per bleed averted was greater for populations at low risk of SRH.Repeating the analysis for cimetidine prophylaxis showed that the cost per bleed averted Was 6.5 fold greater than that for sucralfate.Conclusions: Given the decreasing incidence of SRH and the low efficacy of prophylaxis, the cost of prophylaxis in patients at low risk of SRH is prohibitive.If prophylaxis is deemed essential for high-risk patients, sucralfate is more cost-effective than cimetidine.

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.

Endoscopic evaluation of a gastric ulcer (GU) by a skilled endoscopist gives a correct diagnosis of benign or malignant GU in a high percentage of patients.Aim of the studv.To assess the performances of upper GI endoscopy as a "test" for the diagnosis of malignant GU Method.Identification of all studies published from 1976 to 1994 by search of the "medline" database.Selection of papers in which endoscopic aspect of GU ('benign" vs "malignant") and histologic definitive diagnosis were available.Evaluation of sensitivity (SENS), specificity (SPEC), positive predictive value (PPV), negative predictive value (NPV), diagnostic accuracy (ACC) and "likelihood ratio" (LR) of endoscopy from the literature data.Assessment of peformances of gastroscopy in our series of 762 GU followed for at least 1 year from endoscopic healing.Results.Eight eligible studies (2169 GU) selected.Data are shown in the table:

Methods: A multicentre randomized controlled trial was conducted to evaluate the efficacy of oral mesalazine (5-aminosalicylic acid) for the prevention of post-operative recurrence in 110 patients operated on for Crohn's disease by first intestinal resection. Patients were randomly allocated to receive 2.4 g/day of mesalazine, or no treatment at all. The protocol included colonoscopy with ileoscopy at 6 months and yearly thereafter. Recurrence was defined on the basis of endoscopic criteria and classified as mild or severe.Results: The demographic and pre-trial characteristics were very similar in the two groups of patients. The cumulative proportion of recurrence at 6, 12 and 24 months was significantly lower in the mesalazine group than in untreated group (P = 0.002). At 24 months the cumulative proportions of endoscopic recurrence were 0.52 +/- 0.12 (+/- S.E.M.) and 0.85 (+/- 0.07), respectively. At the same time the cumulative proportions of symptomatic recurrence were 0.18 +/- 0.09 and 0.41 +/- 0.09 (P = 0.006). The cumulative proportions of the severe recurrence was also significantly lower in the mesalazine group (0.17 +/- 0.09 vs. 0.38 +/- 0.09; P = 0.021).Conclusions: The preliminary results of this study show that administration of oral mesalazine soon after surgery is effective in preventing post-operative endoscopic recurrence in Crohn's disease over a 2-year period. It is estimated that this treatment prevents 39% of all recurrences and 55% of the severe recurrences.

Diverticular disease of the colon is a common health problem in western societies. Most patients with colonic diverticula are asymptomatic; it has been estimated that only 20% of individuals harboring diverticula will develop symptoms and signs of illness and a minority will develop major complications. Although the efficacy of a high fiber diet in the management of symptomatic uncomplicated diverticular disease is still controversial, bran and bulking agents are commonly used. Antibiotics are used to treat major inflammatory complications of diverticular disease but apparently there is no rationale for the use of antibiotics in uncomplicated disease where an inflammatory component is by definition excluded. In a multicenter open trial, 217 patients with symptomatic uncomplicated diverticular disease were treated with glucomannan (110 pts) or with glucomannan plus a poorly absorbable antibiotic (rifaximin 400 mg bid for 7 days each month) (107 pts). Clinical evaluation was performed bimonthly for 12 months using a global score system for 8 clinical variables. After 12 months, patients treated with glucomannan plus rifaximin showed a 63.9% reduction of the score as compared to 47.6% in patients treated with glucomannan only (p < 0.001). Cyclic administration of rifaximin appears to be of some advantage in obtaining symptomatic relief in uncomplicated diverticular disease.

The aim of the present study was to evaluate the role of sulglycotide, a molecule with gastroprotective properties, in monotherapy and in association with H2-antagonists in the maintenance treatment of duodenal ulcer. The study was performed using a fully randomized experimental design. Following endoscopic confirmation, 626 patients with healed duodenal ulcer were treated for 6 months with sulglycotide 200 mg tid (293 patients) or sulglycotide + H2-antagonists (333 patients). After 2, 4 and 6 months patients underwent a clinical control whereas an endoscopic control was performed after 6 months. The cumulative percentage of recidivation was 3.6% in the sulglycotide + H2-antagonist treated group, whereas the group treated with sulglycotide alone showed a recidivation rate of 15.4% (p < 0.001). These findings suggest the utility of combined sulglycotide and H2-antagonist treatment in the maintenance therapy for duodenal ulcer.

The aim of this study was to evaluate in Crohn's disease the possible usefulness of alpha 1-antitrypsin clearance and fecal concentration in the early detection of postoperative asymptomatic recurrence. Eleven adult patients with small bowel Crohn's disease undergoing elective resection were enrolled in the study and prospectively followed for one year. Three, six, and 12 months after surgery the alpha 1-antitrypsin clearance and fecal concentration were measured, and the disease activity was assessed. All patients were free of active symptoms throughout the study. One year after surgery small bowel radiology was performed in all patients. Radiographic evidence of recurrent macroscopic disease was found in five of the 11 patients. Three months after surgery both alpha 1-antitrypsin clearance and fecal concentration were significantly lower (P less than 0.01) than before surgery. There was no difference at this time between patients with recurrence and those with no recurrence. In patients with recurrence both alpha 1-antitrypsin clearance and fecal concentration significantly increased at six months in comparison with the values at three months (P less than 0.02). Both measurements were significantly higher at six and 12 months in this group of patients than in those with no recurrence and in normal controls (P less than 0.01). At six and 12 months alpha 1-antitrypsin clearance was above the upper normal limit in all patients with recurrence. We conclude that fecal alpha 1-antitrypsin clearance is a noninvasive, inexpensive, sensitive marker of asymptomatic recurrence in CD patients who are under regular supervision after surgery.