Introduction: Acute gastrointestinal haemorrhage remains the most common medical emergency managed by the gastroenterologists with an incidence of 50–150 per 100.000 of population each year and associated mortality rates of 11–14%.

Introduction: With the development of the technique of laparoscopic surgery laparoscopic bowel surgery gains wider acceptance. Patients suffering from IBD are usually young and potentially need more than one surgery during their life. Thus the use of minimally invasive surgery is justified.

UNLABELLED:Previous studies have suggested an increasing use of complementary and alternative medicine (CAM) in patients with inflammatory bowel disease (IBD). Furthermore, a significant number of IBD patients fail to comply with treatment. The aim of our study was to evaluate the prevalence of non-adherence the use of CAM in Hungarian patients with IBD.METHODS:A total of 655 consecutive IBD patients (Crohn's disease [CD]: 344, age: 38.2 + or - 12.9 years; ulcerative colitis [UC]: 311, age: 44.9 + or - 15.3 years) were interviewed during the visit at specialists by self-administered questionnaire including demographic and disease-related data, as well as items analyzing the extent of non-adherence and CAM use. Patients taking more then 80% of each prescribed medicine were classified as adherent.RESULTS:The overall rate of self reported non-adherence (CD: 20.9%, UC: 20.6%) and CAM (CD: 31.7%, UC: 30.9%) use was not different between CD and UC. The most common causes of non-adherence were: forgetfulness (47.8%), too many/unnecessary pills (39.7%), being afraid of side effects (27.9%) and too frequent dosing. Most common forms of CAM were herbal tee (47.3%), homeopathy (14.6%), special diet (12.2%), and acupuncture (5.8%). In CD, disease duration, date of last follow-up visit, educational level and previous surgeries were predicting factors for non-adherence. Alternative medicine use was associated in both diseases with younger age, higher educational level and immunosuppressant use. In addition, CAM use in UC was more common in females and in patients with supportive psychiatric/psychological therapy.CONCLUSIONS:Non-adherence and CAM use is common in patients with IBD. Special attention should be paid to explore the identified predictive factors during follow-up visits to improve adherence to therapy and improving patient-doctor relationship.

Background/Aims: Adalimumab is a fully human monoclonal antibody targeting tumor necrosis factor with proven efficacy in the treatment of Crohn's disease in clinical trials. In the present study our aim was to investigate the short and medium term efficacy and side effects during induction and maintenance adalimumab therapy in patients with Crohn's disease in specialized centers approved for biological therapy in Hungary until the 1st of November 2009. Methods: Data of 139 CD patients were analyzed. (male/female: 61/78, mean age: 34.4 years, duration: 10.5 years). Indication for biologic therapy was active luminal disease in 81 (58.3%) and fistulizing disease in 58 (41.7%) patients. Previous infliximab therapy was given in 68 (48.9%) patients. Concomitant immunosuppression was given to all patients at induction therapy (steroid 56 (40.3%), azathioprine: 101 (72.7%) or combined: 38 (37.7%)). Medical records were captured prospectively and analyzed retrospectively. Results: After induction therapy (at week 4) only 8 patients were considered primary non-responders. At 12-, 24- and 52 weeks the overall clinical response rate was 86.8% (n=129), 73.3% (n=116) and 59.6 (n=89), while 51.2%, 51.7% and 41.6% patients achieved clinical remission. Need for combined concomitant immunosupression at induction was associated with worse 52-week outcome (remission: 19% vs. 48.5%, p=0.004). Disease duration, location, behavior, perianal disease, CRP, endoscopic severity or induction dose were not associated to medium term response or remission. Complications: 5 abscesses, two herpes zooster infections and one CMV colitis. Two patients had a psoriatic skin reaction. Conclusion: The short and medium term efficacy of adalimumab treatment in this referral population highly exposed to infliximab was comparable to results in clinical trials. Early infectious complications were relatively frequent probably due to the high percentage of triple therapy with immunosupressives.

BACKGROUND/AIMS:Smoking may alter the natural course of Crohn's disease (CD). Smokers are more likely to develop complications, relapses and have a greater risk for surgery. In contrast, in ulcerative colitis (UC), smoking might improve the disease course. Our aim was to assess the combined effect of disease phenotype, smoking, and immunomodulator [azathioprine (AZA), AZA/biological] treatment on the risk of intestinal resection/reoperation in CD and colectomy in UC. PATIENTS/METHODS:Six hundred and eighty-one inflammatory bowel disease patients were analyzed (CD: 340, male/female: 155/185, duration: 9.4+/-7.5 years; UC: 341, male/female: 174/164, duration: 11.5+/-9.7 years). Patients were interviewed on their smoking habits at the time of diagnosis and during the regular follow-up visits. Medical records were retrospectively analyzed. RESULTS:Smoking was present in 45.5% in CD and 15.8% in UC. CD patients who underwent at least one bowel resection comprised 46.5%. In an univariate analysis, disease location, behavior, AZA, or AZA/biological use before surgery [odds ratio (OR): 0.26 and 0.22, P<0.001] and smoking (OR: 1.61, P = 0.03) were associated with risk for first surgery. Smoking, AZA, or AZA/biological (P<0.001) use before first surgery and disease behavior were independently associated with risk for surgery in a proportional Cox-regression analysis. Perianal disease (OR: 3.2, P = 0.001) and frequent relapses (OR: 4.8, P<0.001) but not smoking, AZA, or AZA/biological use after first surgery were predictive for reoperation. In UC, the rate of colectomy was 5.6%. Disease location (P = 0.001) and smoking status (P = 0.02) were independently associated with risk for colectomy in a proportional Cox-regression analysis. CONCLUSION:Our data suggest that early AZA/biological therapy reduces the risk for first operation but not reoperation in CD, in both smokers and nonsmokers. In contrast, smoking was associated with a decreased need for colectomy in UC.

Background: Infliximab (IFX) has proven to be an effective addition to the therapeutic arsenal for refractory, fistulizing, and steroid dependent Crohn's disease (CD), with efficacy in the induction and maintenance of clinical remission of CD. Our objective in this study is to report the nationwide, multicenter experience with IFX induction therapy for CD in Hungary.Methods: During a 6-year-period, beginning in 2000, a total of 363 CD patients were treated with IFX as induction therapy (5 mg/kg IFX infusions given at week 0, 2 and 6) at eleven centers in Hungary in this observational study. Data analysis included patient demographics, important disease parameters and the outcome of IFX induction therapy.Results: Three hundred and sixty three patients (183 women and 180 men) were treated with IFX since 2000. Mean age was 33.5 +/- 11.2 years and the mean duration of disease was 6.7 +/- 6.1 years. The population included 114 patients (31.4%) with therapy-refractory CD, 195 patients (53.7%) with fistulas, 16 patients (4.4%) with both therapy-refractory CD and fistulas, and 26 patients (7.2%) with steroid dependent CD. Overall response rate was 86.2% (313/363). A higher response rate was observed in patients with shorter disease duration (p = 0.05, OR: 0.54, 95% CI: 0.29-0.99) and concomitant immunosuppressant therapy (p = 0.05, OR: 2.03, 95% CI: 0.165-0.596). Concomitant steroid treatment did not enhance the efficacy of IFX induction therapy. Adverse events included 34 allergic reactions (9.4%), 17 delayed type hypersensitivity (4.7%), 16 infections (4.4%), and 3 malignancies (0.8%).Conclusion: IFX was safe and effective treatment in this cohort of Hungarian CD patients. Based on our experience co-administration of immunosuppressant therapy is suggested in patients receiving IFX induction therapy. However, concomitant steroid treatment did not enhanced the efficacy of IFX induction therapy.

Background and Aim: Smoking may alter the natural course of Crohn’s disease (CD). Smokers are more likely to develop complications, relapses and have a greater risk for surgery. In contrast smoking might improve the disease course in ulcerative colitis (UC). Our aim was to assess the combined effect of smoking and immunomodulator (azathioprine, AZA/biological) treatment on the risk of intestinal resection and re-operation in CD and colectomy in UC. Patients and Methods: 504 IBD patients were analyzed (CD: 277, 46.2% males, age at diagnosis: 28.7 (SD 13.2) years, mean duration: 9.5(7.8) years; UC: 227, 48.5% males, age at diagnosis: 34.3 (SD 14.5) years, mean duration: 11.3 (10.4) years). Patients’ medical records have been analyzed retrospectively and patients were asked for smoking status at diagnosis and during follow-up by standardized questionnaires. Results: Smoking was present in 47.1% in CD and 13.2% in UC. 133 CD patients (48%) underwent at least one bowel resection, while at least one reoperation was necessary in 44 (15.9%). In univariate analysis disease location (p = 0.004), behavior (p < 0.0001), AZA or AZA/biological use prior to surgery (OR: 0.19 and 0.227, p < 0.0001 for both) and smoking (OR: 1.79, p = 0.018) were associated with the risk for surgery. Perianal disease (OR: 3.83, p = 0.001) and frequent relapses (OR: 5.85, p < 0.0001) but not smoking status or AZA or AZA/biological use after first surgery were predictive for reoperation. Smoking (OR: 1.91), AZA or AZA/IFX use prior to surgery (OR: 0.19) and disease behavior (OR: 3.13) were independently associated with risk for surgery in a logistic regression analysis. The deleterious effect of smoking was most striking in stenosing disease (pLogRank: 0.028) and females (p = 0.006) in a Kaplan Meier analysis. AZA use decreased the risk for first surgery (p < 0.0001 for both) but not re-operation in patients with and without smoking in the same analysis using LogRank/Breslow tests. In UC, 12 (5.3%) patients had colectomy. Disease location (p = 0.001) but not smoking status was associated with risk for colectomy. Of note, none of the patients with colectomy smoked compared to 14% of patients without colectomy (p =NS). Conclusion: Our data suggest that AZA/biological therapy reduces the risk for first operation but not reoperation in CD in both smokers and none-smokers. The deleterious effect of smoking was most pronounced in females and in patients with stenosing disease.

AIM: To assess the combined effect of disease phenotype, smoking and medical therapy [steroid, azathioprine (AZA), AZA/biological therapy] on the probability of disease behavior change in a Caucasian cohort of patients with Crohn's disease (CD).METHODS: Three hundred and forty well-characterized, unrelated, consecutive CD patients were analyzed (M/F: 155/185, duration: 9.4 +/- 7.5 years) with a complete clinical follow-up. Medical records including disease phenotype according to the Montreal classification, extraintestinal manifestations, use of medications and surgical events were analyzed retrospectively. Patients were interviewed on their smoking habits at the time of diagnosis and during the regular follow-up visits.RESULTS: A change in disease behavior was observed in 30.8% of patients with an initially non-stricturing, non-penetrating disease behavior after a mean disease duration of 9.0 +/- 7.2 years. In a logistic regression analysis corrected for disease duration, perianal disease, smoking, steroid use, early AZA or AZA/biological therapy use were independent predictors of disease behavior change. In a subsequent Kaplan-Meier survival analysis and a proportional Cox regression analysis, disease location (P = 0.001), presence of perianal disease (P < 0.001), prior steroid use (P = 0.006), early AZA (P = 0.005) or AZA/biological therapy (P = 0.002), or smoking (P = 0.032) were independent predictors of disease behavior change.CONCLUSION: Our data suggest that perianal disease, small bowel disease, smoking, prior steroid use, early AZA or AZA/biological therapy are all predictors of disease behavior change in CD patients. (C) 2009 The WJG Press and Baishideng. All rights reserved.

Aims: Adalimumab is a fully human monoclonal antibody targeting tumor necrosis factor. We assess the early efficacy and frequency of side effects during induction and maintenance adalimumab therapy in patients with Crohn's disease.

BACKGROUND:Malignant oesophageal stenosis can be caused by cancer of the oesophagus, gastric cardia, lungs, mediastinum or, rarely, breast. Most of these cases are inoperable due to advanced stage of the disease, comorbidities or age of the patients; and palliative treatment can be applied only. The quality of life is mostly determined by the extent of dysphagia. Several methods are available to palliate dysphagia. Hereby, the authors review their results with palliation of malignant oesophageal obstruction applying self-expanding metal stents. PATIENTS AND METHODS:68 endoscopic stent implantations were performed in 64 patients (15 female and 49 male) with malignant dysphagia between 2003 and 2008. After radiological investigations, distally deployed covered stents with or without an antireflux valve were placed, depending on the localization of the tumour. In one patient with a stenosis localized in the upper third of the oesophagus a proximally deployed covered stent was used. The aim was to re-establish oral nutrition and cover possible fistulas. RESULTS:Significant improvement of swallowing was detected in every patient. Average dysphagia score has improved from 3.2 to 1.7. Technical difficulties during stenting occurred in a relatively low percentage of patients only (2 in 68; i.e. 2.94%). Fistulas were covered in every case. Early stent migration (<7 days) happened in one case. One patient suffered non-fatal myocardial infarction two days after stent placement. In 5 cases tumour in- and overgrowth, in 4 cases bleeding was seen as late complications. Oesophago-tracheal fistula was noted in three patients after stent implantation. Late stent migration (>7 days) occurred in two patients. Re-stenting was necessary in four cases, while three patients needed an upper GI endoscopy for cleansing the stent caused by food obstruction. CONCLUSIONS:According to our data self-expanding metal stents are highly effective and safe for improving dysphagia. Stent-related complications are relatively rare. This method is highly recommended for palliation of malignant dysphagia.

Absztrakt Háttér: A nyelőcsőszűkületet okozó daganat kiindulási helye általában maga a nyelőcső, de okozhat stenosist a cardia, a tüdő, a mediastinum tumora és ritka esetekben mammatumor metastasisa is. Az ilyen esetek nagy része inoperábilis, általában a betegség előrehaladott stádiuma, illetve a komorbiditás és az életkor miatt. A betegek többsége ezért csak palliatív terápiában részesülhet. A legáltalánosabb és az életminőséget leginkább befolyásoló tünet a dysphagia, melynek megoldására több lehetőség is kínálkozik. Dolgozatunkban az öntáguló fémsztentekkel szerzett tapasztalatainkat foglaljuk össze. Betegek és módszerek: 2003–2008 között tumoros nyelészavar/-képtelenség miatt osztályunkon összesen 64 betegnél (15 nő / 49 férfi) végeztünk 68 endoscopos sztentbehelyezést. Radiológiai kivizsgálást követően a tumor pozíciója alapján distalisan nyitódó antireflux-billentyűvel ellátott vagy a nélküli fedett sztenteket alkalmaztunk, egy esetben proximalisan nyitódó fedett sztent került behelyezésre a tumor magas pozíciója miatt. Célunk a per os táplálhatóság biztosítása, illetve az esetleges fistulák fedése volt. Erdemények: A nyelés minden esetben jelentősen javult. A dysphagia score a sztentbehelyezés előtt átlagosan 3,2 volt, míg a sztent behelyezése után 1,7-re csökkent. Fontos adat, hogy a fistulák zárása minden esetben eredményes volt. A sztentek behelyezése kapcsán technikai problémák alacsony arányban (2/68 – 2,94%) adódtak. A beavatkozásokat követően egy esetben észleltünk 7 napon belül migratiót. Egy betegnél a beavatkozást követően 2 nappal nem fatális myocardialis infarctus alakult ki. Késői szövődményként tumorbenövés, illetve túlnövés öt alkalommal, vérzéses szövődmény összesen négy alkalommal jelentkezett. Fistulaképződést három esetben észleltünk. Hét napon túli sztentmigratio két esetben következett be. Resztentelésre összesen négy esetben, falatelakadás miatt ismételt endoscopos beavatkozásra három esetben került sor. Következtetések: A dysphagia-értékek javulása bizonyítja, hogy a fémsztentek hatékonyan javítják a betegek nyelési funkcióját. Tapasztalataink alapján a sztentfüggő szövődmények összaránya alacsony. Véleményünk szerint az öntáguló fémsztentekkel végzett nyelőcső-intubatio biztonságosan és eredményesen alkalmazható a malignus oesophagus obstructio palliatív terápiájában.

We report the case of a 52 years old man who had diabetes mellitus, hypertension, hypothyroidism, depression and severe obesity in his history. In 2001 he underwent a successful surgical approach for severe obesity abroad. The details of the performed operation were unknown at the time of our examinations. Since 2004 sideropenic anemia was recognized, but no further examinations were performed. In 2006 acute, severe gastrointestinal bleeding occurred. Gastroscopy and colonoscopy could not reveal the source of the bleeding. During jejunoscopy an entero-enteral anastomosis could be seen. A lesion of the anastomosis was suggested as the cause of the bleeding. Urgent reconstruction of the anastomosis was performed. For the prevention of postoperative pulmonary embolism oral anticoagulant treatment was introduced. Despite the surgical approach the bleeding could not be stopped, the patient was admitted to our ward for further investigations. There was a huge discrepancy between the amount of transfusions needed by the patient and his slightly positive fecal blood test. Neither melena nor hematochesia could be seen. Repeated gastroscopy, colonoscopy, jejunoscopy and abdominal ultrasound could not identify the source of the bleeding. Tc-labelled red blood cell scintigraphy was performed which proved acute bleeding in the region of the duodenum. Abdominal CT showed a thickening of the wall of the duodenum. The patient underwent laparotomy, which revealed an anatomy identical to an atypical Roux-en-Y gastric bypass surgery with a nearly 1 meter long, blind small bowel segment. The cause of the bleeding was a chronic ulceration of the blind stomach wall invaginated into the duodenum. Malignancy could not be proven by histological evaluation. Antrum resection was performed. No further bleeding was recognized inspite of continuous anticoagulant treatment.

Malignant complications can occur in Crohn's disease. Previous studies have recorded an increased intestinal cancer risk, but there are only a relatively small number of patients reported in the literature with both inflammatory bowel disease and malignant lymphoma. We describe a 48-years-old patient with 8 years long history of Crohn's disease. He admitted to our ward due to newly developed abdominal cramps and vomiting. Abdominal computertomography and radiographic imaging of the gastrointestinal tract showed multiple stenosis and fistulae of the small intestines, with nearly complete bowel obstruction. Resection of the ileum and the cecum was performed. Histological evaluation of the removed tissues revealed anaplastic large T-cell lymphoma of the small intestines. Immunohistochemically the cells were positive for CD3, CD4 and CD30 and were negative for ALK1 (the proliferation index with Ki-67 was 90%). The pre-treatment staging showed multiple pathologic lymph nodes both above and under the diaphragm, pleural fluid and possible involvement of the lungs and the right adrenal gland. The patient previously did not receive any immunosuppressive or biological treatment for Crohn's disease.

Despite the fact, that Crohn's disease appear most frequently in the first three decades of life, and the proportion of ulcerative colitis increases among inflammatory bowel disease patients by the time, approximately 15% of Crohn's disease cases are recognized only after the age of 65.

We report on the case of a 25 years old woman, with a history of hypogammaglobulinemia from the age of 14 years, who was admitted to a county hospital due to diarrhoea and edema of the lower extremities.

Crohn's colitis is often associated with extraintestinal manifestations including local vasculitis, but systemic vasculitis is an exceptional rare finding. Characteristics of patients affected with both diseases have not been fully described.