Appropriateness of therapy for fistulizing Crohn's disease: findings from a national inflammatory bowel disease cohort

Aliment Pharmacol Ther 2010; 32: 1007–1016

Summary

Background About 30–50% of patients with Crohn’s disease (CD) develop fistulae, implying significant disease burden and complicated clinical management. Aim To assess appropriate use of therapy for fistulizing CD patients enrolled in the Swiss Inflammatory Bowel Disease Cohort using criteria developed by the European Panel on the Appropriateness of Crohn’s disease Therapy. Methods Specific questionnaires were used to gather information on disease and its management. We assessed appropriateness of therapy at enrolment for adult CD patients with one or several fistulae. Results Two hundred and eighty‐eight CD patients had fistulizing disease, of which 80% had complex fistulae and 32% currently had active draining fistulae. Mean age (s.d.) at diagnosis was 27 years (11), 51% males. Of the patients, 78% were judged as having globally an appropriate therapy, which was more often given for complex fistulae (87%) than for simple fistulae (67%). Antibiotics, azathioprine/MP, methotrexate and conservative surgery were almost always appropriate. Anti‐tumor necrosis factor α was considered globally appropriate (91%), although most often with an uncertain indication. The 5ASA compounds, steroids and aggressive surgery were most often inappropriate (84%, 58% and 86% respectively). Conclusions Formal appropriateness criteria for CD therapy were applied to a national cohort of IBD patients. For more than three‐quarters of the patients with fistulizing CD, therapy was globally appropriate.     

多排CT小肠成像鉴别小肠结核和克罗恩病的价值

目的 探讨多排CT小肠成像（MDCTE）特征性征象在鉴别诊断肠结核和克罗恩病中的价值。方法 收集安徽医科大学第一附属医院2011年8月至2014年11月经内镜、病理确诊的克罗恩病（CD）22例、结核（ITB）25例患者临床资料。每位患者入院后均行MDCTE检查,记录并分析各种MDCTE征象,寻求鉴别诊断CD和ITB有价值的CT表现。结果 CD和ITB回盲瓣受累分别占54.5%和72.0%,累及降结肠的分别占31.8%和12.0%,累及横结肠分别占18.2%和4.0%;多节段受累患者中,CD组为63.6%,ITB为36.0%;肠系膜侧肠壁增厚在CD中占50.0%,ITB则表现为环形或肠系膜对侧增厚;60.0%的ITB患者和9.1% CD患者有淋巴结中心坏死;36.4%的CD患者出现"梳状征",ITB患者中仅有4.0%,两者差异均有统计学意义（P<0.05）。结论 MDCTE征象中,病变节段数、病变累及部位、"梳状征"和淋巴结坏死情况在鉴别诊断CD和ITB中具有参考价值。     

Antibiotic treatment of small bowel bacterial overgrowth in patients with Crohn's disease

BACKGROUND: Small bowel bacterial overgrowth is common in Crohn's disease but its treatment is not clearly defined. Metronidazole and ciprofloxacin are effective antibiotics in active Crohn's disease. AIM: To investigate the efficacy of metronidazole and ciprofloxacin in the treatment of bacterial overgrowth in patients with Crohn's disease. PATIENTS AND METHODS: We performed the lactulose breath test in 145 consecutive patients affected by Crohn's disease. Patients positive to the lactulose breath test underwent a glucose breath test to confirm the overgrowth. These patients were randomized in two treatment groups: metronidazole 250 mg t.d.s. (Group A) and ciprofloxacin 500 mg b.d. (Group B), both orally for 10 days. The glucose breath test was repeated at the end of treatment. The clinical outcome after therapy was also recorded. RESULTS: Bacterial overgrowth was present in 29 patients (20%). Breath test normalization occurred in 13 out of 15 patients treated by metronidazole and in all 14 patients treated by ciprofloxacin (P = ns). In both groups antibiotic treatment induced an improvement of intestinal symptoms: bloating (Group A 85% and Group B 83%), stool softness (44% and 50%), and abdominal pain (50% and 43%). CONCLUSIONS: Small bowel bacterial overgrowth is a frequent condition in Crohn's disease which can be effectively treated by metronidazole or ciprofloxacin.     

Clinical correlations of small bowel CT and contrast radiology findings in Crohn's disease

BACKGROUNDS AND OBJECTIVE: Aim of the present study was to evaluate the clinical correlates of small bowel CT patterns in patients with Crohn's disease (CD), as compared to barium studies and endoscopic findings, as far as parameters of disease activity are concerned. MATERIAL AND METHODS: Thirty five patients with pathologically proven CD were studied by means of helical single detector CT (13) or multidetector CT (22), after administration of low density contrast by mouth (13) or by nasojeunal tube (22). Eight hours later, all patients were studied with barium administered by mouth (13) or with barium and methilcellulose administered by nasojeunal tube (22). Clinical activity was assessed by CDAI score, ESR, CRP, alpha1 glycoprotein and fibrinogen levels. In twenty one patients, colonoscopy was also performed. RESULTS: Sensitivity of small bowel CT versus endoscopy was of 88% while sensitivity of barium studies was of 77% versus endoscopic findings, and it reached 100% for the combination of both exams. We found positive correlations between the detection at CT of "target sign" and a CDAI score > 150 or abnormal values of CRP, ESR, alpha1 glycoprotein. Abnormal ESR or fibrinogen levels were correlated with the detection of fistulas at CT scans. The diameter of enlarged mesenteric lymph nodes was correlated with alpha1 glycoprotein values. No similar correlations were detected for contrast radiology findings. DISCUSSION: This study underscores the clinical usefulness of performing small bowel CT in adjunct to conventional diagnostic studies in Crohn's disease patients. CT findings (either by oral route or nasojeunal tube) correlate with parameters of disease activity.     

Meta-analysis: colorectal and small bowel cancer risk in patients with Crohn's disease

BACKGROUND: Crohn's disease is associated with small bowel cancer whilst risk of colorectal cancer is less clear. AIM: To ascertain the combined estimates of relative risk of these cancers in Crohn's disease. METHODS: MEDLINE was searched to identify relevant papers. Exploding references identified additional publications. When two papers reviewed the same cohort, the later study was used. RESULTS: Meta-analysis showed overall colorectal cancer relative risk in Crohn's disease as 2.5 (1.3-4.7), 4.5 (1.3-14.9) for patients with colonic disease and 1.1 (0.8-1.5) in ileal disease. Meta-regression showed reduction in relative risk over the past 30 years. Subgroup analysis showed Scandinavia had significantly lower colorectal cancer relative risk than the UK and North America. Cumulative risk analysis showed 10 years following diagnosis of Crohn's disease relative risk of colorectal cancer is 2.9% (1.5%-5.3%). Meta-analysis showed small bowel cancer relative risk in Crohn's disease is 33.2 (15.9-60.9). Small bowel cancer relative risk has not significantly reduced over the last 30 years. CONCLUSION: Relative risk of colorectal and small bowel cancers are significantly raised in Crohn's disease. Cumulative risk of colorectal cancer of 2.9% at 10 years suggests a potential benefit from routine screening. However, the value of screening requires rigorous appraisal.     

Small bowel Crohn's disease: comparison of enteroclysis, bowel sonography and Tc-99m-HMPAO leukocyte scintigraphy

BACKGROUND: Crohn's disease (CD) frequently involves the small bowel. Actually, the diagnosis of CD is made by ileocolonoscopy (IC) and small bowel enteroclysis (SBE), while trans-abdominal bowel sonography (BS) and Tc-99m-HMPAO leukocyte scintigraphy (LS) are only partially used in spite of their minimal invasiveness. AIM: to compare the diagnostic accuracy of these procedures for the diagnosis of small bowel CD. PATIENTS AND METHODS: in about two years a series of consecutive subjects underwent IC, SBE, BS and LS for either suspected or known small bowel CD. RESULTS: Sensitivity, specificity, positive and negative predictive value for CD diagnosis of the studied procedures were respectively: 98%, 97%, 98% and 97% for SBE; 92%, 97%, 98%, and 88% for BS; 90%, 93%, 96% and 85% for LS. In addition, the parallel combined use of BS and LS led to overall sensitivity, specificity, positive and negative predictive value of 100%, 93%, 96%, 100%, respectively. CONCLUSION: SBE, BS and LS are accurate procedures for the diagnosis of small bowel Crohn's disease. The use of BS and LS, particularly in combination, can be proposed as early diagnostic approach to subjects with a suspicion of disease.     

胶囊内镜联合血液学检测诊断小肠克罗恩病的价值

目的 探讨胶囊内镜联合血液学检测诊断小肠克罗恩病的价值.方法 对77例疑似克罗恩病患者分别行血液学检测、结肠镜、胃镜、小肠钡剂造影和胶囊内镜检查,根据胶囊内镜检查结果将患者分为克罗恩病(A组)、疑似克罗恩病(B组)和非特异性小肠炎(C组);以50例健康体检者作为对照组.比较各组血红蛋白和血清白蛋白、C-反应蛋白水平.结果 胶囊内镜检查诊断:A组30例,B组22例,C组25例.77例患者中,胃镜无阳性发现;小肠钡剂造影提示肠腔狭窄4例;结肠镜检查疑似末端回肠克罗恩病14例.四组血红蛋白水平差异有统计学意义(P＜0.01),而血清白蛋白及C-反应蛋白水平差异无统计学意义(P＞0.05).结论 胶囊内镜联合血液学检测能有助于诊断小肠克罗恩病.     

克罗恩病与肠结核鉴别诊断评分系统的建立

目的建立克罗恩病(Crohn's disease,CD)与肠结核(intestinal tuberculosis,ITB)鉴别诊断评分系统,并评价其鉴别诊断效能。方法参照CD与ITB诊断标准,确诊CD 35例,ITB 31例。收集两组患者临床表现、结肠镜检查、实验室检查和病理组织学检查等资料,对以上资料先进行单因素分析,筛选出有统计意义的变量,再行多因素Logistic回归分析,根据回归模型中的β值建立鉴别诊断评分系统。用受试者工作特性(ROC)曲线下面积检验评分系统的鉴别诊断效能。结果 PPD试验强阳性、裂隙状溃疡、环形溃疡、鹅卵石征、非干酪性肉芽肿被纳入多因素Logistic回归模型。根据模型中各变量的β值赋予分值并建立评分系统。该评分系统ROC曲线下面积95%可信限为0.759(0.637,0.880)。结论 CD与ITB鉴别诊断评分系统对两种疾病的鉴别诊断具有较好的区分度,值得进一步研究和推广。     

Inflammatory bowel disease (ulcerative colitis and Crohn's disease): diagnostic criteria and differential diagnosis

Chronic inflammatory bowel diseases (i.e., ulcerative colitis and Crohn's disease) are syndromes in which standardized criteria are necessary in the diagnostic process. The present review is based on the diagnostic criteria used at our institution. We base the diagnosis of ulcerative colitis and Crohn's disease on combined information from the patient history, and radiological, endoscopic and histological findings after exclusion of neoplastic and infectious disease. The patient history must include precise information on the nature and duration of symptoms as well as the presence of relevant influential factors such as travel activity, drug intake and sexual habits. In immunocompromised patients extensive microbiological investigations are required to exclude infection. Typical radiological and colonoscopic findings in ulcerative colitis are mucosal inflammatory changes extending circumferentially and continuously from the rectum and proximally in the colon. In contrast, Crohn's disease is most frequently located in the small bowel and in case of colonic involvement, the rectum is often spared. The best predictors of Crohn's disease are discontinuous lesions, cobblestones and apthous ulceration. Histological changes such as abnormal mucosal architecture and lamina propria cellularity, neutrophil polymorph infiltration and epithelial cell abnormality are useful and reproducible features in the evaluation of colorectal biopsy specimens. The inflammatory bowel diseases, ulcerative colitis and Crohn's disease, continue to be etiological and diagnostic challenges. Increased use of standardized criteria and diagnostic algorithms are essential instruments to improve the overall quality of the management of patients with these diseases.     

Treatment of Crohn's disease with infliximab.

The role of infliximab in managing Crohn's disease (CD) is described. CD is characterized by chronic transmural inflammation at various sites of the gastrointestinal tract, particularly the ileum and colon. The major symptoms are diarrhea, abdominal pain, enterocutaneous and perianal fistulas, and weight loss. Management goals include alleviating symptoms, inducing remission, promoting healing of the intestinal mucosa and fistulas, and modifying the disease process. Drugs traditionally used to manage CD are aminosalicylates, antimicrobials, immunomodulatory agents, and corticosteroids. Infliximab is a chimeric (human-mouse) monoclonal antibody targeted at human tumor necrosis factor-alpha (TNF-alpha), a proinflammatory cytokine important in the pathogenesis of CD. Infliximab antagonizes the biological activity of TNF-alpha by binding to it on macrophage and T-cell surfaces. Clinical trials have shown infliximab to be effective in producing and maintaining a clinical response in patients with refractory, moderate to severe CD. Treatment helps promote healing of intestinal mucosa and closure of fistulas. Infliximab may act more rapidly than most traditional agents and produces less severe adverse effects. The most frequent adverse effects are headache, nausea, and upper-respiratory-tract infections. The recommended dosage is 5 mg/kg i.v. infused over a two-hour period. Infliximab may be given at eight-week intervals for maintenance or management of flare-ups. Infliximab appears useful in the treatment of CD and may improve patients' quality of life.