Recomendaciones del Grupo Español de Trabajo en Enfermedad de Crohn y Colitis Ulcerosa (GETECCU) sobre el uso de tiopurinas en la enfermedad inflamatoria intestinal

Thiopurines (azathioprine and mercaptopurine) are widely used in patients with inflammatory bowel disease. In this paper, we review the main indications for their use, as well as practical aspects on efficacy, safety and method of administration. They are mainly used to maintain remission in steroid-dependent disease or with ciclosporin to control a severe ulcerative colitis flare-up, as well as to prevent postoperative Crohn's disease recurrence, and also in combination therapy with biologics. About 30-40% of patients will not respond to treatment and 10-20% will not tolerate it due to adverse effects. Before they are prescribed, immunisation status against certain infections should be checked. Determination of thiopurine methyltransferase activity (TPMT) is not mandatory but it increases initial safety. The appropriate dose is 2.5 mg/kg/day for azathioprine and 1.5 mg/kg/day for mercaptopurine. Some adverse effects are idiosyncratic (digestive intolerance, pancreatitis, fever, arthromyalgia, rash and some forms of hepatotoxicity). Others are dose-dependent (myelotoxicity and other types of hepatotoxicity), and their surveillance should never be interrupted during treatment. If therapy fails or adverse effects develop, management can include switching from one thiopurine to the other, reducing the dose, combining low doses of azathioprine with allopurinol and assessing metabolites, before their use is ruled out. Non-melanoma skin cancer, lymphomas and urinary tract tumours have been linked to thiopurine therapy. Thiopurine use is safe during conception, pregnancy and breastfeeding.     

Health assessment for migrants and asylum seekers upon arrival and while hosted in reception centres: Italian guidelines

BackgroundDuring 2016–17, national guidelines were developed in order to provide evidence-based recommendations on health assessments for migrants and asylum seekers upon their arrival in Italy.MethodsScientific literature published between 2005 and 2016 was searched in different databases. A free search was also performed on international organizations’ websites in order to identify additional relevant documents. A multidisciplinary panel discussed the resulting evidence and formulated recommendations.ResultsEvidence-based recommendations were formulated: signs and symptoms of specific diseases should to be actively searched for active TB, malaria, STI, intestinal parasites, diabetes, anaemia. In case of other health conditions (latent TB, HIV, HBV, HCV, STI, strongyloides, schistosoma, diabetes), testing should be offered to asymptomatic subjects coming from endemic areas or exposed to risk factors. Mass screening is recommended for anaemia and hypertension; a pregnancy test should be considered, while inclusion in cervical cancer screening and vaccination programs is recommended.A modulated, progressive approach was developed, covering an initial evaluation during rescue operations, a full medical examination at first line reception stage and the referral to national health services during second line reception.ConclusionsIt is important to produce and periodically update guidelines on these issues and local peculiarities should be taken into account in their design and implementation. Guidelines can not only support economic sustainability, but also counteract stigmatization dynamics.     

Extraintestinal Manifestations in Patients with Inflammatory Bowel Disease: Study Based on the ENEIDA Registry

Background

Patients with inflammatory bowel disease (IBD) may present extraintestinal manifestations (EIMs) that affect the joints, skin, eyes, and hepatobiliary area, among others.

Aims

Our aim was to analyse the prevalence and characteristics of EIMs in patients with IBD and to identify the possible risk factors associated with the development of EIMs in the largest series published to date.

Methods

Observational, cross-sectional study including patients from the Spanish ENEIDA registry promoted by GETECCU. We retrospectively identified all cases of EIMs in the ENEIDA registry until January 2018.

Results

The study included 31,077 patients, 5779 of whom had at least one EIM (global prevalence 19%; 95% CI 18.2–19.0). Among the different types of EIMs, rheumatic manifestations had a prevalence of 13% (95% CI 12.9–13.7; 63% of EIMs), with a prevalence of 5% (95% CI 4.7–5.2) for mucocutaneous manifestations, 2.1% (95% CI 1.9–2.2) for ocular manifestations, and 0.7% (95% CI 0.6–0.8) for hepatobiliary manifestations. The multivariable analysis showed that the type of IBD (Crohn’s disease, p?<?0.001), gender (female, p?<?0.001), the need for an immunomodulator (p?<?0.001) or biologic drugs (p?<?0.001), a previous family history of IBD (p?<?0.001), and an extensive location of IBD (p?<?0.001) were risk factors for the presence of EIMs.

Conclusions

One-fifth of patients with IBD may have associated EIMs, with rheumatic manifestations as the most frequent (> 60% of EIMs). Female patients with severe Crohn’s disease represent the group with the highest risk of developing EIMs. These patients should therefore be specially monitored and referred to the corresponding specialist when suggestive symptoms appear.

     

Identification of significant difficulty of selective deep cannulation by a simple predictive model: an endoscopic scale for teaching ERCP

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure associated with a risk of serious complications. This cohort study was designed to assess the accuracy of an endoscopic method aimed at discriminating procedures eligible to teach ERCP: patients with and without significant difficulty of selective deep cannulation (DSDC). METHODS: Clinically relevant variables were analyzed in a cohort of 400 consecutive patients (estimation group = 250 patients; validation group = 150 patients) who underwent an ERCP procedure. RESULTS: Multivariate analysis identified fixated duodenum, inflamed duodenum, soft major papilla, previous biliary surgery, and papilla with ectopion as independent predictors of DSDC. We constructed a model and a score system combining these five variables. The area under the ROC curve was 0.81 for the estimation group and 0.80 for the validation group. Using the best cutoff score (> 1.63), absence of significant DSDC could be excluded with high accuracy (negative predictive value = 89.2%) in 111 (44.4%) of 250 patients. Similarly, it could be excluded with the same certainty in 77 (51.3%) of the 150 patients in the validation group. CONCLUSIONS: A combination of easily accessible variables accurately predicts the absence of significant DSDC in half the patients who underwent the ERCP procedure. This score system discriminates procedures eligible to teach ERCP.     

Acute appendicitis in inactive extensive ulcerative colitis

Appendectomy is associated with a reduced risk of developing ulcerative colitis (UC). In addition, there may be appendicular involvement in UC in patients with extensive or even left-sided disease. However, no data are available on the incidence, clinical presentation and outcome of acute appendicitis in patients previously diagnosed with UC. The impact of appendectomy in this subset of patients also remains to be determined. We describe 2 cases of acute appendicitis in the setting of inactive extensive ulcerative colitis and compare their histologic features with those of the surgical specimens of 2 further UC patients colectomized for refractory and extensive disease.