Approaches in the treatment of perianal fistula in Crohn disease

Perianal fistula is a common complication of Crohn disease, and it is a great burden on the life and psychology of patients, but its treatment is still a difficult problem to face. In recent years, progress in the treatment of Crohn disease has progressed rapidly due to the advent of biological agents, but there has been a lack of research on perianal fistula in Crohn disease, and the direction of research has been scattered; therefore, the author reviews the traditional treatment of perianal fistula in Crohn disease in the context of the available literature and discusses emerging and potential therapeutic approaches. (AU)

Urgent liver retransplantation due to transmission of intrahepatic cholangiocarcinoma by donor: the first report in the literature / Retransplante de fígado urgente devido à transmissão de colangiocarcinoma intra-hepático pelo doador: o primeiro relato da literatura

ABSTRACT BACKGROUND: Liver transplantation represents the best therapeutic modality in end-stage chronic liver disease, severe acute hepatitis, and selected cases of liver tumors. AIMS: To describe a double retransplant in a male patient diagnosed with Crohn's disease and complicated with primary sclerosing cholangitis, severe portal hypertension, and cholangiocarcinoma diagnosed in the transplanted liver. METHODS: A 48-year-old male patient diagnosed with Crohn's disease 25 years ago, complicated with primary sclerosing cholangitis and severe portal hypertension. He underwent a liver transplantation in 2018 due to secondary biliary cirrhosis. In 2021, a primary sclerosing cholangitis recurrence was diagnosed and a liver retransplantation was indicated. Recipient's hepatectomy was very difficult by reason of complex portal vein thrombosis requiring extensive thromboendovenectomy. Intraoperative ultrasound with liver doppler evaluation was performed. Two suspicious nodules were incidentally diagnosed in the donor's liver and immediately removed for anatomopathological evaluation. RESULTS: After pathological confirmation of carcinoma, probable cholangiocarcinoma, at frozen section, the patient was re-listed as national priority and a new liver transplantation was performed within 24 hours. The patient was discharged after 2 weeks. CONCLUSIONS: The screening for neoplasms in donated organs should be part of our strict daily diagnostic arsenal. Moreover, we argue that, for the benefit of an adequate diagnosis and the feasibility of a safer procedure, the adoption of imaging tests routine for the liver donor is essential, allowing a reduction of the costs and some potential risks of liver transplant procedure.

RESUMO RACIONAL: O transplante de fígado representa a melhor modalidade terapêutica na doença hepática crônica terminal, hepatite aguda grave e casos selecionados de tumores hepáticos. OBJETIVOS: Descrever um retransplante duplo em paciente do sexo masculino, diagnosticado com doença de Crohn e complicado com colangite esclerosante primária, hipertensão portal grave e colangiocarcinoma diagnosticado no fígado transplantado. MÉTODOS: Paciente do sexo masculino, 48 anos, diagnosticado com doença de Crohn há 25 anos e complicado com colangite esclerosante primária e hipertensão portal grave. Foi submetido a um transplante de fígado em 2018 devido a cirrose biliar secundária. Em 2021, foi diagnosticada recidiva de colangite esclerosante primária e indicado retransplante hepático. A hepatectomia do receptor foi de alta complexidade devido à trombose complexa da veia porta, exigindo extensa tromboendovenectomia. Foi realizada ultrassonografia intraoperatória com doppler hepático. Dois nódulos suspeitos foram diagnosticados incidentalmente no fígado do doador e imediatamente removidos para avaliação anatomopatológica. RESULTADOS: Após confirmação patológica de carcinoma, provável colangiocarcinoma, pela congelação, o paciente foi relistado como prioridade nacional, e novo transplante hepático foi realizado em 24 horas. O paciente teve alta após 2 semanas. CONCLUSÕES: O rastreamento de neoplasias em órgãos doados deve fazer parte de nosso estrito arsenal diagnóstico diário. Além disso, defendemos que, em benefício de um diagnóstico correto e da viabilidade de um procedimento mais seguro, a adoção de uma rotina de exames de imagem é essencial em doadores hepáticos, permitindo a redução dos custos e alguns riscos potenciais do procedimento de transplante hepático.

A case of Crohn's disease combined with inflammatory myofibroblastoma of abdominal wall / 中南大学学报(医学版)

Inflammatory myofibroblastoma (IMT) is a rare solid tumor, and its etiology and pathogenesis are unclear. Crohn's disease is a non-specific intestinal inflammatory disease. The clinical manifestations, laboratory examinations, and imaging examinations of IMT are not specific, making diagnosis difficult. A case of Crohn's disease combined with IMT of abdominal wall was admitted to the Department of Gastroenterology at the Third Xiangya Hospital, Central South University, on Nov. 21, 2017. This patient was admitted to our hospital because of repeated right lower abdominal pain for 4 years. A 6 cm×5 cm mass was palpated in the right lower abdomen. After completing the transanal double-balloon enteroscopy and computed tomographic enterography for the small intestinal, the cause was still unidentified. The patient underwent surgery due to an abdominal wall mass with intestinal fistula on Sept. 12, 2018 and recovered well currently. According to histopathology and immunohistochemistry, he was diagnosed with Crohn's disease combined with IMT. Up to July 2020, the patients still took azathioprine regularly, without abdominal pain, abdominal distension, and other discomfort, and the quality of his life was good.

Significancia clínica de la presencia de granulomas en enfermedad de Crohn / Clinical significance of the presence of granulomas in Crohn's disease

RESUMEN Los granulomas epitelioides son hallazgos característicos de un grupo de pacientes con enfermedad de Crohn (EC), pero su significancia con respecto a la severidad y progresión de la enfermedad es aún incierta. Objetivo: Evaluar las características clínicas de los pacientes con EC en relación a la presencia o no de granulomas en los hallazgos histológicos. Materiales y métodos: Estudio observacional, descriptivo, retrospectivo en pacientes con diagnóstico de EC desde enero 2004 a diciembre 2019 en el servicio de gastroenterología del Hospital Nacional Guillermo Almenara Irigoyen, Lima-Perú. Resultados: Se incluyó 55 pacientes con media de edad de 56 ± 8,2 años. La mediana de tiempo de enfermedad fue de 16 meses. Tener dos o más recaídas al año (p<0,001; OR= 9,75), edad menor a 30 años (p<0,001; OR=3,57) y un CDAI moderado a severo (≥220 puntos, OR= 11,4; p<0,008) se asoció significativamente con la presencia de granulomas. La actividad endoscópica severa (p<0,003; OR= 9,91) y el fenotipo estenosante-penetrante (p<0,001; OR= 22,1) también mostraron asociación con la presencia de granulomas. El grupo de granulomas presentó mayor probabilidad de uso de corticoides (p<0,024; OR= 3,92) e inmunomodulador (p<0,001; OR= 7,10) además de necesidad de cirugía de resección intestinal (p< 0,027; OR: 5,07). Conclusiones: La presencia de granulomas en EC podría asociarse a mayor severidad clínica, endoscópica, requerimiento de terapia inmunosupresora y mayor necesidad de resección intestinal.

ABSTRACT Epithelioid granuloma is a characteristic histological feature of Crohn's disease (CD), but their significance with respect to the severity and progression of the disease is still uncertain. Objective: To evaluate the clinical characteristics of CD patients in relation to the presence or not of granulomas in histological findings. Materials and methods: An observational, descriptive, retrospective study in patients diagnosed with CD from January 2004 to December 2019 in the gastroenterology department of the Guillermo Almenara Irigoyen National Hospital, Lima-Peru. Results: 55 patients were included. Average age of 56 ± 8.2 years. The median time of disease was 16 months. Have two or more relapses per year (p<0.001; OR=9.75), age less than 30 years (p<0.001; OR=3.57) and a moderate to severe CDAI (≥220 points, OR=11.4, p <0.008) was significantly associated with the presence of granulomas. Severe endoscopic activity (p <0.003; OR=9.91) and the stenosing-penetrating phenotype (p<0.001; OR=22.1) also showed association with the presence of granulomas. The group of granulomas had a higher probability of corticosteroid use (p <0.024; OR=3.92) and immunomodulator (p <0.001; OR=7.10), besides the need for intestinal resection surgery (p<0.027; OR=5.07). Conclusions: The presence of granulomas in CD may be associated with increased clinical severity, endoscopic severity, immunosuppressive therapy requirement and undergo for intestinal resection.

Diagnostic challenge between Crohn's disease and intestinal tuberculosis in chronic diarrhea with ulcerated jejunal stenosis: a case report / Desafío diagnóstico entre la enfermedad de Crohn y la tuberculosis intestinal en la diarrea crónica con estenosis yeyunal ulcerada: reporte de un caso

ABSTRACT Intestinal tuberculosis and Crohn's disease are a diagnostic challenge because of the clinical, radiological and endoscopic similarity. The histological and microbiological findings are positive in less than 50%, which delays the correct treatment, putting the patient at risk. We reported a 34-year-old immunocompetent patient with 4 years of malabsorptive diarrhea, weight loss, nocturnal diaphoresis, abdominal pain and an ulcer with stenosis in the jejunum was found; she received empirical anti- tuberculosis treatment with clinical improvement. Later the culture was positive for M. tuberculosis.

RESUMEN La tuberculosis intestinal y la enfermedad de Crohn son un desafío diagnóstico debido a la similitud clínica, radiológica y endoscópica. Los hallazgos histológicos y microbiológicos son positivos en menos del 50%, lo que retrasa el correcto tratamiento, poniendo en riesgo al paciente. Reportamos un paciente de 34 años inmunocompetente con 4 años de diarrea malabsortiva, pérdida de peso, diaforesis nocturna, dolor abdominal y se encontró una úlcera con estenosis en yeyuno; recibió tratamiento empírico antituberculoso con mejoría clínica. Posteriormente el cultivo fue positivo para M. tuberculosis.

Prevalência e fatores associados ao supercrescimento bacteriano do intestino delgado em pacientes com doença de Crohn: estudo retrospectivo em um centro de referência / Prevalence and factors associated with small intestinal bacterial overgrowth in patients with crohns disease: a retrospective study at a referral center

ABSTRACT BACKGROUND: Small intestinal bacterial overgrowth (SIBO) appears to be common in patients with Crohn's disease (CD). The rate of SIBO has been estimated at 25%-88% in this setting. However, different demographic, socioeconomic, and disease-related factors may exist between South American and North American or European populations that may limit the generalization of these findings, as the data are mainly derived from North American or European studies. OBJECTIVE: We studied the prevalence and predictors of SIBO in CD outpatients. METHODS: In this retrospective study, between June 2011 and June 2016, the medical records of 110 CD patients were assessed for presence of SIBO using the H2/CH4 glucose breath test. Univariate analysis was performed to investigate the potential association between SIBO and demographic, disease-related data, systemic markers of inflammation (C-reactive protein and erythrocyte sedimentation rate). RESULTS: The SIBO rate was high in CD patients (30%). Patients with and without SIBO were comparable according to demographics, systemic inflammatory biomarkers, and disease characteristics, except to the stricturing phenotype more common in the SIBO-positive CD patients (48.5% vs 19.5%, P=0.001). CONCLUSION: In Brazilian CD patients, SIBO is a highly prevalent condition. Stricturing phenotype demonstrated association with SIBO. An individualized screening plan followed by the timely treatment for SIBO should be carried out as part of quality of care improvement in CD individuals.

RESUMO CONTEXTO: O supercrescimento bacteriano de intestino delgado (SBID) parece ser comum em pacientes com doença de Crohn (DC). A taxa de SBID tem sido estimada entre 25-88% neste cenário. Entretanto, diferenças demográficas, socioeconômicas e dos fatores relacionados à doença podem existir entre as populações da América do Sul e da América do Norte ou europeias que podem limitar a generalização destes achados, uma vez que os dados são derivados principalmente de estudos norte-americanos ou europeus. OBJETIVO: Estudar a prevalência e os preditores de SBID em pacientes ambulatoriais com DC. MÉTODOS: Neste estudo retrospectivo os registros médicos de 110 pacientes com DC que haviam sido submetidos ao teste respiratório do hidrogênio e metano expirados para o diagnóstico de SBID, entre junho de 2011 e junho de 2016, foram avaliados. Análise univariada foi realizada para investigar a potencial associação entre SBID com os dados demográficos, relacionados à DC e marcadores sistêmicos de inflamação (proteína C-reativa e velocidade de hemossedimentação). RESULTADOS: A prevalência de SBID foi elevada em pacientes com DC (30%). Os pacientes com e sem SBID foram comparáveis de acordo com os dados demográficos e de biomarcadores de inflamação sistêmica, bem como das características da DC, exceto pelo fenótipo estenosante, mais comum nos pacientes com DC e SBID (48,5% vs 19,5%, P=0,001). CONCLUSÃO: Em pacientes brasileiros com DC, SBID é uma condição altamente prevalente. O fenótipo estenosante demonstrou associação com o SBID. O planejamento de um screening individualizado seguido por tratamento apropriado para SBID deve ser incluído como parte da melhoria na qualidade de cuidados a ser oferecida para os pacientes com DC.

Pneumatosis intestinalis as a presentation of Crohn's disease: a case report / Neumatosis intestinal como presentación de la enfermedad de Crohn: reporte de un caso

ABSTRACT Pneumatosis intestinalis (PI) is defined as presence of gas within the intestinal wall. It is a rare condition, usually associated with a wide variety of pathologies. It requires a special diagnostic approach to determine underlying etiology. We present the case of a 18 year old woman with chronic abdominal pain, who presents with peritoneal signs and pneumoperitoneum. Laparoscopy showed NI. Thereafter, Crohn´s disease was diagnosed by balloon enteroscopy.

RESUMEN La neumatosis intestinal (NI) es la presencia de gas en la pared intestinal. Es un hallazgo infrecuente, generalmente presente en una gran variedad de patologías. Requiere de un abordaje diagnóstico detallado para determinar su etiología. Presentamos el caso de una mujer de 17 años con dolor abdominal crónico, quien se presenta con signos de irritación peritoneal y neumoperitoneo. Con hallazgo quirúrgico de NI en el intestino delgado, a quién mediante enteroscopia se le diagnóstica enfermedad de Crohn.

Epidemiological profile of patients with fistula in ano / Perfil epidemiológico dos pacientes com fístula anal

Abstract Rationale There is a lack of consistent national data on the evaluation of the epidemiological profile of patients with anal fistula. Objective To evaluate the epidemiological profile of patients with anal fistula at a center specialized in coloproctology. Method A cross-sectional, retrospective study was carried out between 2016 and 2018 of patients who underwent surgical procedures for the treatment of fistula in ano by the Department of Coloproctology of the Regional Hospital of Mato Grosso do Sul. Age, gender, disease duration, number of procedures, association with Crohn's disease and other comorbidities were evaluated. The data were tabulated and submitted to statistical treatment considering p < 0.05. Results 93.2% of the patients were less than 60 years old, 66.7% were male, 88.9% had the disease less than one year, the most frequent procedures were fistulotomy (55.6%) and fistulectomy (36.8%), with a greater percentage of patients having undergone only one procedure (74.4%), 8.5% had Crohn's disease, 7.7% systemic hypertension and 3.4% had diabetes mellitus. Conclusion In the studied group, there was a predominance of anal fistulae in men under 60 years old and without comorbidities, diagnosed for up to one year, most of them submitted to fistulotomy or fistulectomy at one time. Patients operated after one year of illness and also those with Crohn's disease were submitted mainly to curettage + seton and multiple procedures.

Resumo Racional Faltam dados nacionais sobre a avaliação do perfil epidemiológico dos pacientes com fístula anal. Objetivo Avaliar o perfil epidemiológico dos pacientes portadores de fístula anal em um centro especializado em coloproctologia. Método Estudo retrospectivo, transversal, realizado no período de 2016 a 2018 dos pacientes que realizaram procedimentos cirúrgicos para o tratamento da fístula anal pelo serviço de Coloproctologia do Hospital Regional de Mato Grosso do Sul. Avaliou-se idade, gênero, tempo de doença, procedimento realizado, número de procedimentos, associação com doença de Crohn e outras comorbidades. Os dados foram tabulados e submetidos a tratamento estatístico considerando-se significativo p < 0,05. Resultados 93,2% dos pacientes tinham menos de 60 anos, 66,7% eram do gênero masculino, 88,9% tinham a doença a menos de um ano, os procedimentos mais realizados foram a fistulotomia (55,6%) e a fistulectomia (36,8%, sendo que um percentual maior de pacientes havia sido submetido a apenas um procedimento (74,4%); 8,5% tinham doença, 7,7% hipertensão arterial sistêmica e 3,4% diabetes mellitus. Conclusão Na amostra estudada houve predomínio de fístulas anais em homens com menos de 60 anos e sem comorbidades, com diagnóstico de até um ano, a maioria submetida à fistulotomia ou fistulectomia em um tempo. Pacientes operados após um ano de doença e também os com Doença de Crohn foram submetidos principalmente à curetagem + sedenho e múltiplos procedimentos.

Escala de autoavaliação Inflammatory Bowel Disease-Fatigue: tradução, adaptação cultural e propriedades psicométricas da versão Brasileira (IBD-F Brasil) / The inflammatory bowel disease-fatigue patient self-assessment scale: translation, cross-cultural adaptation and psychometric properties of the brazilian version (ibd-f brazil)

ABSTRACT BACKGROUND: Fatigue is a common symptom in patients with inflammatory bowel diseases (IBD). A translated and culturally adapted, instrument with robust psychometric for measuring fatigue in Brazilian patients with IBD is needed. OBJECTIVE: To translate and cross-culturally adapt the inflammatory Bowel Disease Fatigue Scale (IBD-F) into Brazilian-Portuguese and to test its measurement properties in Brazilian patients with IBD. METHODS: Data from 123 patients with IBD were collected. In addition to IBD-F, the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) was used. The measurement properties tested were: internal consistency, reproducibility (reliability and agreement), construct validity, internal and external responsiveness, and ceiling and floor effects. RESULTS: The Brazilian-Portuguese version of the IBD-F showed excellent internal consistency (Cronbach's alpha of 0.95), excellent reproducibility (ICC=0.97) and a minimal detectable change of 6.0 points. The construct validity was demonstrated with a good correlation between the IBD-F and FACIT-F (r=- 0.46). Effect sizes used for measuring internal responsiveness were moderate among those with Crohn's (0.66) disease and low in patients with ulcerative colitis (0.24). The Brazilian-Portuguese version of the IBD-F presented with high external responsiveness for Crohn's disease (0.84) and with low external responsiveness for ulcerative colitis (0.33). The area under the curve considered for responsiveness was 0.84. Twenty-five percent of floor effects and no ceiling effect were recorded. CONCLUSION: The Brazilian-Portuguese version of IBD-F has adequate measurement properties and its use can be recommended in clinical practice and research.

RESUMO CONTEXTO: A fadiga é um sintoma comum em pacientes com doenças inflamatórias intestinais (DII). Um instrumento de avaliação de fadiga traduzido, culturalmente adaptado e com psicometria robusta para medir a fadiga em pacientes brasileiros com DII é necessário. OBJETIVO: Traduzir e adaptar culturalmente a Inflammatory Bowel Disease Fatigue Scale (IBD-F) para o português do Brasil e testar suas propriedades de medida em pacientes brasileiros com DII. MÉTODOS: Foram coletados dados de 123 pacientes com DII. Além do IBD-F, foi utilizada a Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F). As propriedades de medida testadas foram: consistência interna, reprodutibilidade (confiabilidade e concordância), validade de construto, responsividade interna e externa e efeitos teto e chão. RESULTADOS: A versão em português do IBD-F mostrou excelente consistência interna (alfa de Cronbach de 0,95), excelente reprodutibilidade (ICC=0,97) e uma diferença mínima detectável de 6,0 pontos. A validade do construto foi demonstrada por meio de uma boa correlação entre o IBD-F Brasil e o FACIT-F (r= -0,46). Na análise de responsividade interna, os tamanhos de efeito obtidos foram moderado entre aqueles com doença de Crohn (0,66) e baixo em pacientes com colite ulcerativa (0,24). O IBD-F Brasil apresentou alta responsividade externa entre aqueles com doença de Crohn (0,84) e baixa responsividade externa em pacientes colite ulcerativa (0,33). A área sob a curva considerada para responsividade foi de 0,84. Foram registrados 25% de efeito chão e nenhum efeito teto nas avaliações realizadas. CONCLUSÃO: O IBD-F Brasil possui propriedades de medida adequadas e seu uso pode ser recomendado na prática clínica e na pesquisa em pacientes com DII.

Papel de la medicina regenerativa y los sellantes en la enfermedad de Crohn perianal / Role of regenerative medicine and sealants in perianal Crohn's disease

La enfermedad de Crohn constituye una enfermedad inflamatoria crónica que puede cursar con fistulas complejas en hasta un 20% de los pacientes. A pesar de la intensificación del tratamiento, asociado o no a la cirugía, todavía es considerable el porcentaje de pacientes que no responden al tratamiento. En los últimos años se ha empezado a desarrollar nuevas terapias que permitan conseguir una mayor tasa de curación de estos pacientes, con las mínimas complicaciones posibles. Es cuando aparecen agentes que pretenden de forma directa el sellado o intervienen en la reducción local de la inflamación. Es objetivo de este artículo mostrar el papel de la Medicina Regenerativa en el tratamiento de estos pacientes.

Crohn's disease is a chronic inflammatory disease that can occur with complex fistulas in up to 20% of patients. Despite the intensification of treatment, associated with no surgery, the percentage of patients who do not respond to treatment is still considerable. In recent years, new therapies have been developed to achieve a higher cure rate for these patients, with the minimum possible complications. It is when agents appear to pretend as seal fistula tract as the local reduction of inflammation. The aim of this article is to show the role of Regenerative Medicine in the treatment of these patients.

Tratamiento exitoso del pioderma grangrenoso con metotrexate en paciente con enfermedad de Crohn / Successful treatment of gangrenous pyoderma with methotrexate in a patient with Crohn's disease

El pioderma gangrenoso (PG), es una dermatosis neutrofílica, cutáneo-ulcerativa, no infecciosa, que ocurre hasta en un 2% de los pacientes con enfermedad de Crohn (EC). Su aparición suele ser independiente del curso clínico de la EC. Las terapias más utilizadas han sido los corticoides sistémicos, la ciclosporina y la terapia biológica, los cuales han mostrado buenos resultados. El Metotrexate (MTX) es un fármaco antimetabolito con actividad antiinflamatoriaque se caracteriza por una dosificación semanal, un inicio de acción más rápida, con buen perfil de seguridad relacionado con neoplasias malignas y sobretodo un menor costo. Posee eficacia en la inducción de la remisión en pacientes con EC, sin embargo su eficacia en el manejo de manifestaciones extraintestinales como el PG es incierta. Presentamos el caso de un varón joven que acude a urgencias por diarrea crónica, pérdida de peso, y fiebre acompañado de un nódulo doloroso, eritematoso, situado a nivel pretibial compatible con PG en el contexto de EC. Fue manejado inicialmente con corticoides sistémicos sin mejoría. De tal forma, se inició terapia concomitante con MTX con respuesta clínica y analítica favorable. En conclusión, la terapia concomitante de cortiocoides sistémicos y MTX en pacientes con EC con PG podría suponer un tratamiento alternativo al no contar con disponibilidad de ciclosporina o terapia biológica en nuestro medio.

Pyoderma gangrenosum (PG) is a neutrophilic, cutaneous-ulcerative, non-infectious dermatosis that occurs in up to 2% of patients with Crohn's disease (CD). Its appearance is usually independent of the clinical course of CD. The most used therapies have been systemic corticosteroids, cyclosporine and biological therapy, which have shown good results. Methotrexate (MTX) is an antimetabolite drug with anti-inflammatory activity characterized by a weekly dosage, a faster onset of action, with a good safety profile related to malignant neoplasms and, above all, a lower cost. It is effective in the induction of remission in patients with CD, however its efficacy in the management of extraintestinal manifestations such as PG is uncertain. We present the case of a young man who comes to the emergency room with an history of chronic diarrhea, weight loss, and fever accompanied by a painful, erythematous nodule, located at the lower extremity compatible with PG in the context of CD. It was initially managed with systemic corticosteroids without improvement. Concomitant therapy with MTX was started with a favorable clinical outcome. In conclusion, the concomitant therapy of systemic corticosteroids and MTX in patients with CD with PG could be an alternative treatment in cases where cyclosporine or biological therapy is not available.

Pancreatic endosonographic findings and clinical correlation in Crohn's disease

OBJECTIVES: We aimed to evaluate the incidence of pancreatic alterations in Crohn's disease using endoscopic ultrasound (EUS) and to correlate the number of alterations with current clinical data. METHODS: Patients diagnosed with Crohn's disease (n=51) were examined using EUS, and 11 variables were analyzed. A control group consisted of patients with no history of pancreatic disease or Crohn's disease. Patients presenting with three or more alterations underwent magnetic resonance imaging (MRI). Pancreatic function was determined using a fecal elastase assay. RESULTS: Two of the 51 patients (3.9%) presented with four EUS alterations, 3 (5.9%) presented with three, 11 (21.5%) presented with two, and 13 (25.5%) presented with one; in the control group, only 16% presented with one EUS alteration (p<0.001). Parenchymal abnormalities accounted for 39 of the EUS findings, and ductal abnormalities accounted for 11. Pancreatic lesions were not detected by MRI. Low fecal elastase levels were observed in 4 patients, none of whom presented with significant pancreatic alterations after undergoing EUS. Ileal involvement was predictive of the number of EUS alterations. CONCLUSION: A higher incidence of pancreatic abnormalities was found in patients with Crohn's disease than in individuals in the control group. The majority of these abnormalities are related to parenchymal alterations. In this group of patients, future studies should be conducted to determine whether such morphological abnormalities could evolve to induce exocrine or endocrine pancreatic insufficiency and, if so, identify the risk factors and determine which patients should undergo EUS.

Analysis of the clinical characteristics of perianal fistulising crohn's disease in a single center / Análise das características clínicas da doença de crohn fistulizante perianal em um único centro

ABSTRACT Background: Clinical characteristics are keys to improve identification and treatment of Crohn´s disease (CD) so that large sample analysis is of great value. Aim: To explore the clinical characteristics of perianal fistulising CD. Methods: Analysis of 139 cases focused on their clinical data. Results: The proportion of males and females is 3.3:1; the mean age is 28.2 years; 47.5% of patients had anal fistula before CD diagnosis. Patients with prior perianal surgery and medication accounted for 64.7% and 74.1% respectively. The L3 type of lesion was present in 49.6% and the B1 and B2 types for 51.8% and 48.2% respectively; complex anal fistula was diagnosed in 90.6%. Symptoms of diarrhea were found in 46% and perianal lesions alone in 29.5% of patients. Abnormal BMI values was present in 44.6%; active CD activity index in 64.7%; and 94.2% had active perianal disease activity index. A proportion of patients manifest abnormal C-reactive protein, erythrocyte sedimentation rate, platelet, hemoglobin and albumin. Conclusion: We suggest that patients with anal fistula associated to these clinical features should alert the medical team to the possibility of CD, which should be further investigated through endoscopy and imaging examination of alimentary tract to avoid the damage of anal function by routine anal fistula surgery.

RESUMO Racional: As características clínicas são fundamentais para melhorar a identificação e o tratamento da doença de Crohn (DC), de modo que a análise da amostra seja de grande valor. Objetivo: Explorar as características clínicas da DC fistulizante perianal. Métodos: Análise de 139 casos focados em seus dados clínicos. Resultados: A proporção de homens e mulheres foi de 3,3: 1; a média de idade de 28,2 anos; 47,5% dos pacientes tiveram fístula anal antes do diagnóstico de DC. Pacientes com cirurgia perianal prévia e medicação representaram 64,7% e 74,1%, respectivamente. O tipo de lesão L3 estava presente em 49,6% e os tipos B1 e B2, em 51,8% e 48,2%, respectivamente; fístula anal complexa foi diagnosticada em 90,6%. Sintomas de diarréia foram encontrados em 46% e lesões perianais isoladas em 29,5% dos pacientes. Valores anormais de IMC estavam presentes em 44,6%; índice de atividade DC ativa em 64,7%; e 94,2% tinham índice de atividade de doença perianal ativo. Proporção significativa de pacientes tinha proteína-C reativa, taxa de sedimenta do eritrócito, plaquetas hemoglobina e albumina anormais. Conclusão: Sugere-se que pacientes com fístula anal associada às essas características clínicas alertem a equipe médica para a possibilidade de DC, que deve ser investigada por endoscopia e exame de imagem do trato digestivo para evitar dano na função anal pela operação que rotineiramente é realizada no tratamento da fístula anal.

Transplantation of adipose-derived mesenchymal stem cells in refractory crohn's disease: systematic review / Transplante de células-tronco mesenquimais derivadas do tecido adiposo na doença de crohn refratária: revisão sistemática

ABSTRACT Background: Crohn's disease is a pathological condition that has different options of treatment, but there are patients who need other therapeutic approach, such as the use of adipose-derived mesenchymal stem cells. Aim: Systematic literature review to determine the different ways of adipose-derived mesenchymal stem cells administration in humans with luminal refractory and perianal fistulizing Crohn's disease. Methods: It was conducted a search for articles (from 2008 to 2018) on PubMed and ScienceDirect databases using the keywords Crohn's disease, fistulizing Crohn's disease, luminal Crohn's disease and transplantation of mesenchymal stem cells or mesenchymal stem cells or stromal cells. Thirteen publications were selected for analysis. Results: Only one study referred to the luminal Crohn´s disease. The number of cells administered was variable, occurring mainly through subcutaneous adipose tissue by liposuction. It could be highlighted the autologous transplant with exclusive infusion of mesenchymal stem cells. The procedures involved in pre-transplant were mainly curettage, setons placement and stitching with absorbable suture, and conducting tests and drug treatment for luminal Crohn´s disease. During transplant, the injection of mesenchymal stem cells across the fistula path during the transplant was mainly on the intestinal tract wall. Conclusion: Although the use of mesenchymal stem cells is promising, the transplant on the luminal region should be more investigated. The injection of mesenchymal stem cells, exclusively, is more explored when compared to treatment with other products. The preparation of the fistulizing tract and the location of cell transplantation involve standardized health care in most studies.

RESUMO Racional: Há diferentes opções de tratamento para a doença de Crohn, porém, em alguns casos, há a necessidade de outras abordagens terapêuticas, como o uso de células-tronco mesenquimais derivadas do tecido adiposo. Objetivo: Revisar sistematicamente a literatura para determinar as diferentes formas de administração das células-tronco mesenquimais derivadas do tecido adiposo em seres humanos com doença de Crohn refratária luminal e fistulizante perianal. Método: Buscaram-se artigos publicados entre 2008 e 2018 nas bases de dados PubMed e ScienceDirect, pelos descritores: Crohn's disease, fistulizing Crohns disease, luminal Crohns disease e transplantation of mesenchymal stem cells ou mesenchymal stem cell ou stromal cells. Treze artigos foram selecionados. Resultados: Somente um trabalho se referiu à doença luminal. A quantidade de células administradas foi variável, obtendo-se principalmente do tecido adiposo subcutâneo por lipoaspiração. Destacou-se o transplante autólogo com a infusão exclusiva de células-tronco mesenquimais. Os procedimentos realizados no pré-transplante foram principalmente o de curetagem, colocação de setons e suturas com fio absorvível, e de exames e tratamento medicamentoso para a doença luminal. No transplante, ocorreu a injeção das células por todo o trajeto fistuloso, principalmente nas paredes do trato. Conclusão: Embora o uso de células-tronco mesenquimais seja promissor, o transplante na região luminal deve ser mais investigado. A injeção exclusiva de células-tronco mesenquimais é mais explorada quando comparada ao tratamento conjunto com outros produtos. A forma de preparo do trato fistuloso e o local de transplante envolvem cuidados médicos padronizados na maioria dos estudos.

Comparison of conventional and structured report in the evaluation of Crohn's disease through enterography / Comparação entre laudo convencional e estruturado na avaliação da Doença de Crohn por enterografia

ABSTRACT Context: There is an increasing interest in the standardization of the evaluation of imaging exams, especially enterography in Crohn's disease. Objective: To compare the quality of the conventional report with the structured report in computed tomography enterography in Crohn's disease. Method: Nine CT enterographies of patients with Crohn's disease with conventional reports were performed; after the standardization of the structured report by the radiology department of a university hospital that is a reference in the care of patients with inflammatory bowel diseases, the same exams were reevaluated, and new reports were issued, without the radiologists having access to the previous report; the 18 reports underwent evaluation of five specialists in Inflammatory Bowel Diseases, resulting in 90 analyses of the report; the specialists evaluated the following criteria: clarity of the information of the report, ease in characterizing the extension of the disease, ease in defining the presence of complications, usefulness of the exam to define the behavior, and ease in defining the activity of the disease, with the use of a 0-10 score. The statistical analysis was perfrmed with Wilcoxon's non-parametric test, considering a significance level of 5%. Results: The mean scores assigned to the exam reports, using both reports (unstructured and structured) ranged from 7.98 to 9.16; however, the scores of the structured reports were significantly higher (p < 0.003). Conclusion: In the specialists' evaluation, the structured report was shown to be of better quality than the unstructured one in the CT enterography of patients with Crohn's Disease.

RESUMO Contexto: Há cada vez maior interesse em padronização na avaliação de exames de imagem, em especial a enterografia na Doenca de Crohn. Objetivo: Comparar a qualidade do laudo convencional com o estruturado na enterografia por tomografia computadorizada na Doença de Crohn. Método: Foram realizados nove enterografias por TC de pacientes com Doença de Crohn com laudos convencionais; após a padronização do laudo estruturado pelo serviço de radiologia um hospital universitário, referência no atendimento de pacientes com doenças inflamatórias intestinais, os mesmos exames foram reavaliados e novos laudos foram emitidos, sem que os radiologistas tivessem acesso ao laudo anterior; os 18 laudos foram submetidos a avaliação de cinco especialistas em Doenças Inflamatórias Intestinais, resultando em 90 análises de laudo; os especialistas avaliaram os seguintes critérios: clareza das informações do laudo, facilidade em caracterizar a extensão da doença, facilidade em definir a presença de complicações, utilidade do exame para definir a conduta e facilidade em definir a atividade da doença, conferindo uma pontuação de 0 a 10. A análise estatística foi realizada com o teste não paramétrico de Wilcoxon, considerando-se nível de significância de 5%. Resultados: os escores médios atribuídos aos laudos do exame, usando ambos os relatórios (não estruturado e estruturado), variaram de 7,98 a 9,16; todavia, os escores dos laudos estruturados foram significativamente maiores (p < 0,003). Conclusão: Na avaliação dos especialistas o laudo estruturado mostrou-se de melhor qualidade que o não estruturado na enterografia por tomografia computadorizada de pacientes com Doença de Crohn.

Risk factors for postoperative complications in Crohn disease: analysis of 173 patients / Fatores de risco para complicações pós-operatórias na Doença de Crohn: análise de 173 pacientes

ABSTRACT Background and objectives: Surgery for Crohn disease has a wide range of factors that are being studied as possible risk factors for postoperative complications. The later are a major problem in those patients and are associated with longer hospital stays and increased mortality and morbidity. Despite the debate regarding the influence of patients' characteristics, preoperative and operative details, the risk factors are not fully identified. The debate has been focused on the new medical therapy and the time of surgery. Our goal was to help identify and confirm risk factors for postoperative complications. Materials and methods: A retrospective cohort study including all patients operated due to Crohn disease in São João Hospital Center from 2010 to 2015. We analyzed patient, preoperative and surgical characteristics. For postoperative complications data only those occurring within 30 days were included. Results: Neither age at diagnosis or previous corticotherapy/anti-TNF/ustekinumab was significantly associated with an increased risk in postoperative complications. Only age at surgery >40 years (Montreal Classification A1 + A2 vs. A3; OR = 4.12; p < 0.05) and the group others (occlusion vs. others [combination of intestinal perforation, mesenteric ischemia and postoperative complications] vs. fistula/abscess as indication for surgery; OR = 4.12; p < 0.05) remained as independent risk factors after multivariable regression analysis. Conclusions: We described clear associations between age at surgery >40 years and the group others (intestinal perforation, mesenteric ischemia and postoperative complications) and overall postoperative complications in Crohn disease. These results may suggest that surgery does not need to be delayed and, in some cases, should be anticipated.

RESUMO Introdução e objetivos: Vários fatores têm sido estudados como possíveis fatores de risco para complicações pós-operatórias na doença de Crohn. Estas complicações estão associadas a estadias mais prolongadas no hospital e a um aumento da mortalidade. Apesar do debate relativo à influência das características dos pacientes, pré-operatórias e operatórias, os fatores de risco ainda não estão completamente identificados. Atualmente, o debate centra-se nos avanços da terapia médica e no melhor momento para realizar a operação. O objetivo era identificar os fatores de risco para complicações pós- operatórias. Materiais e métodos: Realizamos um estudo retrospectivo incluindo todos os pacientes operados devido à doença de Crohn no Hospital São João desde 2010 até 2015. Analisamos as características dos doentes, as pré e as pós-operatórias. Apenas foram incluídos os dados relativos a complicações no período de 30 dias após a cirurgia. Resultados: A idade ao diagnóstico e o uso prévio de corticoterapia/anti-TNF/ustekinumab não foram associados a um aumento no risco de complicações pós-operatórias. Apenas a idade na cirurgia superior aos 40 anos (Classificação de Montreal A1 + A2 vs. A3; OR = 4.12; p < 0.05) e o grupo 'outros' (oclusão vs. outros [combinação de perfuração intestinal, isquemia mesentérica e complicações pós-operatórias] vs. fistula/abscesso como indicação para cirurgia; OR = 4.12; p < 0.05) são fatores de risco independentes. Conclusões: Descrevemos uma associação clara entre a idade na cirurgia superior aos 40 anos e o grupo 'outros' e a existência de complicações pós-operatórias na doença de Crohn. A cirurgia não deve ser adiada e, em alguns casos, seria benéfico antecipá-la.

Deficiência de vitamina D entre pacientes com doença inflamatória intestinal na Argentina: um estudo transversal / Vitamin d deficiency among inflammatorybowel disease patients in argentina: a cross-sectional study

ABSTRACT BACKGROUND: An association has been established between low serum values of vitamin D and inflammatory bowel disease. There is a lack of evidence on whether this association is still observed in regions where sun exposure throughout the year is higher. OBJECTIVE: To compare the prevalence of vitamin D deficiency between inflammatory bowel disease patients and healthy controls. METHODS: Inflammatory bowel disease patients were consecutively enrolled as cases. Age and gender-matched healthy subjects who agreed to undertake a determination of serum vitamin D were enrolled as controls. Demographic features, medical treatment, need for hospital admission at diagnosis, steroid treatment, smoking, need for surgical treatment were evaluated as factors associated with vitamin D deficiency. RESULTS: Overall, 59 patients with a diagnosis of either Crohn's disease or ulcerative colitis were enrolled, as well as 56 controls. Median age was 41 years (19-79) and 56% were male. Vitamin D deficiency was observed in 66.1% of inflammatory bowel disease patients versus 21.42% of healthy controls (OR 7.15 (3.1-16.48), P=0.001). Among inflammatory bowel disease patients, male gender, disease duration, moderate-to-severe disease and hospital admission at the moment of diagnosis were found to be associated with vitamin D deficiency. On multivariate analysis, only longer disease duration [(OR 1.01 (1-1.06)] and hospital admission at diagnosis [(OR 5.63 (1.01-31.61)] were found to be significantly associated with the latter. CONCLUSION: Vitamin D deficiency was more frequent among inflammatory bowel disease patients. Longer disease duration and need for hospital admission at diagnosis were associated to vitamin D deficiency among these patients.

RESUMO CONTEXTO: Uma associação foi estabelecida entre os baixos valores séricos de vitamina D e doença inflamatória intestinal. Falta evidência se esta associação ainda é observada em regiões onde a exposição ao sol durante todo o ano é maior. OBJETIVO: Comparar a prevalência de deficiência de vitamina D entre pacientes com doença inflamatória intestinal e indivíduos controles saudáveis. MÉTODOS: Pacientes com doença inflamatória intestinal foram consecutivamente selecionados. Indivíduos saudáveis combinados da mesma idade e gênero que concordaram em fornecer uma determinação da vitamina D do soro foram considerados como controles. Características demográficas, tratamento médico, necessidade de admissão hospitalar no diagnóstico, tratamento de esteroides, tabagismo, necessidade de tratamento cirúrgico foram avaliados como fatores associados à deficiência de vitamina D. RESULTADOS: No geral, 59 pacientes com diagnóstico de doença de Crohn ou colite ulcerosa foram observados, bem como 56 controles. A idade mediana era de 41 anos (19-79) e 56% eram do sexo masculino. A deficiência de vitamina D foi observada em 66,1% dos pacientes com doença inflamatória intestinal versus 21,42% dos controles saudáveis (OR 7,15 (3.1-16.48), P=0,001). Entre os pacientes com doença inflamatória intestinal, sexo masculino, duração da doença, doença de moderada a severa e admissão hospitalar no momento do diagnóstico foram associados com a deficiência de vitamina D. Na análise multivariada, apenas a duração da doença [(OR 1; 1 (1-1,06)] e a admissão hospitalar no diagnóstico [(OR 5,63 (1,01-31,61)] foram encontradas significativamente associadas ao último. CONCLUSÃO: A deficiência de vitamina D foi mais frequente entre os pacientes com doença inflamatória intestinal. Maior duração da doença e necessidade de admissão hospitalar no diagnóstico foram associadas à deficiência de vitamina D entre esses pacientes.