Fatores associados com a escolha da terapia nos pacientes com doença inflamatória intestinal no Brasil / Factors associated with patient´s preference in choosing their therapy for inflammatory bowel disease in brazil

BACKGROUND: Biological therapy and new drugs have revolutionized the treatment of inflammatory bowel disease. Ideally, the choice of medication should be a shared decision with the patient, aiming at greater satisfaction, compliance, and consequently, favorable clinical outcome. OBJECTIVE: This study aims to evaluate patient's preferences in the choice of their therapy and the factors that influence this choice. METHODS: This cross-sectional study enrolled 101 outpatients with Crohn's disease or ulcerative colitis. The inclusion criteria were age ≥18 years and no previous exposure to biological therapy. Patients' preferences were assessed through questions that addressed the preferred mode of administration (oral, subcutaneous, or intravenous) and the factors that determined the choice of medication (efficacy, medical indication, fear of medication, convenience, mode of application, and personal doctors' indication). RESULTS: The mean age was 43.6±13.5 years, 75.3% were female, and 81.2% were cases of ulcerative colitis. Regarding the mode of administration, the majority of patients preferred oral (87.1%), followed by intravenous (6.93%) and subcutaneous (5.94%) medications. The reasons were "I prefer to take it at home" (42.57%), "I have more freedom" (36.63%), "I don't like self-application" (29.70%), and "I believe it works better" (19.80%). Younger patients and patients in clinical disease activity preferred intravenous mode compared to the oral route (P<0.05). Doctor's opinion (98%) was an important factor associated with the medication choice. CONCLUSION: Oral route was the preferred mode of administration and most patients took their physician's opinion into account in their choice of medication.

RESUMO CONTEXTO: A terapia biológica e os novos medicamentos revolucionaram o tratamento da doença inflamatória intestinal. A escolha do medicamento deve ser compartilhada com o paciente, visando maior satisfação, adesão e, consequentemente, desfecho clínico favorável. OBJETIVO: Este estudo teve como objetivo avaliar as preferências do paciente na escolha de sua terapia e os fatores que influenciaram essa escolha. MÉTODOS: Este estudo transversal incluiu 101 pacientes ambulatoriais com doença de Crohn ou retocolite ulcerativa. Os critérios de inclusão foram idade ≥18 anos e nenhuma exposição prévia à terapia biológica. A preferência dos pacientes foi avaliada por meio de perguntas que abordaram o modo de administração preferido (oral, subcutâneo ou intravenoso) e os fatores que determinaram a escolha do medicamento (eficácia, indicação médica, medo da injeção, conveniência, modo de aplicação e opinião pessoal do médico). RESULTADOS: A idade média foi de 43,6±13,5 anos, 75,3% eram mulheres e 81,2% eram portadores de retocolite ulcerativa. Em relação ao modo de administração, a maioria dos pacientes preferiu os medicamentos orais (87,1%), seguidos dos endovenosos (6,93%) e subcutâneos (5,94%). Os motivos foram "prefiro aplicar em casa" (42,57%), "tenho mais liberdade com essa medicação" (36,63%), "não gosto de autoaplicação" (29,70%) e "acredito que funcione melhor" (19,80%). Pacientes jovens e pacientes em atividade clínica preferiram a via intravenosa em comparação com a via oral (P<0,05). A opinião do médico (98%) foi um fator importante associado à escolha do medicamento. CONCLUSÃO: A via oral foi preferida e a maioria dos pacientes levou em consideração a opinião do seu médico na escolha do medicamento.

Octreótido de liberación prolongada para el tratamiento de hemorragia digestiva alta en Pediatría / Long-acting Release Octreotide for Pediatric Upper Gastrointestinal Bleeding

Resumen: Introducción: La hemorragia digestiva por hipertensión portal, sin alternativa de tratamiento endos- cópico o quirúrgico por localizaciones ectópicas, no identificadas del sitio de sangrado o caracterís ticas anatómicas, constituye un desafío terapéutico en Pediatría. El tratamiento habitual incluye la infusión de octreótido endovenoso. En los últimos años, la presentación de octreótido de liberación prolongada (OCT-LAR) para administración mensual intramuscular, resulta una alternativa tera péutica atractiva. Objetivo: Reportar el caso de un lactante con hemorragia digestiva por hiperten sión portal que recibió tratamiento exitoso con OCT-LAR. Caso Clínico: Paciente de 8 meses de vida, con malformación de vena porta extrahepática y episodios reiterados de sangrados digestivos con re querimientos transfusionales e infusiones de octréotido, sin posibilidad de tratamiento endoscópico o quirúrgico. Indicamos OCT-LAR intramuscular mensualmente. Después de diez meses de iniciado el tratamiento, el paciente no repitió sangrados digestivos y no presentó efectos adversos relacionados a la medicación. Conclusión: Consideramos que el reporte de este caso puede resultar de utilidad al presentar una nueva alternativa para el tratamiento de pacientes pediátricos con sangrado digestivo por hipertensión portal sin posibilidades terapéuticas convencionales.

Abstract: Introduction: Upper gastrointestinal bleeding (UGIB) secondary to portal hypertension (PHT), without endoscopic or surgical treatment options due to an ectopic or unidentified bleeding site or the patient's anatomic characteristics, is challenging in pediatric hepatology. The usual treatment in these cases includes intravenous Octreotide. Recently, the availability of long-acting release Octreo tide (OCT-LAR) for monthly intramuscular administration has become an interesting therapeutic alternative. Objective: To report the case of an infant with UGIB due to PHT who was successfully treated with OCT-LAR. Clinical Case: Eight-month-old patient with repeated episodes of UGIB due to extrahepatic portal vein malformation, requiring blood transfusions, and intravenous octreotide infusions. As neither endoscopic nor surgical treatment were feasible, we decided to start IM OCT- LAR monthly. After ten months of treatment, the patient did not present bleeding episodes. No medication-related events were observed. Conclusion: We consider that this report could help in the management of similar pediatric patients with UGIB due to PHT without conventional therapeutic possibilities.

The impact of small intestinal bacterial overgrowth on the growth of children and adolescents / Impacto do sobrecrescimento bacteriano no intestino delgado sobre o peso e a estatura de crianças e adolescentes

ABSTRACT Objective: To evaluate the association between small intestinal bacterial overgrowth (SIBO) and weight and height impairment in children and adolescents with gastroenterology diseases. Methods: Observational and retrospective study. All 162 patients aged less than 19 years old who underwent breath test in search of SIBO between 2011 and 2016 were studied. Breath test was collected after the intake of 10 grams of lactulose. The concentration of hydrogen and methane was measured for 180 minutes after the beginning of the test by 12i QuinTronMicroLyzer device. Results: SIBO was identified in 51 (31.5%) patients. There was no difference between the age of those with (mean=8.7y.o; 25th and 75th percentile: 4.6 and 11.3) and without (mean=7.9y.o 25th and 75th percentile: 4.8 and 12.2) SIBO (p=0.910). There was no association between gender and SIBO (male 26.3% vs. female 36.3%, p=1.00). A lower median of height-for-age Z score (mean=-1.32; 25th and 75th percentile: -2.12 and -0.08 vs. mean=-0.59; 25th and 75th percentile: -1.57 and 0.22; p=0.04) was demonstrated in children with SIBO when compared with children without it. There was no difference between the BMI-for-age Z score of patients with (mean=-0.48) and without SIBO (mean=-0.06) (p=0.106). The BMI of patients with SIBO (median=15.39) was lower than of those without it (median=16.06); however, the statistical analysis was not significant (p=0.052). The weight-for-age Z score was lower in patients with SIBO (mean=-0.96) than in those without SIBO (mean=-0.22) (p=0.02) Conclusions: Children and adolescents with SBIO associated with diseases of the gastrointestinal tract have lower weight and height values.

RESUMO Objetivo: Avaliar a existência de associação entre sobrecrescimento bacteriano no intestino delgado (SBID) e comprometimento de peso e estatura em crianças e adolescentes com doenças do aparelho digestivo. Métodos: Estudo observacional e retrospectivo em ambulatório de gastroenterologia pediátrica. Foram incluídos todos os 162 pacientes com idade inferior a 19 anos que realizaram teste respiratório para pesquisa de SBID entre 2011 e 2016. O teste respiratório foi realizado após ingestão de dez gramas de lactulose. Foram determinadas as concentrações de hidrogênio e metano em aparelho 12i QuinTron MicroLyzer até 180 minutos após o início do teste respiratório. Resultados: SBID foi caracterizado em 51 (31,5%) dos 162 pacientes. Não houve diferença na idade das crianças com (mediana=8,7 anos; percentil 25-75: 4,6-11,3) e sem (mediana=7,9 anos; percentil 25-75: 4,8-12,2) SBID (p=0,910). Não se observou associação entre SBID e sexo (masculino 27,4% e feminino 36,6%; p=0,283). O escore Z da estatura-idade nos pacientes com SBID (mediana=-1,32; percentil 25-75: -2,12—0,08) foi menor (p=0,040) do que naqueles sem SBID (mediana=-0,59; percentil 25-75: -1,57-0,22). Na comparação do escore Z de índice de massa corpórea-idade não foi observada diferença entre os grupos com (média=-0,489±1,528) e sem (média=-0,067±1,532) SBID (p=0,106). Nos pacientes com menos de 10 anos de idade, o escore Z de peso-idade foi menor nos pacientes com SBID (média=-0,968±1,359) do que nos sem SBID (média=-0,223±1,584) (p=0,026). Conclusões: Crianças e adolescentes com SBID associado a doenças do trato gastrintestinal apresentam menores valores de peso e estatura.

Sarcopenia e gravidade da doença hepática gordurosa não-alcoólica / Sarcopenia and severity of non-alcoholic fatty liver disease

ABSTRACT BACKGROUND: Non-alcoholic fatty liver disease is characterized by deposition of lipids in the hepatic parenchyma exceeding 5% of liver weight in the absence of other conditions, such as viral or alcoholic hepatitis and metabolic disease. Non-alcoholic fatty liver disease is the most common form of chronic liver disease in several countries. In addition to liver complications, recent studies have shown a relation between liver fat and sarcopenia. OBJECTIVE: Determine the association between sarcopenia and the severity of non-alcoholic hepatic steatosis diagnosed by abdominal ultrasonography. METHODS: A clinical, cross-sectional study was conducted with a sample of male and female adults (18 to 70 years of age) submitted to ultrasonography for the investigation of non-alcoholic hepatic steatosis. Evaluations were also performed for the determination of upper and lower limb muscle strength. Data analysis was performed with the aid of the SPSS 22.0 program and involved ANCOVA and the Bonferroni post hoc test, with P-value <0.05 considered indicative of statistical significance. RESULTS: One hundred two patients were submitted to abdominal ultrasonography, 57.8% of whom presented some degree of non-alcoholic hepatic steatosis. The presence and degree of fatty liver infiltration were significantly associated with the sarcopenic index, determined by the ratio between upper and lower limb strength and BMI (P=0.009 and post-test P=0.028 for upper limbs; P=0.006 and post-test P=0.013 for lower limbs). CONCLUSION: In the present study, an association was found between the sarcopenic index and non-alcoholic hepatic steatosis, with an inversely proportional relation between this index and the severity of fatty infiltration. This finding offers further evidence of the metabolic interaction of the liver, adipose tissue and muscle.

RESUMO CONTEXTO: A doença hepática gordura não-alcoólica caracteriza-se pela deposição de lipídios no parênquima hepático, excedendo 5% do peso do fígado na ausência de outras afecções como hepatites virais, alcoólicas ou doenças metabólicas. A doença hepática gordura não-alcoólica tem sido observada como a forma mais comum de doença hepática crônica em diversos países. Além das complicações hepáticas, estudos recentes têm demonstrado a relação entre a presença de gordura hepática e a sarcopenia. OBJETIVO: Determinar a associação entre a sarcopenia e a gravidade da esteatose hepática não-alcoólica diagnosticada pela ultrassonografia abdominal. MÉTODOS: Estudo clínico e transversal com amostra de pacientes de ambos os sexos, de 18 a 70 anos de idade, diagnosticados como portadores ou não de esteatose hepática não-alcoólica pela ultrassonografia e submetidos à avaliação da força muscular dos membros superiores e inferiores. Os dados foram inseridos no programa estatístico SPSS 22.0, analisados através do teste ANCOVA e pós-teste de Bonferroni, sendo considerado significante P<0,05. RESULTADOS: Foram avaliados pela ultrassonografia abdominal 102 pacientes e destes, 57,8% apresentaram algum grau de esteatose hepática não-alcoólica. A presença e os graus da infiltração gordurosa no fígado tiveram associação estatisticamente significativa com o índice sarcopênico, determinado pela razão entre força muscular dos membros superiores e inferiores e o IMC (P=0,009 e pós-teste P=0,028 MMSS; P=0,006 e pós-teste P=0,013 MMII). CONCLUSÃO: Observou-se associação entre o índice sarcopênico e a presença de esteatose hepática não-alcoólica, com relação inversamente proporcional entre esse índice e a gravidade da infiltração gordurosa, reforçando a interação do eixo metabólico entre fígado, tecido adiposo e músculo.

Atividade física de vida diária, capacidade de exercício e qualidade de vida de pacientes com doença de Crohn em remissão induzida por infliximabe: um estudo preliminar / Physical activity in daily life, exercise capacity and quality of life in patients with crohn's disease on infliximab-induced remission: a preliminary study

ABSTRACT BACKGROUND: Physical activity in daily life and exercise capacity have not been assessed in patients with Crohn's disease to date. OBJECTIVE: To evaluate the physical activity in daily life, exercise capacity, quality of life, and prevalence of mood disorders in patients with moderate-to-severe Crohn's disease on infliximab-induced remission and the possible associations among variables. METHODS: A cross-sectional preliminary study was conducted. Twenty-six patients with Crohn's disease and 20 controls were selected. Participants underwent evaluation of physical activity in daily life (triaxial accelerometer), exercise capacity (shuttle walk test), handgrip strength, quality of life, and presence of mood disorders. RESULTS: The number of steps taken (7446±3081 vs 7898±2487), active time (80.6±42 vs 89.7±24.3min), shuttle walk test distance [665 (405) vs 710 (409) m] and handgrip strength [31 (15) vs 29 (20) kgf did not show any difference between the patients with Crohn's disease and the controls. The time spent lying down [95.8 (68.8) vs 60.9 (74.7) min] was greater and some domains of the quality of life were superior in the patients with Crohn's disease. No correlation was observed between the physical activity in daily life and quality of life or presence of mood disorders in patients with Crohn's disease. CONCLUSION: Patients with Crohn's disease on infliximab-induced remission, despite to more time spent lying down, they have the same level of physical activity in daily life and exercise capacity min compared with the controls.

RESUMO CONTEXTO: A atividade física na vida diária e a capacidade de exercício não tem sido avaliada em pacientes com doença de Crohn. OBJETIVO: Avaliar a atividade física na vida diária, capacidade de exercício, qualidade de vida e distúrbios de humor em pacientes com doença de Crohn moderada-grave em remissão induzida pelo infliximabe, e as possíveis associações entre essas variáveis. MÉTODOS: Este foi um estudo preliminar transversal, envolvendo 26 pacientes com doença de Crohn e 20 controles. Os participantes realizaram as seguintes avaliações: atividade física na vida diária por meio de um acelerômetro triaxial, capacidade de exercício (teste de Shuttle), força de preensão palmar, qualidade de vida e distúrbios do humor. RESULTADOS: O número de passos registrados (7446±3081 vs 7898±2487), o tempo ativo (80,6±42,0 vs 89,7±24,3min), a distância caminhada no teste de Shuttle 665 (405) vs 710 (409) m, e a força de preensão manual 31(15) vs 29 (20) kgf não mostraram diferenças entre os pacientes com doença de Crohn e os controles, respectivamente. O tempo gasto na posição deitada 95.8 (68.8) vs 60.9 (74.7) min, e alguns domínios da qualidade de vida foram maiores nos pacientes com doença de Crohn. Nenhuma correlação foi observada entre a atividade física na vida diária e a qualidade de vida ou distúrbios do humor nos pacientes com doença de Crohn. CONCLUSÃO: Pacientes com doença de Crohn em remissão induzida por infliximabe, apesar de passarem mais tempo deitados, apresentam mesmo nível de atividade física e capacidade de exercício quando comparados aos controles.

Determination of Rifaximin Treatment Period According to Lactulose Breath Test Values in Nonconstipated Irritable Bowel Syndrome Subjects

Small intestinal bacterial overgrowth (SIBO) can partly explain irritable bowel syndrome (IBS), and rifaximin has been observed to improve abdominal symptoms in nonconstipated IBS patients. However, there are few reports on the association of the rifaximin treatment periods with the results of a lactulose breath test (LBT). Therefore, we performed a retrospective review of patient charts to investigate the relation between the rifaximin treatment periods with LBT results in nonconstipated IBS patients. We also evaluated the time to achieve a symptomatic improvement in the IBS patients as compared to the changes in the LBT. We reviewed the charts for patients who showed IBS symptoms with documented positive results for LBT during their initial visit and who had a follow-up LBT after treatment with rifaximin. The LBT values were compared to the subjects' symptom scores. A total of 102 subjects had a follow-up LBT to assess LBT normalization. The subjects were divided into groups according to treatment periods of 4 weeks (n = 36), 8 weeks (n = 43), and 12 weeks (n = 23). The groups with a longer treatment exhibited an increase in the hydrogen gas value at 90 min and its sum during 90 min at the initial LBT. There were significant differences in hydrogen gas value at 90 min and in its sum during 90 min at the initial LBT between the groups treated for 4 and 12 weeks. The most significant treatment response was observed during the first 4 weeks for all treatment groups. Symptomatic improvement occurred earlier than LBT normalization in the treatment period over 4 weeks. The results indicate that different rifaximin treatment periods are needed in accordance with LBT levels to effectively eradicate SIBO.

Effect of DA-9701 on Colorectal Distension-Induced Visceral Hypersensitivity in a Rat Model

BACKGROUND/AIMS: DA-9701 is a newly developed drug made from the vegetal extracts of Pharbitidis semen and Corydalis tuber. The aim of this study was to evaluate the effect of DA-9701 on colorectal distension (CRD)-induced visceral hypersensitivity in a rat model. METHODS: Male Sprague-Dawley rats were subjected to neonatal colon irritation (CI) using CRD at 1 week after birth (CI group). At 6 weeks after birth, CRD was applied to these rats with a pressure of 20 to 90 mm Hg, and changes in the mean arterial pressure (MAP) were measured at baseline (i.e., without any drug administration) and after the administration of different doses of DA-9701. RESULTS: In the absence of DA-9701, the MAP changes after CRD were significantly higher in the CI group than in the control group at all applied pressures. In the control group, MAP changes after CRD were not significantly affected by the administration of DA-9701. In the CI group, however, the administration of DA-9701 resulted in a significant decrease in MAP changes after CRD. The administration of DA-9701 at a dose of 1.0 mg/kg produced a more significant decrease in MAP changes than the 0.3 mg/kg dose. CONCLUSIONS: The administration of DA-9701 resulted in a significant increase in pain threshold in rats with CRD-induced visceral hypersensitivity.

Action of phosphorylated mannanoligosaccharides on immune and hematological responses and fecal consistency of dogs experimentally infected with enteropathogenic Escherichia coli strains

The therapeutic action of phosphorylated mannanoligosaccharides (MOS) was investigated regarding its prebiotic activity on enteropathogenic Escherichia coli (EPEC). Diarrhea was induced in dogs by experimental infection with EPEC strains. Then MOS was supplied once a day, in water for 20 days. Immunological (IgA and IgG), hematological (lymphocytes, neutrophils and monocytes) and bacteriological variables (PCR detection of the eae gene of EPEC recovered from stool culture), as well as occurrence of diarrhea were evaluated. All strains caused diarrhea at 24, 48 and 72 h after infection. PCR results indicated that E. coli isolated from stool culture of all infected animals had the eae gene. There was no significant difference among groups as to number of blood cells in the hemogram and IgA and IgG production. MOS was effective in recovering of EPEC-infected dogs since prebiotic-treated animals recovered more rapidly from infection than untreated ones (p < 0.05). This is an important finding since diarrhea causes intense dehydration and nutrient loss. The use of prebiotics for humans and other animals with diarrhea can be an alternative for the treatment and prophylaxis of EPEC infections.

Uso do octreotide no tratamento do quilotórax e quiloperitôneo / Use of octreotide in the treatment of chylothorax and chyloperitoneum / Uso del octreotide en el tratamiento del quilotórax y quiloperitoneo

Relato de três casos de quilotórax e um caso de ascite quilosa em crianças em pós-operatório de cirurgia cardíaca, que evoluíram sem resposta ao tratamento clínico habitual, baseado em jejum e nutrição parenteral prolongada. Tratamento com octreotide na dose inicial de 1,0 mcg/kg/h foi escolhido, com aumento progressivo de 1,0 mcg/kg/h/dia até a dose máxima de 4,0 mcg/kg/h. Todos os casos tiveram resposta favorável, com redução progressiva do débito do dreno, até resolução do quadro, sem efeito colateral significativo.

Report of three cases of chylothorax and one case of chylous ascites in children who had undergone cardiac surgery with no response to routine clinical treatment, based on fasting and long-term parenteral nutrition. Treatment with octreotide at an initial dose of 1.0 mcg/kg/h was chosen, with a gradual increase of 1.0 mcg/kg/hr/day until a maximum dose of 4.0 mcg/kg/h. All cases had a favorable response, with gradual reduction of drainage output until prognosis improvement with no significant side effects.

Relato de tres casos de quilotórax y un caso de ascitis quilosa en niños en postoperatorio de cirugía cardíaca, que evolucionaron sin respuesta al tratamiento clínico habitual, basado en ayuno y nutrición parenteral prolongada. Fue elegido tratamiento con octreotide en dosis inicial de 1,0 mcg/kg/h , con aumento progresivo de 1,0 mcg/kg/h/día hasta la dosis máxima de 4,0 mcg/kg/h. Todos los casos tuvieron respuesta favorable, con reducción progresiva del débito del drenaje, hasta resolución del cuadro, sin efecto colateral significativo.

Congenital chylothorax treated with octreotide.

Congenital chylothorax is the accumulation of lymphatic fluid within the pleural space. Cases unresponsive to conservative management usually require surgery. Octreotide has been used successfully to treat post-traumatic chylothoraces in the pediatric and adult population. Its exact mode of action is uncertain but it is believed to reduce lymphatic drainage by a direct action on splanchnic lymph flow. We report a case of congenital chylothorax where surgery was avoided with the compassionate trial of the somatostatin analogue, octreotide. A 33 week gestation female infant, born with the presence of large bilateral pleural effusion, was unresponsive to conservative management. Octreotide was commenced on day 15, with 10 days of an octreotide infusion, initially 0.5 microg/kg per hour and increased daily by 1 microg/kg per hour to 10 microg/kg per hour. Treatment was associated with prompt respiratory improvement prior to cessation of pleural drainage over the 10 day. She remains well at 6 months of age. Further studies are required to ascertain its true value in congenital chylothorax.

Lack of effect of Helicobacter pylori on symptom improvement with a prokinetic medication, cisapride, in patients with non-ulcer dyspepsia.

OBJECTIVE: This study was undertaken to determine whether H. pylori infection has an effect on the improvement of dyspeptic symptoms in response to a prokinetic agent, cisapride, in patients with non-ulcer dyspepsia (NUD). MATERIAL AND METHOD: 35 NUD patients (16 M, 19 F) who had no underlying medical condition and negative upper endoscopy were included in the present study. Each patient received a 2-wk treatment of cisapride (Prepulsid, 10 mg, tid ac). H. pylori infection was determined using a rapid urease test (CLO test). Gastric emptying (GE) scintigraphy and dyspeptic symptom scores were evaluated before and at the end of the treatment. GE was evaluated in 22 healthy volunteers as normal controls. RESULTS: Half time (T1/2) GE of NUD patients was 90.9 +/- 28 min which was significantly longer than controls (77.6 +/- 14 min; p < 0.05) and was shortened to 73.6 +/- 22 min (p < 0.0001) at the end of the treatment. Cisapride significantly improved total dyspeptic symptom scores [7 (2-18) to 3 (0-11), p < 0.0001]. The symptom score improvement was not affected by H. pylori infection [H. pylori positive: 6 (2-18) to 2.5 (0-9), p < 0.0001; H. pylori negative: 9 (4-16) to 3 (0-11), p < 0.0001] or GE status [delayed GE: 10 (5-16) to 3 (15), p < 0.05; non delayed GE: 6 (2-18) to 2 (0-11); p < 0.0001]. CONCLUSIONS: Cisapride improves dyspeptic symptoms regardless of H. pylori and GE status. These results suggest that gastric emptying and H. pylori infection are not essential to determine prior to prescribing a prokinetic agent, cisapride, in patients with NUD.

Comparison of Rifaximin and Lactulose for the Treatment of Hepatic Encephalopathy: A Prospective Randomized Study

Rifaximin has been reported to be effective for the treatment of hepatic encephalopathy (HE) in Europe. However, it is unknown whether Rifaximin is effective for the treatment of HE in Koreans, therefore we conducted a open-label prospective randomized study to evaluate the efficacy of rifaximin versus lactulose in Korean patients. Fifty-four patients with liver cirrhosis and hepatic encephalopathy were enrolled. Thirty-two patients were randomized to receive rifaximin and 22 to receive lactulose both over a 7-day periods. Before and at the end of treatment, gradation of blood ammonia, flapping tremor, mental status, number connection test (NCT) were performed and estimation of HE indexes determined. Both rifaximin and lactulose were effective in the majority of patients (84.4% and 95.4%, respectively, p=0.315). Blood NH3, flapping tremor, mental status, and NCT was significantly improved by rifaximin and lactulose, and the post- treatment levels of these measures were similar for the rifaximin and lactulose-treated groups, as was the HE index (rifaximin group (10.0-->> 4.2, p=0.000) ; lactulose group (11.3-->> 5.0, p=0.000) ). One patient treated with rifaximin complained of abdominal pain, which was easily controlled. There was no episode of renal function impairment in either treatment group. Rifaximin proved to be as safe and as effective as lactulose for the treatment of Korean patients with hepatic encephalopathy.

A Case of Refractory Pediatric Crohn's Disease with a Successful Treatment by Infliximab Therapy / 대한소화기학회지

Crohn's disease is a chronic inflammatory bowel disease which affects mainly children and young adults, and its cause remains unknown so far. Infliximab, a monoclonal antibody to the pivotal cytokine tumor necrosis factor-alpha, has been approved as a drug for both induction and maintenance therapy for moderately to severely active, or fistula-complicated Crohn's disease. The authors report a 12-year-old male patient diagnosed as Crohn's disease complicated with a perianal fistula, which was refractory to the conventional therapy. After the 0, 2, and 6 week scheduled intravenous infusion of infliximab, the patient reached to clinical remission in both subjective symptoms and objective manifestations. For children or young adults who develop Crohn's disease in a refractory course, infliximab may serve as a drug which leads to a clinical improvement or even to an extent of remission.

Can octreotide be the first line treatment for chylothorax?

BACKGROUND: Chylothorax is a rare but serious condition with a high rate of morbidity that may lead to death. It may be spontaneous or a complication of cardiac surgery. Treatment of this potentially harmful condition is not well established and may comprise dietary interventions. In order to avoid surgery, somatostatin and octreotide have been recently suggested as new modalities for the treatment of chylothorax. OBJECTIVE: To study the efficacy of octreotide for the treatment of chylothorax. METHOD: Cases reports. RESULT: The authors report two cases of chylothorax successfully treated with intravenous infusion of octreotide as an adjunct to conventional treatment. Furthermore, the authors report their last case who were treated successfully with octreotide as the first line drug without diet modification. CONCLUSION: It seems that octreotide is effective, noninvasive and safe. It can be used as an optional or first line treatment for chylothorax.

Oral erythromycin for treatment of feeding intolerance in preterm infants: a preliminary report.

Feeding intolerance is a common problem in preterm infants resulting in a prolonged hyperalimentation which is associated with an increased risk of serious and sometimes even life threatening complications, including cholestasis jaundice, liver impairment, nutritional deficiency, biochemical rickets and catheter-related septicaemia. Erythromycin, a commonly used macrolide antibiotic, has been reported as having potent prokinetic properties and enhancing gastrointestinal motor activity. The authors, therefore, conducted a preliminary study of oral erythromycin for the treatment of feeding intolerance in preterm infants to evaluate the safety and efficacy of this drug. AIM: To evaluate the safety and efficacy of oral erythromycin as a prokinetic agent in promoting enteral feeding in preterm infants with feeding intolerance. METHOD: Preterm infants, gestational age (GA) < or = 36 wk, who met the feeding intolerance criteria, were enrolled in the study. Inclusion criteria included infants who received enteral feeding less than half of full feeding or less than 75 ml/kg/day by day 14 post-natal age or gastric residual > or = 50 per cent of a given amount of feeding, more than 2 consecutive feeds by day 7 post-natal age. All patients received oral erythromycin ethylsuccinate 12 mg/kg every six hours for 2 days, then 3 mg/kg every six hours for 5 days. The times taken to establish full enteral feeding after the drug treatment and time to stop hyperalimentation were recorded. Potential adverse effects of erythromycin were assessed. Response to treatment was defined as decreased gastric residual < 30 per cent of a similar amount of the previous feed and was able to continue to full feeding. RESULTS: Ten preterm infants were enrolled in this study with a mean GA of 30.8 weeks (26-35), mean birth weight of 1,489 g (range 900-2,560 g) and mean age at entry of 9.2 days (range 7-12 days). Nine of 10 infants responded to treatment within 24 hours. The average time to establish full enteral feeding after the drug treatment was 6.6 days (range 4-10 days). None of the infants developed adverse effects such as vomiting, diarrhea, or pyloric stenosis. CONCLUSION: The preliminary data indicates that oral erythromycin is effective and safe in facilitating enteral feeding in preterm infants with feeding intolerance. Infants can achieve full feeding within a week after treatment, and this may shorten the course of hyperalimentaiton. Further randomized controlled trials are warranted.

Clinical use of erythromycin in children with gastrointestinal dysmotility.

Intolerant feeding is a common symptom in gastrointestinal disorders which is commonly found in systemic diseases. Prokinetic drugs play a role in management. A low dose of erythromycin has an effect on improvement of antroduodenal motility and gastric emptying in children and adults. The objective of this study was to evaluate the efficacy of intravenous erythromycin in the treatment of GI dysmotility in children. Retrospective studies were performed in the Department of Pediatrics, Siriraj Hospital, Mahidol University between 1996 and 2000 in 22 patients with intolerance of feeding due to GI dysmotility. Their ages ranged from 11 days to 12 years (42.1 +/- 48.1 months). The patients were divided into 2 groups: 12 critically ill and 10 non-critically ill patients. Dosages of intravenous erythromycin were 1-3 mg/kg/dose every 6 hours. The result of treatment was evaluated as: good (tolerant feeding), fair (tolerant feeding but needing erythromycin for longer than 1 month) and failed (intolerant feeding). All non-critically ill patients had improved symptoms with 9 +/- 4.3 days duration of treatment. In the other group, 8 patients had good results with 10.9 +/- 6 days of treatment. Two patients needed the drug for longer than 1 month and the other 2 patients did not respond and died due to severe infection. Low dose intravenous erythromycin had good efficacy in the treatment of intolerant feeding related to GI dysmotility in children.

Recidiva de la microlitiasis vesicular: estudio controlado con diferentes dosis de acido ursodesoxicolico / Recurrence of vesicular microlithiasis: controlled study with different dosis of ursodeoxycholic acid

Con la finalidad de hallar la dosis óptima de mantenimiento en pacientes, que previamente habían disuelto médicamente la microlitiasis vesicular (MLV) dentro de un protocolo establecido con ácido ursodesoxicólico (AUDC), fueron randomizados por el método "doble ciego" a recibir un comprimido diario posprandial de 150 mg de AUDC (grupo A, 15 pts.) o bien en la misma forma pero 300 mg (grupo B, 15 pts). Valorando el período libre de enfermedad con entrevistas clínicas periódicas y ecografías semestrales (días 0, 180 y 360). Al cabo de 12 meses de seguimiento terapéutico, la recidiva litiásica fue del 6.7 por ciento (1/15) en el grupo B vs un 66 por ciento (10/15) en el grupo A, (P< 0.005). Cuando se examina la recidiva en función del tipo de cálculos, esta fue del 8 por ciento (1/12) en las formas únicas vs un 55,5 por ciento (10/18) en las litiasis múltiples (P< 0.005). La recurrencia fue siempre sintomática (cólico vesicular), presentándose en 11 de 30 recidivados, como MLV en 7 y como "barro biliar" en los 4 restantes. Se concluye que 300 mg/día de AUDC fueron eficaces para prevenir la recidiva al cabo de un año en más del 90 por ciento de los tratados y sin efectos adversos. Los dos factores de riesgo estadísticamente signigicativos asociados a recurrencia fueron: las dosis bajas de AUDC y las MLV múltiples pretratamiento. El "barro biliar" se presentó conformando el espectro de la enfermedad vesicular litiásica, constituyendo el 36 por ciento de las recidivas.