Subjective expectations regarding longevity and future health: a cross-sectional survey among patients with Crohn's disease.

AIM: The aim was to explore the subjective health expectations (sHE) of patients with Crohn's disease (CD) for both the near future and the elderly. METHOD: A cross-sectional survey was performed in four gastroenterology centres in Hungary. Consecutive outpatients with CD with age ≥ 18 were recruited. Socio-demographic and disease characteristics were recorded and the Crohn's Disease Activity Index (CDAI), Perianal Disease Activity Index, Patients' Global Assessment (PGA) and current pain visual analogue scale (VAS) were assessed. Subjective life expectancy (sLE) was explored and compared to statistical life expectancy. Current health and sHE for 1 year ahead and for ages 60/70/80/90 were assessed using the descriptive system of the EQ-5D-3L. RESULTS: In all, 206 patients (54.9% men) with a mean age of 34.7 (SD 10.5 years) and disease duration of 10.5 (SD 6.3) years were studied. The CDAI score was 110.5 (SD 77.0) and 66% were treated by biologic drugs. Mean current EQ-5D-3L score was 0.80 (SD 0.17) and patients expected a 0.05 (SD 0.15) improvement within a year (P < 0.05). For ages 60/70/80/90, a mean EQ-5D-3L score of 0.59, 0.38, 0.10 and -0.12 respectively was provisioned. Age, current health status, sLE, PGA and pain VAS showed significant correlation with both 1-year and older age sHE (P < 0.05). Long-term sHE and sLE were negatively affected by the presence of extraintestinal manifestations but not by previous CD-related surgery. CONCLUSION: Patients with CD expect severe deterioration in health in later life. Given that unrealistic sHE may affect patients' current quality of life and health behaviour, we encourage physicians to explore and consider CD patients' sHE in clinical care.

Randomised clinical trial: mesalazine versus placebo in the prevention of diverticulitis recurrence.

BACKGROUND: Previous studies have reached conflicting conclusions regarding the efficacy of mesalazine in the prevention of recurrent diverticulitis. AIM: To investigate the efficacy and safety of mesalazine granules in the prevention of recurrence of diverticulitis after acute uncomplicated diverticulitis. METHODS: Two phase 3, randomised, placebo-controlled, double-blind multicentre trials (SAG-37 and SAG-51) investigated mesalazine granules in patients with prior episodes (<6 months) of uncomplicated left-sided diverticulitis. Patients were randomised to receive either 3 g mesalazine once daily or placebo (SAG-37, n=345) or to receive either 1.5 g mesalazine once daily, 3 g once daily or placebo for 96 weeks (SAG-51, n=330). The primary endpoint was the proportion of recurrence-free patients during 48 weeks (SAG-37 and SAG-51) or 96 weeks (SAG-51) of treatment. RESULTS: Mesalazine did not increase the proportion of recurrence-free patients over 48 or 96 weeks compared to placebo. In SAG-37, the proportion of recurrence-free patients during 48 weeks was 67.9% with mesalazine and 74.4% with placebo (P=.226). In SAG-51, the proportion of recurrence-free patients over 48 weeks was 46.0% with 1.5 g mesalazine, 52.0% with 3 g mesalazine and 58.0% with placebo (P=.860 for 3 g mesalazine vs placebo) and over 96 weeks 6.9%, 9.8% and 23.1% respectively (P=.980 for 3 g mesalazine vs placebo). Patients with only one diverticulitis episode in the year prior to study entry had a lower recurrence risk compared to >1 episode. Safety data revealed no new adverse events. CONCLUSION: Mesalazine was not superior to placebo in preventing recurrence of diverticulitis.

Early clinical remission and normalisation of CRP are the strongest predictors of efficacy, mucosal healing and dose escalation during the first year of adalimumab therapy in Crohn's disease.

BACKGROUND: Adalimumab is a fully human monoclonal antibody targeting tumour necrosis factor with proven efficacy in the treatment of Crohn's disease (CD). AIM: To investigate the predictors of medium-term clinical efficacy and mucosal healing during adalimumab therapy, in patients with CD, in specialised centres approved for biological therapy in Hungary. METHODS: Data capture of the 201 CD patients was standardised and prospective (male/female: 112/89, median age: 33.0 years, duration: 8 years). Previous infliximab therapy had been administered in 48% of patients, concomitant steroids in 41%, azathioprine in 69% and combined therapy in 27% of patients. RESULTS: Overall clinical response and remission rates at 24 weeks were 78% and 52%, respectively; at 52 weeks were 69% and 44%, respectively. Endoscopic improvement and healing were achieved in 43% and 24% of patients. In a logistic regression model, clinical efficacy and CRP at week 12, need for combined immunosuppression at induction, shorter disease duration and smoking were identified as independent predictors for 12-month clinical outcome, whereas CRP at week 12, clinical remission at week 24, inflammatory parameters and nonsmoking were associated to endoscopic improvement/healing. Intensification to weekly dosing was needed in 16% of patients. Parallel azathioprine therapy and clinical remission at week 12 were inversely associated with dose escalation. CONCLUSIONS: Clinical efficacy and normalised CRP at week 12 (early deep clinical remission) are associated with medium-term clinical efficacy and mucosal healing during adalimumab therapy, whereas need for combined immunosuppression at induction and smoking status are predictors for non-response. Parallel azathioprine therapy may decrease the probability for dose escalation.

Esophageal intramural metastasis from adenocarcinoma of the gastroesophageal junction.

Among a total of 143 patients examined for diagnosis of adenocarcinoma of the cardia, intramural esophageal metastases were verified in six patients (4.19 %). In each case the diagnosis was confirmed by histological examination. The histological structure of the primary tumors and metastases was the same. Metastases were detected by endoscopic ultrasound examination in three cases. All the cardia tumors proved to be well advanced. As well as endoscopic identification of the primary tumor, thorough examination of the proximal part of the esophagus is of great importance.

[Siewert-Stein classification of adenocarcinoma of the esophagogastric junction]. / Az oesophagogastricus junctio adenocarcinomáinak Siewert-Stein klasszifikációjáról.

Nowadays the terminology used for the definition of adenocarcinomas at the oesophagogastric junction is "cardiac carcinoma", which can be easily misunderstood. This definition of adenocarcinomas of the oesophagogastric junction does not allow correct comparison of diagnosis (endoscopic, radiological and pathologic), epidemiology and surgical therapy in national and international aspects, because different tumours can develope in the same area, and all called cardia tumors. Siewert and Stein recommended a classification to solve this problem. The classification of the tumours is morphological/topographical. Type I is adenocarcinoma of the distal part of the oesophagus. Type II is adenocarcinoma of the real cardia and type III is subcardial gastric adenocarcinoma. At classification, we always consider results of endoscopy (ortograde and retroflexed view of the oesophago-gastric junction), the x-rays of the oesophagus and stomach, findings at the operation and pathohistologic results. Between 1/1/1974 and 31/12/2000, a total number of 50,878 upper panendoscopic examinations were performed at the Endoscopic Laboratory of the Surgical Department. Adenocarcinoma of the cardia was diagnosed in 488 patients. According to the Siewert-Stein classification, type I tumour was found in 123 (25.2%), type II in 240 (49.18%), and type III was present in 125 (25.61%) patients. The importance of this classification is it enables unified pre-operative assessment and it can also help to decide the type of the surgical intervention. In our patients with type I cancer--depending of the size of the tumour--distal 2/3 oesophagectomy with the resection of the proximal lesser curve of the stomach or total gastrectomy were performed. In the first group oesophago-jejuno-gastrostomy, in case of total gastrectomy Roux-en-Y loop anastomosis was created. In patients with types II and III cancers total gastrectomy was performed. In every patient lymphadenectomy was performed. We suggest the use of this new classification in clinical, gastroenterology--with special regard to the endoscopy--and pathology.

[Endoscopic diagnosis of gastrointestinal bleeding of unknown origin]. / Az ismeretlen eredetú gasztrointesztinális vérzések enteroszkópos diagnosztikája.

In recent years push enteroscopy has become the most important method in the examination of patients with obscure gastrointestinal bleeding. We summarise our experiences with 148 enteroscopies performed on 140 patients with bleeding of unknown origin. The source of bleeding could be identified in 81 patients (57.86%). The most common lesions were small bowel tumors (13.57%) and vascular malformations (12.86%). Several patients (22.86%) referred for enteroscopy had lesions in the esophagus, stomach and proximal duodenum that were missed at upper endoscopy. The authors conclude that push enteroscopy has a major role in the evaluation of patients with obscure gastrointestinal bleeding. Enteroscopy should be the first diagnostic step after negative esophago-gastroduodenoscopy and negative colonoscopy. Enteroscopy seems to be superior to other diagnostic methods. It is well tolerable and is not time consuming.

[Thrombophilia in ulcerative colitis]. / Thrombophilia jelensége colitis ulcerosában.

The authors report a combined occurrence of thrombophilia and colitis ulcerosa and provide an analysis of relevant references in earlier works. It is likely intertwinning of the two disease's symptoms, the chronic cause of the condition and the underlying molecular biology variations cannot be traced back to a single cause. Further research is required to establish whether the protein-C anomaly exhibited in the presented case is general in this condition or an individual occurrence. The publication emphasises that in future cases it will be advisable to perform tests capable of proving or refuting the abnormality of protein-C.

[Pharmacologic therapy of Crohn's disease and ulcerative colitis]. / A Crohn-betegség és a colitis ulcerosa gyógyszeres kezelése.

Important progress has been made in recent years in the understanding of pathogenesis of Crohn's disease and ulcerative colitis, but the cause of IBD remains obscure, so curative therapy is still lacking. Current treatment strategies as sulphasalazine, mesalasine, glucocorticosteroids are mainly anti-inflammatory. In the past years the greatest advances have been characterised by the more widespread use of topically acting steroids, immunosuppressants and by the introduction of immunomodulatory agents as cytokines and anticytokines. The author summarises the standard therapy and new possibilities of medical treatment for IBD and suggests some algorythms for clinical practice.

Tissue concentrations and correlations of prostaglandins in healthy and inflamed human esophageal and jejunal mucosa.

The PGE2, PGF2 alpha, PGI2, and TXB2 content in biopsies of healthy esophageal mucosa and inflamed mucosa and from subjects with chronic esophagitis was measured and statistically analyzed. No significant differences were found between the tissue concentrations of prostaglandins in the inflamed and the healthy mucosa, except for elevated PGI2 content in the inflamed esophageal mucosa in comparison to healthy mucosa. The prostaglandin content of jejunal mucosa was unchanged in jejunitis and in atrophy compared to findings in healthy subjects. Regression analysis revealed a significant negative correlation between the PGF2 alpha and PGI2 content in both inflamed esophageal and inflamed jejunal mucosa. In healthy mucosa, no correlation was found between the tissue concentrations of these two prostaglandins, either in the esophagus or in the jejunum. These results suggest the redistribution of cyclic endoperoxide metabolism under certain pathological conditions.

[Diagnostic problems of Wilson disease]. / A Wilson-kór diagnosztikájának problémái.

A family (three siblings) of Wilson's-disease is described. The authors review the pathogenesis, diagnostics, pathology and treatment of Wilson's-disease. The diagnostic difficulties are emphasised. The variety of liver lesions are demonstrated in the different grades of the disease. The importance of the early diagnosis is stressed.

Intraoperative colonoscopy.

The authors performed intraoperative colonoscopy in 31 patients. This examination is done if preoperative colonoscopy was not performed or incomplete, and intraoperative difficulty occurs. In addition, it is indicated to localize non-palpable lesions, to perform polypectomy (if unsuccessful preoperatively but manageable intraoperatively), to define the site of endoscopic polypectomy, in certain instances to determine the resection plane, and after resection of constrictive tumours to look over the proximal intestinal section, to detect the synchronous lesions. It is emphasized that by their method the opening of the lumen becomes avoidable thus resulting in a decreased postoperative morbidity and mortality.

[Endoscopic study of the small intestine]. / A vékonybél endoscopos vizsgálata.

The author summarises the possibilities of small bowel endoscopy. In case of haemorrhage of unknown origin, enteroscopy may be helpful. Sonde type fiber- or video-enteroscopes can be used. This procedure is time-consuming and needs an experienced team. In case of life-threatening bleeding intraoperative enteroscopy is recommended. "Push" enteroscopy is the best, rapid method in the diagnostics of suspected diffuse intestinal diseases or circumscript lesions of the proximal small bowel. Adult or pediatric colonoscopies or jejunoscopes are available for this investigation. Endoscopic biopsy specimens are suitable for histological examination and for enzyme assay as well. Aspiration of jejunal fluid for bacteriological culture is a way for revealing of bacterial overgrowth. The author emphasises the importance of the deep duodenoscopy made by an upper panendoscope in the diagnostics of villous atrophy.

[Gallstone ileus after endoscopic sphincterotomy]. / Epeköileus endoscopos sphincterotomia után.

The authors report on a case of gallstone ileus developed after endoscopic sphincterotomy (EST). The patient had to be operated and recovered uneventfully after enterotomy. Emphasis is placed on the importance of patient's observation after EST so this rare complication could be revealed in time.

[Tomato skin in the common bile duct after endoscopic sphincterotomy]. / Endoszkópos sphincterotomia után a közös epevezetékbe jutott paradicsomhéjakról.

Lithotomy and endoscopic sphincterotomy were carried out in a 83-year-old woman because of choledocholithiasis. One year later calculi and tomato skins were found in the common bile duct. Significance is attributed to the tomato skins in the development of calculi. The attention is drawn to the observation that operative interventions performed through the Vater's papilla, spontaneous or iatrogenic choledochoduodenal fistulas create favourable conditions for foreign material to get into the choledochus and this may cause lithogenesis.

Measurement and demonstration of lactase and sucrase activities in jejunal mucosa.

Jejunal lactase and sucrase activities were demonstrated on endoscopically obtained biopsy specimens by a rapid test which had been developed earlier. The results were compared with enzyme activities found by Dahlquist's method. The data suggest that the rapid test is suitable for the semiquantitative determination of lactase and sucrase, and the results correlate with enzyme activities measured by the Dahlquist assay. The main advantage of the test is that it is rapid, simple, and cheap, and because no special equipment is necessary, it can be used in any endoscopic department.

[A rapid test for the analysis of lactase and sucrase activity in the jejunum (a comparative study)]. / A jejunum laktáz és szaharáz aktivitásának kimutatása gyorsteszttel. (Osszehasonlítóvizsgálat)]

Jejunal lactase and sucrase activities were demonstrated in biopsy specimens obtained endoscopically using a rapid test which had been developed previously. The results were compared with enzyme activities determined by Dahlquist's method. The data suggest that the rapid test is suitable for the demonstration about the presence of lactase and sucrase, and the results are correlated with enzyme activities measured by assay. The main advantage of the test, that it is rapid, simple and cheap, no special equipments are necessary, so it can be used in every endoscopic department.