Evaluation and management of esophageal manifestations in systemic sclerosis.

Systemic sclerosis (SSc) is a multisystemic autoimmune connective tissue disorder; in the gastrointestinal tract, the esophagus is the most commonly affected organ. Symptoms of esophageal disease are due to gastroesophageal reflux disease (GERD) and esophageal motor dysfunction. Since the development of high-resolution manometry (HRM), this method has been preferred for the study of SSc patients with esophageal involvement. Using HRM, classic scleroderma esophagus, defined as absent or ineffective peristalsis of the distal esophagus in combination with a hypotensive lower esophageal sphincter, was found in as many as 55% of SSc patients. Endoscopy is the appropriate test for evaluating dysphagia and identifying evidence and possible complications of GERD. In the therapeutic area, treatment ranges from general supportive measures to the administration of drugs such as proton pump inhibitors and/or prokinetics. However, as many SSc patients do not respond to existing therapies, there is an urgent need for new therapeutic modalities. Buspirone, a 5-hydroxytryptamine 1A receptor agonist, could be a putative therapeutic option, as it was found to exert a significant beneficial effect in SSc patients with esophageal involvement. This review summarizes our knowledge concerning the evaluation and management of esophageal manifestations in SSc patients, including emerging therapeutic modalities.

Predictors of tissue healing in ulcerative colitis patients treated with anti-TNF.

AIM: To identify factors predicting mucosal healing in ulcerative colitis patients treated with anti-TNFα agents with or without azathioprine. METHODS: In a prospective, multicenter, one-year study biologic naïve patients aged 25-65 years, with corticosteroid-dependent or refractory colitis received combination treatment with anti-TNFα and azathioprine for 6 months followed by anti-TNFα monotherapy. Patients who denied combination therapy or were outside this age range received anti-TNFα monotherapy (controls). Before and at weeks 12 and 54 of treatment the total Mayo score was calculated. Mucosal healing was defined as endoscopic subscore of 0. Mucosal expression of T helper (Th) cell-lineage specific transcription factors (Tbet, Gata3, Rorc, FoxP3) before treatment was also associated with mucosal healing. RESULTS: Of 67 patients, 58 (86.6%) received combination and 9 (13.4%) anti-TNFα monotherapy. Overall 29 (43.3%) patients achieved mucosal healing; rates were higher in patients receiving combination therapy vs. monotherapy (p=0.03) and in azathioprine naïve vs. exposed patients in the combination group (p=0.01). Mucosal healing was associated with lower pre-treatment mucosal expression of transcription factor Th1-Tbet (p<0.05) and higher expression of Th17-Rorc (p<0.05). CONCLUSIONS: Mucosal healing was associated with combination therapy, especially in biologic and azathioprine-naïve patients and pre-treatment mucosal expression of specific Th specific transcripting factors (Tbet and Rorc).

Reliability and applicability of two-dimensional shear-wave elastography for the evaluation of liver stiffness.

BACKGROUND/AIM: Two-dimensional shear-wave elastography (2D-SWE) is a new elastographic technique that is increasingly being used across several indications. We assessed the reliability and applicability of 2D-SWE in patients with various chronic liver diseases and attempted to identify parameters potentially affecting liver stiffness. METHODS: We included all patients with chronic liver disease who underwent 2D-SWE examination over a 15-month period. Patients with acute hepatitis, active cholestatic disease, or severe heart failure were excluded. The procedures were performed by three adequately trained operators. Standard operating procedures for liver ultrasonography and elastography were followed. RESULTS: 2D-SWE was reliable in 98% of 605 patients. SD to mean liver stiffness value ratio greater than 9.14%, which was considered an indicator of reliability, was associated independently with age more than 50 years, obesity, or overweight, and use of statins for hyperlipidemia. 2D-SWE was applicable, requiring a median time of 7 min per examination and exceeding 15 min in only 5.5% of patients. Worse applicability expressed as duration more than 0.7 min per reliable measurement was associated independently with age more than 50 years and obesity. The mean and median liver stiffness values were 11.6 and 7.7 kPa, respectively. Liver stiffness more than 7.7 kPa was associated independently with age more than 50 years and increased waist circumference. CONCLUSION: 2D-SWE represents an applicable method of assessment of liver fibrosis that can provide reliable results in the vast majority of patients with chronic liver diseases. Older age and obesity may affect the reliability and applicability of the method as well as the severity of liver fibrosis.