Re-introduction of azathioprine in previously intolerant patients.

BACKGROUND AND AIMS: Azathioprine is an important steroid sparing agent in the management of patients with inflammatory bowel disease. However, side effects are a problem in a significant minority of patients. We proposed that desensitization might increase the number of patients able to tolerate the drug. METHODS: Successive inflammatory bowel disease patients who were intolerant to azathioprine in our hospital gastroenterology clinic were invited to recommence the drug at a low dose, gradually building up to a therapeutic dose. Patients were observed for the recurrence of side effects. Patients who did not wish to participate were offered alternative immunosuppressant therapy. RESULTS: Fourteen patients elected to attempt desensitization. Nine of these (64%) were able to tolerate a full dose of azathioprine. The remainder suffered a return of their side effects and were offered alternative treatment. CONCLUSIONS: Azathioprine can be tolerated in some people who have been previously intolerant by the use of desensitization.

Making the diagnosis of coeliac disease: is there a role for push enteroscopy?

Coeliac disease is one of the most common genetically based diseases. The wide clinical spectrum of the disease and the availability of highly specific antibody testing have led to an increased number of patients undergoing gastroscopy with distal duodenal biopsies. Histological confirmation of the characteristic small bowel changes with partial or total villous atrophy remain the gold standard for making a diagnosis. Patients with positive antibodies but initially negative or uncertain biopsies pose a particular diagnostic dilemma. Due to the patchiness of the histological changes, push enteroscopy with jejunal biopsies can play a valuable role in this group of patients. Similarly, patients with refractory coeliac disease can benefit from push enteroscopy with jejunal biopsies.