Severe eosinophilic infiltration in colonic biopsies predicts patients with ulcerative colitis not responding to medical therapy.

AIM: Eosinophils are potent proinflammatory cells that are involved in the pathogenesis of ulcerative colitis (UC). We evaluated the infiltration of eosinophils into the lamina propria in patients with active and inactive ulcerative colitis (UC) and investigated its clinical significance, among other variables, in predicting the outcome of medical treatment in active disease. METHOD: We studied colorectal biopsy specimens from 18 UC patients with disease in long-standing remission, from 22 patients with active disease who responded to therapy (12 with complete response and 10 with partial response) and from 10 patients who were nonresponders. Demographic information was obtained at baseline, and clinical, endoscopic and laboratory data were obtained at baseline and 12 weeks post-treatment. We evaluated five histological features: mucosal ulceration; mucosal erosions; crypt abscesses; cryptitis; and eosinophilic infiltration of the lamina propria. The severity of these lesions was graded as: none or minimal; mild; moderate; or severe. Statistical analyses were performed between responders and nonresponders for differences in demographic, clinical, laboratory, endoscopic and histological parameters. RESULTS: Laboratory, endoscopic and histological parameters were significantly improved after treatment only in the complete responders group. Analyses of baseline data revealed no significant differences in parameters between complete or partial responders and nonresponders, except for a less severe eosinophilic infiltration of lamina propria in complete responders (P < 0.05). Multiple logistic regression analysis showed that severe eosinophilic infiltration in colonic biopsies was the most significant predictor of poor response to medical therapy. CONCLUSION: Assessing the severity of eosinophilic infiltration in the lamina propria of colonic biopsies in patients with ulcerative colitis could be a valuable predictive tool of response to medical therapy.

Total knee arthroplasty in severe valgus deformity: interest of combining a lateral approach with a tibial tubercle osteotomy.

INTRODUCTION: Among the patients requiring total knee arthroplasty (TKA), approximately 10-15% presents with a valgus deformity (VD). Severely deformed valgus knees represent a surgical challenge. The purpose of this study is to evaluate the results of TKA in grade II and III valgus knee deformities (Ranawat classification), focusing on axis correction, by using a lateral parapatellar capsulotomy combined with tibial tubercle osteotomy. HYPOTHESIS: The lateral approach in combination with a tibial tuberosity osteotomy is highly beneficial in the treatment of severe valgus knees in patients undergoing primary TKA, for correction of anatomical axis. PATIENTS AND METHODS: Between January 1995 and December 2001, 33 patients with severe VD, grade II and III, were treated with TKA by one surgeon. Twenty-six patients (19 male, seven female) with mean age of 72 years (57-79) were dealt with a resurfacing posterior stabilized design; whereas in seven cases, a constrained type implant was used. These seven patients were excluded from the study. Two more patients were lost for follow-up and were also excluded. The axis deviation of the remaining 24 patients ranged from 15 to 35 degrees, (average 23°). A lateral parapatellar arthrotomy, in combination with tibial tubercle osteotomy was used. Patients' clinical evaluation - using the International Knee Society (IKS) score - with simultaneous radiological assessment was performed yearly after the operation; and for a mean follow-up time of 11.5 years (8 to 15 years). RESULTS: The mean IKS score improved from 44 points (34 to 52) preoperatively, to 91 points (68 to 100) postoperatively, at the last follow-up. In terms of alignment parameter, only two knees had a residual valgus deviation greater than 7° (ideal range : 3-7°). One knee exhibited a 9° valgus, and another one 10°, according to anatomical axis measurments. In one case, there was a 5mm proximal migration of the osteotomised tuberosity fragment, due to breakage of the screw. However, the final outcome was not affected. There were no cases of tibial tubercle's non-union; neither of delayed instability. CONCLUSION: The lateral approach is a useful approach in the treatment of severe valgus knee deformity in patients undergoing primary TKA. Anatomical axis restoration is facilitated, as the contracted structures are easily accessed and, in severe cases, the patellar alignment may be achieved by displacing the osteotomised tubercle. However, careful fixation of the tuberosity is mandatory. LEVEL OF EVIDENCE: Level IV, prospective study of case series.

A study comparing tolerability, satisfaction and acceptance of three different techniques for esophageal endoscopy: sedated conventional, unsedated peroral ultra thin, and esophageal capsule.

Three methods of esophagoscopy are available until now: sedated conventional endoscopy, unsedated ultrathin endoscopy, and esophageal capsule endoscopy. The three methods carry comparable diagnostic accuracy and different complication rates. Although all of them have been found well accepted from patients, no comparative study comprising the three techniques has been published. The aim of this study was to compare the three methods of esophagoscopy regarding tolerability, satisfaction, and acceptance. Twenty patients with large esophageal varices and 10 with gastroesophageal reflux disease were prospectively included. All patients underwent consecutively sedated conventional endoscopy, unsedated ultrathin endoscopy, and esophageal capsule endoscopy. After each procedure, patients completed a seven-item questionnaire. The total positive attitude of patients toward all methods was high. However, statistical analysis revealed the following differences in favor of esophageal capsule endoscopy: (i) total positive attitude has been found higher (chi(2)= 18.2, df = 2, P= 0.00), (ii) less patients felt pain (chi(2)= 6.9, df = 2, P= 0.03) and discomfort (chi(2)= 22.1, df = 2, P= 0.00), (iii) less patients experienced difficulty (chi(2)= 13.7, df = 2, P= 0.01), and (iv) more patients were willing to undergo esophageal capsule endoscopy in the future (chi(2)= 12.1, df = 2, P= 0.002). Esophageal capsule endoscopy was characterized by a more positive general attitude and caused less pain and discomfort. Sedated conventional endoscopy has been found more difficult. More patients would repeat esophageal capsule endoscopy in the future. Patients' total position for all three available techniques for esophageal endoscopy was excellent and renders the observed advantage of esophageal capsule endoscopy over both sedated conventional and unsedated ultrathin endoscopy a statistical finding without a real clinical benefit.

Cholestatic hepatitis with severe systemic reactions induced by trimethoprim-sulfamethoxazole.

Trimethoprim-Sulfomethoxazole (TMP-SMX) related hepatotoxicity and associated severe systemic reaction are not frequent and documented only in case reports. We report a case of a 30-year-old man, who underwent a 15-day therapy with TMP-SMX for urinary tract infection and two weeks later developed acute cholestatic hepatitis, fever and a skin rash followed by severe systemic reaction. He was admitted in Intensive Care unit and with supportive therapy and prednisolone administration, he showed subsequent improvement over a period of few days. He had fully recovered months later. All tests for other causes of liver disease were negative and his liver biopsy showed evidence of drug-induced hepatic injury.

Focal fatty liver sparing lesion presenting as a "pseudotumour": case report.

We are reporting our experience of a case of "focal fatty liver sparing lesion" in a 24-year-old patient, without any evident predisposing factors for fatty infiltration of the liver. Fatty liver infiltration was sparing the posterior part of liver segment VI, defining an area which was mimicking a lesion on US and CT. Fatty liver infiltration is usually diffuse but may be patchy or localized. Occasionally, focal areas of normal parenchyma in an otherwise diffuse fatty liver may simulate mass lesions. Typically, these "pseudolesions" appear as echo-poor areas against a background of bright echoes due to fatty infiltration and may pose a difficult diagnostic problem. We present this case and discuss the investigation process in order to differentiate this lesion from a hepatic tumor.

Needle-knife fistulotomy versus needle-knife precut papillotomy for the treatment of common bile duct stones.

BACKGROUND: The aim of this prospective study was to evaluate and compare the efficacy and safety of two different precutting techniques in the treatment of 103 consecutive patients with choledocholithiasis. METHODS: The patients were randomized into two groups. The first group included 74 patients who underwent needle-knife fistulotomy avoiding the papillary orifice followed by standard papillotomy. Fifty-two of these patients had a final diagnosis of choledocholithiasis. The second group included 79 patients who underwent needle-knife precut papillotomy starting from the papillary orifice followed by standard papillotomy. Fifty-one of these patients had a final diagnosis of choledocholithiasis. RESULTS: Precutting was successful in 90.54% of patients in the needle-knife fistulotomy group and 88.6% of patients in the needle-knife precut papillotomy group. Stone extraction without mechanical lithotripsy was achieved in 40 of 48 (83.33%) patients in the needle-knife fistulotomy group and 45 of 46 (97.82%) patients in the needle-knife precut papillotomy group (p < 0.05). For the other patients, stone extraction was achieved with the aid of a mechanical lithotriptor. Complications were as follows for the needle-knife fistulotomy and needle-knife precut papillotomy groups, respectively: bleeding, 6.75% and 5.06%; perforation, 2.7% and 2. 53%; cholangitis, 1.35% and 0; pancreatitis, 0 and 7.59% (p < 0.05); hyperamylasemia, 2.7% and 17.72% (p < 0.01); and death, 0 and 1.26%. CONCLUSIONS: Both methods are effective in the management of choledocholithiasis. When needle-knife fistulotomy is performed, however, lithotripsy is needed more often. Needle-knife fistulotomy is safer than needle-knife precut papillotomy with respect to pancreatic complications.

Sump syndrome: endoscopic treatment and late recurrence.

OBJECTIVE: Biliary sump syndrome is a rare complication of biliary-enteric anastomosis. Classically, the distal bile duct becomes obstructed by food, stones, or debris after choledochoenterostomy. Endoscopic sphincterotomy has been recommended as the primary and definitive treatment modality. The aim of our study was to confirm the short and long term therapeutic efficacy of endoscopic treatment in a long follow-up period. METHODS: The series include 31 patients with characteristic clinical illness after choledochoduodenostomy. All of them were successfully treated by endoscopic sphincterotomy and bile duct clearance with a balloon catheter or basket. The follow-up period ranged from 18 to 84 months (median: 51 months). RESULTS: Clinical improvement was immediate in all patients. No complications were recorded. Recurrence of the syndrome, with restenosis of the sphincterotomy opening, was observed in six patients (19%) and was treated successfully and safely with a new papillotomy. Sump syndrome recurrence occurred 31-72 months (median: 58.5 months) after the initial treatment. CONCLUSIONS: We report a considerably high recurrence rate of sump syndrome after initially successful endoscopic management and its effective endoscopic treatment with a new papillotomy. We still believe that the primary therapeutic approach in patients with sump syndrome should be endoscopic.

Mediators of inflammation: production and implication in inflammatory bowel disease.

Ulcerative colitis and Crohn's disease, regardless of the initiating events, share common immunologically mediated pathways of tissue injury and repair. Although their etiology remains unknown, increasing evidence suggests that activated immunological effector mechanisms within the intestinal mucosa are responsible for the pathogenesis of the diseases. Activation of immune, mesenchymal and epithelial cells; transmigration of leukocytes from the circulation to the sites of inflammation; tissue damage; and healing phase are mediated by a number of soluble mediators released by activated intestinal cells. These mediators are involved in a network of cell communication, affecting immune response, synthesis and release of enzymes, and cell proliferation. In the last decades, the identification of potential mediators in intestinal inflammation has expanded to include eicosanoids, platelet activating factor, biogenic amines, kinins, proteases, reactive oxygen species, complement components, cytokines, chemokines, nitric oxide, and neuropeptides. An increasing understanding suggests that in inflammatory bowel disease, regardless of the predisposing and trigger factors, a disruption of certain regulatory mechanisms, mediated by these soluble molecules, results in pathological immune responses to antigens and in chronic inflammation.

Gastroscopic findings in Mediterranean Kaposi's sarcoma (non-AIDS).

The frequency and degree of gastrointestinal involvement in patients with Mediterranean Kaposi's sarcoma (non-AIDS), a newly recognized form of Kaposi's sarcoma, is unknown. Eighty-seven patients with Mediterranean Kaposi's sarcoma proven by skin and/or nodal biopsy underwent endoscopic study of the upper gastrointestinal tract. Of these, 71 (81.6%) had gastrointestinal lesions. All these patients had lesions in the stomach. Additional lesions were detected in the esophagus in 19 patients and in the proximal duodenum in 8 patients, whereas additional lesions in both the esophagus and duodenum were identified in 2 patients. The lesions were classified into 4 types according to their size, shape, and color. Most types of lesions showed characteristic discoloration, but lesions with the appearance and color of normal mucosa that histologically were shown to be Kaposi's sarcoma were also identified. The high prevalence of gastrointestinal involvement in patients with Mediterranean Kaposi's sarcoma (non-AIDS) suggests that an endoscopic examination of the upper gastrointestinal tract may be useful in non-AIDS-related forms of Kaposi's sarcoma.