SARS-CoV-2 Igg seroprevalence in IBD patients treated with biologics: first vs. second pandemic wave in a prospective study.

OBJECTIVE: In a prospective study, SARS-CoV-2 IgG seroprevalence was assessed during the second pandemic wave (W2) in a cohort of Inflammatory Bowel Disease (IBD) patients using biologics. The secondary aim was to compare, in the same cohort, the frequency of seropositivity and of COVID-19 during the second vs. the first (W1) wave. PATIENTS AND METHODS: From November 2020 to March 2021, SARS-CoV-2 IgG seropositivity and the prevalence of COVID-19 were assessed in a cohort of IBD patients using biologics already studied at W1. INCLUSION CRITERIA: age ≥ 18 years; diagnosis of IBD; follow-up; written consent. EXCLUSION CRITERIA: SARS-CoV-2 vaccination. Risk factors for infection, compatible symptoms, history of infection or COVID-19, nasopharyngeal swab test were recorded. Data were expressed as median [range]. The χ2 test, Student's t-test, logistic regression analysis was used. RESULTS: IBD cohort at W1 and W2 included 85 patients: 45 CD (52.9%), 40 UC (47.1%). When comparing the same 85 patients at W2 vs. W1, a higher SARS-CoV-2 seroprevalence at W2 was at the limit of the statistical significance (9.4% vs. 2.3%; p=0.05). The prevalence of COVID-19 at W2 vs. W1 was 3.5% (3/85) vs. 0% (0/85) (p=0.08). Contacts with COVID-19 patients and symptoms compatible with COVID-19 were more frequent at W2 vs. W1 (18.8 % vs. 0%; p=0.0001; 34.1% vs. 15.3%; p=0.004). At W2, history of contacts and new onset diarrhea were more frequent in seropositive patients [4/8 (50%) vs. 12/77 (15.6%); p=0.01 and 4/8 (50%) vs. 2/77 (2.6%); p=0.0001]. At W2, the risk factors for seropositivity included cough, fever, new onset diarrhea, rhinitis, arthromyalgia, dysgeusia/anosmia at univariate (p<0.05), but not at multivariate analysis. History of contacts was the only risk factor for seropositivity at univariate (p=0.03), but not at multivariate analysis (p=0.1). CONCLUSIONS: During W2, characterized by a high viral spread, IBD and biologics appeared not to increase the prevalence of SARS-CoV-2 infection or COVID-19 disease. New onset diarrhea mimicking IBD relapse may be observed in patients with SARS-CoV-2 infection.

Multiple hepatic and brain abscesses caused by Parvimonas micra: A case report and literature review.

Gram-positive anaerobic cocci (GPAC) are responsible for 30% of anaerobic infections. Parvimonas micra is an emergent pathogen that is part of the oral and gastrointestinal commensal flora, and its role in several infection processes has recently emerged thanks to the improvement of diagnostic techniques. P. micra bacteraemia is reported in immunocompromised patients and is often complicated by abscesses. Here, we present a case study of multiple hepatic and brain abscesses caused by P. micra bacteraemia in a patient with complicated diverticulitis.

Low prevalence of SARS-CoV-2 infection in inflammatory bowel disease.

OBJECTIVE: Treatments used in Inflammatory Bowel Disease (IBD) have been associated with enhanced risk of viral infections and viral reactivation, however, it remains unclear whether IBD patients have increased risk of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection. The aim of the study was to examine the prevalence of SARS-CoV-2 IgG positivity in IBD patients followed at our referral center. The role of treatments for IBD and risk factors for infection were also evaluated. PATIENTS AND METHODS: In a prospective study, all IBD patients followed at our referral centre between May 27th and July 21st, 2020 and fulfilling the inclusion criteria were tested for SARS-CoV-2 IgG. Specific IgG antibodies were evaluated by a commercial ELISA kit and SARS-CoV-2 nasopharyngeal swab was performed in seropositive patients. RESULTS: Two-hundred and eighteen patients, 128 Crohn's disease (CD) and 90 Ulcerative colitis (UC) [age 44, (19-77) years; ongoing biologics in 115 (52.7%)] were enrolled. No patient had major SARS-CoV-2-related symptoms. SARS-CoV-2 IgG were detected in 3 out of 218 (1.37%) patients with IBD (2 CD and 1 UC), all on biologics (2.6%). In all of the 3 seropositive patients, the nasopharyngeal swab was negative. There was no relationship between SARS-CoV-2 seroprevalence and the demographic/clinical characteristics of IBD patients. In contrast, history of recent travel was more frequent in the SARS-CoV-2 seropositive patients (2/3; 66.6%) than in SARS-CoV-2 seronegative patients [7/215 (3.25%); p<0.0001]. CONCLUSIONS: The prevalence of SARS-CoV-2 IgG seropositivity in IBD patients appears to be comparable to the non-IBD population and not influenced by ongoing treatments. Risk factors for infection common to the general non-IBD population should be considered when managing patients with IBD.

13C urea breath test to identify Helicobacter pylori Infection in patients with upper gastrointestinal bleeding admitted to the Emergency Department.

OBJECTIVE: Upper gastrointestinal bleeding (UGIB) is a cause of Emergency Department (ED) visits. Peptic ulcer secondary to H. pylori (HP) infection and/or to the use of NSAIDs is the most frequent cause. The aim of the study is to evaluate directly in the ED the prevalence of HP infection through Urea Breath test (UBT) in patients admitted to the ED for UGIB. PATIENTS AND METHODS: We enrolled 87 patients (58M/29F) with a mean age of 63.8 + 11.7 yrs with an active UGIB who performed EGDS and UBT. RESULTS: 34.4% of patients performing EGDS and UBT resulted positive to HP. Peptic ulcer was present in 20/30 (66.7%) of HP+ compared to 20/57 (35.1%) of HP- (p<0.001), and also gastritis and/or duodenitis were mostly present in HP+ (23.3% vs. 15.8%) (p<0.05). A biopsy was performed in only 31% of patients with a positive rate of 33.3%. In 78% we obtained a correspondence between UBT and biopsy results. Compared to biopsy result, we obtained for UBT a positive predictive value (PPV) of 71% and a negative predictive value (NPV) of 80%. Taking the UBT as a gold standard, we obtained for biopsies a PPV of 69% and a NPV of 85%. CONCLUSIONS: Our study confirms that the use of UBT directly in ED in patients with UGIB allows for a rapid, reliable and non-invasive diagnosis of HP infection as a causative agent for bleeding, thus permitting a right etiological treatment.

Hepatic follicular lymphoma in an old patient with Crohn's disease: a rare case and review of the literature.

OBJECTIVE: Crohn's Disease (CD) has been associated with non-Hodgkin lymphoma. Follicular Lymphoma (FL) limited to the liver is extremely rare, accounting for 1% to 4.4% of all Primary Hepatic Lymphoma (PHL). CASE PRESENTATION: In 2018, an 85-years old male patient with post-operative recurrence of ileal CD referred rare episodes of fever and mild diffuse abdominal pain. Since cholecystectomy in 2001, clinical history was characterized by recurrent episodes of cholangitis and common bile duct stones. In 2018, ultrasonography and MRI showed a solid focal hepatic lesion (FHL)(4.5 cm x 2.5 cm) in the IV hepatic segment. The radiographic aspect of the lesion was unusual. Initially, focal nodular hyperplasia was suspected. Clinical history of cholangitis and radiological findings subsequently suggested a diagnosis of Hepatic Abscess (HA). A progressive enlargement of the FHL (7.3 cm x 5.8 cm) despite antibiotic treatments, led to perform a liver biopsy. Histological and immunophenotypical analysis of the FHL (7.5 cm x 5.4 cm) enabled a final diagnosis of FL. The "in situ" hybridization for Epstein-Barr virus (EBER) was negative. No additional lesions related to FL were initially detected, thus suggesting a very rare case of PHL in an old patient with CD never treated with thiopurines. CONCLUSIONS: This case report highlights the need to consider a rare diagnosis of FL of the liver in patients showing a challenging focal hepatic lesion of unknown origin.

Unexpected macrophage activation syndrome in a healthy young woman: a case report.

Macrophage activation syndrome (MAS) is a life-threatening condition and a medical emergency with a high-risk of mortality. It belongs to a group of diseases known as "hemophagocytic lymphohistiocytosis", characterized by a cytokine storm, with secretion of tumor necrosis factor, interleukins and interferon-gamma, and an inappropriate activation of macrophages and T-lymphocytes. Some inflammatory and systemic autoimmune diseases, such as systemic juvenile idiopathic arthritis, Still's disease and systemic lupus erythematosus, can develop into macrophage activation syndrome. This is the first episode of macrophage activation syndrome (MAS) in a young healthy woman. She arrived at the Emergency Department complaining of four days of weakness and fever not responsive to paracetamol. She had no significant past medical history, her mother suffered from rheumatoid arthritis. In the Emergency Department, we performed laboratory exams, autoimmune and infectious disease screening, bone marrow biopsy. The final diagnosis was of macrophage activation syndrome. Macrophage activation syndrome, in extremely rare cases, can arise independently years before the manifestation of an autoimmune disease. Persistent fever, high level of inflammatory markers and pancytopenia should raise suspicion in healthy people, especially when associated with a family history of autoimmune disease. Early diagnosis and consequent early treatment are fundamental to avoid progressive tissue damage that can lead to organ failure and death.

Acute uncomplicated diverticulitis: key points for early management. A single-centre retrospective study.

OBJECTIVE: Acute uncomplicated diverticulitis is an important clinical condition usually managed in clinical practice with antibiotic therapies and hospitalization in ward. In this setting, recent papers and guidelines suggest to limit the use of antibiotics in selected cases and encourage an early discharge in low-risk patients. The purpose of this retrospective study is to identify serological inflammatory markers and CT findings of acute uncomplicated diverticulitis (AUD) at the onset of the disease and the correlation with the need for in-patient or out-patient management. PATIENTS AND METHODS: It was used a database drawn from the collection of the patients admitted to our Emergency Room from January 2016 to 2019 and undergoing urgent abdominal CT-scan for suspicious of acute diverticulitis. For each patient we considered biochemical and radiological parameters at the onset of the disease and if patients were managed as in-patients (hospitalization in ward) or as out-patient (early discharged or after observation in Short Stay Unit). RESULTS: Among patients with early diagnosis of AUD, 108 (65%) were hospitalized in ward with mean time of in-stay of 6.94 days, while only 58 (35%) patients with same diagnosis were managed as out-patient and early discharged from emergency room or after observation in short stay unit with a mean time of in-stay significantly shorter (3.39 days, p-value 0.0007). Higher levels of C reactive protein and the length of colon involved considered as percentage (%) in comparison with the entire colon were significantly related to the need for hospitalization (p-value 0.03). CONCLUSIONS: Biochemical parameters and a more advanced radiological evaluation, as the length (%) of colon involved, could allow a stratification of patients with diagnosis of AUD at the admission and help physicians in the early management.

The role of gut microbiota in mediating obesity and diabetes mellitus.

OBJECTIVE: This review inspects the relations between the microbiota and the intestinal immune system in the advancement of metabolic illnesses, such as obesity and diabetes mellitus. The role of the microbiota in intestinal immune defense and the control of metabolism are subject to examination. MATERIALS AND METHODS: In type 1 diabetes, the adhesion proteins prompt inside the intestinal epithelium prompt a more significant immune response that may result in the destruction of pancreatic ß cells by CD8+ T-lymphocytes, as well as increased articulation of interleukin-17, which is associated with autoimmunity. Studies suggest that the beginning of metabolic ailments and certain co-morbidities can be viewed in light of the protection between the gut microbiota and the intestinal immune system. The gut microbiota is analyzed as a key regulator of metabolic ailments. Research demonstrates that obese patients with type 2 diabetes have a certain gut microbiota and that the microbiota is translocated from the gut to the tissues in conjunction with the illness, which instigates inflammation. RESULTS: Research in animals and people suggests that a probiotic supplement may regulate the gut microbiota, thereby improving the prognosis for diabetes. CONCLUSIONS: The mechanism underlying this phenomenon relates to a decrease in the inflammatory reaction and oxidative stress, as well as a decrease in leaky gut. Such reactions increase insulin sensitivity and reduce autoimmune responses.

The efficacy of a mix of three probiotic strains in reducing abdominal pain and inflammatory biomarkers in acute uncomplicated diverticulitis.

OBJECTIVE: Acute Uncomplicated Diverticulitis (AUD) is defined as the inflammation of a colon diverticulum, often involving colic wall and pericolic fat. Conventional treatment of AUD includes antibiotics, usually ciprofloxacin and metronidazole, fasting, and fluid therapy. The aim of this study was to test the efficacy of a mix of three probiotic strains (Bifidobacterium lactis LA 304, Lactobacillus salivarius LA 302, Lactobacillus acidophilus LA 201; Lactibiane Iki®, Biocure [PiLeJe Groupe], Italy/PiLeJe Laboratoire, France) in association with conventional antibiotics in treating AUD compared to conventional antibiotics used alone. PATIENTS AND METHODS: We enrolled 84 (25M/59F mean age 61.5 ± 11.5 years) consecutive patients who came to the Emergency Department of the Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy, with a diagnosis of AUD confirmed by CT scan. After routine blood test and dosage of C-reactive protein (C-RP), patients were randomly divided into two groups: Probiotic group (42 patients, 10M/32F mean age 32.23 ± 10.3 years) was treated with ciprofloxacin 400 mg twice a day and metronidazole 500 mg three times a day for one week and simultaneously supplemented with the probiotic mix, 1 sachet twice a day for 10 days. Control group (42 patients, 15M/27F mean age 59.01 ± 11.3 years) received the same antibiotic treatment without the probiotic mix. All patients filled a daily Visual Analog Scale (VAS) for assessment of abdominal pain, with a range value from 0 (asymptomatic) to 10, and CRP value was determined on admission and at discharge. RESULTS: As regards abdominal pain, on Day 3, Group A showed a significant decrease of 4.06 points (51.4%) in VAS score compared to a decrease of 2.79 points (34.9%) in Group B. On Day 5 the decrease was of 6.3 points (80%) in Group A and of 4.85 points (61%) in Group B. VAS score was reduced by 7.59 points (96%) in Group A and 6.1 points (76%) in Group B on Day 7 +, and by 7.8 points (99%) in Group A and 7.2 points (90%) in Group B on Day 10. About inflammation, Group A showed a decrease in C-RP value of 64%, compared to a decrease of only 35% in Group B. We also observed that the duration of hospitalization was significantly shorter for patients in Group A: 89 h (3.7 days) in Group A vs. 101 h (4.2 days) in Group B (p=0.03). CONCLUSIONS: Our results indicated showed that the supplement with the probiotic mix of Bifidobacterium lactis LA 304, Lactobacillus salivarius LA 302, and Lactobacillus acidophilus LA 201 in combination with the standard antibiotic therapy for AUD reduced abdominal pain and inflammation significantly more than antibiotic treatment used alone. These findings could be due to the anti-inflammatory activity of the probiotic mix. Larger studies are needed to validate its use in the clinical practice.

Effect of Lactobacillus reuteri (DSM 17938) on methane production in patients affected by functional constipation: a retrospective study.

OBJECTIVE: Constipation is a common symptom affecting up to 30% of the Western population and is strongly associated with the presence of intestinal methanogens, which may directly inhibit motor activity. Two recent studies performed on adult and children affected by chronic constipation showed that the supplementation with L. reuteri significantly improved bowel movements. Whether its action is related to a decreasing of methane (CH4) production has never been tested. We have therefore designed a study aimed at testing this hypothesis. PATIENTS AND METHODS: Data of 20 adults (12 females, mean age 36.2 ± 13.7) affected by functional constipation, treated with the probiotic L. reuteri (DSM 17938) for 4 weeks who performed a H2/CH4 lactulose breath test (LBT) in our institution showing a CH4 production higher than 5 ppm were retrospectively analyzed from March to June 2015. Data recorded in their stool diary, reporting the frequency of defecations and stool consistency were also analysed, as well as the result of the LBT performed at the end of the treatment with L. reuteri. RESULTS: Four weeks of L. reuteri administration was associated with a significant decrease of mean CH4 production determined by LBT (from 20.8 ± 15 to 8.9 ± 8.6; p < 0.0001 CI 95%) and of AUC value (from 5101.5 ± 3571.13 to 2128.4 ± 2110.8; p < 0.0001 CI 95%). Moreover, a total disappearance of CH4 production (< 5 ppm at LBT) was observed in 11 patients, while, we did not observe any significant decrease of H2 production (from 13.2 ± 8.8 to 11.4 ± 7.3, CI 95%, n.s.). CONCLUSIONS: This study highlights for the first time the beneficial effect of Lactobacillus reuteri (DSM 17938) on chronic constipation, via a significant decrease of CH4 production.

Safety and efficacy of low doses of diclofenac on acute pain in the emergency setting.

Diclofenac is the most widely prescribed non-steroidal anti-inflammatory drug worldwide. Data collected during the last 10 years reported a dose-duration dependent increasing of cardiovascular risk associated with the use of diclofenac, supporting the evidence of a close association with the degree of COX-2 inhibition achieved in vivo. Nevertheless, the amplitude of cardiovascular risk associated with the administration of diclofenac at low doses and for the short-term duration is still poorly defined. Indeed, data did not show a clear and strong increasing of the risk for daily doses of 75 and of 50 mg. Concerning duration, while the identification of a safe temporal window is less defined, some studies reported an absence or a very low risk when the exposure is shorter than 30 days. Today, new low-dosage diclofenac formulations are available, allowing to reduce the systemic exposure, the degree of COX-2 inhibition and possibly the risk of occurrence of cardiovascular events. This is the reason why those new formulations may represent the ideal drug for the management of pain in the emergency setting.

Helicobacter pylori infection is associated with high methane production during lactulose breath test.

OBJECTIVE: Despite a growing interest toward the interplay between H. pylori and gastric microbiota, few data are available about this correlation. The aim of this study was to explore the relationship between H. pylori infection and gas production during lactulose breath test. MATERIALS AND METHODS: Data of patients undergoing both 13C-urea breath test (UBT) and lactulose breath test (LBT) under standard conditions in our GI unit were retrospectively analyzed. GI symptoms, such as dyspepsia, bloating, abdominal pain/discomfort, and epigastric pain on an eleven-point scale were also analyzed and correlate with the results of those tests. H2 and CH4 were calculated using the trapezoidal rule; a considerable CH4 production was defined by AUCCH4 ≥1200 ppm*4h. Statistical analyses were performed with Fisher's exact test and independent samples Mann-Whitney test. RESULTS: Data of 136 patients during a period of time of 3 months were analyzed. 36 patients (26.5%) showed a positive UBT. We do not find any difference as regards age, sex, symptom complaints, and small intestinal bacterial overgrowth between HP negative and positive patients. A greater methane production was observed in infected rather than non-infected patients (47.2% vs. 26% respectively, p=0.02). Furthermore, 25% infected and 10% non-infected produced greater amounts of CH4 compared to H2, resulting in a AUCCH4/AUCH2 ratio >1 (p=0.046). CONCLUSIONS: This study shows for the first time, a significant association between H. pylori infection and methane production, suggesting that H. pylori might influence gut microbiota composition. Further studies are needed to clarify mechanisms underlying this phenomenon.

High dose amoxicillin-based first line regimen is equivalent to sequential therapy in the eradication of H. pylori infection.

OBJECTIVE: Helicobater (H.) pylori eradication rates with standard first-line triple therapy have declined to unacceptable levels. To date, amoxicillin-resistant H. pylori strains have rarely been detected. Whether increasing the dosage of amoxicillin in a standard 7 days eradicating regimen may enhance its efficacy is not known. The aim of this paper is to compare the efficacy of a 7 days high-dose amoxicillin based first-line regimen with sequential therapy. PATIENTS AND METHODS: We have retrospectively analyzed data from 300 sex and age matched patients, who underwent 3 different therapeutic schemes: (1) standard LCA, lansoprazole 30 mg bid, clarithromycin 500 mg bid and amoxicillin 1000 mg bid for 7 days; (2) high dose LCA (HD-LCA), lansoprazole 30 mg bid, clarithromycin 500 mg bid and amoxicillin 1000 mg tid for 7 days; (3) sequential LACT, lansoprazole 30 mg bid plus amoxicillin 1000 mg bid for 5 days, followed by lansoprazole 30 mg bid, clarithromycin 500 mg bid and tinidazole 500 mg bid for 5 days. Eradication was confirmed by 13C-urea breath test. Compliance and occurrence of adverse effects were also assessed. RESULTS: Eradication rates were: 55% for LCA, 75% for HD-LCA and 73% for LACT. Eradication rates were higher in HD-LCA group compared to LCA (p<0.01), while no significant differences were observed in HD-LCA group compared to LACT (p=ns). Compliance and occurrence of adverse effects were similar among groups. CONCLUSIONS: High-dose amoxicillin based eradicating treatment is superior to standard triple therapy and equivalent to sequential therapy; compared to the latter, the shorter duration may represent an advantage.

A bedside test for Clostridium Difficile infection: an Emergency Department use. Preliminary results.

OBJECTIVE: Clostridium Difficile (CD) infection is a severe cause of diarrhea in patients with prolonged hospitalization and/or previously treated with antibiotics. CD's A and B toxins are responsible for either diarrhea or septical status as well as other complications including toxic megacolon. Toxins isolation, usually performed by a central microbiological laboratory (CML), is mandatory for the final diagnosis of the disease. The clinical suspect of CD infection (CDI) results in the isolation of the patients, until the fecal test does not exclude the disease. Positive patients need to maintain isolation and start a specific antibiotic therapy. The aim of this study was to verify the sensitivity and specificity of a rapid test for the diagnosis of CDI. PATIENTS AND METHODS: We enrolled 20 (13F/7M, mean age 70 ± 12 yrs) consecutive pts who accessed the Emergency Department (ED) with diarrhea and a clinical suspect of CDI. An immune-enzymatic bedside test (Beta Dignostici, Messina, Italy) for the detection of GDH, toxin A and B of CD was used. The results of this test were then compared to the CML one's, on the same patient. RESULTS: 6 patients resulted positive to the bedside test compared to 7 of CML test (86% of concordance). In this patient, the bedside test showed a strong positivity for GDH without signs of toxin, meanwhile the CML test revealed the toxins. Possibly, the lower toxins concentration in this patient was responsible for such discordance. Both tests showed a full concordance for negative patients. Another interesting finding is that the bedside test provides results in only 5 minutes, compared to several hours (even 48) of CML test. CONCLUSIONS: The bedside test is a rapid and affordable tool for rapid diagnosis of CD infection especially in a ED where the positivity of the test affects either hospitalization or treatment.

Efficacy and safety of infliximab and adalimumab in Crohn's disease: a single centre study.

BACKGROUND: Infliximab and adalimumab are highly effective in Crohn's Disease (CD). This is supported by clinical trials and open-label studies using either infliximab or adalimumab, thus not allowing a proper comparison between these anti-TNFs in CD. AIM: To evaluate the efficacy and safety of infliximab and adalimumab in active CD. METHODS: In a longitudinal study, CD patients with indication for anti-TNFs were treated with infliximab or adalimumab. RESULTS: Ninety-three patients were treated with infliximab (n = 44) or adalimumab (n = 49). In the infliximab group, the induction was completed by 77.3% of patients, due to no response (n = 2), delayed hypersensitivity reactions (DHR) or infusion reactions (n = 8). Maintenance with infliximab was completed by 60% of patients, due to clinical worsening or loss of efficacy (n = 5), DHR or infusion reactions (n = 5). In the adalimumab group, all patients completed the induction, while maintenance was completed by 67% of patients, due to clinical worsening or loss of efficacy (n = 8), DHR (n = 1), other causes (n = 7). In both groups, the CDAI significantly reduced at baseline vs. each visit (P < 0.04). The Kaplan-Meier survival analysis performed to evaluate the risk of steroid-free remission in patients treated with infliximab vs. adalimumab detected no differences (log-rank test P = 0.4). Cox proportional-hazards regression identified two predictors of steroid-free remission using anti-TNFs: no smokers [HR = 2.94 (1.52-5.70), P = 0.001] and non stricturing non penetrating behaviour [HR = 3.116 (1.06-9.13), P = 0.03826]. CONCLUSIONS: Infliximab and adalimumab showed a similar efficacy. No smoking and non-stricturing non-penetrating behaviour were predictors of steroid-free remission.

Endoscopic vs ultrasonographic findings related to Crohn's disease recurrence: a prospective longitudinal study at 3 years.

BACKGROUND AND AIMS: Ileocolonoscopy (IC) is the gold standard for assessing Crohn's Disease (CD) recurrence after ileo-colonic resection. In a prospective longitudinal study we compared findings related to CD recurrence when using techniques visualizing either the luminal or the extraluminal surface (IC and small bowel follow through, SBFT vs Small Intestine Contrast Ultrasonography, SICUS). METHODS: From 2003 to 2008, 25 CD patients undergoing ileo-colonic resection were enrolled. Clinical assessment (CDAI) was performed at 1, 2 and 3 years. IC was performed at 1 (n=25) and 3 years (n=15), SBFT at 2 years (n=21) and SICUS at 1 (n=25), 2 (n=21) and 3 years (n=15). Recurrence was assessed by SBFT and SICUS (bowel wall thickness, BWT) when using IC as gold standard. RESULTS: At 1 year, all patients were inactive and recurrence was detected by IC in 24/25 (96%) and by SICUS in 25/25 patients. At 2 years, 6/21 patients (29%) were active and recurrence was detected by SBFT in 12/21 (57%) and by SICUS in 21/21 patients. At 3 years, 5/15 patients (33%) were active, IC showed recurrence in 14/15 (93%), and SICUS in 15/15 patients. The endoscopic score at 1 year was higher in patients developing relapse at 2 years (n=5) than in patients maintaining remission (n=10) (median: 4, range 3-4 vs 2, range 0-3; p=0.003). The same finding was not observed by using SICUS (median BWT at 1 year: 5, range 4-7 vs 3.7, range 3.5-6; p=0.19). CONCLUSIONS: Although IC and SICUS provide a different view of the bowel wall, in experienced hands SICUS provides findings compatible with endoscopic recurrence after ileo-colonic resection for CD. Discrepant findings may be observed in a low proportion of patients with minor lesions related to CD recurrence.

Non-invasive techniques for assessing postoperative recurrence in Crohn's disease.

Postoperative recurrence after ileo-colonic resection is a feature of Crohn's Disease (CD), almost 73% of patients show endoscopic recurrence at 1 year and 90% at 3 years. After surgical resection for CD, symptoms may be related to the surgical resection itself. Moreover, the development of an early severe endoscopic recurrence within 1 year represents a risk factor for early clinical recurrence. On the basis of these observations, the early detection and assessment of asymptomatic endoscopic recurrence may allow a timely and appropriate treatment of CD patients after ileo-colonic resection. At this purpose, conventional colonoscopy with ileoscopy currently represents the gold standard for assessing CD recurrence, graded according to the Rutgeerts' score. Lesions compatible with CD recurrence can be also detected by conventional radiology, including small bowel follow through and enema, both associated with a high radiation exposure. Due to the ineluctable course of CD after resection, and to the need of a proper follow up for assessing CD recurrence, several alternative, non invasive techniques have been searched in order to assess the post-operative recurrence, including: faecal alpha 1-antitrypsin clearance, faecal calprotectin, 99Tc-HMPAO scintigraphy, virtual colonoscopy, ultrasonography and, more recently, wireless capsule endoscopy (WCE) and Small Intestine Contrast Ultrasonography (SICUS). Among these, current evidences suggest that in experienced hands, ultrasound examination by SICUS represents a non-invasive technique useful for assessing recurrence in CD patients under regular follow up after surgery. The same findings are suggested for WCE, although the impact risk related to the recurrence or to the surgical anastomosis itself limits the use of this non-invasive technique for assessing CD recurrence after surgery.