Efficacy of adalimumab in patients with Crohn's disease and failure to infliximab therapy: a clinical series.

BACKGROUND: adalimumab, a human anti-TNF, is an effective induction and maintenance therapy for patients with moderate to severe Crohn's disease. It seems to be effective in patients with resistance to infliximab, too, though the experience is more limited. AIM: to evaluate the efficacy of adalimumab, in patients with Crohn's disease (CD) and failure to previous treatment with infliximab. METHODS: twenty-five patients with CD and failure to previous treatment with infliximab were enrolled; they were treated with 160/80 (24 patients) and 80/40 (1 patient) induction doses. We analyze clinical response to treatment with adalimumab by the Crohn's disease Activity Index (CDAI) and plasma concentration of C-reactive protein (CRP), steroid sparing and complete fistula closure at week 48. RESULTS: eighteen out of twenty-five patients (72%) achieved clinical remission (CDAI score < 150) at week 24 and 15/25 (60%) patients at week 48. There was a statistically significant difference(p < 0.01) in CRP serum levels from 21 to 8 mg/dl at week 48.Nine out of fifteen patients (60%) treated with corticosteroids were able to discontinue steroids. Three out of eleven patients (27%) with fistulizing Crohn's disease had complete fistula closure after the treatment. Seventy two percent of the patients (18/25) needed to increase adalimumab to weekly dose, in order to maintain clinical response. Five out of twenty-five patients (20%) had adverse events; two of them (8%) with serious adverse events (tuberculous meningitis and abdominal abscess) that forced the withdrawal of treatment. CONCLUSIONS: according to these data, adalimumab provides a clinical and analytical improvement in patients with CD and failure to previous therapy with infliximab.

PillCamColon Capsule for the study of colonic pathology in clinical practice. Study of agreement with colonoscopy.

INTRODUCTION: several studies have pointed out the effectiveness of the PillCam colon capsule endoscopy (CCE) compared with the colonoscopy in the study of the colonic pathology. AIMS AND METHODS: the objective of our study was to assess the agreement in the diagnosis of CCE with conventional colonoscopy as well as its sensitivity and specificity, and to describe the findings of the CCE in our clinical practice. Consecutive patients with abdominal symptoms were included in the study. The CCE was performed as previously reported (with PEG and sodium phosphate as laxative agents). The nature and location of the findings, colonic transit time, complications, cleanliness degree and consistency with diagnostic colonoscopy, when performed, were analyzed. RESULTS: a total of 144 subjects (67 women and 77 men); (52.17 ± 16.71 years) with the following indications were included: screening of Colorectal cancer (88 patients), control after polipectomy (24), incomplete colonoscopy (7), rectal bleeding (10), anemia (8), diarrhea (7). The CCE exploration was complete in 134/144 cases (93%), with no case of retention. The preparation was good-very good in 88/134 (65,6%), fair in 26/134 (19,4%) and poor in 20/134 (15%) of the cases. The average colonic transit was of 140.76 min (9-603). Any adverse effect was notified.In 44 cases a colonoscopy was carried out after CCE (results were hidden from another endoscopist). Compared to colonoscopy, the rate of agreement was 75,6%, the sensitivity was 84% and the specificity 62,5%, PPV was 77,7% and NPV was 71,4%.The colonic findings in 134 CCE were: in 34 cases CCE it did not show lesions, diverticulosis in 63 explorations, polyps in 43, angiodysplasias in 15, Crohn's Disease in 9 and ulcerative colitis in other 8 cases. CONCLUSIONS: the CCE is an effective and reliable technique for the detection of lesions in colon, and because of its high agreement with the colonoscopy, it could be useful in clinical practice. Further studies with large seria and cost-effectiveness analysis are needed to confirm these data.

PillCam© Colon Capsule for the study of colonic pathology in clinical practice. Study of agreement with colonoscopy

Introduction: several studies have pointed out the effectiveness of the PillCam© colon capsule endoscopy (CCE) compared with the colonoscopy in the study of the colonic pathology. Aims and methods: the objective of our study was to assess the agreement in the diagnosis of CCE with conventional colonoscopy as well as its sensitivity and specificity, and to describe the findings of the CCE in our clinical practice. Consecutive patients with abdominal symptoms were included in the study. The CCE was performed as previously reported (with PEG and sodium phosphate as laxative agents). The nature and location of the findings, colonic transit time, complications, cleanliness degree and consistency with diagnostic colonoscopy, when performed, were analyzed. Results: a total of 144 subjects (67 women and 77 men); (52.17±16.71 years) with the following indications were included: screening of Colorectal cancer (88 patients), control after polipectomy (24), incomplete colonoscopy (7), rectal bleeding (10), anemia (8), diarrhea (7). The CCE exploration was complete in 134/144 cases (93%), with no case of retention. The preparation was good-very good in 88/134 (65,6%), fair in 26/134 (19,4%) and poor in 20/134 (15%) of the cases. The average colonic transit was of 140.76 min (9-603). Any adverse effect was notified. In 44 cases a colonoscopy was carried out after CCE (results were hidden from another endoscopist). Compared to colonoscopy, the rate of agreement was 75,6%, the sensitivity was 84% and the specificity 62,5%, PPV was 77,7% and NPV was 71,4 %. The colonic findings in 134 CCE were: in 34 cases CCE it did not show lesions, diverticulosis in 63 explorations, polyps in 43, angiodysplasias in 15, Crohn´s Disease in 9 and ulcerative colitis in other 8 cases. Conclusions: the CCE is an effective and reliable technique for the detection of lesions in colon, and because of its high agree - ment with the colonoscopy, it could be useful in clinical practice. Further studies with large seria and cost-effectiveness analysis are needed to confirm these data(AU)

Macroscopic small bowel mucosal injury caused by chronic nonsteroidal anti-inflammatory drugs (NSAID) use as assessed by capsule endoscopy.

OBJECTIVE: To evaluate the type, frequency, and severity of macroscopic small bowel mucosal injury after chronic NSAID intake as assessed by capsule endoscopy (CE), as well as to correlate the severity of gastroduodenal and intestinal damage in these patients. MATERIAL AND METHODS: A prospective, endoscopist-blind, controlled trial. Sixteen patients (14F/2M; age: 57.06 +/- 10.16 yrs) with osteoarthritis (OA) on chronic therapy with NSAIDs underwent CE and upper gastrointestinal endoscopy (UGE). Seventeen patients with OA (9F/2M; age: 57.47 +/- 9.82 yrs) who did not take NSAIDs were included as a control group. A scale ranging from 0 to 2 (0 = no lesions, 1-minor = red spots or petechiae, denuded areas and/or 1-5 mucosal breaks; 2-major = > 5 mucosal breaks and/or strictures, or hemorrhage) was designed to assess the severity of small bowel mucosal injuries. RESULTS: CE found intestinal lesions in 75% (12/16) of patients in the study group and in 11.76% (2/17) of controls (p < 0.01). Seven out of 16 NSAID consumers (43.75%) and none in the control group (0%) had a major small bowel mucosal injury (p < 0.01). The percentages of patients with grade 1 and 2 gastroduodenopathy in the study group, as assessed by UGE, were 37.14 and 23.81%, respectively. There was no significant difference in the rate of major enteropathy between patients with none or minor gastroduodenal injury, and those with major gastroduodenopathy (43.75 vs. 40%; p = N.S.). CONCLUSIONS: Chronic NSAID intake is associated with a high rate of small bowel mucosal injuries. Our data have failed to demonstrate a relationship between the severity of gastroduodenal and intestinal injury.

Macroscopic small bowel mucosal injury caused by chronic nonsteroidal anti-inflammatory drugs (NSAID) use as assessed by capsule endoscopy

Objective: to evaluate the type, frequency, and severity of macroscopicsmall bowel mucosal injury after chronic NSAID intake asassessed by capsule endoscopy (CE), as well as to correlate the severityof gastroduodenal and intestinal damage in these patients.Material and methods: a prospective, endoscopist-blind,controlled trial. Sixteen patients (14F/2M; age: 57.06 ± 10.16yrs) with osteoarthritis (OA) on chronic therapy with NSAIDs underwentCE and upper gastrointestinal endoscopy (UGE). Seventeenpatients with OA (9F/2M; age: 57.47 ± 9.82 yrs) who didnot take NSAIDs were included as a control group. A scale rangingfrom 0 to 2 (0 = no lesions, 1-minor = red spots or petechiae,denuded areas and/or 1-5 mucosal breaks; 2-major = > 5mucosal breaks and/or strictures, or hemorrhage) was designed toassess the severity of small bowel mucosal injuries.Results: CE found intestinal lesions in 75% (12/16) of patientsin the study group and in 11.76% (2/17) of controls (p <0.01). Seven out of 16 NSAID consumers (43.75%) and none inthe control group (0%) had a major small bowel mucosal injury (p< 0.01). The percentages of patients with grade 1 and 2 gastroduodenopathyin the study group, as assessed by UGE, were37.14 and 23.81%, respectively. There was no significant differencein the rate of major enteropathy between patients withnone or minor gastroduodenal injury, and those with major gastroduodenopathy(43.75 vs. 40%; p = N.S.).Conclusions: chronic NSAID intake is associated with a highrate of small bowel mucosal injuries. Our data have failed to demonstratea relationship between the severity of gastroduodenaland intestinal injury(AU)

[Is capsule endoscopy useful in children with chronic abdominal pain?]. / Es útil la cápsula endoscópica en niños con dolor abdominal crónico?

Chronic abdominal pain is highly prevalent in school-aged children and is one of the most frequent disorders in our environment. The aim of the present study was to evaluate the usefulness of capsule endoscopy (CE) in patients with chronic abdominal pain. Sixteen patients (nine boys and seven girls), aged between 5 and 16 years old, with chronic abdominal pain for at least 12 months were studied. In all patients the results of hemograms, biochemical investigations, urine sediment test, Helicobacter pylori breath test and celiac serology were normal. In all children, gastroscopy, small bowel follow-through, abdominal ultrasound and colonoscopy were normal. All patients received CE by mouth. In 43.75 % of the patients studied (7/16), the capsule showed evidence of nodular lymphoid hyperplasia, mainly located in the ileum. In one girl, oxyuriasis was observed in the cecum and in another girl aphthous lesions were observed in the ileum. These lesions suggested small bowel Crohn's disease. CE mainly showed images compatible with nodular lymphoid hyperplasia, with unknown clinical significance. Consequently, we conclude that CE does not provide useful information in patients with abdominal pain without other symptoms.

¿Es útil la cápsula endoscópica en niños con dolor abdominal crónico? / Is capsule endoscopy useful in children with chronic abdominal pain?

El dolor abdominal crónico afecta a un alto porcentaje de niños en edad escolar, lo que la convierte en una de las patologías más frecuentes en nuestro medio. El objetivo es valorar si la cápsula endoscópica (CE) permite identificar lesiones intestinales en estos pacientes. Se han incluido 16 pacientes (9 niños y 7 niñas) con edades comprendidas entre los 5 y 16 años con dolor abdominal crónico de más de 12 meses de evolución. Todos tenían realizados hemograma, bioquímica, sedimento de orina, test de aliento para Helicobacter pylori y serología para enfermedad celíaca, que eran negativos. A todos se les había realizado una gastroscopia, y una colonoscopia que resultaron negativas, así como un tránsito gastrointestinal y una ecografía abdominal, sin hallazgos de interés. En el 43,75 % de los pacientes estudiados (7/16) la CE mostró imágenes compatibles con hiperplasia folicular linfoide localizadas en el íleon. En una niña se observaron oxiuros en ciego y en otra, lesiones aftosas ileales compatibles con enfermedad de Crohn. La CE muestra en la mayoría de los casos imágenes compatibles con hiperplasia nodular linfoide intestinal, con dudosa significación clínica, por lo que podemos concluir que la CE no aporta nada específico en niños con dolor abdominal crónico

Chronic abdominal pain is highly prevalent in school-aged children and is one of the most frequent disorders in our environment. The aim of the present study was to evaluate the usefulness of capsule endoscopy (CE) in patients with chronic abdominal pain. Sixteen patients (nine boys and seven girls), aged between 5 and 16 years old, with chronic abdominal pain for at least 12 months were studied. In all patients the results of hemograms, biochemical investigations, urine sediment test, Helicobacter pylori breath test and celiac serology were normal. In all children, gastroscopy, small bowel follow-through, abdominal ultrasound and colonoscopy were normal. All patients received CE by mouth. In 43.75 % of the patients studied (7/16), the capsule showed evidence of nodular lymphoid hyperplasia, mainly located in the ileum. In one girl, oxyuriasis was observed in the cecum and in another girl aphthous lesions were observed in the ileum. These lesions suggested small bowel Crohn's disease. CE mainly showed images compatible with nodular lymphoid hyperplasia, with unknown clinical significance. Consequently, we conclude that CE does not provide useful information in patients with abdominal pain without other symptoms

Previously unknown stricture due to radiation therapy diagnosed by capsule endoscopy.

Radiation enteritis is a complex clinical entity secondary to the affectation of intestinal epithelial cells as a result of radiation in the management of pelvic malignancies that may occasionally cause intestinal strictures. We present the case of a 60 year-old woman who had been diagnosed ten years before with endometrial adenocarcinoma, and who underwent hysterectomy with double adnexectomy and subsequent radiation therapy. The patient consulted for abdominal pain and ferropenic anemia of several years standing, and had negative results following radiographic and endoscopic conventional techniques, reason why she was subjected to a capsule endoscopy study that revealed the presence of an ulcerated ileal stricture, which caused the asymptomatic retention of the capsule within the ileum. A laparotomy was subsequently performed--the strictured segment was resected and the capsule retrieved. The histologic examination of the resected segment confirmed the capsule endoscopy-raised suspicion of radiation enteritis. This case shows the role capsule endoscopy may play in the diagnosis of this condition.

Estenosis de origen actínico no conocida diagnosticada mediante capsuloendoscopia / Previously unknown stricture due radiation therapy diagnosed by capsule endoscopy

La enteritis actínica es una entidad producida por la afectaciónde las células intestinales como consecuencia del tratamiento radioterápicode tumores abdomino-ginecológicos, que en ocasionespuede causar áreas estenóticas.Presentamos el caso de una mujer de 60 años, diagnosticadadiez años antes de adenocarcinoma de endometrio, que fue tratadacon resección intestinal y radioterapia abdomino-pélvica. Lapaciente acudió por dolor abdominal y anemia ferropénica deaños de evolución, con técnicas radiológicas y endoscópicas convencionalesnegativas. La realización de una capsuloendoscopiareveló la presencia de una estenosis ileal ulcerada, que causó la retenciónasintomática de la cápsula en íleon. Se indicó de formaelectiva la realización de una laparotomía con resección del segmentoestenótico y extracción de la cápsula, confirmándose histológicamentela sospecha capsuloendoscópica de enteritis actínica.Este caso ilustra el papel que la capsuloendoscopia puede jugaren esta entidad de difícil diagnóstico

Radiation enteritis is a complex clinical entity secondary to theaffectation of intestinal epithelial cells as a result of radiation in themanagement of pelvic malignancies that may occasionally causeintestinal strictures.We present the case of a 60 year-old woman who had been diagnosedten years before with endometrial adenocarcinoma, andwho underwent hysterectomy with double adnexectomy and subsequentradiation therapy. The patient consulted for abdominalpain and ferropenic anemia of several years’ standing, and hadnegative results following radiographic and endoscopic conventionaltechniques, reason why she was subjected to a capsule endoscopystudy that revealed the presence of an ulcerated ilealstricture, which caused the asymptomatic retention of the capsulewithin the ileum. A laparotomy was subsequently performed – thestrictured segment was resected and the capsule retrieved. Thehistologic examination of the resected segment confirmed thecapsule endoscopy-raised suspicion of radiation enteritis. Thiscase shows the role capsule endoscopy may play in the diagnosisof this condition