Update of the PANCCO clinical practice guidelines for the treatment of ulcerative colitis in the adult population.

Ulcerative colitis (US) is a chronic disease of unknown etiology. It is incurable and its clinical course is intermittent, characterized by periods of remission and relapse. The prevalence and incidence of the disease has been increasing worldwide. The update presented herein includes the participation of healthcare professionals, decision-makers, and a representative of the patients, all of whom declared their conflicts of interest. Answerable clinical questions were formulated, and the outcomes were graded. The information search was conducted on the Medline/PubMed, Embase, Epistemonikos, and LILACS databases, and covered grey literature sources, as well. The search was updated on November 30, 2020, with no restrictions regarding date or language. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification system was implemented to establish the strength of the recommendation and quality of evidence. A formal consensus was developed, based on the RAND/UCLA methodology and the document was peer reviewed. The short version of the Clinical Practice Guidelines for the Treatment of Ulcerative Colitis in the Adult Population is presented herein, together with the supporting evidence and respective recommendations. In mild-to-moderate UC, budesonide MMX is an option when treatment with 5-ASA fails, and before using systemic steroids. In moderate-to-severe UC, infliximab, adalimumab, vedolizumab, ustekinumab, and tofacitinib can be used as first-line therapy. If there is anti-TNF therapy failure, ustekinumab and tofacitinib provide the best results. In patients with antibiotic-refractory pouchitis, anti-TNFs are the treatment of choice.

Manifestaciones reumatológicas y sistémicas en pacientes con enfermedad inflamatoria intestinal / Rheumatological and systemic manistestations in patients with inflammatory bowel disease

Introducción: La Enfermedad Inflamatoria Intestinal (EII) comprende la Enfermedad de Crohn (EC) y la Colitis Ulcerosa (CU). La frecuencia del compromiso sistémico en la EII es entre 20 y 40%, y las manifestaciones más frecuentes son las dermatológicas, oculares, articulares y hepatobiliares. Ante la falta de datos sobre la frecuencia y características de dichas manifestaciones en nuestra población, decidimos evaluar la prevalencia de las manifestaciones clínicas extraintestinales en pacientes argentinos con diagnóstico de EII, evaluar sus características, determinar su asociación con la CU y/o EC y examinar el compromiso axial radiológico de estos pacientes. Materiales y métodos: Se estudiaron 95 pacientes consecutivos con diagnóstico establecido de EII. Se completó un cuestionario registrando datos demográficos y clínicos de la EII. Dos médicos realizaron un examen físico completo reumatológico. Se realizaron radiografías de columna lumbar y cervical, pelvis panorámica y sacroilíacas por técnica de Fergusson puntuadas según criterios de New York. Las radiografías fueron leídas por un investigador independiente que desconocía los datos clínicos de los pacientes. Resultados: Se incluyeron 95 pacientes, 39,9% eran de sexo masculino. La edad mediana fue de 37 años y la mediana de tiempo de evolución de la EII fue de 6 años. En relación al diagnóstico, 75,8% tenían CU y 22,11% EC; un paciente presentaba ambos diagnósticos (CU y EC) y otro tenía enfermedad intestinal indiferenciada. Las manifestaciones no reumatológicas más frecuentes fueron: úlceras orales 38,9%, uveítis 10,5%, cervicitis/uretritis 8,4%, eritema nodoso 6,3%, psoriasis 2,1% y pioderma gangrenoso 1,1%. En cuanto a las manifestaciones reumatológicas: lumbalgia inflamatoria 44,2%, artritis periférica 27,4%, talalgia 24,2%, dactilitis 13,7% y entesitis 11,6%...(AU)

ntroduction:Inflammatory Bowel Disease (IBD) includes CrohnÆsDisease (CD) and Ulcerative Colitis (UC). The frequency of systemicinvolvement in IBD is between 20 and 40%, and most common mani-festations are dermatologic, ocular, articular and hepatobiliary. In theabsence of data on the frequency and characteristics of such eventsin our population, we decided to evaluate the prevalence of extrain-testinal manifestations in argentinian patients diagnosed with IBD,evaluate their characteristics, determine its association with UC and/or CD and examine the radiographic engagement of these patients.Materials and Methods:95 consecutive patients with an estab-lished diagnosis of IBD were included. A questionnaire was com-pleted collecting demographic and clinical data of IBD patients. Twophysicians performed a complete rheumatological examination. Ra-diographs were read by an independent investigator blinded to theclinical data of patients.Results:95 patients were included, 39.9% were male. The medianage was 37 years and median duration of IBD was 6 years. 75.8%had UC and 22.11% CD, one patient had both diagnoses (UC and CD)and one had undifferentiated intestinal disease. The most frequentnon-rheumatological manifestations were 38.9% oral ulcers, uveitis10.5%, cervicitis/urethritis 8.4%, erythema nodosum 6.3%, psoria-sis 2.1% and pyoderma gangrenosum 1.1%. As for rheumatologicalmanifestations: inflammatory back pain 44.2%, peripheral arthritis27.4%, heel pain 24.2%, dactylitis 13.7% and enthesitis 11.6%. Nosignificant differences in the frequency of these manifestations be-tween different types of IBD were observed. Sacroiliitis with greaterthan or equal to 2 graduation was detected in 23.8% of patients, andthis was significantly more frequent in patients with CD...(AU)

Manifestaciones reumatológicas y sistémicas en pacientes con enfermedad inflamatoria intestinal / Rheumatological and systemic manistestations in patients with inflammatory bowel disease

Introducción: La Enfermedad Inflamatoria Intestinal (EII) comprende la Enfermedad de Crohn (EC) y la Colitis Ulcerosa (CU). La frecuencia del compromiso sistémico en la EII es entre 20 y 40%, y las manifestaciones más frecuentes son las dermatológicas, oculares, articulares y hepatobiliares. Ante la falta de datos sobre la frecuencia y características de dichas manifestaciones en nuestra población, decidimos evaluar la prevalencia de las manifestaciones clínicas extraintestinales en pacientes argentinos con diagnóstico de EII, evaluar sus características, determinar su asociación con la CU y/o EC y examinar el compromiso axial radiológico de estos pacientes. Materiales y métodos: Se estudiaron 95 pacientes consecutivos con diagnóstico establecido de EII. Se completó un cuestionario registrando datos demográficos y clínicos de la EII. Dos médicos realizaron un examen físico completo reumatológico. Se realizaron radiografías de columna lumbar y cervical, pelvis panorámica y sacroilíacas por técnica de Fergusson puntuadas según criterios de New York. Las radiografías fueron leídas por un investigador independiente que desconocía los datos clínicos de los pacientes. Resultados: Se incluyeron 95 pacientes, 39,9% eran de sexo masculino. La edad mediana fue de 37 años y la mediana de tiempo de evolución de la EII fue de 6 años. En relación al diagnóstico, 75,8% tenían CU y 22,11% EC; un paciente presentaba ambos diagnósticos (CU y EC) y otro tenía enfermedad intestinal indiferenciada. Las manifestaciones no reumatológicas más frecuentes fueron: úlceras orales 38,9%, uveítis 10,5%, cervicitis/uretritis 8,4%, eritema nodoso 6,3%, psoriasis 2,1% y pioderma gangrenoso 1,1%. En cuanto a las manifestaciones reumatológicas: lumbalgia inflamatoria 44,2%, artritis periférica 27,4%, talalgia 24,2%, dactilitis 13,7% y entesitis 11,6%...

ntroduction:Inflammatory Bowel Disease (IBD) includes Crohn’sDisease (CD) and Ulcerative Colitis (UC). The frequency of systemicinvolvement in IBD is between 20 and 40%, and most common mani-festations are dermatologic, ocular, articular and hepatobiliary. In theabsence of data on the frequency and characteristics of such eventsin our population, we decided to evaluate the prevalence of extrain-testinal manifestations in argentinian patients diagnosed with IBD,evaluate their characteristics, determine its association with UC and/or CD and examine the radiographic engagement of these patients.Materials and Methods:95 consecutive patients with an estab-lished diagnosis of IBD were included. A questionnaire was com-pleted collecting demographic and clinical data of IBD patients. Twophysicians performed a complete rheumatological examination. Ra-diographs were read by an independent investigator blinded to theclinical data of patients.Results:95 patients were included, 39.9% were male. The medianage was 37 years and median duration of IBD was 6 years. 75.8%had UC and 22.11% CD, one patient had both diagnoses (UC and CD)and one had undifferentiated intestinal disease. The most frequentnon-rheumatological manifestations were 38.9% oral ulcers, uveitis10.5%, cervicitis/urethritis 8.4%, erythema nodosum 6.3%, psoria-sis 2.1% and pyoderma gangrenosum 1.1%. As for rheumatologicalmanifestations: inflammatory back pain 44.2%, peripheral arthritis27.4%, heel pain 24.2%, dactylitis 13.7% and enthesitis 11.6%. Nosignificant differences in the frequency of these manifestations be-tween different types of IBD were observed. Sacroiliitis with greaterthan or equal to 2 graduation was detected in 23.8% of patients, andthis was significantly more frequent in patients with CD...

The IL-1 gene family and bone involvement in celiac disease.

Celiac disease (CD) is associated with decreased bone mineral mass. Its pathogenesis is multifactorial since both systemic and local mechanisms may play a role. Our objective was to determine whether single-nucleotide polymorphisms in genes encoding members of the interleukin-1 family are associated with bone damage measured by densitometry in a series of 71 adult CD patients assessed at diagnosis. When compared with non-carrier CD patients, carriers of allele T of the interleukin-1beta gene (IL1B-511T) had a significantly lower bone mass at the total skeleton level (p = 0.0484) and a greater prevalence of osteopenia/osteoporosis (p = 0.0102). To our knowledge, this is the first evidence on the association between a genetic predisposition and low bone mass in CD patients. This finding supports the postulated inflammation-associated bone loss pathogenesis as one of the causes of bone weakness in CD.

Prevención del cáncer colorrectal (CCR) / Prevention of colorectal cancer

Colorectal cancer (CRC) is the second leading cause of cancer death in Argentina. The cumulative lifetime risk of developing CRC for both men and women is 4-6%. Despite advances in the management of this disease, the 5-year survival rate is about 60% because only 35% of patients are diagnosed when the disease is localized. Risk factors for CRC include age, diet and life style factors, personal or family history of adenomas or CRC and personal history of inflammatory bowel disease. Scientific evidence shows that primary and secondary prevention, through screening programs, permit to reduce incidence and mortality significantly. Chemopreventive agents, including nonsteroidal antiinflammatory drugs, folate, and calcium, have been shown to have some preventive effect. Physical inactivity and excess body weight are consistent risk factors for CRC. Tobacco exposure, diet high in red meat and low in vegetables and alcohol consumption, probably in combination with a diet low in folate, appear to increase risk. The dietary fiber and risk of CRC has been studied but the results are still inconclusive. Screening for CRC is cost-effective compared with no screening, but a single optimal strategy cannot be determined from the currently available data. The advantages and disadvantages or limitations of screening modalities for CRC are analyzed. The literature and clinical practice guidelines are reviewed, with an emphasis on advances and evolving screening methods and recommendations for patients with average, moderate and high-risk CRC.

El cáncer colorrectal (CCR) ocupa el segundo lugar en mortalidad por tumores malignos en Argentina. Elriesgo de padecer un CCR a través de toda la vida es de 4-6%. A pesar de los avances en el tratamiento, la sobrevidaa 5 años del CCR se ubica en el 60% debido a que sólo el 35% de los pacientes tienen enfermedadlocalizada en el momento del diagnóstico. Los factores de riesgo incluyen la edad, dieta y estilo de vida, historia personal o familiar de adenomas o CCR y antecedentes de enfermedad inflamatoria intestinal. La evidenciacientífica permite señalar que la prevención primaria y secundaria a través de programas de pesquisapermitiría reducir la incidencia y la mortalidad significativamente. Agentes quimiopreventivos, como los antiinflamatorios no esteroideos, ácido fólico y calcio han mostrado algún efecto preventivo. El sedentarismoy el exceso de peso son convincentes factores de riesgo de CCR. El tabaco, una dieta rica en carnes rojas,pobre en vegetales y el consumo de alcohol, probablemente en combinación con una reducción de la ingestade ácido fólico, parecen incrementar el riesgo de CCR. La relación entre la ingesta de fibra y el riesgo deCCR ha sido largamente estudiada pero los resultados no son aún concluyentes. La pesquisa del CCR es costoefectivacomparada con su no realización. Se analizan las ventajas y desventajas o limitaciones de las diferentes estrategias. La literatura y las distintas normativas fueron revisadas evaluando los avances, nuevos métodosy recomendaciones para personas con riesgo promedio, moderado y alto.

Prevención del cáncer colorrectal (CCR) / Prevention of colorectal cancer

Colorectal cancer (CRC) is the second leading cause of cancer death in Argentina. The cumulative lifetime risk of developing CRC for both men and women is 4-6%. Despite advances in the management of this disease, the 5-year survival rate is about 60% because only 35% of patients are diagnosed when the disease is localized. Risk factors for CRC include age, diet and life style factors, personal or family history of adenomas or CRC and personal history of inflammatory bowel disease. Scientific evidence shows that primary and secondary prevention, through screening programs, permit to reduce incidence and mortality significantly. Chemopreventive agents, including nonsteroidal antiinflammatory drugs, folate, and calcium, have been shown to have some preventive effect. Physical inactivity and excess body weight are consistent risk factors for CRC. Tobacco exposure, diet high in red meat and low in vegetables and alcohol consumption, probably in combination with a diet low in folate, appear to increase risk. The dietary fiber and risk of CRC has been studied but the results are still inconclusive. Screening for CRC is cost-effective compared with no screening, but a single optimal strategy cannot be determined from the currently available data. The advantages and disadvantages or limitations of screening modalities for CRC are analyzed. The literature and clinical practice guidelines are reviewed, with an emphasis on advances and evolving screening methods and recommendations for patients with average, moderate and high-risk CRC.(AU)

El cáncer colorrectal (CCR) ocupa el segundo lugar en mortalidad por tumores malignos en Argentina. Elriesgo de padecer un CCR a través de toda la vida es de 4-6%. A pesar de los avances en el tratamiento, la sobrevidaa 5 años del CCR se ubica en el 60% debido a que sólo el 35% de los pacientes tienen enfermedadlocalizada en el momento del diagnóstico. Los factores de riesgo incluyen la edad, dieta y estilo de vida, historia personal o familiar de adenomas o CCR y antecedentes de enfermedad inflamatoria intestinal. La evidenciacientífica permite señalar que la prevención primaria y secundaria a través de programas de pesquisapermitiría reducir la incidencia y la mortalidad significativamente. Agentes quimiopreventivos, como los antiinflamatorios no esteroideos, ácido fólico y calcio han mostrado algún efecto preventivo. El sedentarismoy el exceso de peso son convincentes factores de riesgo de CCR. El tabaco, una dieta rica en carnes rojas,pobre en vegetales y el consumo de alcohol, probablemente en combinación con una reducción de la ingestade ácido fólico, parecen incrementar el riesgo de CCR. La relación entre la ingesta de fibra y el riesgo deCCR ha sido largamente estudiada pero los resultados no son aún concluyentes. La pesquisa del CCR es costoefectivacomparada con su no realización. Se analizan las ventajas y desventajas o limitaciones de las diferentes estrategias. La literatura y las distintas normativas fueron revisadas evaluando los avances, nuevos métodosy recomendaciones para personas con riesgo promedio, moderado y alto.(AU)

Budesonide enema in pouchitis--a double-blind, double-dummy, controlled trial.

BACKGROUND: Pouchitis has been suggested to be a recurrence of ulcerative colitis in a colon-like mucosa. Topical steroids are a valid therapeutic alternative for distal forms of ulcerative colitis. AIM: To investigate the efficacy and tolerability of budesonide enema in the treatment of pouchitis compared with oral metronidazole. MATERIALS AND METHODS: Twenty-six patients with an active episode of pouchitis (defined as a pouchitis disease activity index score >or= 7) and no treatment during the previous month were randomized to receive either budesonide enema (2 mg/100 mL at bedtime) plus placebo tablets or oral metronidazole (0.5 g b.d.) plus placebo enema in a prospective, double-blind, double-dummy, 6-week, controlled trial. RESULTS: Based on the intention-to-treat principle, we detected a significant improvement in disease activity at the end of the first week with both drugs (P < 0.01). After that, improvement was moderated until stabilization at 4 weeks in both treatments. The per protocol analysis showed that both drugs had similar efficacy in terms of disease activity, clinical and endoscopic findings. Fifty-eight per cent and 50% of patients improved (decrease in pouchitis disease activity index >or= 3) with budesonide enema and metronidazole, respectively (odds ratio, 1.4; confidence interval, 0.2-8.9). Adverse effects were observed in 57% of patients given metronidazole and in 25% of patients given budesonide. CONCLUSIONS: Budesonide enemas are an alternative treatment for active pouchitis, with similar efficacy but better tolerability than oral metronidazole.

Serum transforming growth factor-beta1 levels increase in response to successful anti-inflammatory therapy in ulcerative colitis.

OBJECTIVE: To investigate serum levels of transforming growth factor-beta1 and interferon-gamma in active ulcerative colitis and to assess changes during treatment. METHODS: We prospectively evaluated serum from 25 patients with untreated active ulcerative colitis and 19 healthy controls. Disease activity score (DAI), serum transforming growth factor-beta1 and interferon-gamma levels were measured at baseline and after 7 days of conventional treatment. Disease activity score and transforming growth factor-beta1 were also assessed at 42 days. RESULTS: Baseline transforming growth factor-beta1 levels were significantly higher in patients than in controls (P < 0.02). On the 7th day, transforming growth factor-beta1 levels increased only in patients who responded (P < 0. 01); variations in transforming growth factor-beta1 levels and disease activity score were inversely correlated (r=- 0.72, P < 0. 001). At day 42, serum transforming growth factor-beta1 decreased significantly compared with the 7th day (P < 0.05). While in controls, interferon-gamma was undetectable; untreated patients had higher, widely variable, levels. At day 7, responders had higher interferon-gamma values than unresponsive cases. Variations in interferon-gamma correlated moderately with changes in transforming growth factor-beta1 (r=0.53, P < 0.05). Cytokine response did not depend upon the type of treatment. CONCLUSIONS: Both transforming growth factor-beta1 and interferon-gamma may play a role in the injury-repair process in active ulcerative colitis. Variations in circulating transforming growth factor-beta1 levels in the first week of treatment seem to be related to the therapeutic response.

High frequencies of telomeric associations, chromosome aberrations, and sister chromatid exchanges in ulcerative colitis.

OBJECTIVE: Chromosome instability provides a predisposing background to malignancy, contributing to the crucial genetic changes in multistep carcinogenesis. The aim of this work was to analyze chromosome instability in patients with ulcerative colitis (UC) to achieve a better understanding of the increased risk for colorectal cancer. METHODS: Peripheral blood lymphocyte cultures from 20 untreated UC patients and 24 controls were used to study chromosome instability by assessing telomeric associations (TAS), chromosome aberrations (CA), and sister chromatid exchanges (SCE). RESULTS: Mean frequencies of TAS and CA were significantly increased in UC patients compared to controls (p < 0.001). Chromosomes 10, 11, 21, 16, and 19 were the most frequently involved in TAS. A total of 104 CA clustered in 66 breakpoints could be exactly localized. Seven nonrandom bands significantly affected in UC patients were found (p < 0.004), showing a significant correlation with the location of cancer breakpoints (p < 0.003), particularly with colorectal carcinoma rearrangements. SCE analysis showed higher levels in patients compared to controls (p < 0.006), but no differences were observed in cell cycle kinetics. CONCLUSIONS: Our results demonstrate the presence of an unstable genome in UC patients that could be related to the cancer development observed in this disease.

Increased mucosal levels of leukotriene B4 in pouchitis: evidence for a persistent inflammatory state.

DESIGN AND METHODS: In order to evaluate its possible role in the pathogenesis of pouchitis we measured the release, into the incubation medium of leukotriene B4 from mucosal samples from patients with ileal pouch-anal anastomosis and correlated release with clinical, endoscopic and histological features. RESULTS: Leukotriene B4 release was significantly elevated in patients with active pouchitis in comparison to those with a normal pouch mucosa (P < 0.007). No overlap was observed between leukotriene B4 levels from patients with active pouchitis samples and those obtained from individuals without pouchitis. Effective treatment of pouchitis was associated with a significant reduction in leukotriene B4 mucosal release to the incubation medium (P < 0.03). However, even in remission, levels of leukotriene B4 release remained significantly increased in these patients in comparison to people who never experienced pouchitis (P < 0.003). A modest correlation was observed between pouchitis disease activity index and leukotriene B4 release (r = 0.596; P < 0.01). CONCLUSION: These results suggest that the increased production of leukotriene B4 may be implicated in the pathogenesis of pouchitis. The persistence of an increased mucosal release of leukotriene B4 in pouchitis patients during clinical remission suggests the presence of a chronic, ongoing, underlying inflammatory process.

Faecal alpha 1-antitrypsin concentration in the diagnosis and management of patients with pouchitis.

OBJECTIVE: To investigate the role of faecal alpha 1-antitrypsin concentration in the diagnosis and management of patients with ileal pouch-anal anastomosis. DESIGN: Prospective study. METHODS: Fifty-two measurements of faecal alpha 1-antitrypsin concentration were taken from 33 patients operated on for ulcerative colitis. RESULTS: Patients with active pouchitis (44.4 +/- 7.1 mg%) had a three-fold higher mean faecal alpha 1-antitrypsin concentration than patients in remission (13.7 +/- 1.3 mg%; P < 0.0001), than patients who had never had pouchitis (14.4 +/- 2.3 mg%; P < 0.003) and than patients with incontinent ileostomies (12.7 +/- 1.3 mg%; P < 0.004). Faecal alpha 1-antitrypsin measurements were 80% sensitive and 97% specific for active pouchitis. A significant positive correlation between the pouchitis disease activity index and faecal protein loss was observed (r = 0.702; P < 0.0001). The correlations between protein loss and other parameters were weaker (protein loss versus clinical score, r = 0.309; versus endoscopic score, r = 0.583; and versus histologic score, r = 0.558). CONCLUSION: Faecal alpha 1-antitrypsin concentration is a good indicator of the degree of intestinal inflammation in pouchitis and may be useful as a quantitative index of disease activity in prospective studies.

Fecal alpha 1-antitrypsin clearance in the differential diagnosis of steatorrhea.

We reviewed the fecal fat excretion and alpha 1-antitrypsin clearance results of 160 patients with steatorrhea in whom a final diagnosis was obtained, based on history, physical examination, and radiological, functional and morphological tests. Twenty-two patients had pancreatic diseases and 138 had steatorrhea due to gastrointestinal diseases. alpha 1-antitrypsin clearance was invariably normal in chronic pancreatitis, but there was only a 23 to 50% of correct etiological classification when the combination of steatorrhea and normal alpha 1-antitrypsin clearance was present. However, none of our patients diagnosed of chronic pancreatitis had abnormal alpha 1-antitrypsin clearance. The combination of steatorrhea and normal clearance of alpha 1-antitrypsin was a modest clue for diagnosis of pancreatic malabsorption.

Fecal alpha 1-antitrypsin clearance in the differential diagnosis of steatorrhea.

We reviewed the fecal fat excretion and alpha 1-antitrypsin clearance results of 160 patients with steatorrhea in whom a final diagnosis was obtained, based on history, physical examination, and radiological, functional and morphological tests. Twenty-two patients had pancreatic diseases and 138 had steatorrhea due to gastrointestinal diseases. alpha 1-antitrypsin clearance was invariably normal in chronic pancreatitis, but there was only a 23 to 50

of correct etiological classification when the combination of steatorrhea and normal alpha 1-antitrypsin clearance was present. However, none of our patients diagnosed of chronic pancreatitis had abnormal alpha 1-antitrypsin clearance. The combination of steatorrhea and normal clearance of alpha 1-antitrypsin was a modest clue for diagnosis of pancreatic malabsorption.

Fecal alpha 1-antitrypsin clearance in the differential diagnosis of steatorrhea.

We reviewed the fecal fat excretion and alpha 1-antitrypsin clearance results of 160 patients with steatorrhea in whom a final diagnosis was obtained, based on history, physical examination, and radiological, functional and morphological tests. Twenty-two patients had pancreatic diseases and 138 had steatorrhea due to gastrointestinal diseases. alpha 1-antitrypsin clearance was invariably normal in chronic pancreatitis, but there was only a 23 to 50

of correct etiological classification when the combination of steatorrhea and normal alpha 1-antitrypsin clearance was present. However, none of our patients diagnosed of chronic pancreatitis had abnormal alpha 1-antitrypsin clearance. The combination of steatorrhea and normal clearance of alpha 1-antitrypsin was a modest clue for diagnosis of pancreatic malabsorption.

Celiac sprue after surgery of the upper gastrointestinal tract. Report of 10 patients with special attention to diagnosis, clinical behavior, and follow-up.

The clinical onset of celiac sprue (CS) may be precipitated by upper digestive tract surgery. We report a series of 10 patients who developed CS after diverse types of peptic ulcer surgery. Six were male and 4 female. Gastrectomy with Billroth II anastomosis was performed in 5 patients, truncal vagotomy and pyloroplasty in 2, parietal cell vagotomy and pyloroplasty in 1, and vagotomy with gastrojejunal anastomosis in 2. We found that eight patients had had previous symptoms that suggested CS. Symptoms occurred early in the postoperative period. Severe diarrhea and striking weight loss were the most prominent clinical findings. The response to gluten-free diet was independent of the type of surgical procedure performed and was similar to that observed in the general celiac population.

Alpha 1-antitrypsin clearance as an aid in the management of patients with celiac disease.

One hundred and thirty-two different intestinal alpha 1-antitrypsin clearance tests were performed in 48 untreated adult celiac patients, 64 patients taking a gluten-free diet, and 20 adult healthy controls. In the untreated group, 95% of patients had enteric protein loss with values higher than the upper limit of normality (mean +/- 2 SD). In the treated group of patients, only 22% had abnormal levels of alpha 1-antitrypsin clearance. Sixteen patients who had elevated clearance before treatment had decreased clearance after an average of 7.4 months on a gluten-free diet. There was a significant relation (p less than 0.05) between the alpha 1-antitrypsin clearance and the degree of alteration of the jejunal histological structure. We conclude that enteric protein loss is a very frequent finding in celiac patients and the measurement of alpha 1-antitrypsin clearance may be a reliable method to evaluate the activity of the disease and useful in following the efficacy of treatment.

Short-term antibiotic treatment in Whipple's disease.

We report the results of short-term antibiotic treatment in 19 patients with Whipple's disease (WD). The diagnosis was based on clinical features and on a characteristic small bowel biopsy. Patients received treatment for a mean of 7.9 weeks (range 4-20). Fourteen were treated with de-methyl-chlortetracycline (600 mg/day), and 1 also received chloramphenicol (1 g/day); 1 was treated with ampicillin (2 g/day), and 4 were treated with amoxicillin (1.5 g/day). In all patients, the clinical response was rapid and excellent, body weight increased significantly, diarrhea subsided, and fecal fat values returned to normal. Intestinal biopsies obtained after treatment was completed showed significant improvement based on a decrease in the number of macrophages staining positive with periodic acid-Schiff (PAS), normalization of villous structure, and decreased dilatation of lymphatic channels; free bacilli were absent, as shown both by light and electron microscopy. Seventeen patients have been followed for a mean of 99.4 months (range 6-300). Two died 30 and 72 months after diagnosis of Whipple's disease, 1 of laryngeal carcinoma and the other of colonic carcinoma. Fifteen patients are in excellent health. Three patients treated with tetracycline have had clinical and/or histologic relapses. In our experience, short-course antibiotic treatment with tetracycline or ampicillin and derivatives can be effective in WD, with few relapses and excellent outcome. No neurologic symptoms, either initially or during follow-up were observed.

Gluten challenge in patients with celiac disease: evaluation of alpha 1-antitrypsin clearance.

Our aim in this study was to monitor changes of the intestinal structure by alpha 1-antitrypsin clearance (alpha 1-ATCL) in order to offer an alternative to the gluten challenge biopsy. In addition, we evaluated the possibility of reducing the time of gluten challenge. Twelve patients had a presumptive diagnosis of celiac disease based on clinical and histological grounds. They were studied when the jejunal histology was normal after gluten-free diet and an alpha 1-ATCL was normal. The gluten was introduced by returning to a normal diet. The challenge lasted 4 wk. We measured alpha 1-ATCL at the end of the 1st and 4th wk, and a new jejunal biopsy was obtained at the end of the 4th wk. By wk 1, alpha 1-ATCL was abnormal in 11 patients but normal in one. By wk 4, alpha 1-ATCL was abnormal in 10 patients and still normal in one. The post-challenge biopsies showed atrophy in 11 and was normal only in the patient with normal alpha 1-ATCL at wk 1 and 4. One patient with abnormal alpha 1-ATCL had to stop the challenge at the first week. The patient with normal clearance at wk 1 and 4 and normal biopsy at wk 4 had abnormal results at 6 months. These data support our hypothesis that alpha 1-ATCL can be used as evidence of gluten toxicity after gluten challenge, and that this test can be abnormal as early as 1 wk after gluten is reintroduced.

Fecal fat concentration in the differential diagnosis of steatorrhea.

Many approaches have been proposed to differentiate between steatorrhea due to pancreatic insufficiency and intestinal disease. Bo-Linn and Fordtran recently suggested that fecal fat concentration (FFC) is a useful screening test for this distinction. Our aim was to validate their result in a large group of patients. Fecal fat concentrations were calculated for 613 fecal fat tests in 538 patients. Included were 88 patients with pancreatic steatorrhea (13 pancreatic carcinoma, 6 cystic fibrosis, and 69 chronic pancreatitis) and 525 with nonpancreatic steatorrhea. The mean FFC of patients with pancreatic disease (15.0 +/- 1.9 g%, mean +/- SEM) was significantly higher than that of patients with other diseases causing malabsorption (8.9 +/- 0.3 g%, p less than 0.001). Forty-two percent of patients with pancreatic steatorrhea had an FFC below 10 g%. The overlapping of the FFC of steatorrhea due to pancreatic disease and that produced by celiac disease, gastric resection, and other conditions suggests that this approach does not differentiate between pancreatic and intestinal steatorrhea.

[Primary lymphoma of the small bowel and malabsorption]. / Linfoma primario de intestino delgado y malabsorción.

Between 1974 and 1984 we saw 69 patients with lymphoma that involved the gastrointestinal tract. In ten patients the lymphoma compromised the small bowel and were associated to malabsorption. Seven patients fulfilled the criteria to be considered as primary small bowel lymphoma. We presumed the intestinal origin in the other 3 patients, but it was impossible to confirm it. The peroral small bowel biopsy showed histological findings compatible with celiac disease in 7 patients. Other particular histological signs were patchy alterations, inconstant epithelial pseudo-stratification and ulcerations. In 2 cases we found findings that suggested the diagnosis of lymphoma. In 50% of patients we found unspecific malabsorption signs in the small bowel radiology. We found giant ulcers and stenosis too. The gluten-free diet or the steroid therapies resulted in temporary or inconstant improvement. The laparotomy was the most effective diagnostic approach. It was performed electively in 6 patients and in 1 because of a small bowel perforation. The primary small bowel lymphoma is an entity of difficult diagnosis. The most important trouble is to differentiate it with celiac disease.