Long term benefit of one year infliximab administration for the treatment of chronic refractory pouchitis.

BACKGROUND-AIM: The aim of this study is to identify the long term benefit of one year infliximab administration for the treatment of chronic refractory pouchitis following ileo-pouch anal anastomosis (IPAA) for ulcerative colitis (UC). METHODS: Seven patients with chronic refractory pouchitis diagnosed by clinical, endoscopic and histological criteria received infliximab 5 mg/kg at 0, 2, and 6 weeks and thereafter every 2 months for 1 year. Three patients had fistulae (1 pouch-bladder, 2 perianal) and 4 extraintestinal manifestations (2 erythema nodosum, 2 arthralgiae). All patients were refractory to antibiotics and 3 to azathioprine. Crohn's disease was excluded after re-evaluation of the history and small bowel examination with enteroclysis or capsule endoscopy. Clinical response was classified as complete, partial and no response. Fistulae closure was classified as complete, partial and no closure. The pouchitis disease activity index (PDAI) was used as an outcome measure. All patients were followed up for 3 years after discontinuation of infliximab therapy. RESULTS: After 1 year of infliximab administration 5 patients had complete clinical response, 1 partial clinical response and 1 no response, while 2 out of the 3 patients with fistulae had a complete closure. The median PDAI dropped from 11 (baseline) (range, 10-14) to 5 (range, 3-8). Extraintestinal manifestations were in complete remission too. Three years after completion of therapy, all patients with complete clinical response at one year remained in remission. CONCLUSIONS: One year infliximab administration is associated with a long term benefit in patients with chronic refractory pouchitis following IPAA for UC.

[Placenta previa percreta with bladder involvement managed conservatively--case report]. / Zachowawcze postepowanie w placenta previa percreta przerastajacym sciany pecherza moczowego--opis przypadku.

Placenta percreta is potentially a life-threatening condition. Pelvic organ invasion of the placenta carries high mortality and morbidity to the mother and fetus. We present a 33 year old gravida 3, para 2-0-0 female with placenta previa, percreta with bladder invasion. Placental invasion caused a giant vesicouterine fistula. The pregnant woman was managed conservatively until 33 weeks gestation, at which time she underwent a classical cesarean section. Postoperatively the patient was treated with methotrexate. Immediately postpartum the placenta was left in situ and successfully removed transvaginally after 11 weeks postpartum.

Treatment of malignant enterovesical fistula with octreotide.

Surgical treatment for internal fistula is rarely indicated for terminally ill patients with cancer because of their poor prognoses. Reports of surgical or pharmacologic treatment of vesicoenteric fistula in terminally ill patients with cancer are rare. A 73-year-old woman with rectal cancer that had directly invaded the bladder and metastasized to the liver was admitted to our hospital with high fever and severe perineal pain. Retrograde urography indicated an enterovesical fistula. Although the urinary tract infection was treatable with antibiotics, frequent episodic pain, due to urethritis secondary to the fistula, was not alleviated with opioid and topical treatment. Three days after starting octreotide 0.3 mg/d, the severe pain was alleviated, and follow-up retrograde urography revealed closure of the fistula. This suggests that treatment with octreotide may have enabled closure of the fistula. Thus, octreotide should be considered a viable therapeutic option in terminally ill patients with inoperable internal fistula.

Hormonal dependence of fistulas communicating with the uterus.

The conventional management of urogenital fistulas is surgical but a recent review of world data showed a high efficacy of hormonal manipulation by the induction of amenorrhea in the treatment of vesicouterine fistulas (VUFs). In fact, VUFs were first demonstrated to be hormonally regulated due to the fistulous canal being lined by endometrium. In this report, we suggest and discuss that, in women of reproductive age, the phenomenon of hormonal regulation is likely to be present in other fistulas communicating with the uterus, like ureterouterine and enterouterine fistulas.

Successful management of vesicouterine fistula by luteinizing hormone-releasing hormone analog.

Vesicouterine fistula is a rare complication of cesarean section. Although surgical repair was mandatory for the management of the fistula previously, a recent review showed high efficacy of hormonal manipulation by the induction of amenorrhea. Herein, we report a new case of vesicouterine fistula secondary to cesarean section successfully treated by luteinizing hormone-releasing hormone analog for 6 months. Conservative hormonal treatment for vesicouterine fistula caused by cesarean section should be considered before surgical repair.

Infliximab treatment of Crohn disease ileovesical fistula.

Ileovesical fistula is a rare inaugural complication of Crohn disease. Current approaches associate antibiotics, total parenteral nutrition and various combinations of immunomodulatory agents. However, only a minority of fistulas subside under conventional treatment, as most of them ultimately require complex surgery to excise and close the structures involved. We report the case of a 31-year-old patient successfully treated by targeting the local production of tumour necrosis factor alpha with infliximab.

[The prolonged administration of intravenous immunoglobulins as a treatment for refractory fistulous Crohn's diseases]. / Administración prolongada de inmunoglobulinas intravenosas como tratamiento de la enfermedad de Crohn fistulosa refractaria.

Fistulating Crohn's disease is present in 17-35% of non-surgically treated patients and in up to 45% of surgically treated ones. Among the several therapeutic alternatives for this disease is intravenous immunoglobulin administration. We present a 28-year-old woman with refractory fistulating Crohn's disease who improved after prolonged immunoglobulin administration (32 months).

Youssef's syndrome: an appraisal of hormonal treatment.

Two cases of vesicouterine fistula, caused by lower-segment cesarean section, are presented. Both cases had classical symptoms of Youssef's syndrome, i.e. cyclic hematuria, absence of vaginal bleeding and complete urinary continence. These patients were treated by the continuous administration of an estrogen-progestogen combination for 6 months. However, it failed in 1 case requiring transabdominal transperitoneal closure of the fistula with an interposition of omentum. We feel that hormonal treatment may be tried as first modality in the treatment of Youssef's syndrome, before resorting to surgery.

[Conservative treatment of urogenital fistula following gynecological surgery: the value of fibrin glue]. / Traitement conservateur des fistules urogénitales après chirurgie gynécologique: intérêt de la colle de fibrine.

Ureteric and bladder vaginal fistulas are recognized complications of gynaecologic surgery. We report on 4 cases of fistulas (2 uretero-vaginal and 2 vesico-vaginal) successfully treated by urinary drainage associated with plugging of fistula with fibrin sealant. Efficiency of conservative treatments is directly related to early application. Mechanical and biological properties of fibrin sealant explain its possible role in recovery, without increasing risk of viral transmission.

Management of bladder fistulas in Crohn's disease.

We reviewed the course of 500 patients with Crohn's disease to document the incidence, the nature, and the results of management of fistulas to the bladder. Seventeen patients (14 men and three women) had developed enterovesical fistulas: 16 had pneumaturia. The barium radiographs demonstrated the fistula in only 37%. All had received sulfasalazine, and most were treated with corticosteroids and antibiotics intermittently; two had successful control of their urinary symptoms on this regimen. Eight patients who received 6-mercaptopurine (6-MP) in addition tolerated the urinary fistula well, so that we encourage a trial of 6-MP for this complication of Crohn's disease. Six patients continue on medical therapy alone after a mean of 5.3 years. There were no instances of pyelonephritis during 60 patient years. Eleven patients eventually underwent bowel resection, but in only two was persistence of the enterovesical fistula the primary indication for elective surgery, and in both, it was the patient's choice. Visualization of the fistula on barium enema radiograph or presence of a connection between the sigmoid and the bladder were not associated with adverse outcome. An enterovesical fistula in Crohn's disease rarely leads to serious complications and can often be treated successfully with medical therapy alone: by itself, it need not serve as an indication for surgery.

Pneumaturia: need for diagnostic alertness.

Pneumaturia, an air-filled urinary bladder with or without passage of gas in the urine, is a rare phenomenon in the general population, but is more frequent in defined high-risk subgroups. Relevant symptomatology may be hardly noticeable for a relatively long period; however, the outcome may be serious and sometimes fatal. We present three such cases and discuss diagnostic and therapeutic aspects.

Internal fistulas in Crohn's disease.

There is doubt about the timing of surgery for patients with internal fistulas in Crohn's disease. Although immediate operative intervention for all patients has been advocated, such a policy has not always been followed at St. Mark's Hospital. Between 1971 and 1982, 83 internal fistulas were identified in 59 patients with Crohn's disease. Fifty-nine fistulas arose primarily from the small intestine and involved another segment of the bowel, five were between large bowel and duodenum, and three between areas of large bowel. Sixteen fistulas (ten from ileum and six from large bowel) involved the bladder. Thirty-six patients with 54 fistulas underwent immediate surgical treatment. Fifteen patients with 20 fistulas required surgery later. There was one postoperative death among the 51 patients treated surgically and one late death unrelated to the treatment of the fistula. Of the remaining 49 surgically treated patients, 46 were traced and remain well, six after further surgery. Eight patients with nine fistulas (four involving the bladder) were treated at St. Mark's without operation. One later required surgery elsewhere for an enterocutaneous fistula, but the remaining seven patients are well. This study suggests that the presence of an internal fistula, even if it involves the bladder, is not an absolute indication for immediate surgery and that the severity of the symptoms should dictate the treatment policy.

Conservative treatment of selected patients with colovesical fistula due to diverticulitis.

Thirty patients with colovesical fistula due to diverticulitis were encountered in the past ten years. Six patients did not receive any of the standard operative therapies. Four of these patients were observed for three to 14 years with nonoperative management, with little inconvenience and without significant complications. Five of the 24 patients in the surgical group died in the postoperative period. Nonoperative therapy seems to be a viable option in selected patients.

Vesico-uterine fistula treated by amenorrhoea induced with contraceptive steroids. Two case reports.

Two women with vesico-uterine fistulae causing amenorrhoea and cyclic hematuria were successfully treated by the continuous administration of an oestrogen-progestogen combination for six months.