Evolution of Clinical Behavior in Crohn's Disease: Factors Associated with Complicated Disease and Surgery.

BACKGROUND: The phenotypic expression of Crohn's disease may vary over time. Establishment of Crohn's disease phenotypes is important for definition of patient care strategies. AIMS: The aim of the study was to evaluate the long-term evolution of patients based on disease phenotypes and the main factors associated with this evolution. METHODS: Data from 179 patients were collected from a unicentric prospective database. Montreal classification was employed. Kaplan-Meier method was used to estimate the cumulative probability of complication development and surgery. Poisson regression for multivariate analysis was applied. The Local Institutional Review Board approved the research. RESULTS: Female: 54.2%. Mean age at diagnosis: 32.7 (±13.7) years. Behavior at presentation: inflammatory 62.0%, stricturing 24.6%, penetrating 13.4%; perianal disease: 31.8%; median follow-up time: 65.2 months (IQR 31.0-108.8). Behavior at follow-up period end: inflammatory 43.6%, stricturing 38.0%, penetrating 18.4%; perianal disease: 46.4%. Cumulative probability of being complication free in 5, 10, and 20 years: 86.3, 66.4, and 52.2%, respectively. Cumulative probability of being surgery free in 5, 10, and 20 years: 87.3, 79.2, and 64.1%, respectively. L1 and L4 locations, use of immunosuppressive therapy, smoking, number of hospitalization/patient-year, abdominal surgery, age at diagnosis <40 years, and biological therapy were the factors associated with changes in phenotype or development of complications and perianal disease. CONCLUSION: Clinical behavior altered in about one-third of patients. The most frequent complication was a change to stricturing pattern. Disease location, current smoker, immunosuppressive therapy use, hospitalization, and abdominal surgery were factors associated with an unfavorable clinical evolution.

Could gastric histology be a useful marker for making decision on Helicobacter pylori eradication therapy in patients with dyspepsia?

CONTEXT: It still remains an open debate whether Helicobacter pylori eradication is beneficial or not for the improvement of symptoms in functional dyspepsia. Differences in geographic distribution, the worldwide H. pylori genetic variability and the fact that the outcome of infection is strongly related to the virulence of the infecting strain are factors that might be driving ongoing controversies. OBJECTIVE: To study the correlation between gastric histology and H. pylori serology status in patients with dyspepsia. METHODS: This is a cross-sectional study where 40 consecutive dyspeptic patients (28 women and 12 men, mean age 48.5 years) with endoscopically normal stomachs were selected from the endoscopy unit at a university hospital in Recife, PE, Northeast of Brazil, between March 1998 and July 1999. Patients underwent gastric mucosal biopsy and serological tests (anti-Hp and anti-CagA antibodies). Gastric biopsies were examined using H-E and Giemsa stains and gastritis was classified and graded (mild, moderate or severe) according to 'the updated Sydney System-Houston, 1994'. RESULTS: Among 40 patients with dyspepsia the gastric histology revealed that about (1/4) had moderate (25%) or severe (2.5%) gastritis. This subgroup of patients also had a greater positive frequency of anti-Hp (100% vs 41%; P = 0.0005) and anti-CagA (91% vs 58%; P = 0.09) antibodies when compared with those with normal histology (27.5%) or mild gastritis (45%). CONCLUSION: Since upper gastrointestinal endoscopy is part of the functional dyspepsia investigation and serology for anti-CagA antibody is not available in daily clinical practice, by biopsying gastric mucosa we would only be able to selectively apply H. pylori eradication therapy for those with histology that best correlate with virulent infecting strains (moderate or severe gastritis)--around (1/4) of our study patients with dyspepsia.