在治疗克罗恩病相关性黏膜溃疡中应用英夫利昔单抗定期维持治疗优于间断治疗

Background: The endoscopic substudy of the ACCENT I (A Crohn’s Disease Clinical Trial Evaluating Infliximab in a New Long-term Treatment Regimen) Crohn’s disease trial examined the effects of infliximab on mucosal inflammation and mucosal healing, and assessed their impact on outcomes. Design: ACCENT I was a randomized, double-blind, parallel group study. Setting: This study took place at multiple centers in North America, Europe, and Israel. Main Outcome Measurements: Ileocolonoscopic examinations were performed at weeks 0, 10, and 54. Complete mucosal healing was defined as the Absence of all mucosal ulcerations. The end point of principal interest was the proportion of patients randomized as responders with mucosal healing at week 10. The proportion of responderswho demonstrated mucosal healing at week 54 or at both weeks 10 and 54 is also summarized. Changes in Crohn’s disease endoscopic index of severity (CDEIS) scores from baseline to week 10 and 54 were calculated for all patients in this substudy. Results: Complete mucosal healing by week 10 occurred in significantly more week 2 responders who had received 3 doses of infliximab compared with a single dose (31% vs. 0% , p = 0.010). A significantly higher proportion of week 2 responders in the combined scheduled maintenance group had complete mucosal healing at week 54 compared with the episodic group (50% vs. 7% , p = 0.007). The results for all patients are consistent with those for week 2 responders only. Significantly greater improvement in the CDEIS occurred with scheduled maintenance compared with episodic treatment at week 10 (p ≤ 0.001) and week 54 (p = 0.026). Notably, no strong relationship between clinical remission and complete mucosal healing was found. Overall, mucosal healing appeared to correlate with fewer hospitalizations, although these results were not statistically significant. Conclusions: Scheduled infliximab maintenance therapy resulted in more improvement in mucosal ulceration and in higher rates of mucosal healing. There was a numerical trend for patients with better mucosal healing to have a lower rate of Crohn’s disease-related hospitalizations.

对90岁及以上患者应用治疗性ERCP的有效性与安全性研究

Background: Therapeutic ERCP has an established role in the treatment of pancreatobiliary diseases, but little information is available on the outcomes of this procedure in patients 90 years of age and older. Objective: To evaluate the efficacy and the safety of therapeutic ERCP in an extremely elderly cohort. Design: Retrospective study. Setting: Two Greek cohorts of patients ≥ 90 and 70 to 89 years of age who underwent therapeutic ERCPs. Patients: Sixty-three patients aged 90 years and older (group A) and 350 patients 70 to 89 years of age (group B). Interventions: A retrospective review of therapeutic ERCPs was performed between 1994 and 2000 on both groups, identified by using a database linked to the endoscopy reporting system in our department. Main Outcome Measurements: Efficacy and safety of therapeutic ERCPs. Concomitant diseases, complications, and outcome were also evaluated. Results: Group A patients had a higher incidence of concomitant diseases than group B patients (100% vs 72.8% , respectively). The rate of post-ERCP early complications was low in both groups: 6.3% in group A and 8.4% in group B. The frequency of ERCP related mortality was 1.6% (1 patient) in group A and 0.6% (2 patients) in group B. Group A required endoscopic sessions for stone clearance and mechanical lithotripsy more frequently than group B (20.6% vs 11.4% and 17.5% vs 10.3% , respectively). No patient in either group experienced subjective deterioration inmental status, and the 3 patients who died required ventilatory support before death. Late complications occurred in 2.3% of patients in group B. Conclusions: Therapeutic ERCP is safe and effective for the treatment of pancreatobiliary diseases in extremely elderly patients, and advanced age per se should not impinge on decisions relating to its use.

胃电图和胃肠激素水平在化疗相关性消化不良中的作用

Background: The aim of this study was to investigate the relationship among motility disorders, dyspeptic symptoms, and plasma levels of gastrointestinal hormones in cancer patients who were well controlled for post-chemotherapy emesis. Methods: Twenty-five cancer patients treated with standard dosages of antiemetics and chemotherapies completed the study. Gastrointestinal symptoms were investigated by detailed questionnaire and visual analog score. Motility was investigated by cutaneous electrogastrography, and by blood levels of gastrin, serotonin, vasopressin, and substance P, before and 7 days after chemotherapy. Results: Before chemotherapy, no patient complained of dyspeptic symptoms, and no differences in electrogastrography (EGG) or in circulating peptide levels were found between patients who developed dyspepsia and those who did not. After chemotherapy, 13 patients suffered from dysmotility-like symptoms (total symptom score, 11.5 [2.5-37.9]; median value and 5th-95th percentiles), with susceptibility to nausea, early satiety, and postprandial fullness being the major complaints. As regards EGG parameters, a significant reduction (P = 0.04; Mann-Whitney test) in the normal slow-wave percentage and significantly increased tachygastria percentage were found in dyspeptic patients compared with symptom-free patients. The tachygastria percentage was significantly associated with susceptibility to nausea score, in a non-linear fashion (R2 = 0.37). Dyspeptic patients showed lower levels of substance P and gastrin than patients who were not dyspeptic, but this difference had no clinical significance for dyspepsia. Conclusions: Chemotherapy may induce upper gastrointestinal symptoms suggestive of motility disorders. These dyspeptic symptoms were associated with EGG alterations, but not with variations in circulating peptides. Other hormones or pathophysiological factors, not considered in the present work, could be actively involved in these dyspeptic symptoms.

基于多变量模型诊断自身免疫性肝病的临床亚型

Background: Diagnosing autoimmune hepatitis (AIH), primary biliary cirrhosis (PBC), primary sclerosing cholangitis, and other autoimmune liver diseases remains an imperfect process. We need a more accurate, evidence-based diagnostic system. Methods: We conducted a national survey and identified 988 cases of liver disease which did not satisfy the inclusion criteria for any liver disease of known etiology. We expected these cases to include autoimmune liver disease (AILD) and its variant forms. We selected 269 prototype cases for which histological re-evaluation of liver biopsy by independent expert hepatopathologists and the original diagnosis coincided. We did a multiple logistic regression analysis to determine explanatory variables that would distinguish cases of AIH and PBC from those of non-AIH and non-PBC, respectively. We constructed a multivariable diagnostic formula that gave AIH and PBC disease probabilities and validated it in a study of an additional 371 cases (validation group). Results: Based on the results of the statistical analysis, we selected three laboratory tests and four histological features as independent variables correlated to the diagnosis of both AIH and PBC. For the validation group, assuming that the original diagnosis was correct, the sensitivity and specificity for AIH were 86.3%and 92.4%, respectively. For PBC the sensitivity and specificity were 82.5%and 63.7%, respectively. A detailed analysis of inconsistent cases showed that the diagnosis based on the formula had given the correct diagnosis, for either AIH or PBC, except for 5 cases (1.3%) in which disease probability was low for both. Conclusions: A seven-variable formula based on three laboratory tests and four histological features gives significant information for the diagnosis of AILD.

超选择性动脉栓塞术成功治疗克罗恩病回肠末端致命性出血

A case of life-threatening lower gastrointestinal hemorrhage from Crohn’s disease is reported. Several promising studies have recently been published that describe super selective embolization for the treatment of massive lower gastrointestinal hemorrhage in patients with bleeding colonic diverticular disease and angiodysplasia, and success rates of 74%-93%have been reported. But in patients with Crohn’s disease, successful superselective embolization has rarely been reported. This is a report of successful superselective embolization in a patient with Crohn’s disease; this should be the initial treatment of choice in Crohn‘s disease in an attempt to avoid surgical resection, because repeated resections predispose patients to the development of short-bowel syndrome.

国际自身免疫性肝病组评分系统:是否有助于诊断非酒精性脂肪肝的自身免疫性肝炎

Background: There are no surrogate serum markers for autoimmune hepatitis (AIH) and nonalcoholic fatty liver disease (NAFLD). An AIH scoring system was reported by the International Autoimmune Hepatitis Group; however, the criteria did not focus on making the distinction between AIH and NAFLD. We examined the effectiveness of using the AIH score for diagnosing AIH in NAFLD patients. We also identified the prevalence of autoimmune phenomena, in terms of various auto-antibodies, including antinuclear antibodies (ANA), to determine whether these markers had any clinicopathological significance, and whether they were related to the patients’clinical courses. Methods: We studied 212 patients (103 males and 109 females) with biopsy-proven NAFLD. The AIH score of each patient was calculated without including the liver biopsy results. The patients were divided into three groups based on their clinicopathological features: the overlap group (those with clinical and histological features of both NAFLD and AIH), the systemic group (those with systemic antoimmune disease other than AIH), and the “other" group (patients with no antoimmune disease). To evaluate the clinicopathological significance of ANA in NAFLD patients, those without autoimmune diseases (the “others" group)were classified according to their ANA positivity and ANA titer. Results: Seventy patients (33.0%) were positive for ANA. Among the female patients, 106 patients (97.2%) had an AIH score of 10 or more. Of the 103 male patients, 21 (20.4%) had an AIH score of 10 or more. However, after liver biopsy, only 1 patient (0.5%) could be classified as “definite AIH". In the NAFLD patients without autoimmune diseases (“other" group), multivariate logistic regression analysis found that female sex was an independent predictor of the presence of ANA (P = 0.029). In contrast, multivariate logistic regression analysis found that severe obesity (body mass index [BMI], ≥30kg/m2) was the only independent predictor of the presence of an ANA titer of 1∶80 or more (P = 0.026). Conclusions: The AIH score without liver biopsy findings was not useful for diagnosing AIH in NAFLD patients. In patients with elevated ANA titers and risk factors for NAFLD, it is very important to perform a liver biopsy to make a definitive diagnosis before treatment.

在直接经皮内镜下空肠造瘘术之前进行腹部CT检查以预测结果

Background: Direct percutaneous endoscopic jejunostomy (DPEJ) placement succeeds in 72% to 86% of attempts. Failure is most often because of inadequate transillumination or gastroduodenal obstruction. Even in failed cases, patients are exposed to the risks of anesthesia, exploratory percutaneous needle punctures, and the cost burden of suboptimal resource utilization. Hence, a preprocedure predictor of outcome would be useful. Objective: To evaluate whether review of clinically available abdominal CTs can predict the outcome of subsequent DPEJ attempts. Design: Retrospectively conducted blinded review of abdominal CTs performed within 30 days before attempted DPEJ. Objective anatomic features potentially pertinent to DPEJ success were scored, and a prediction of the anticipated procedural outcome was made. Setting: A large tertiary referral center. Patients: A total of 115 patients who underwent attempted DPEJ and who also had an abdominal CT in the preceding 30 days. Main Outcome Measurements: Reviewer’s overall prediction of success, 3 objective anatomic measurements. Results: For the overall prediction of success, a CT performed poorly, with a sensitivity of 60% , a specificity of 53% , a positive predictive value of 71% , and a negative predictive value of 40% . Mean abdominal-wall thickness was significantly greater in the failures than the successes (27 vs 21 mm, P = .02), and just 39% of the procedures in patients with an abdominal-wall thickness >3 cm were successful. Limitations: Retrospective. Conclusions: Failed DPEJ attempts were associated with greater patient abdominal-wall thickness, and this should be taken into consideration before attempted DPEJ. Otherwise, review of existing abdominal CTs appears to have limited utility in predicting DPEJ outcome.

在初始应用EUS引导一步术建立入路之后进行胰腺假性囊肿或脓肿的内镜下治疗

Background: In this prospective case series, endoscopic management of pancreatic pseudocysts and Abscesses was investigated following an EUS-guided 1- step procedure for initial transmural access. Methods: Endoscopic drainage of pancreatic pseudocysts and Abscesses was performed in 35 patients (mean age, 51 years; range, 21- 81 years) by using interventional echoendoscopes (FG38UX and EG3830UT; Pentax-Hitachi, Lü bbecke, Germany). Interventions were performed by using a 1- step device consisting of a needle-wire suitable for cutting current, a 5.5F dilator, and an 8.5F plastic endoprosthesis (Giovannini Needle Wire Oasis, Cook Endoscopy,Winston-Salem, NC). Results: Endoscopic stent placement was successful in 33 of 35 patients (94% ), whereas repeated needle passages were unsuccessful in 2 cases (pancreatic pseudocystwall, 7 mm). No procedure-related complications, such as bleeding, perforation, or pneumoperitoneum, were observed. All subsequent complications, such as ineffective drainage (9% ), stent occlusion (12% ), or cyst infection (12% ), were managed endoscopically. Fourteen patients (43% ) demonstrated sustained clinical improvement and cyst resolutio upon placement of the initial 8.5F transmural drain. Ten patients (30% ) did not reveal a 50% reduction in cyst size on day 3, but cyst resolution was achieved by additional endoscopic cyst irrigation. Nine patients (27% ) with primary or secondary cyst infection underwent endoscopic balloon dilation and prolonged endoscopic drainage procedures to achieve cyst resolution. The overall resolution rate was 88% , with a recurrence rate of 12% , based on a mean follow-up period of 24 months. Conclusion: This 1- step EUS-guided technique with a needle-wire device provides safe transmural access and allows subsequent effective endoscopic management of pancreatic pseudocysts and Abscesses.

采用Levovist增强的血管后相超声对肝硬化结节性病变进行鉴别诊断:与超顺磁性氧化铁增强的磁共振成像的对比研究

Background: We investigated the diagnostic utility of post-vascular phase contrast-enhanced ultrasonography (US) and superparamagnetic iron oxide (SPIO)enhanced magnetic resonance imaging (MRI) as compared to the histological diagnosis of differential grades of hepatocellular carcinomas (HCCs). Methods: Forty-nine patients with histologically characterized liver nodules (well-differentiated HCC, n = 20; moderately differentiated HCC, n = 19; poorly differentiated HCC, n = 1; dysplastic nodule, n = 9) received contrast-enhanced US and SPIO-MRI. Subsequently, we quantitatively evaluated the relationships between the images of the nodules and their histological diagnosis and differential grades. Results: The ratio of the echogenicity of the tumorous area to that of the nontumorous area with post-vascular phase contrast-enhanced US (post-vascular phase ratio) decreased as nodules became less differentiated (P < 0.05; Kruskal-Wallis test). The ratio of the intensity of the nontumorous area to that of the tumorous area on SPIO-enhanced MR images (SPIO intensity index) also decreased as nodules became less differentiated (P < 0.01). The post-vascular phase ratio correlated with the SPIO intensity index for HCCs and dysplastic nodules (r = 0.76). The conformity of the result from the post-vascular phase contrast-enhanced US and SPIO-MRI was 96%. Conclusions: Contrast-enhanced US is a valuable method for predicting the histological grade of HCCs in cirrhotic patients, and may be a good alternative to SPIO-enhanced MRI.

幽门螺杆菌根除后反流性食管炎状况

Background: We aimed to determine the incidence and causative factors of reflux esophagitis following Helicobacter pylori eradication in Japanese patients. Methods: In patients in whom reflux esophagitis could not be detected endoscopically,we conducted an annual follow-up observation in 326 H. pylori-cured patients, 199 H. pylori-positive patients, and 151 H. pylori-negative patients, to study the incidence and causative factors of reflux esophagitis. Results: Development of reflux esophagitis was observed in 74 (22.7%) of the H. pylori-cured patients during a median follow-up period of 6.0 years, in 16 (8.0%) of the H. pylori-positive patients during a median follow-up period of 5.0 years, and in 29 (19.2%) of the H. pylori-negative patients during a median follow-up period of 5.4 years. The results, after correction for sex and age, showed that H. pylori-cured patients had a significantly higher risk of reflux esophagitis than H. pylori-positive patients (risk ratio, 2.43; P< 0.01), but their risk did not differ from that in the H. pylori-negative patients. It was also shown that hiatal hernia (risk ratio, 4.01; P< 0.01) and smoking history (risk ratio, 1.77; P< 0.05) were significant risk factors for the development of reflux esophagitis. Conclusions: With regard to the development of reflux esophagitis following H. pylori eradiation therapy, we observed that the frequency was higher in H. pylori-cured patients than in H. pylori-positive patients, but the frequency in H. pylori-cured patients and H. pylori-negative patients was the same. We elucidated that hiatal hernia and smoking history are important risk factors for reflux esophagitis.

欧洲人群克罗恩病的队列研究表明确诊后10年死亡率增高

Background:No previous correlation between phenotype at diagnosis of Crohn’ disease(CD)and mortality has been performed.We assessed the predictive value of phenotype at diagnosis on overall and disease related mortality in a European cohort of CD patients.Methods:Overall and disease related mortality were recorded 10 years after diagnosis in a prospectively assembled,uniformly diagnosed European population based inception cohort of 380 CD patients diagnosed between 1991 and 1993.Standardised mortality ratios(SMRs)were calculated for geographic and phenotypic subgroups at diagnosis.Results:Thirty seven deaths were observed in the entire cohort whereas 21.5 deaths were expected(SMR 1.85(95%Cl 1.30-2.55)).Mortality risk was significantly increased in both females(SMR 1.93(95%Cl 1.10-3.14))and males(SMR 1.79(95%Cl 1.11-2.73)).Patients from northern European centres had a significant overall increased mortality risk(SMR 2.04(95%Cl 1.32-3.01))whereas a tendency towards increased overall mortality risk was also observed in the south(SMR 1.55(95%Cl 0.80-2.70)).Mortality risk was increased in patients with colonic disease location and with inflammatory disease behaviour at diagnosis.Mortality risk was also increased in the age group above 40 years at diagnosis for both total and CD related causes.Excess mortality was mainly due to gastrointestinal causes that were related to CD.Conclusions:This European multinational population based study revealed an increased overall mortality risk in CD patients 10 years after diagnosis,and age above 40 years at diagnosis was found to be the sole factor associated with increased mortality risk.

慢性肾功能衰竭患者受损的胃动力及其与胃肠症状的关系

Background: Gastrointestinal (GI) symptoms are common in patients with chronic renal failure (CRF), but the pathogenesis of these symptoms is unclear. Gastric motor function in CRF patients remains controversial, and the correlation between GI symptoms and gastric motility is also unclear. The aim of this study was to elucidate the relationship between gastric motility and GI symptoms in patients with CRF. Methods: Gastric motility was evaluated with cutaneously recorded electrogastrographs (EGGs) and gastric emptying of a solid meal, using 13C-octanoic acid breath testing, in 21 patients with predialysis endstage CRF and in 21 matched healthy controls. GI symptom severity was quantified in all patients. Results: The CRF patients had a significantly lower incidence of normogastria postprandially and a lower power ratio than did healthy controls on the EGGs, with the CRF patients showing delayed gastric emptying. Three patients with normal gastric motility had no GI symptoms, and ten patients with both abnormal EGG and delayed gastric emptying had significantly higher GI symptom scores than the patients without abnormalities. Conclusions: The patients with CRF showed gastric hypomotility, including impaired gastric myoelectrical activity and delayed gastric emptying. Gastric hypomotility appears to be an important factor in the generation of GI symptoms in patients with CRF.