Outcome in obscure gastrointestinal bleeding after capsule endoscopy

AIM: To investigate the clinical impact of capsule endoscopy(CE) after an obscure gastrointestinal bleeding(OGIB) episode, focusing on diagnostic work-up, followup and predictive factors of rebleeding. METHODS: Patients who were referred to Hospital del Mar(Barcelona, Spain) between 2007 and 2009 for OGIB who underwent a CE were retrospectively analyzed. Demographic data, current treatment with non-steroid antiinflammtory drugs or anticoagulant drugs, hemoglobin levels, transfusion requirements, previous diagnostic tests for the bleeding episode, as well as CE findings(significant or non-significant), work-up and patient out-comes were analyzed from electronic charts. Variables were compared by χ 2 analysis and Student t test. Risk factors of rebleeding were assessed by Log-rank test, Kaplan-Meier curves and Cox regression model. RESULTS: There were 105 patients [45.7% women, median age of 72 years old(interquartile range 56-79)] and a median follow-up of 326 d(interquartile range 123-641) included in this study. The overall diagnostic yield of CE was 58.1%(55.2% and 63.2%, for patients with occult OGIB and overt OGIB, respectively). In 73 patients(69.5%), OGIB was resolved. Multivariate analysis showed that hemoglobin levels lower than 8 g/dL at diagnosis [hazard ratios(HR) = 2.7, 95%CI: 1.9-6.3], patients aged 70 years and above(HR = 2.1, 95%CI: 1.2-6.1) and significant findings in CE(HR = 2.4, 95%CI: 1.1-5.8) were independent predictors of rebleeding. CONCLUSION: One third of the patients presented with rebleeding after CE; risk factors were hemoglobin levels < 8 g/dL, age ≥ 70 years or the presence of significant lesions.

Evaluation of 5 versus 10 granulocyteaphaeresis sessions in steroid-dependent ulcerative colitis: A pilot, prospective, multicenter, randomized study

AIM： To evaluate the efficacy of 5 compared to ：tO granulocyteaphaeresis sessions in patients with active steroid-dependent ulcerative colitis. METHODS： In this pilot, prospective, multicenter randomized trial, 20 patients with moderately active steroid-dependent ulcerative colitis were randomized to 5 or 10 granulocyteaphaeresis sessions. The primary objective was clinical remission at wk 17. Secondary measures included endoscopic remission and steroid consumption.RESULTS： Nine patients were randomized to 5 granulocyteaphaeresis sessions （group 1） and 11 patients to 10 granulocyteaphaeresis sessions （group 2）. At wk 17, 37.5% of patients in group 1 and 45.45% of patients in group 2 were in clinical remission. Clinical remission was accompanied by endoscopic remission in all cases. Eighty-six percent of patients achieving remission were steroid-free at wk 17. Daily steroid requirements were significantly lower in group 2. Eighty-nine per cent of patients remained in remission during a one year follow-up. One serious adverse event, not related to the study therapy, was reported. CONCLUSION： Granulocyteaphaeresis is safe and effective for the treatment of steroid-dependent ulcerative colitis. In this population, increasing the number of aphaeresis sessions is not associated with higher remission rates, but affords a significant steroid-sparing effect.

New genes emerging for colorectal cancer predisposition

Colorectal cancer(CRC)is one of the most frequent neoplasms and an important cause of mortality in the developed world.This cancer is caused by both genetic and environmental factors although 35%of the variation in CRC susceptibility involves inherited genetic differences.Mendelian syndromes account for about5%of the total burden of CRC,with Lynch syndrome and familial adenomatous polyposis the most common forms.Excluding hereditary forms,there is an important fraction of CRC cases that present familial aggregation for the disease with an unknown germline genetic cause.CRC can be also considered as a complex disease taking into account the common diseasecommom variant hypothesis with a polygenic model of inheritance where the genetic components of common complex diseases correspond mostly to variants of low/moderate effect.So far,30 common,low-penetrance susceptibility variants have been identified for CRC.Recently,new sequencing technologies including exomeand whole-genome sequencing have permitted to add a new approach to facilitate the identification of new genes responsible for human disease predisposition.By using whole-genome sequencing,germline mutations in the POLE and POLD1 genes have been found to be responsible for a new form of CRC genetic predisposition called polymerase proofreading-associated polyposis.

Effectiveness of infliximab after adalimumab failure in Crohn's disease

AIM:To evaluate the effectiveness of infliximab as a second-line therapy in Crohn's disease patients after adalimumab failure. METHODS:A historical cohort study in a community-based gastroenterology practice evaluated Crohn's disease patients treated with infliximab (induction plus maintenance) after adalimumab failure. Patients were identified using a large Spanish database (ENEIDA). RESULTS:We included 15 Crohn's disease patients who received infliximab after adalimumab failure. Five patients discontinued adalimumab due to loss of response, 3 due to adverse events and 7 due to partial response. After infliximab therapy was started, all patients who had interrupted adalimumab due to loss of efficacy regained response. All patients who discontinued adalimumab due to adverse events responded to infliximab and maintained this response; one of these patients had an uneventful course on infliximab, but 2 developed adverse events. None of the 7 patients who interrupted adalimumab due to partial response reached remission with infliximab. CONCLUSION:Switching from adalimumab to infliximab may be useful in patients who develop adverse effects or loss of response, however, the benefit of infliximab in primary nonresponders was not established.

Narrow band imaging and white light endoscopy in the characterization of a polypectomy scar:A single-blind observational study

AIM To assess the incremental benefit of narrow band imaging(NBI) and white light endoscopy(WLE), randomizing the initial technique for the detection of residual neoplasia at the polypectomy scar after an endoscopic piecemeal mucosal resection(EPMR).METHODS We conducted an observational study in an academic center to assess the incremental benefit of NBI and WLE randomly applied 1:1(NBI-WLE or WLE-NBI) in the follow-up of a post-EPMR scar by the same endoscopist.RESULTS A total of 112 EPMR scars were included. The median baseline polyp size was 20 mm(interquartile range: 14-30). At first review, NBI and WLE showed good sensitivity(85.0% vs 78.9%), specificity(77.1% vs 84.2%) and overall accuracy(80.0% vs 82.5%). NBI after WLE(WLE-NBI group) improved accuracy, but this difference was not statistically significant [area under the curve(AUC): 86.8% vs 81.6%, P = 0.15]. WLE after NBI(NBI-WLE group) did not improve accuracy(AUC: 81.4% vs 81.1%, P = 0.9). Overall, recurrence was found in 39/112(34.8%) lesions.CONCLUSION Although no statistically significant differences were found between the two techniques at the first postEPMR assessment, the use of NBI after WLE may improve residual neoplasia detection. Nevertheless, biopsy is still required in the first scar review.

Colorectal cancer prognosis twenty years later

AIM:To evaluate changes in colorectal cancer(CRC) survival over the last 20 years.METHODS:We compared two groups of consecutive CRC patients that were prospectively recruited:Group Ⅰincluded 1990 patients diagnosed between 1980 and 1994.GroupⅡincluded 871 patients diagnosed in 2001.RESULTS:The average follow up time was 21 mo(1-229)for GroupⅠand 50 mo(1-73.4)for GroupⅡ.Overall median survival was significantly longer in Group Ⅱthan in GroupⅠ(73 mo vs 25 mo,P<0.001)and the difference was significant for all tumor stages.Post surgical mortality was 8% for GroupⅠand 2% for Group Ⅱ(P<0.001).Only 17% of GroupⅠpatients received chemotherapy compared with 50% of GroupⅡpatients(P<0.001).CONCLUSION:Survival in colorectal cancer patients has doubled over the past 20 years.This increase seems to be partly due to the generalization in the administration of chemotherapy and to the decrease of post surgical mortality.