Use of thiopurines in inflammatory bowel disease

The use of thiopurines as immunosuppression for the treatment of refractory or chronic active inflammatory bowel disease is established for both Crohn's disease and ulcerative colitis.Nevertheless,many questions remain concerning the optimal treatment regimens of azathioprine,6-mercaptopurine and thioguanine.We will briefly summarize dose recommendations,indications for thiopurine therapy and side effects which are relevant in clinical practice.We discuss some currently debated topics,including the combination of azathioprine and allopurinol,switching of thiopurine therapy in case of side effects,the use of azathioprine in pregnancy,the infection risk using thiopurines and the evidence when to stop thiopurines.Excellent reviews have been published on the thiopurine metabolic pathway which will not be discussed here in detail.

Late biliary complications in human alveolar echinococcosis are associated with high mortality

AIM:To evaluate the incidence of late biliary complications in non-resectable alveolar echinococcosis(AE)under long-term chemotherapy with benzimidazoles.METHODS:Retrospective analysis of AE patients with biliary complications occurring more than three years after the diagnosis of AE.We compared characteristics of patients with and without biliary complications,analyzed potential risk factor for biliary complications and performed survival analyses.RESULTS:Ninety four of 148 patients with AE in Zurich had non-resectable AE requiring long-term benzimidazole chemotherapy,of which 26(28%)patients developed late biliary complications.These patients had a median age of 55.5(35.5-65)years at diagnosis of AE and developed biliary complications after 15(8.25-19)years of chemotherapy.The most common biliary complications during long-term chemotherapy were late-onset cholangitis(n=14),sclerosing cholangitis-like lesions(n=8),hepatolithiasis(n=5),affection of the common bile duct(n=7)and secondary biliary cirrhosis(n=7).Thirteen of the 26 patients had undergone surgery(including 12 resections)before chemotherapy.Previous surgery was a risk factor for late biliary complications in linear regression analysis(P=0.012).CONCLUSION:Late biliary complications can be observed in nearly one third of patients with non-resectable AE,with previous surgery being a potential risk factor.After the occurrence of late biliary complications,the median survival is only 3 years,suggesting that late biliary complications indicate a poor prognostic outcome.

Perianal fistulodesis–A pilot study of a novel minimally invasive surgical and medical approach for closure of perianal fistulae

BACKGROUND Perianal fistulae strongly impact on quality of life of affected patients.AIM To challenge and novel minimally invasive treatment options are needed.METHODS Patients with Crohn’s disease(CD)in remission and patients without inflammatory bowel disease(non-IBD patients)were treated with fistulodesis,a method including curettage of fistula tract,flushing with acetylcysteine and doxycycline,Z-suture of the inner fistula opening,fibrin glue instillation,and Zsuture of the outer fistula opening followed by post-operative antibiotic prophylaxis with ciprofloxacin and metronidazole for two weeks.Patients with a maximum of 2 fistula openings and no clinical or endosonographic signs of a complicated fistula were included.The primary end point was fistula healing,defined as macroscopic and clinical fistula closure and lack of patient reported fistula symptoms at 24 wk.RESULTS Fistulodesis was performed in 17 non-IBD and 3 CD patients,with a total of 22 fistulae.After 24 wk,all fistulae were healed in 4 non-IBD and 2 CD patients(overall 30%)and fistula remained closed until the end of follow-up at 10-25 mo.In a secondary per-fistula analysis,7 out of 22 fistulae(32%)were closed.Perianal disease activity index(PDAI)improved in patients with fistula healing.Low PDAI was associated with favorable outcome(P=0.0013).No serious adverse events were observed.CONCLUSION Fistulodesis is feasible and safe for perianal fistula closure.Overall success rates is at 30%comparable to other similar techniques.A trend for better outcomes in patients with low PDAI needs to be confirmed.