Postoperative diarrhea in Crohn's disease:Pathogenesis,diagnosis,and therapy

Diarrhea is a frequent symptom in postoperative patients with Crohn’s diseases(CD),and several different mechanisms likely account for postoperative diarrhea in CD.A targeted strategy based on a comprehensive understanding of postoperative diarrhea is helpful for better postoperative recovery.

关节镜治疗髋臼盂唇损伤的疗效分析

目的评估关节镜下髋关节盂唇修复的临床疗效。方法选取63例关节镜下行髋关节盂唇撕裂修复患者,手术适应证为不同原因的腹股沟区疼痛伴或不伴机械症状,非手术治疗≥6个月无效;术前影像学检查及术中关节镜探查证实存在髋关节盂唇撕裂,且无关节炎病变(T?nnis≤1级)。发病时间0.5～11.0年,平均3.1年;随访时间12～36个月,平均26个月。采用改良Harris髋关节评分(MHHS)和髋关节功能评分(HOS)、日常生活髋关节功能评分(HOS-ADL)对疗效进行评估。结果 Cam撞击伴盂唇撕裂14例,Pincer撞击伴盂唇撕裂11例,混合型撞击伴盂唇撕裂27例,单纯盂唇撕裂11例,11例患者伴有髋臼软骨损伤。手术前后MHHS、HOS、HOS-ADL评分比较,差异有统计学意义(P<0.05)。结论对于无关节炎病变的髋撞击盂唇损伤患者,关节镜下治疗髋撞击、修复盂唇撕裂,有良好的效果;由于盂唇对于髋关节长期功能完整具有重要作用,建议尽可能进行盂唇缝合修复。

Impact of enteral nutrition on energy metabolism in patients with Crohn's disease

AIM: To investigate the impact of enteral nutrition(EN) on the body composition and metabolism in patientswith Crohn's disease(CD). METHODS: Sixty-one patients diagnosed with CD were enrolled in this study. They were given only EN(enteral nutritional suspension, TPF, non-elemental diet) support for 4 wk, without any treatment with corticosteroids, immunosuppressive drugs, infliximab or by surgical operation. Body composition statistics such as weight, body mass index, skeletal muscle mass(SMM), fat mass, protein mass and inflammation indexes such as C-reactive protein(CRP), erythrocyte sedimentation rate(ESR) and CD activity index(CDAI) were recorded before and after EN support. RESULTS: The 61 patients were divided into three groups according to CDAI before and after EN support: A(active phase into remission via EN, n = 21), B(remained in active phase before and after EN, n = 19) and C(in remission before and after EN, n = 21). Patients in group A had a significant increase in SMM(22.11 ± 4.77 kg vs 23.23 ± 4.49 kg, P = 0.044), protein mass(8.01 ± 1.57 kg vs 8.44 ± 1.45 kg, P = 0.019) and decrease in resting energy expenditure(REE) per kilogram(27.42 ± 5.01 kcal/kg per day vs 22.62 ± 5.45 kcal/kg per day, P < 0.05). There was no significant difference between predicted and measured REE in active CD patients according to the HarrisBenedict equation. There was no linear correlation between the measured REE and CRP, ESR or CDAI in active CD patients. CONCLUSION: EN could decrease the hypermetabolism in active CD patients by reducing the inflammatory response.

Conservative treatment of early postoperative small bowel obstruction with obliterative peritonitis

AIM:To investigate the effect of somatostatin and dexamethasone on early postoperative small bowel obstruction with obliterative peritonitis(EPSBO-OP).METHODS:This prospective randomized study included 70 patients diagnosed with EPSBO-OP from June2002 to January 2009.Patients were randomized into two groups:a control group received total parenteral nutrition and nasogastric(NG)tube feeding;and an intervention group received,in addition,somatostatin and dexamethasone treatment.The primary endpoints were time to resolution of bowel obstruction and length of hospital stay,and the secondary endpoints were daily NG output and NG feeding duration,treatment-related complications,postoperative obstruction relapse,and patient satisfaction.RESULTS:Thirty-six patients were allocated to the intervention group and 34 to the control group.No patient needed to undergo surgery.Patients in the intervention group had an earlier resolution of bowel obstruction(22.4±9.1 vs 29.9±10.1 d,P=0.002).Lower daily NG output(583±208 vs 922±399 mL/d,P<0.001),shorter duration of NG tube use(16.7±8.8vs 27.7±9.9 d,P<0.001),and shorter length of hospital stay(25.8 vs 34.9 d,P=0.001)were observed in the intervention group.The rate of treatment-related complications(P=0.770)and relapse of obstruction(P=0.357)were comparable between the two groups.There were no significant differences in postoperative satisfaction at 1,2 and 3 years between the two groups.CONCLUSION:Somatostatin and dexamethasone for EPSBO-OP promote resolution of obstruction and shorten hospital stay,and are safe for symptom control without increasing obstruction relapse.

S-adenosylmethionine in treatment of cholestasis after total parenteral nutrition: laboratory investigation and clinical application

Objective: To observe the effects of S-adenosylmethio-nine (SAMe) in the treatment of cholestasis after totalparenteral nutrition (TPN).Methods: Thirty SD rats were randomly divided intocontrol group, hypercalorie group, hypercalorie+SAMegroup, sepsis group and sepsis+SAMe group to com-pare their states of cholestasis. Sixteen patients re-ceived SAMe because of cholestasis after prolongedTPN, and the therapeutic efficacy was observed.Results: Bile flow was obviously decreased and theserum levels of total bile acid and gamma-glutamyltranspeptidase(γ-GT) were markedly increased in thehypercalorie and sepsis groups. Meanwhile, hepatocytefatty degeneration, dilatation of cholangioles, and bilesludge could be seen microscopically. SAMe adminis-tration in the hypercalorie+SAMe and sepsis+SAMegroups could increase the bile flow, decrease theserum levels of total bile acid and γ-GT, reduce thepathological damage to the liver, and clear the bilesludge in the cholangioles. Cholestasis and abnormalliver function were the main manifestations of the 16patients before SAMe administration. After SAMe treat-ment for 3 weeks, serum levels of total bilirubin, al-kaline phosphatase(AKP), γ-GT, alanine aminotrans-ferase(ALT), and aspartate aminotransferase(AST)were obviously decreased, and normalized in the 4thweek.Conclusion: SAMe could prevent and treat cholestasiswithout discontinuation of TPN.

Endoscopic closure instead of surgery to close an ileal pouch fistula with the over-the-scope clip system

An ileal pouch fistula is an uncommon complication after an ileal pouch anal anastomosis. Most patients who suffer from an ileal pouch fistula will need surgical intervention. However, the surgery can be invasive and has a high risk compared to endoscopic treatment. The over-the-scope clip(OTSC) system was initially developed for hemostasis and leakage closure in the gastrointestinal tract during flexible endoscopy. There have been many successes in using this approach to apply perforations to the upper gastrointestinal tract. However, this approach has not been used for ileal pouch fistulas until currently. In this report, we describe one patient who suffered a leak from the tip of the "J" pouch and was successfully treated with endoscopic closure via the OTSC system. A 26-year-old male patient had an intestinal fistula at the tip of the "J" pouch after an ileal pouch anal anastomosis procedure. He received endoscopic treatment via OTSC under intravenous anesthesia, and the leak was closed successfully. Endoscopic closure of a pouch fistula could be a simpler alternative to surgery and could help avoid surgeryrelated complications.

Confusing untypical intestinal Behcet's disease:Skip ulcers with severe lower gastrointestinal hemorrhage

Behcet's disease(BD) is a rare and life-long disorder characterized by inflammation of blood vessels throughout the body. BD was originally described in 1937 as a syndrome involving oral and genital ulceration in addition to ocular inflammation. Intestinal BD refers to colonic ulcerative lesions documented by objective measures in patients with BD. Many studies have shown that over 40% of BD patients have gastrointestinal complaints. Symptoms include abdominal pain, diarrhea, nausea, anorexia and abdominal distension. Although gastrointestinal symptoms are common, the demonstration of gastrointestinal ulcers is rare. This so-called intestinal BD accounts for approximately 1% of cases. There is no specific test for BD, and the diagnosis is based on clinical criteria. The manifestations of intestinal BD are similar to those of other colitis conditions such as Crohn's disease or intestinal tuberculosis, thus, it is challenging for gastroenterologists to accurately diagnose intestinal BD in patients with ileocolonic ulcers. However, giant ulcers distributed in the esophagus and ileocecal junction with gastrointestinal hemorrhage are rare in intestinal BD. Here, we present a case of untypical intestinal BD. The patient had recurrent aphthous ulceration of the oral mucosa, and esophageal and ileo-colonic ulceration, but no typical extra-intestinal symptoms. During examination, the patient had massive acute lower gastrointestinal bleeding. The patient underwent ileostomy after an emergency right hemicolectomy and partial ileectomy, and was subsequently diagnosed with incomplete-type intestinal BD by pathology. The literature on the evaluation and management of this condition is reviewed.

Role of mesenteric component in Crohn’s disease:A friend or foe?

Crohn’s disease(CD)is a complex and relapsing gastrointestinal disease with mesenteric alterations.The mesenteric neural,vascular,and endocrine systems actively take part in the gut dysbiosis-adaptive immunity-mesentery-body axis,and this axis has been proven to be bidirectional.The abnormalities of morphology and function of the mesenteric component are associated with intestinal inflammation and disease progress of CD via responses to afferent signals,neuropeptides,lymphatic drainage,adipokines,and functional cytokines.The hypertrophy of mesenteric adipose tissue plays important roles in the pathogenesis of CD by secreting large amounts of adipokines and representing a rich source of proinflammatory or profibrotic cytokines.The vascular alteration,including angiogenesis and lymphangiogenesis,is concomitant in the disease course of CD.Of note,the enlarged and obstructed lymphatic vessels,which have been described in CD patients,are likely related to the early onset submucosa edema and being a cause of CD.The function of mesenteric lymphatics is influenced by endocrine of mesenteric nerves and adipocytes.Meanwhile,the structure of the mesenteric lymphatic vessels in hypertrophic mesenteric adipose tissue is mispatterned and ruptured,which can lead to lymph leakage.Leaky lymph factors can in turn stimulate adipose tissue to proliferate and effectively elicit an immune response.The identification of the role of mesentery and the crosstalk between mesenteric tissues in intestinal inflammation may shed light on understanding the underlying mechanism of CD and help explore new therapeutic targets.

Current status of novel biologics and small molecule drugs in the individualized treatment of inflammatory bowel disease

Treatment strategies for inflammatory bowel disease(IBD)are rapidly evolving with the development of biologics and small molecule drugs(SMDs).However,these drugs are not guaranteed to be effective in all patients,and a“ceiling effect”of biologic monotherapy may occur.This issue highlights an unmet need for optimizing the use of biologics and predicting therapeutic responses.Thus,the development of new drugs with novel mechanisms of action is urgently needed for patients with primary nonresponse and secondary loss of response to conventional biologics and SMDs.In addition,combining different biologics or SMDs has been proposed as a novel strategy to enhance treatment efficacy in IBD,which theoretically has multidimensional anti-inflammatory potential.Based on the current evidence available for IBD,dual targeted therapy may be a promising strategy for refractory IBD patients who have failed in multiple biologic treatments or who have extraintestinal manifestation.Additionally,identifying the subgroup of IBD patients who are responding to biological combination therapies is also equally important in stable disease remission.In this review,we summarize the newly developed biologics and SMDs and the current status of biologics/SMDs to highlight the development of individualized treatment in IBD.

Perforating and nonperforating indications in repeated surgeries for Crohn's disease

BACKGROUND Despite advances in medical therapy for Crohn’s disease(CD),most patients with CD require repeated resection surgeries.AIM To analyze the perforating and nonperforating indications of repeated CD operations and identify the anastomosis characteristics for postoperative CD.METHODS We retrospectively reviewed 386 patients who underwent at least one resection for CD between 2003 and 2013.Clinical characteristics of each surgery were collected.Univariate and multivariate analyses were performed to determine risk factors for recurrence.RESULTS The indication for reoperation in CD tends to be the same as that for primary operation,i.e.,perforating disease tends to represent as perforating disease and nonperforating as nonperforating.Concordance was found between the first surgery and second surgery in terms of the indication for the operation(P=0.006),and the indication for the third surgery was also correlated with that for the second surgery(P=0.033).Even if the correlation of surgical indications between repeated operations,the rate of perforating indication for the second and third surgeries was significantly higher than that of the first surgery.In addition,the presence of perforating CD was a predictor of recurrence for both the first and second surgeries.Moreover,anastomotic lesions were the most common sites of recurrence after the operation.Based on the importance of anastomosis,anastomosis might be a new type of disease location for the classification of postoperative CD.CONCLUSION CD not only has stable characteristics but also progresses chronically.Perforation is a progressive surgical indication for Crohn’s disease.For CD after surgery,anastomosis may be a new classification of disease location.

肠道减压治疗克罗恩病急性小肠梗阻的前瞻性评估

背景:保守治疗对于克罗恩病急性小肠梗阻是必要的,可避免急症手术。本研究旨在评估采用长胃肠减压管治疗克罗恩病急性小肠梗阻的疗效。方法:本研究为前瞻性观察研究。对用于治疗克罗恩病急性肠梗阻的长胃肠减压管(LT组)和传统鼻胃管(GT组)两种胃肠减压方法进行对比分析。首要结局指标是避免急症手术。此外,分析胃肠减压失败及后续手术干预的预测因素。结果:27例行LT减压和42例行GT减压的克罗恩病急性小肠梗阻患者纳入研究。LT组中有12例(44.4%)患者保守治疗成功,无需手术干预;而GT组中仅有9例(21.4%)患者无需急症手术(P<0.05)。无论是非手术还是手术患者,LT组患者症状缓解的时间均显著快于GT组(均P<0.01)。48小时引流量>500 mL是需手术干预的危险因素,而置管后C反应蛋白下降则是一保护因素(均P<0.05)。对于手术患者,LT组暂时性肠造口率和切口感染率均显著低于GT组(均P<0.05)。对于非手术患者,LT组与GT组的梗阻复发率,无论是内科复发还是外科复发,差异均无统计学意义(均P>0.05)。结论:内镜下放置长胃肠减压管可改善克罗恩病急性肠梗阻患者的急症状态。引流量和置管后C反应蛋白的变化可作为是否需要后续手术干预的临床预测指标。与传统鼻胃管减压相比,采用长管进行胃肠减压,短期并发症更少,且远期梗阻复发率不会增加。

A cytotoxic pyrrolidinoindoline diketopiperazine dimer from the algal fungus Eurotium herbariorum HT-2

A new cytotoxic pyrrolidinoindoline diketopiperazine dimer, cristatumin E （1）, was isolated from the fermentation broth of the algal fungus Eurotium herbariorum HT-2 associated with the marine algae, Enteromorpha prolifera. The structure was determined by spectroscopic analyses and Marfey＇s amino acid analysis. Cristatumin E （1） showed cytotoxicity against K562 tumor cell line and antibacterial activity against Enterobacter aerogenes and Escherichia coli with IC50 and MIC values of 8.3, 44.0 and 44.0 μmol/L, respectively.