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Volume 75 - 2012 - Fasc.4 - Original articles

Impact of steroid-avoidance immunosuppression on long-term outcome after liver transplantation for HCV cirrhosis : the need for well documented long-term follow-up

Aim : study impact of steroid avoidance on HCV recurrence after transplantation. Methods and material : 35 HCV pats, being part of prospective, randomized, double-blind, placebo-controlled study comparing Tacrolimus (TAC)-Placebo (PLAC) (n=14) to TAC-short-term (2 mo) low-dose steroid (STER) (n = 21), had 5 years follow-up. Primary endpoint was 1 and 5 years survival ; secondary (compos- ite) endpoint comprised HCV related cirrhosis, re-transplantation (re-LT) and death. Results : 1 and 5-years survival were 93% and 75% in TAC- PLAC group ; 91% and 66% in TAC-STER group (p 0.38). Two (14.3%) TAC-PLAC pats died due to HCV cirrhosis at 54 and 72 mo ; 7 (33%) TAC-STER pats died due to cholestatic hepatitis at 5.8 and 9 mO. to cirrhosis at 18, 22, 34, 73 and 79 mo (p 0.20). Composite endpoint at 5 years didn't show advantage in favor of TAC-PLAC patients (5/14 [35.7%] vs. 9/21 [42.8%] pts, p.0.69). Early biopsies seemed more favorable in TAC-PLAC pats; at 5 years results were identical for both groups. Only 1 (7.1%) TAC- PLAC and 2 (9.5%) TAC-STER pats needed rejection treatment. Conclusion: immunosuppression using steroid avoidance or short-term use had similar outcomes. Well documented long-term follow-up, including biopsies, is necessary in order to make conclu- sions in relation to impact of steroid use on outcome of HCV liver recipients. (Acta gastroenterol. belg., 2012, 75, 411-418).


Longitudinal changes in liver fibrosis in children with sickle cell disease under- going chronic transfusion therapy

Background and study aims : The progression of liver injury from transfusional iron overload in sickle cell disease (SCD) is poorly understood. We sought to identify predictors liver fibrosis development over time. Patients and methods : We performed a retrospective cohort study of chronically transfused SCD patients who had = 2 serial liver biopsies. Core biopsies were scored for fibrosis in a blinded fashion. Primary analyses evaluated longitudinal changes in liver fibrosis and changes in surrogate markers. Secondary analyses determined the relationship between liver iron concentration (LIC) and serum biomarkers. Results : 26 people had = 2 serial biopsies for evaluation (n = 70 biopsies total). Fibrosis was Ishak grade 0 or 1 in all biopsies. Evaluation of the first 2 biopsies showed fibrosis regression (n = 6), development (n=2), persistence (n=1), and absence (n=17). There was no consistent association of fibrosis with LIC over time, or between changes in fibrosis status and surrogate markers. For predicting fibrosis on a cross-sectional basis, ALT and ferritin performed moderately (AUCs 0.80 and 0.63, respectively) but LIC performed poorly (AUC 0.30). The highest positive likelihood ratios for fibrosis were for ferritin cutoff of 5000 ng/mL (LR + 5.7) and ALT cutoff of 65 U/L (LR + 5.2). Conclusions : Liver fibrosis progression is minimal in chronical- ly transfused SCD. LIC does not correlate well with fibrosis devel- opment. We propose routine liver biopsies are not necessary com- ponents in the standard monitoring of chronically transfused SCD patients. (Acta gastroenterol. belg., 2012, 75, 419-424).


Safety and cost of infliximab for the treatment of belgian pediatric patients with Crohn's disease

Biologicals have become an important component in the treat- ment of Crohn's disease in children. Their increased and long term use raises safety concerns. We describe safety and cost of inflix- imab in Belgian pediatric Crohn's disease patients. All patients on infliximab as part of the present or past treatment for Crohn's Disease until January 1st 2011 were selected from an existing data- base. Information on disease phenotype, medication and adverse events were extracted. Adverse events occurred in 25.9% of patients exposed to infliximab of which 29.6% were severe. In total 31.7% of patients stopped infliximab therapy. The main reasons for discontinuation were adverse events in 45.4% and loss of response in 30.3%. No malignancies or lethal complications occurred over this 241 patient year observation period. Immuno- modulators were concomitant medication in 75% of patients and were discontinued subsequently in 38.4% of them. The cost of infliximab infusions per treated patient per year in the Belgian health care setting is approximately 9 474 eurO. including only medication and hospital related costs. Even though infliximab is relatively safe in pediatric CD on the short term, close follow-up and an increased awareness of the possible adverse reactions is highly recommended. Adverse reactions appeared in 25.9% of all patients and were the main reason for discontinuation. Treatment cost has to be balanced against efficacy and modifications in disease course. In the Belgian health care system, the medication is available to all patients with moderate to severe CD. (Acta gastro- enterol. belg., 2012, 75, 425-431).


The Blatchford Score is an useful index in the management of Mallory-Weiss tear and gastrointestinal bleeding Experience from an urban Community Hospital

Objectives : The purpose of this study was to determine the utility of individual clinical parameters as well as a composite index like the Blatchford score in predicting the need for endoscopic inter- vention and prognosticating the out come in patients with Mallory Weiss tear presenting with gastrointestinal bleeding. Methods : We retrospectively reviewed our endoscopy database and our EMR system to identify patients with Mallory Weiss tear and collect relevant data. Results : A total of 38 cases with Mallory-Weiss tear were identi- fied at our center over a 5 year period. Thirty-two patients present- ed with gastrointestinal bleeding constituting 3.1% of all cases pre- senting with upper gastrointestinal bleeding. Nine (28%) of 32 patients were found to have active bleeding or stigmata of recent bleeding at endoscopy and required endoscopic therapy. The Blatchford score ranged from 0 to 11 in the patients with gastro- intestinal bleeding. Nine patients had a Blatchford score < 6 (four 0, five 1-4) while 23 patients had a score > 6. None of the patients with a score < 6 required endoscopic intervention or a blood trans- fusion while 9 (39%) patients with a score > 6 required endoscopic intervention and 17 (74%) required a blood transfusion. Length of stay was significantly longer in patients with a score > 6. Conclusions : The Blatchford score can be a useful index to risk stratify patients with Mallory Weiss tear who present with gastro- intestinal bleeding with regards to hospital admission and identify- ing patients who warrant urgent endoscopic intervention, require blood transfusion and are likely to have a longer length of stay. (Acta gastroenterol. belg., 2012, 75, 432-437).


Topical Diltiazem vs. topical Glyceril trinitrate in the treatment of chronic anal fissure : A prospective, randomized, double-blind trial

Background and study aims : Chemical sphincterotomy is a new way for the treatment of chronic anal fissure which avoids the risk of faecal incontinence associated with traditional surgical methods. The aim of this study was to compare topical Diltiazem with topi- cal Glyceril trinitrate in the treatment of chronic anal fissure. Patients and methods : 61 patients (10 Male, 51 Female) between 16-81 years of age with chronic anal fissure were included in this prospective, randomized, double-blind trial. The patients were randomly allocated to either Diltiazem gel (2%) or Glyceril trini- trate ointment (0.2%) and were asked to use the treatment twice daily for 8 weeks. Each patient was reviewed every two weeks ; pain scores, healing and side effects were assessed. Results : Healing occurred in 33 of 36 (91.66%) patients treated with Diltiazem after 6 weeks and 15 of 25 (60%) patients treated with Glyceril trinitrate after 8 weeks which shows a significant dif- ference in favour of Diltiazem (P < 0.001). The rest of the patients were either non-compliant or did not heal and underwent surgery. Headache occurred in all of the patients treated with Glyceril trini- trate but none of the patients treated with Diltiazem developed headache. The frequency of other side-effects was also less in patients treated with Diltiazem (P < 0.001). Conclusions : Diltiazem gel was found to be superior to Glyceril trinitrate ointment due to significantly higher healing rate and fewer side-effects. (Acta gastroenterol. belg., 2012, 75, 438-442).