Étude de l'impact de la rémission profonde sur l'histoire naturelle et les complications de la maladie de Crohn anopérinéale fistulisante

Introduction : Le traitement de la maladie de Crohn anopérinéale fistulisante repose sur une approche médico-chirurgicale combinant antibiothérapie, drainage, immunosuppresseurs et anti-TNF a. L'évaluation de la réponse au traitement est clinique mais aussi radiologique grâce à l'utilisation de l'IRM périnéale. La notion de rémission profonde, définie par une IRM périnéale normale associée à un examen clinique périnéal normal pourrait être utilisée comme un objectif thérapeutique à atteindre. Néanmoins, le devenir à long terme des patients en rémission profonde atteints de lésions anopérinéales doit être mieux connu. Objectif : Décrire l'histoire naturelle et les complications des patients atteints de maladie de Crohn anopérinéale fistulisante selon la présence d'une rémission profonde ou non (IRM et clinique) sous traitement anti-TNFa. Patients et Méthodes : 48 patients atteints d'une maladie de Crohn avec LAP suivis dans notre centre tertiaire entre 2000 et 2017, ayant bénéficié d'une IRM périnéale après au moins un an de traitement anti-TNF ont été inclus. L'analyse des données était rétrospective. Les évènements défavorables périnéaux et luminaux en lien avec la maladie de Crohn (modification du traitement, hospitalisation, récidive, chirurgie) étaient recueillis. Le pronostic des patients en rémission profonde (score de Van Assche à 0 et absence de prise de contraste des trajets fistuleux) sous anti-TNF était comparé à celui des patients présentant une IRM pathologique persistante. Résultats :48 patients ont été inclus (30 femmes et 18 hommes). La médiane de suivi était de 62 mois. La médiane de survie sans évènement défavorable était de 96 mois (69-116) dans le groupe rémission profonde versus 12 mois (3-20) dans le groupe des patients ayant une IRM pathologique en début de suivi (p Conclusion : Les patients en rémission profonde définie par la cicatrisation IRM périnéale associée à une rémission clinique présentent un meilleur pronostic à long terme en terme de survie sans récidive, de nombre d'hospitalisation et de durée d'hospitalisation. Cette rémission profonde semble être un objectif important dans la prise en charge de cette pathologie

A systematic literature review on solitary rectal ulcer syndrome is there a therapeutic consensus in 2018?

International audiencePurpose - To screen all treatments tested for solitary rectal ulcer syndrome (SRUS) without rectal prolapse and to assess their efficacy. Method - A systematic review was performed according to the PRISMA guidelines, focusing on the treatment of SRUS without rectal prolapse. The types of treatment and their efficacy were collected and critically assessed. Results - A selection of 20 studies among the 470 publications focusing on SRUS provided suitable data for a total of 516 patients. Only 2 studies were randomised prospective trials that focused on argon plasma treatment. The mean follow-up was 21.8 months and ranged from 0.25 to 90 months. Most of the studies focused on surgery, including rectopexy, stapled transanal rectal resection, excision of the ulcer, the Delorme procedure, proctectomy, low anterior resection, and ostomy. Populations of the studies were heterogeneous and selected outcomes were specific (failure of medical or surgical treatment). Conservative treatment (high-fibre diet, laxatives, change of defecatory habits, and biofeedback treatment) induced a symptomatic improvement in 71/91 patients (63.6%) and healing of mucosal lesion in 17/51 patients (33.3%). Surgeries (all types) improved SRUS in 77% (54-100%) of patients. Argon plasma coagulation is a promising technique but longer follow-up is necessary. Conclusions - The general quality of the studies focusing on the treatment of SRUS was poor due to the heterogeneity of the population, the sample size of the cohorts, and the heterogeneity of efficacy assessments. The therapeutic approach appears to be multimodal and multidisciplinary and validated in centres of expertise. Further studies evaluating multimodal strategies are needed

Quality of life in 1870 patients with constipation and/or fecal incontinence Constipation should not be underestimated

International audienceBackground - Quality of life is increasingly seen as important, but remains difficult to assess in patients with functional anorectal complaints. Objective - We aimed to quantify quality of life and to analyse the symptomatic descriptors associated with a poor outcome in patients with faecal incontinence (FI) and/or constipation. Methods - The characteristics of the patients, data from self-administered questionnaires and from physical examinations were evaluated prospectively for all cases of functional anorectal disease over a period of thirteen years. Functional anorectal disease included faecal incontinence (FI) and/or constipation. Patients with scores in the lowest quartile of the Gastrointestinal Quality of Life Index (GIQLI) were considered to have suffered severe alterations to their quality of life, and were compared with the other patients. Results - In total, 1870 patients with functional anorectal disease were included (470 with a severely altered quality of life (GIQLI < 70)). Constipation predominated (1212/1870; 65.1%) and severe FI was frequent (761/1870; 40.9%). Severely altered quality of life was significantly associated with constipation (P = 0.0001), urinary urgency and incontinence (P = 0.0001), depression (P = 0.001), diabetes (P = 0.0224), severe FI (P = 0.0001), neurological disease (P = 0.0138) and liquid stools (P = 0.0002) in multivariate analysis. Conclusion - Several treatable factors are associated to an impaired quality of life in patients with functional anorectal disorders. Intervention studies are mandatory (stool consistency and frequency)

Management of solitary rectal ulcer syndome Results of a french national survey Société Nationale Française de Coloproctologie SNFCP, France

International audienceThere is no consensus on the treatment for solitary rectal ulcer syndrome (SRUS). This study aimed to obtain information from physicians treating patients with SRUS in a French medical surgical society to facilitate management plans and to develop a support algorithm. Members of the French National Society of Coloproctology (SNFCP) were invited to complete a survey that included twenty items about therapeutic management and healing criteria. Overall, 91 practitioners (median age 52 [42-59] years) responded to the questionnaire; 64/91 (70.3%) were proctologists, and 27/91 (29.7%) were colorectal surgeons. Only 15 members (16.5%) followed more than 5 patients with SRUS per year. The therapeutic objectives were to improve both patient symptoms (100%) and quality of life (98.9%). Laxative treatment and first-line rehabilitation were agreed upon by 83.5% and 73% of the respondents, respectively. Surgery, mainly rectopexy, was offered after failed medical treatment by 81.1% of the practitioners (79.1%). The first-line strategy preferred by the professionals included laxatives and biofeedback rehabilitation. Surgical treatment, preferably rectopexy, was proposed as a second intervention. No consensus was reached regarding other therapeutic alternatives, and additional studies are required to clarify their indications

Assessment of pyloric sphincter distensibility and pressure in patients with diabetic gastroparesis

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Solitary rectal ulcer syndrome in 102 patients: Do different phenotypes make sense?

International audienceBackground - Little is known about the pathophysiological mechanisms of solitary rectal ulcer syndrome (SRUS). Aims - We aim to identify the different phenotypes, taking into account complaints, anatomy and anorectal physiology. Methods - Complaints, endoscopy results, and physiology data of patients with histologically proven SRUS were collected and analysed. The associated anorectal diseases were faecal incontinence and obstructed defecation. The clinical aspects of SRUS were compared, and factors associated with anorectal diseases were identified. Results - Overall, 102 consecutive patients were included. The predominant lesion was a rectal ulcer (66%), and inflammation of the rectal wall was present in 42% of patients. Abnormal rectal capacities and/or rectal perception was observed in more than half. Nearly half (52%) of the patients met the criteria for obstructed defecation and they tended to more frequently have psychiatric disease (66.7% vs 33.3%; p=0.07). Patients with faecal incontinence (17%) reported more self-perception of anal procidentia (p=0.01) and were more likely to have inflammation of the rectal wall (p=0.02), high-grade internal rectal procidentia (p=0.06) and anal hypotonia (p=0.004); their maximum tolerable volume was lower (p=0.004). Conclusion - The characteristics of patients with SRUS suggest different phenotypes. This may be a way to develop a comprehensive treatment strategy

Deep remission on magnetic resonance imaging impacts outcomes of perianal fistulizing Crohn’s disease

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