A modern multidisciplinary approach to the treatment of enterocutaneous fistulas in Crohn\u2019s disease patients

Introduction: Enterocutaneous fistulas (ECFs) is a manifestation of penetrating Crohn\u2019s disease (CD) that is challenging to treat and has considerable morbidity and mortality rates. Areas covered: This review aims to explore the practical and updated principles for the optimal treatment of ECFs in CD patients. Expert Opinion: Optimal ECF management requires a multidisciplinary approach. Treatment first includes fluid resuscitation and electrolyte rebalancing with control of sepsis by means of antibiotics and, when indicated, drainage of infected collections. Subsequent therapeutic steps include nutritional support, control of the fistula output and treatment of peristomal skin. Anti-TNF-\u3b1 therapy seems to have limited utility only after sepsis is resolved and intestinal stenosis excluded. However, ECFs heal in only approximately one-third of cases without surgical intervention. Thus, correct surgical timing combined with adequate nutritional support, sepsis resolution and skin care is considered the appropriate preoperative setting

Acute uncomplicated diverticulitis: key points for early management. A single-centre retrospective study

OBJECTIVE: Acute uncomplicated diverticulitis is an important clinical condition usually managed in clinical practice with antibiotic therapies and hospitalization in ward. In this setting, recent papers and guidelines suggest to limit the use of antibiotics in selected cases and encourage an early discharge in low-risk patients. The purpose of this retrospective study is to identify serological inflammatory markers and CT findings of acute uncomplicated diverticulitis (AUD) at the onset of the disease and the correlation with the need for in-patient or out-patient management. PATIENTS AND METHODS: It was used a database drawn from the collection of the patients admitted to our Emergency Room from January 2016 to 2019 and undergoing urgent abdominal CT-scan for suspicious of acute diverticulitis. For each patient we considered biochemical and radiological parameters at the onset of the disease and if patients were managed as in-patients (hospitalization in ward) or as out-patient (early discharged or after observation in Short Stay Unit). RESULTS: Among patients with early diagnosis of AUD, 108 (65%) were hospitalized in ward with mean time of in-stay of 6.94 days, while only 58 (35%) patients with same diagnosis were managed as out-patient and early discharged from emergency room or after observation in short stay unit with a mean time of in-stay significantly shorter (3.39 days, p-value 0.0007). Higher levels of C reactive protein and the length of colon involved considered as percentage (%) in comparison with the entire colon were significantly related to the need for hospitalization (p-value 0.03). CONCLUSIONS: Biochemical parameters and a more advanced radiological evaluation, as the length (%) of colon involved, could allow a stratification of patients with diagnosis of AUD at the admission and help physicians in the early management

Multiparametric Evaluation Predicts Different Mid-Term Outcomes in Crohn's Disease

Aim: To evaluate if a single and/or combined (clinical, endoscopic and radiological) assessment could predict clinical outcomes in Crohn's disease (CD). Methods: We prospectively evaluated 57 CD cases who underwent both a colonoscopy and a CT-enterography (CTE). Harvey-Bradshaw Index (HBi), SES-CD (and/or Rutgeerts score) and the radiological disease activity were defined to stratify patients according to clinical, endoscopic and radiological disease activity respectively. Hospitalizations, surgery, therapeutic changes and deaths were evaluated up to 36 months (time 1) for 53 patients. Results: CTE and endoscopy agreed in stratifying disease activity in 47% of cases (k = -0.05; p = 0.694), CTE and HBi in 35% (k = 0.09; p = 0.08), endoscopy and HBi in 39% (k = 0.13; p = 0.03). Taken together, CTE, endoscopy and HBi agreed only in 18% of cases (k = 0.01; p = 0.41). Among the 11 cases with mucosal healing, only 3 (27%) showed transmural healing. Patients with endoscopic activity needed significantly more changes of therapy compared to patients with endoscopic remission (p = 0.02). Patients with higher transmural or clinical activity at baseline required significantly more hospitalizations (p < 0.01). Hospitalization rate decreases with an increase in the number of parameters indicating remissions at baseline (p = 0.04). Conclusions: Clinical, endoscopic and radiological assessments offer complementary information and could predict different mid-term outcomes in CD. (c) 2018 S. Karger AG, Basel

Challenges in crohn’s disease management after gastrointestinal cancer diagnosis

Crohnʹs disease (CD) is a chronic inflammatory bowel disease with a progressive course, potentially affecting the entire gastrointestinal tract from mouth to anus. Several studies have shown an increased risk of both intestinal and extra‐intestinal cancer in patients with CD, due to long‐standing transmural inflammation and damage accumulation. The similarity of symptoms among CD, its related complications and the de novo onset of gastrointestinal cancer raises difficulties in the differential diagnosis. In addition, once a cancer diagnosis in CD patients is made, selecting the appropriate treatment can be particularly challenging. Indeed, both surgical and oncological treatments are not always the same as that of the general population, due to the inflammatory context of the gastrointestinal tract and the potential exacerbation of gastrointestinal symptoms of patients with CD; moreover, the overlap of the neoplastic disease could lead to adjustments in the pharmacological treatment of the underlying CD, especially with regard to immunosuppressive drugs. For these reasons, a case‐by‐case analysis in a multidisciplinary approach is often appropriate for the best diagnostic and therapeutic evaluation of patients with CD after gastrointestinal cancer onset