Inflammatory bowel disease: past, present, and future

Crohn’s disease and ulcerative colitis, collectively known as the inflammatory bowel diseases (IBD), are largely diseases of the twentieth century, and are associated with the rise of modern, Westernized industrial society. Although the causes of these diseases remain incompletely understood, the prevailing model is that the intestinal flora drives an unmitigated intestinal immune response and inflammation in the genetically susceptible host. A review of the past and present of these diseases shows that detailed description preceded more fundamental elucidation of the disease processes. Working out the details of disease pathogenesis, in turn, has yielded dividends in more focused and effective therapy for IBD. This article highlights the key descriptions of the past, and the pivotal findings of current studies in disease pathogenesis and its connection to medical therapy. Future directions in the IBD will likely explicate the inhomogeneous causes of these diseases, with implications for individualized therapy

Cyst fluid analysis in the differential diagnosis of pancreatic cystic lesions: A pooled analysis

Background: Pancreatic cystic tumors commonly include serous cystadenoma (SCA), mucinous cystadenoma (MCA), and mucinous cystadenocarcinoma (MCAC). A differential diagnosis with pseudocysts (PC) can be difficult. Radiologic criteria are not reliable. The objective of the study is to investigate the value of cyst fluid analysis in the differential diagnosis of benign (SCA, PC) vs. premalignant or malignant (MCA, MCAC) lesions. Methods: A search in PubMed was performed with the search terms cyst, pancrea, and fluid. Articles about cyst fluid analysis of pancreatic lesions that contained the individual data of it least 7 patients were included in the study. Data of all individual patients were combined and were plotted in scatter grams. Cutoff levels were determined. Results: Twelve studies were included, which comprised data of 450 patients. Cysts with an amylase concentration 800 ng/mL strongly suggested MCA or MCAC (sensitivity 48%, specificity 98%). A carbohydrate-associated antigen (CA) 19-9 <37 U/mL strongly Suggested PC or SCA (sensitivity 19%, specificity 98%). Cytologic examination revealed malignant cells in 48% of MCAC (n = 111). Discussion: Most pancreatic cystic tumors should be resected without the need for cyst fluid analysis. However, in asymptomatic patients, in patients with an increased surgical risk, and, in patients in whom there is a diagnostic uncertainty about the presence of a PC, cyst fluid analysis helps to determine the optimal therapeutic strategy

IBD and genetics:New developments

BACKGROUND: Inflammatory bowel disease (IBD) is a complex disorder with an aetiology that is only partly understood. Apart from environmental factors, inheritance contributes to IBD. REVIEW: Family studies show an increased risk among family members of a patient with IBD, particularly among first-degree relatives. In twin studies, concordance for disease type and localization is observed. In genetically isolated groups there is a higher prevalence of IBD. For instance. Ashkenazi Jews carry the highest risk. Further evidence comes from animal species that spontaneously develop IBD. Unlike Mendelian inheritance, in complex genetic diseases like IBD, genes are expected to be low penetrant and therefore less prone to selection, which results in higher expected gene frequencies. NOD2/CARD15, the first gene associated with IBD, is a polymorphic gene involved in the innate immune system. The gene has over 60 variations. Three of these play a role in 27% of patients with CD, with a predilection for patients with ileal disease. CONCLUSION: Genetics plays an important role in unravelling the pathogenesis of IBD leading to possible new therapeutic approache

Outcome of palliative care regimens in patients with advanced oesophageal cancer detected during explorative surgery

Background: The outcome of different palliative regimens was investigated in patients with incurable oesophageal carcinoma identified during surgical exploration. Patients and Methods: Between January 1992 and December 2002, 203 patients with oesophageal cancer underwent surgery after a standard staging procedure including computer tomography and endoscopic ultrasonography. The data from 78 patients, rendered incurable at exploration and who subsequently underwent palliative interventions, were analysed retrospectively. Results: The median survival in the whole group was 8.9 (1-105) months. Patients treated with chemotherapy had a higher median survival of 11.6 months compared with that of the other palliatively-treated patients: 8.4 months (p=0.003). Overall, intraluminal stenting was the palliative measure of dysphagia in 25 patients (32.3%). Conclusion: Patients with incurable oesophageal carcinoma have a poor overall survival of less than 9 months. Stenting is frequently (32%) needed for ultimate palliation of dysphagia after primary treatment. In a selective. group, palliative chemotherapy offered a survival benefit compared with othered treatment modalities

Influence of tumor characteristics on the accuracy of endoscopic ultrasonography in staging cancer of the esophagus and esophagogastric junction

Background and Study Aims: Endoscopic ultrasonography (EUS) is the most accurate method of assessing the locoregional extent of cancer of the esophagus and esophagogastric junction. The aim of this study was to evaluate the influence of tumor-related factors such as length and location on the accuracy of EUS in staging these tumors. Patients and Methods: Between January 1997 and September 2002, 280 consecutive patients underwent preoperative EUS for staging cancer of the esophagus and esophagogastric junction. The influence of histopathology, the presence of Barrett's dysplasia or stenosis, and the location and length of the primary tumor on the accuracy of EUS for T, N, and M staging were studied. Results: The overall accuracy rates of EUS for assessing the T, N, and M stages were 73%, 80%, and 78%, respectively. The influence of the tumor's histopathology and the presence of Barrett's dysplasia or stenosis was minimal. The accuracy of EUS was greater in tumors 5 cm or less in size than in tumors larger than 5 cm (82 % vs. 52 % for the T stage, P <0.05; 88 % vs. 59 % for the N stage, P <0.05; and 92 % vs. 56 % for the M stage, P <0.001). The low accuracy of T staging in larger tumors may be due to the exclusion of patients with local unresectability or distant metastases. EUS was also significantly better in esophageal tumors, particularly for identifying celiac trunk metastases (93% vs. 63%; P <0.001). Conclusions: The accuracy of EUS for staging esophageal cancer is lower in tumors larger than 5 cm and in esophagogastric junction tumors than in tumors 5 cm in size or less and in esophageal tumors. These findings should be considered when treatment decisions are being taken