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Ulcerative colitis practice guidelines in adults (update): American College of Gastroenterology, Practice Parameters Committee.

Guidelines for clinical practice are intended to indicate preferred approaches to medical problems as established by scientifically valid research. Double-blind placebo-controlled studies are preferable, but compassionate use reports and expert review articles are utilized in a thorough review of the literature conducted through Medline with the National Library of Medicine. When only data that will not withstand objective scrutiny are available, a recommendation is identified as a consensus of experts. Guidelines are applicable to all physicians who address the subject without regard to the specialty training or interests and are intended to indicate the preferable but not necessarily the only acceptable approach to a specific problem. Guidelines are intended to be flexible and must be distinguished from standards of care, which are inflexible and rarely violated. Given the wide range of specifics in any health-care problem, the physician must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. Guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the Board of Trustees. Each has been extensively reviewed and revised by the Committee, other experts in the field, physicians who will use them, and specialists in the science of decision of analysis. The recommendations of each guideline are therefore considered valid at the time of their production based on the data available. New developments in medical research and practice pertinent to each guideline will be reviewed at a time established and indicated at the publication in order to assure continued validity.

Adult↗

Functional results and visceral perception after ileo neo-rectal anastomosis in patients: a pilot study.

INTRODUCTION: To reduce pouch related complications after restorative proctocolectomy, an alternative procedure was developed, the ileo neo-rectal anastomosis (INRA). This technique consists of rectal mucosa replacement by ileal mucosa and straight ileorectal anastomosis. Our study provides a detailed description of the functional results after INRA. PATIENTS AND METHODS: Eleven patients underwent an INRA procedure with a temporary ileostomy. Anorectal function tests were performed two months prior to and six and 12 months after closure of the ileostomy and comprised: anal manometry, ultrasound examination, rectal balloon distension, and transmucosal electrical nerve stimulation (TENS). Function was subsequently related to the histopathology of rectal biopsy samples. RESULTS: Median stool frequency decreased from 15/24 hours (10-25) to 6/24 hours (4-11) at one year. All patients reported full continence. Anal sensibility, and resting and squeeze pressures did not change after INRA. Rectal compliance decreased (2.1 (0.7-2.8) v 1.5 (0.4-2.2) and 1.4 (0.8-3.7) ml/mm Hg (p=0.03)) but the maximum tolerated volume increased (70 (50-118) v 96 (39-176) (NS) and 122 (56-185) ml (p=0.03)). Decreasing rectal sensitivity was found: the maximum tolerated pressure increased (14 (8-24) v 22 (8-34) (NS) and 26 (14-40) (p=0.02)) and the rectal threshold for TENS displayed a similar tendency. All patients displayed a low grade chronic inflammatory infiltrate in neorectal biopsy samples before closure of the ileostomy, with no change during follow up. CONCLUSIONS: The technique of INRA provides a safe alternative for restorative surgery. Stool frequency after INRA improves with time and seems to be related to decreasing sensitivity and not to histopathological changes in the neorectum. Furthermore, after the INRA procedure, all patients reported full continence.

Adenomatous Polyposis Coli↗

Anti-tumour necrosis factor therapy for ulcerative colitis: evidence to date.

Infliximab, the chimeric monoclonal antibody directed against tumour necrosis factor (TNF)-alpha, has profoundly changed therapy for Crohn's disease (CD). However, for ulcerative colitis (UC), before the publication of ACT 1 and ACT 2 (Active Ulcerative Colitis Trials 1 and 2), there were only a few open-label and controlled trials that evaluated the role of infliximab in the treatment of UC. Results from these earlier studies were equivocal and ambiguous. However, the ACT 1 and ACT 2 trials were large, randomised and placebo-controlled, and have shown that infliximab is significantly more efficacious than placebo in treating both corticosteroid-responsive and -refractory moderate to severe UC. Data from these two studies showed that in patients with moderate to severe UC, treatment with infliximab (5 and 10 mg/kg), compared with placebo, led to significantly higher rates of clinical response, clinical remission and mucosal healing. However, a significant proportion of patients who were receiving oral corticosteroids at the start of the trials, remained on corticosteroids despite infliximab therapy. Additionally, the safety profile of the drug was found to be similar to what has been reported in clinical studies of infliximab in patients with CD. On the basis of currently available data, we use infliximab as a remission-inducing agent in patients who have moderate to severe UC and are either refractory to or intolerant of mesalazine (5-ASA) products and immunomodulators. Moreover, infliximab seems to be a reasonable therapeutic modality for remission maintenance in those patients with UC in whom mesalazine products and immunomodulators have failed. Although data are limited, infliximab may be considered as a remission-inducing agent in patients with moderate to severe UC which is refractory to oral corticosteroids. However, the role of infliximab in the treatment of UC patients who are dependent on oral corticosteroids is still unclear and, therefore, should be considered only in patients who cannot be successfully transitioned to or are intolerant of oral immunomodulators. Furthermore, infliximab may be an alternative to ciclosporin (cyclosporin) in hospitalised patients with severe to moderately severe but not fulminant UC who do not respond to intravenous corticosteroids. At present, there is insufficient evidence to advocate using infliximab as a first-line agent for UC patients with mild or moderate to severe disease. Future randomised, controlled trials with clearly defined patient populations should further help to clarify the definitive role of infliximab in the therapeutic scheme for UC.

Adrenal Cortex Hormones↗

Ostomy care and the consultant pharmacist.

Many long-term care residents have ostomies. Three types of ostomy are most common: ostomies of the small bowel (ileostomies/jejunostomies), ostomies of the large bowel (colostomy), and urostomies. Ostomates (people who have had an ostomy) must deal with their physical and psychological repercussions. Complications may include dermatological problems, short-bowel syndrome, and vitamin deficiencies. When the ostomy involves the bowel, medication absorption may be affected. Pharmacists should be aware of contraindicated medications, as well as those that change the color or odor of effluent or stool.

Aged↗

[Ileoanal reservoir: new concepts and current results].

More than 1,800 ileoanal pouches have been performed at the Mayo Clinic since 1981 and results have been satisfactory in more than 90% of the patients. However, we continue to search for alternatives to improve postoperative results and avoid the complications that currently occur in a minority of patients. During the last two years new concepts and surgical techniques for the construction of the ileoanal reservoir have been described. Herein we present those innovations and compare them to our current institutional practice.

Adenomatous Polyposis Coli↗

Serologic markers in inflammatory bowel disease: state of the art.

A variety of serologic tests are emerging that are relevant to the diagnosis and treatment of Crohn's disease and ulcerative colitis. These laboratory tests include: anti-neutrophil cytoplasmic antibody with perinuclear staining (pANCA); anti-Saccharomyces cerevisiae antibody (ASCA); outer membrane porin C (Omp C); and I2 antibody (novel homologue of the bacterial transcription-factor families). The potential roles for serologic testing for inflammatory bowel disease (IBD) include adjunctive diagnostic testing in patients with known IBD, screening testing for IBD in patients with compatible gastrointestinal symptoms, and serving as a marker of unique disease course or prediction of response to specific treatments. This article reviews the use of pANCA, ASCA, I2, and Omp C in patients with IBD.

Antibodies, Antineutrophil Cytoplasmic↗

Principles of ostomy management in the oncology patient.

Fecal and urinary diversions are fairly common among patients diagnosed with abdominal and pelvic malignancies who have undergone removal of the bladder or rectum or who have suffered from obstruction caused by tumor invasion or radiation damage. Effective ostomy management is important in palliative care and involves establishment of an effective pouching system, attention to diversion-specific alterations in dietary and fluid intake, and management of peristomal and stomal complications. Management of colostomy must include measures to prevent or manage constipation, management of ileostomy must include strategies for maintenance of fluid-electrolyte balance and prevention of food blockage, and management of urinary diversion must include options to be used at night and a focus on consistent adequate fluid intake. Common peristomal and stomal complications may necessitate use of barrier products, convex pouching systems to compensate for retraction, and/or binders. Surgery may be needed if incarcerated hernias, persistent prolapse, or stenosis severe enough to interfere with function occur.

Colorectal Neoplasms↗