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Primary biliary cirrhosis and ulcerative colitis: a case report and review of literature.

AIM: To summarize the characteristics of patients suffered from primary biliary cirrhosis associated with ulcerative colitis. METHODS: To report a new case and review the literature. RESULTS: There were 18 cases (including our case) of primary biliary cirrhosis complicated with ulcerative colitis reported in the literature. Compared with classical primary biliary cirrhosis, the patients were more often males and younger similar. The bowel lesions were usually mild with proctitis predominated. While ulcerative colitis was diagnosed before primary biliary cirrhosis in 13 cases, the presentation of primary biliary cirrhosis was earlier than that of ulcerative colitis in our new case reported here. The prevalence of primary biliary cirrhosis among patients of ulcerative colitis was almost 30 times higher than in general population. CONCLUSION: Association of primary biliary cirrhosis with ulcerative colitis is rare. It should be considered in the differential diagnosis of hepatobiliary disease in patients with ulcerative colitis, and vice versa.

Adult↗

Three-dimensional conformal therapy versus standard radiation therapy in localized carcinoma of prostate: an update.

This study updates technical principles and results of 3-dimensional conformal radiation therapy (3D-CRT) in localized carcinoma of the prostate. Between January 1992 and December 1999, 312 patients were treated with 3D-CRT and 135 patients were treated with bilateral arcs standard radiation therapy (SRT) alone for clinical stage T1b-c or T2 histologically confirmed prostate cancer. None of these patients received hormonal therapy. Mean follow-up for patients in the 3D-CRT group was 3.2 years (range, 2-5.9 years) and for SRT patients, 4.7 years (range, 4-7 years). For 3D-CRT, 7 intersecting fields were used (cerrobend blocking or multileaf collimation) to deliver 68-74 Gy to the prostate. Standard radiation therapy consisted of bilateral 120 degree rotational arcs, with portals using 2-cm margins around the prostate to deliver 68-70 Gy to the prostate. The criterion for chemical disease-free survival was a postirradiation prostate-specific antigen (PSA) value following the American Society for Therapeutic Radiology and Oncology guidelines. Symptoms during treatment were quantitated weekly, and late effects were assessed every 4-6 months. Dose-volume histograms showed a two-thirds reduction with 3D-CRT in normal bladder or rectum receiving > or = 70 Gy with 3D-CRT. Higher 5-year chemical disease-free survival was observed with 3D-CRT (75%; for T1b-c and 79%; for T2 tumors) compared with SRT (61% and 65%, P = 0.01 and P = 0.12, respectively). There was no statistically significant difference in chemical disease-free survival in patients with Gleason score of < or = 4 (P = 0.85), but, with Gleason score of 5-7, the 5-year survival rates were 83% with 3D-CRT and 59% with SRT (P < or = 0.01). In 245 patients with pretreatment PSA of < or = 10 ng/mL treated with 3D-CRT, the chemical disease-free rate was 80% versus 72% in 98 patients treated with SRT (P = 0.21). In patients with PSA of 10.1-20 ng/mL, the chemical disease-free survival rate for 50 patients treated with 3D-CRT was 71% compared with 43% for 20 patients treated with SRT (P = 0.02). The corresponding values were 59% and 16%, respectively, for patients with PSA levels > 20 ng/mL (P = 0.09). On multivariate analysis, the most important prognostic factors for chemical failure were pretreatment PSA (P = 0.004), nadir PSA (P = 0.001), and 3D-CRT technique (P = 0.012). Moderate dysuria was reported by 2%-5% of patients treated with 3D-CRT in contrast to 6%-9% of patients treated with SRT. The incidence of moderate loose stools or diarrhea, usually after the fourth week of treatment, was 3%-5% in the 3D-CRT patients and 8%-19% in the SRT group. Late intestinal grade 2 morbidity (proctitis or rectal bleeding) was 1% in the 3D-CRT group in contrast to 7% in SRT patients. The 3D-CRT spares more normal tissues, yields higher chemical disease-free survival, and results in less treatment morbidity than SRT in treatment of stage T1-T2 prostate cancer. Follow-up at > or = 10 years is needed to confirm these observations.

Adenocarcinoma↗

A population-based study on the incidence of inflammatory bowel disease in Oviedo (Northern Spain).

OBJECTIVE: to assess the incidence of inflammatory bowel disease in Oviedo (Northern Spain), and to describe the clinical features of new patients. PATIENTS AND METHODS: a prospective population-based study was made at the Health Area IV, Principality of Asturias (Oviedo, 312,324 inhabitants). All new diagnosed patients with inflammatory bowel disease were registered over a 2-year period. RESULTS: a total of 85 patients were included, 47 of these with ulcerative colitis (UC), 37 with Crohńs disease (CD), and 1 with undetermined colitis. The overall adjusted incidence rate of UC and CD per 105 inhabitants between 15-64 years was 9.1 (95% CI: 5-13.1) and 7.5 (95% CI: 3.8-11.2), respectively. The global male/female ratio was 0.9, without significant differences between both diseases. CD patients were younger than those with UC (33 +/- 15 years vs 45 +/- 20 years; p < 0.05). Mostly, CD patients were diagnosed at an age younger than 35 years (65%), while UC patients were diagnosed at an age between 25 and 64 years (81%). Disease extension in UC was proctitis in 11%, left-side colitis in 53% and extensive colitis in 36%. With respect to CD, the ileo-colonic form predominated (49%), followed by the ileal (40%) and colonic (11%) forms; an inflammatory, stenotic and fistulous pattern was seen in 54, 22 and 24% of patients, respectively. CONCLUSIONS: in our area, the incidence of CD is similar to that in other Northern European countries, while UC has a lower incidence. CD mainly affects young people, while UC predominates in middle-aged patients. At diagnosis, UC is predominantly localized, the ileo-colonic form and an inflammatory pattern being most frequent in CD patients.

Adolescent↗

Epidemiology of chronic inflammatory bowel disease in the Northern area of Huelva.

OBJECTIVE: To know the different epidemiologic aspects of chronic inflammatory bowel disease (IBD) in the Northern area of the province of Huelva. MATERIAL AND METHODS: we carried out a retrospective (1980-1996) and prospective (1996-2003) study of all patients diagnosed with IBD in the Northern area of Huelva, with 77,856 inhabitants. The distribution of Crohn s disease (CD) and ulcerative colitis (UC) was analyzed, as well as sex, age and smoking habit at the time of diagnosis, familial aggregation, appendicectomy rate, phenotype (anatomical site and clinical types), extraintestinal manifestations, and immunosuppressive therapy or surgical requirements. RESULTS: 70 patients with IBD were studied, 40 with UC and 30 with CD. Sex distribution was 39 (55.7%) males (55% with CD vs 56.6% with UC; NS) and 31 (44.3%) females (45% with CD vs 43.3% with UC; NS). Mean age at presentation was 44.7 +/- 19.32 years in UC vs 32.3 +/- 16.43 in CD; p < 0.001. Familial association was 7.1%. Previous appendicectomy was referred in 2.5% of patients with UC vs 36.7% of those with CD (p < 0.001), and the percentage of smokers was also higher in CD 66.7% vs CU 12.5% (p < 0.001). Anatomical site in UC was: proctitis, 20%; proctosigmoiditis/left colon, 42.5%; extensive colitis, 25%; and pancolitis, 12.5%; in CD was: terminal ileum, 43.3%; colon, 20%; and ileo-colon, 36.7%. The disease patterns were: inflammatory 56.7%, obstruction 26.7%, and fistulization 16.7%. Extraintestinal manifestations were diagnosed in 7.5% of patients with UC vs 16.6% patients with CD; surgery was performed in one patient with UC vs 10 with CD, and one patient with UC required immunosuppressive treatment vs 12 with CD. A multivariant analysis showed that younger age and smoking habit were risk factors for CD vs advanced age in UC, in which case, the smoking habit was a protective factor. The mean incidence rate of IBD starting from 1996 and expressed in cases/100,000 inhabitants/year was 5.2 for UC and 6.6 for CD. CONCLUSIONS: The mean incidence of UC in our area was 5.2 cases/100,000/inhabitants/year, and 6.6 for CD. Patients presenting with CD are diagnosed at a significantly younger age that those with UC; the smoking habit is a risk factor for CD while it protects from UC. The characteristics of IBD in our geographical area do not differ substantially from those in other regions of Spain.

Adult↗

Diagnostic and treatment recommendations on perianal Crohn's disease.

Treatment of perianal fistulas in Crohn's disease should be defined on an individual basis. A combined medical and surgical approach is the optimal treatment. Adequate management of perianal fistula disease is based on the presence or absence of active proctitis, anatomic location, and fistula type. Furthermore, the presence of perianal abscesses must be ruled out. This evaluation includes digital rectal examination, endoscopy, and examination under anesthesia combined with pelvic magnetic resonance imaging or anorectal endoscopy ultrasonography findings.

Algorithms↗

[Transurethral intracavitary irradiation for carcinoma of the prostate].

This paper describes a new technique and preliminary clinical results of remote after-loading transurethral irradiation for cancer of the prostate. As of January 1986, twelve patients with adenocarcinoma of the prostate have been treated by our radiotherapy technique. Clinically, 3 patients were in stage B2, 3 in stage C, 3 in stage D1 and 3 in stage D2. These patients have been followed up for 13 to 33 months with a median follow-up period of 20.6 months. The dose of transurethral irradiation was 9-10 Gy. to the prostatic capsule and about 2 Gy. to the rectum in one procedure. We repeated this radiotherapy 3 to 4 times within an about 1-month period. Three patients in stage D1 and one patient in stage C received an additional external beam radiation (40 Gy.) to the entire pelvis. A needle biopsy was also performed every 4-6 months after irradiation. Local tumor response proved rapid and satisfactory as verified by a rectal examination and ultrasonography. The biopsies revealed a 70% negative rate within one year. The most common side effect was transient frequency observed in 7 patients. Severe complications such as incontinence, urethral stricture, or proctitis were not evident. This study suggests that intracavitary irradiation of cancer of the prostate is effective and safe. This method may have wider application.

Adenocarcinoma↗

Anorectal gonococcal infection.

Anorectal gonococcal infection is common in women and homosexual men. In women with uncomplicated gonorrhea, the mean prevalence rate of anorectal involvement is 44%, with lone involvement of the anorectum in 4%. Among homosexual men with gonorrhea, anorectal infection occurs in 45%, although more than 90% of all male patients with anorectal gonorrhea admit to homosexual rectal intercourse. This infection is usually asymptomatic but occasionally presents with acute or chronic symptoms that mimic other causes of proctitis. Whereas currently recommended regimens for uncomplicated gonorrhea appear effective for anorectal gonorrhea in women, results in men have not been adequately evaluated. Available data showed failure rates from 7% to 35%; however, only one study used a currently accepted regimen. Further controlled studies in male patients with anorectal gonorrhea are clearly needed to establish optimal therapeutic regimens. Diligent contact tracing of all male homose.xual cases appears to be the only effective means of control at present.

Anti-Bacterial Agents↗

Opportunistic infections and immune deficiency in homosexual men.

A syndrome of opportunistic infections and acquired immune deficiency occurred among four previously healthy homosexual men. Fever, leukopenia, and diminished delayed hypersensitivity were accompanied by various degrees of proctitis, perianal ulcerations, and lymphadenopathy. The infectious agents included Pneumocystis carinii, Cryptococcus neoformans, Candida albicans, herpes simplex virus, and cytomegalovirus. The immune deficiency was characterized as a persistent and profound selective decrease in the function as well as number of T lymphocytes of the helper/inducer subset and a possible activation of the suppressor/cytotoxic subset. Three patients died despite aggressive anti-infective therapy.

Adult↗

[Brachytherapy boost irradiation in the treatment of high risk, localised prostate cancer. Initial national experience in Hungary].

PURPOSE: To describe the technique and early results of ultrasound (US)-guided interstitial prostate brachytherapy (BT) introduced at our institute. MATERIALS AND METHODS: Between December 2001 and July 2002, ten patients with clinically localised, high risk prostate cancer were treated with external beam irradiation and high dose rate (HDR) BT boost at the Radiotherapy Department of National Institute of Oncology, Budapest. Using CT based treatment planning, 46 Gy was delivered to the whole pelvis and then the prostate and vesicles were treated up to a total dose of 60 Gy by conformal external beams. BT boost was given in the first four weeks of external irradiation. Nine patients were under total androgen blockade. The interstitial BT was performed in spinal anaesthesia. Steel needles were implanted into the prostate using transrectal US guidance. The Ir-192 HDR isotope was loaded into the needles by remote control after-loading equipment. Treatment planning was based on transversal ultrasound images. The target volume was the whole prostate. The median number of inserted needles was 9 (range: 5-13). The prescribed dose to the surface of the prostate was 8 or 10 Gy, and the maximum reference dose of the urethra or rectum was less than 125% and 80% of the prescribed dose, respectively. PSA (prostate specific antigen) levels and acute side effects were monitored and documented regularly. RESULTS: The prescribed treatment was completed on all patients. The median follow-up time from the completion of the radiotherapy was 6 months (range: 2-11 months). Perioperative side effects (haematuria caused by puncture of the bladder) occurred in two cases. Acute grade 2 toxicity was observed in four patients: genitourinal inflammation in 4, and proctitis in 2 cases. No PSA relapse occurred so far. CONCLUSION: In our study we described our technique of interstitial BT boost as a part of prostate radiotherapy used for the first time in Hungary. The US based treatment planning resulted in adequate dose distribution in all cases. Incidence of perioperative and acute side effects were comparable to data known from the literature. Appropriate technical background and well organised team work are needed to ensure the good quality of the treatment.

Aged↗

Helicobacter bilis/Helicobacter rodentium co-infection associated with diarrhea in a colony of scid mice.

An outbreak of diarrhea spanning 3 months occurred in a breeding colony of scid/Trp53 knockout mice. Approximately a third of the 150 mice were clinically affected, with signs ranging from mucoid or watery diarrhea to severe hemorrhagic diarrhea with mortality. Helicobacter bilis and the newly recognized urease-negative organism H. rodentium were isolated from microaerobic culture of feces or cecal specimens from affected mice. Dual infection with H. bilis and H. rodentium were confirmed by culture and polymerase chain reaction (PCR) in several animals. Both Helicobacter species rapidly colonized immunocompetent sentinel mice exposed to bedding from cages containing affected mice, but the sentinel remained asymptomatic. Mice with diarrhea had multifocal to segmental proliferative typhlitis, colitis, and proctitis. Several affected mice had multifocal mucosal necrosis with a few focal ulcers in the cecum, colon, and rectum. Mice with diarrhea were treated with antibiotic food wafers (1.5 mg of amoxicillin, 0.69 mg of metronidazole, and 0.185 mg of bismuth/mouse per day) previously shown to eradicate H. hepaticus in immunocompetent mice. Antibiotic treatment resulted in resolution of diarrhea, but not eradication of H. bilis and H. rodentium; mice continued to have positive PCR results after a 2-week treatment regimen, and clinical signs of diarrhea returned in some mice when treatment was suspended. To the authors' knowledge, this is the first report of natural infection with either H. bilis and/or H. rodentium causing acute diarrheal disease and suggests that H. bilis and/or H. rodentium can be an important pathogen for scid mice.

Animals↗

[Stenoses of the small and large bowel following radiotherapy of female genital cancer (author's transl)].

Stenoses of the lower intestinal tract following radiotherapy of female genital cancer occur at a frequency of 2-5%; the terminal ileum as well as the sigma are often involved. From 1966-1976 110 patients were treated at the Department of Surgery of the University Hospital of Hamburg. 43 patients required surgical treatment; stenosis of the sigma was the most frequent indication followed by ileus of the small intestines, haemorrhagic proctitis, ulcer of the anterior rectal wall and vesico-recto-vaginal fistula. The following operations were performed: Resection of the small intestines or enterolysis (n = 11), resection of the descending colon (n = 8), abdominal perineal excision of the rectum (n = 4), transversostomy (n = 14) and fistula plastics. - From our experience, intestinal reactions after radiation must be suspected when 1. the total irradiation dose is over 6000 R, 2. radium implants are used, 3. previous operations and abdominal inflammatory lesions restrict the movement of the intestines.

Aged↗

Herpes simplex genitalis type 2: our experiences.

OBJECTIVE: To review the recent research in genital HSV infection and to pay attention to this problem in Slovene population. METHODS: Review of all papers in the field on Medline 1994-98. A descriptive retrospective analysis of symptoms, seroprevalence, treatment, complications and follow-up of 49 HSV-1 and HSV-2 seropositive patients. RESULTS: Five patients with overt genital herpes were HSV-1 seropositive, and four were HSV-1 and HSV-2 seropositive. One patient had extragenital spread and HSV proctitis. Treatment consisted of 1 gr daily dose of Acyclovir (ACV) in combination with topical ACV for two to three weeks. Recurrences were intermittently treated in three patients and one started suppressive treatment. Three pregnancies terminated vaginally with healthy babies. CONCLUSIONS: According to literature overview and our experiences, more attention should be paid on revealing mild forms of genital herpes in order to diminish the spread of infection and its consequences.

Acyclovir↗

Drug treatment of common STDs: Part II. Vaginal infections, pelvic inflammatory disease and genital warts.

The Centers for Disease Control and Prevention (CDC) released new guidelines for the treatment of sexually transmitted diseases (STDs) in 1998. Several treatment advances have been made since the previous guidelines were published. Part II of this two-part series on STDs describes recommendations for the treatment of diseases characterized by vaginal discharge, pelvic inflammatory disease, epididymitis, human papillomavirus infection, proctitis, proctocolitis, enteritis and ectoparasitic diseases. Single-dose therapies are recommended for the treatment of several of these diseases. A single 1-g dose of oral azithromycin is as effective as a seven-day course of oral doxycycline, 100 mg twice a day, for the treatment of chlamydial infection. Erythromycin and ofloxacin are alternative agents. Four single-dose therapies are now recommended for the management of uncomplicated gonococcal infections, including 400 mg of cefixime, 500 mg of ciprofloxacin, 125 mg of ceftriaxone or 400 mg of ofloxacin. Advances in the treatment of bacterial vaginosis also have been made. A seven-day course of oral metronidazole is still recommended for the treatment of bacterial vaginosis in pregnant women, but intravaginal clindamycin cream and metronidazole gel are now recommended in nonpregnant women. Single-dose therapy with 150 mg of oral fluconazole is a recommended treatment for vulvovaginal candidiasis. Two new topical treatments, podofilox and imiquimod, are available for patient self-administration to treat human papillomavirus infection. Permethrin cream is now the preferred agent for the treatment of pediculosis pubis and scabies.

Anti-Infective Agents↗

[Medical therapy in ulcerative colitis].

Salazosulfapyridine(SASP) and 5-aminosalicyclic acid(5-ASA) are useful in the therapy of mildly to moderately active ulcerative colitis. 5-ASA lacks sulfa moiety of SASP and is associated with a decreased incidence of side effects. In patients with moderate or severe ulcerative colitis, glucocorticoids which may be given in conjunction with SASP or 5-ASA are beneficial in producing remission. Proctitis or left-sided colitis is effectively treated with glucocorticoid enemas. If symptoms are refractory to outpatient management, the patient should be hospitalized and given initial therapy with glucocorticoids. Total colectomy(ileo-anal anastomosis; IAA et al) must be considered for acutely ill patients not responding to intensive medical therapy. Early surgical consultation is necessary in severely ill patients.

Anti-Inflammatory Agents↗

[Treatment of mild and moderate ulcerative colitis].

Selection of treatment for ulcerative colitis is based on the definition of clinical severity. In those medication is a main course. Mild and moderate cases are treated mainly with salicylazosulfapyridine or mesalazine. Patients with proctitis-type are added betamethazone suppositories and those with left-sided and total colitis-type predonisolone enema therapy simultaneously. If there is no response, they are given additional oral predonisolone. Even after remission, patients should be carefully observed. A good patient-physician relationship, continuation of maintenance therapy, and periodic follow-up examinations using colonoscopy or barium enema are essential to successful long-term management of this disease. Patients who have repeated relapsing should receive the stronger treatment, according to the endoscopic findings and clinical course in addition to the clinical severity.

Anti-Inflammatory Agents↗

Incidence of ulcerative colitis, 1980-1995--a prospective study in an urban population in Germany.

A prospective, population-based study was carried out from 1980 to 1984 and again from 1991 to 1995 to determine the incidence of ulcerative colitis in an urban area in Germany. Patients with proctitis were excluded from this analysis. 74 (1980-84) and 76 (1991-95) patients newly diagnosed with ulcerative colitis were identified. A slight rise in the age- and sex-standardized incidence rate from 2.4/10(5) in 1980-84 (95% CI 1.8/10(5) to 3.0/10(5)) to 3.0 (95% CI 2.4/10(5) to 3.7/10(5)) in 1991-95 was primarily due to a significant increase of the disease in young woman. A male preponderance in the earlier time period was hereby leveled out. There were no differences in the extent of the disease and the severity of symptoms. However, the time from onset of symptoms to diagnosis was reduced from a median of nine months in the 1980s to two months in the more recent period.

Adolescent↗

[Colorectal neoplasms in patients with ulcerative rectocolitis. Their surgical treatment and follow-up].

Patients with ulcerative colitis (UC), especially those with a long-term standing or severe disease, show a higher incidence of colorectal neoplasms. Dysplasia represents the most important risk-factor for malignancy in patients with UC. From 1989 to 1999, 71 patients with UC, were surgically treated at our Institution. Indications for surgery were: non responding disease or refractory bleeding in 61; pathologic evidence of severe dysplasia during endoscopic surveillance in 5 patients, evidence of a neoplasm in the remaining 5 patients. Operative mortality was 1.4%. Infections of the surgical wound has been the most common postoperative complication. In 4 cases pouchitis has been reported. In 7 patients because of progression of the proctitis a second surgical treatment has been made. When surgical treatment is indicated in the course of ulcerative colitis, several operations may be performed. In the large majority of patients, total colectomy, mucosectomy and ileal pouch-anal anastomosis is the procedure of choice.

Adenocarcinoma↗

Prior transurethral resection does not increase morbidity following real-time ultrasound-guided prostate seed implantation.

PURPOSE: Patients with localized prostate cancer who had a prior open prostatectomy or transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH) may be at risk for greater morbidity when treated with brachytherapy. This analysis examines the morbidity following brachytherapy using the real-time method to determine if patients with a history of TURP are at increase risk for developing complications. MATERIALS AND METHODS: An ultrasound-guided transperineal interactive prostate seed was implanted in 419 patients with T1-T2 prostate cancer. All patients were implanted using a peripheral weighting of sources (75%) with the interior sources placed at least 5 mm from the urethra. The patients were divided into two groups: group 1 consisted of 376 patients (89.7%) without a prior TURP, and group 2 consisted of 43 patients (10.3%) who had a TURP prior to their implant. The mean age, prostate-specific antigen level, Gleason score, clinical stage, prostate volume, isotope implanted, and number of patients treated with neoadjuvant hormone therapy were comparable for both groups. RESULTS: Median follow-up for group 1 was 12 months and for group 2 was 18 months. No patients suffered from radiation-related proctitis or cystitis in either group of patients. Two patients in group 2 implanted with iodine 125 and who had a history of two prior TURPs developed mild superficial urethral necrosis (SUN). The actuarial freedom from developing superficial urethral necrosis at 4 years was 84% in patients with a history of prior TURP. There were no episodes of SUN in group 1 and no cases of incontinence reported in either group of patients. The actuarial rate of potency was 78% at 2 years. CONCLUSION: Whereas other techniques of seed implantation report incontinence in patients who had a prior open prostatectomy or TURP, the real-time method combined with peripheral loading avoids this complication.

Adult↗