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Clinics in Colon and Rectal Surgery Jul 2017When created properly, an ileostomy or colostomy can dramatically improve a patient's quality of life. Conversely, when a patient develops complications related to their... (Review)
Review
When created properly, an ileostomy or colostomy can dramatically improve a patient's quality of life. Conversely, when a patient develops complications related to their stoma, the impact on physical and mental health can be profound. Unfortunately, significant morbidity is associated with stoma creation conveying high rates of both early and late-term complications. Early complications include stomal ischemia/necrosis, retraction, mucocutaneous separation, and parastomal abscess. Late complications include parastomal hernia, prolapse, retraction, and varices. This review will discuss commonly occurring nondermatological stoma complications and detail management strategies for the ostomate and the surgeon.
PubMed: 28684937
DOI: 10.1055/s-0037-1598160 -
Clinics in Colon and Rectal Surgery May 2019Ileostomy or colostomy formation is an important component of many surgical procedures performed for a wide range of disorders of the gastrointestinal tract. Despite the... (Review)
Review
Ileostomy or colostomy formation is an important component of many surgical procedures performed for a wide range of disorders of the gastrointestinal tract. Despite the frequency with which intestinal stomas are created, stoma-related complications remain common and are associated with significant morbidity as well as cost. Some of the most prevalent complications of stoma formation which will be detailed in this article include peristomal skin complications, retraction, stomal necrosis, stomal stenosis, prolapse, bleeding, dehydration from high ostomy output, and parastomal hernia. The authors will review these common complications, detail means to avoid or prevent them, and outline recommendations for management.
PubMed: 31061647
DOI: 10.1055/s-0038-1676995 -
Journal of Visualized Experiments : JoVE Feb 2012Inflammatory bowel disease (IBD) encompasses a range of intestinal pathologies, the most common of which are ulcerative colitis (UC) and Crohn's Disease (CD). Both UC...
Inflammatory bowel disease (IBD) encompasses a range of intestinal pathologies, the most common of which are ulcerative colitis (UC) and Crohn's Disease (CD). Both UC and CD, when present in the colon, generate a similar symptom profile which can include diarrhea, rectal bleeding, abdominal pain, and weight loss.(1) Although the pathogenesis of IBD remains unknown, it is described as a multifactorial disease that involves both genetic and environmental components.(2) There are numerous and variable animal models of colonic inflammation that resemble several features of IBD. Animal models of colitis range from those arising spontaneously in susceptible strains of certain species to those requiring administration of specific concentrations of colitis-inducing chemicals, such as dextran sulphate sodium (DSS). Chemical-induced models of gut inflammation are the most commonly used and best described models of IBD. Administration of DSS in drinking water produces acute or chronic colitis depending on the administration protocol.(3) Animals given DSS exhibit weight loss and signs of loose stool or diarrhea, sometimes with evidence of rectal bleeding.(4,5) Here, we describe the methods by which colitis development and the resulting inflammatory response can be characterized following administration of DSS. These methods include histological analysis of hematoxylin/eosin stained colon sections, measurement of pro-inflammatory cytokines, and determination of myeloperoxidase (MPO) activity, which can be used as a surrogate marker of inflammation.(6) The extent of the inflammatory response in disease state can be assessed by the presence of clinical symptoms or by alteration in histology in mucosal tissue. Colonic histological damage is assessed by using a scoring system that considers loss of crypt architecture, inflammatory cell infiltration, muscle thickening, goblet cell depletion, and crypt abscess.(7) Quantitatively, levels of pro-inflammatory cytokines with acute inflammatory properties, such as interleukin (IL)-1β, IL-6 and tumour necrosis factor (TNF)-α,can be determined using conventional ELISA methods. In addition, MPO activity can be measured using a colorimetric assay and used as an index of inflammation.(8) In experimental colitis, disease severity is often correlated with an increase in MPO activity and higher levels of pro-inflammatory cytokines. Colitis severity and inflammation-associated damage can be assessed by examining stool consistency and bleeding, in addition to assessing the histopathological state of the intestine using hematoxylin/eosin stained colonic tissue sections. Colonic tissue fragments can be used to determine MPO activity and cytokine production. Taken together, these measures can be used to evaluate the intestinal inflammatory response in animal models of experimental colitis.
Topics: Animals; Colitis; Cytokines; Dextran Sulfate; Disease Models, Animal; Enzyme-Linked Immunosorbent Assay; Inflammatory Bowel Diseases; Male; Mice; Mice, Inbred C57BL; Peroxidase
PubMed: 22331082
DOI: 10.3791/3678 -
The New England Journal of Medicine Dec 2005Infliximab, a chimeric monoclonal antibody directed against tumor necrosis factor alpha, is an established treatment for Crohn's disease but not ulcerative colitis. (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Infliximab, a chimeric monoclonal antibody directed against tumor necrosis factor alpha, is an established treatment for Crohn's disease but not ulcerative colitis.
METHODS
Two randomized, double-blind, placebo-controlled studies--the Active Ulcerative Colitis Trials 1 and 2 (ACT 1 and ACT 2, respectively)--evaluated the efficacy of infliximab for induction and maintenance therapy in adults with ulcerative colitis. In each study, 364 patients with moderate-to-severe active ulcerative colitis despite treatment with concurrent medications received placebo or infliximab (5 mg or 10 mg per kilogram of body weight) intravenously at weeks 0, 2, and 6 and then every eight weeks through week 46 (in ACT 1) or week 22 (in ACT 2). Patients were followed for 54 weeks in ACT 1 and 30 weeks in ACT 2.
RESULTS
In ACT 1, 69 percent of patients who received 5 mg of infliximab and 61 percent of those who received 10 mg had a clinical response at week 8, as compared with 37 percent of those who received placebo (P<0.001 for both comparisons with placebo). A response was defined as a decrease in the Mayo score of at least 3 points and at least 30 percent, with an accompanying decrease in the subscore for rectal bleeding of at least 1 point or an absolute rectal-bleeding subscore of 0 or 1. In ACT 2, 64 percent of patients who received 5 mg of infliximab and 69 percent of those who received 10 mg had a clinical response at week 8, as compared with 29 percent of those who received placebo (P<0.001 for both comparisons with placebo). In both studies, patients who received infliximab were more likely to have a clinical response at week 30 (P< or =0.002 for all comparisons). In ACT 1, more patients who received 5 mg or 10 mg of infliximab had a clinical response at week 54 (45 percent and 44 percent, respectively) than did those who received placebo (20 percent, P<0.001 for both comparisons).
CONCLUSIONS
Patients with moderate-to-severe active ulcerative colitis treated with infliximab at weeks 0, 2, and 6 and every eight weeks thereafter were more likely to have a clinical response at weeks 8, 30, and 54 than were those receiving placebo. (ClinicalTrials.gov numbers, NCT00036439 and NCT00096655.)
Topics: Adult; Antibodies; Antibodies, Antinuclear; Antibodies, Monoclonal; Chi-Square Distribution; Colitis, Ulcerative; Double-Blind Method; Female; Humans; Infections; Infliximab; Male; Remission Induction; Tumor Necrosis Factor-alpha
PubMed: 16339095
DOI: 10.1056/NEJMoa050516 -
Gastroenterology Jun 2021The incidence and prevalence of Crohn's disease (CD) is rising globally. Patients with moderate to severe CD are at high risk for needing surgery and hospitalization and... (Review)
Review
The incidence and prevalence of Crohn's disease (CD) is rising globally. Patients with moderate to severe CD are at high risk for needing surgery and hospitalization and for developing disease-related complications, corticosteroid dependence, and serious infections. Optimal management of outpatients with moderate to severe luminal and/or fistulizing (including perianal) CD often requires the use of immunomodulator (thiopurines, methotrexate) and/or biologic therapies, including tumor necrosis factor-α antagonists, vedolizumab, or ustekinumab, either as monotherapy or in combination (with immunomodulators) to mitigate these risks. Decisions about optimal drug therapy in moderate to severe CD are complex, with limited guidance on comparative efficacy and safety of different treatments, leading to considerable practice variability. Since the last iteration of these guidelines published in 2013, significant advances have been made in the field, including the regulatory approval of 2 new biologic agents, vedolizumab and ustekinumab. Therefore, the American Gastroenterological Association prioritized updating clinical guidelines on this topic. To inform the clinical guidelines, this technical review was completed in accordance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. The review addressed the following focused questions (in adult outpatients with moderate to severe luminal CD): overall and comparative efficacy of different medications for induction and maintenance of remission in patients with or without prior exposure to tumor necrosis factor-α antagonists, comparative efficacy and safety of biologic monotherapy vs combination therapy with immunomodulators, comparative efficacy of a top-down (upfront use of biologics and/or immunomodulator therapy) vs step-up treatment strategy (acceleration to biologic and/or immunomodulator therapy only after failure of mesalamine), and the role of corticosteroids and mesalamine for induction and/or maintenance of remission. Finally, in adult outpatients with moderate to severe fistulizing CD, this review addressed the efficacy of pharmacologic interventions for achieving fistula and the role of adjunctive antibiotics without clear evidence of active infection.
Topics: Adult; Crohn Disease; Decision Support Systems, Clinical; Disease Management; Female; Gastroenterology; Humans; Male; Practice Guidelines as Topic; Rectal Fistula; Severity of Illness Index; Societies, Medical
PubMed: 34051985
DOI: 10.1053/j.gastro.2021.04.023 -
World Journal of Gastroenterology Jul 2021Perianal Crohn's disease remains a challenging condition to treat and can have a substantial negative impact on quality of life. It often requires combined surgical and... (Review)
Review
Perianal Crohn's disease remains a challenging condition to treat and can have a substantial negative impact on quality of life. It often requires combined surgical and medical interventions. Anti-tumor necrosis factor (anti-TNF) therapy, including infliximab and adalimumab, remain preferred medical therapies for perianal Crohn's disease. Infliximab has been shown to be efficacious in improving fistula closure rates in randomized controlled trials. Clinicians can be faced with a number of questions relating to the optimal use of anti-TNF therapy in perianal Crohn's disease. Specific issues include evaluation for the presence of perianal sepsis, the treatment target of therapy, the ideal time to commence treatment, whether additional medical therapy should be used in conjunction with anti-TNF therapy, and the duration of treatment. This article will discuss key studies which can assist clinicians in addressing these matters when they are considering or have already commenced anti-TNF therapy for the treatment of perianal Crohn's disease. It will also discuss current evidence regarding the use of vedolizumab and ustekinumab in patients who are failing to achieve a response to anti-TNF therapy for perianal Crohn's disease. Lastly, new therapies such as local injection of mesenchymal stem cell therapy will be discussed.
Topics: Crohn Disease; Humans; Infliximab; Quality of Life; Rectal Fistula; Treatment Outcome; Tumor Necrosis Factor Inhibitors; Tumor Necrosis Factor-alpha
PubMed: 34321838
DOI: 10.3748/wjg.v27.i25.3693 -
The New England Journal of Medicine Feb 2004Infliximab, a monoclonal antibody against tumor necrosis factor, is an effective maintenance therapy for patients with Crohn's disease without fistulas. It is not known... (Clinical Trial)
Clinical Trial Randomized Controlled Trial
BACKGROUND
Infliximab, a monoclonal antibody against tumor necrosis factor, is an effective maintenance therapy for patients with Crohn's disease without fistulas. It is not known whether infliximab is an effective maintenance therapy for patients with fistulas.
METHODS
We performed a multicenter, double-blind, randomized, placebo-controlled trial to evaluate the efficacy of infliximab maintenance therapy in 306 adult patients with Crohn's disease and one or more draining abdominal or perianal fistulas of at least three months' duration. Patients received 5 mg of infliximab per kilogram of body weight intravenously on weeks 0, 2, and 6. A total of 195 patients who had a response at weeks 10 and 14 and 87 patients who had no response were then randomly assigned to receive placebo or 5 mg of infliximab per kilogram every eight weeks and to be followed to week 54. The primary analysis was the time to the loss of response among patients who had a response at week 14 and underwent randomization.
RESULTS
The time to loss of response was significantly longer for patients who received infliximab maintenance therapy than for those who received placebo maintenance (more than 40 weeks vs. 14 weeks, P<0.001). At week 54, 19 percent of patients in the placebo maintenance group had a complete absence of draining fistulas, as compared with 36 percent of patients in the infliximab maintenance group (P=0.009).
CONCLUSIONS
Patients with fistulizing Crohn's disease who have a response to induction therapy with infliximab have an increased likelihood of a sustained response over a 54-week period if infliximab treatment is continued every 8 weeks.
Topics: Adult; Aged; Antibodies, Monoclonal; Crohn Disease; Cutaneous Fistula; Double-Blind Method; Drug Tolerance; Female; Gastrointestinal Agents; Humans; Infliximab; Infusions, Intravenous; Intestinal Fistula; Male; Middle Aged; Rectal Fistula; Recurrence; Remission Induction; Treatment Outcome; Tumor Necrosis Factor-alpha
PubMed: 14985485
DOI: 10.1056/NEJMoa030815 -
Nutrients Jun 2021Probiotics have been shown to benefit patients with constipation and depression, but whether they specifically alleviate constipation in patients with depression remains... (Randomized Controlled Trial)
Randomized Controlled Trial
Probiotics have been shown to benefit patients with constipation and depression, but whether they specifically alleviate constipation in patients with depression remains unclear. The aim of this study was to investigate the effect of strain Shirota (LcS), formerly strain Shirota, on constipation in patients with depression with specific etiology and gut microbiota and on depressive regimens. Eighty-two patients with constipation were recruited. The subjects consumed 100 mL of a LcS beverage (10 CFU/mL) or placebo every day for 9 weeks. After ingesting beverages for this period, we observed no significant differences in the total patient constipation-symptom (PAC-SYM) scores in the LcS group when compared with the placebo group. However, symptoms/scores in item 7 (rectal tearing or bleeding after a bowel movement) and items 8-12 (stool symptom subscale) were more alleviated in the LcS group than in the placebo group. The Beck Depression Index (BDI) and Hamilton Depression Rating Scale (HAMD) scores were all significantly decreased, and the degree of depression was significantly improved in both the placebo and LcS groups ( < 0.05), but there was no significant difference between the groups. The LcS intervention increased the beneficial , and levels and decreased the bacterial levels related to mental illness, such as , and Additionally, the interleukin (IL)-1β, IL-6, and tumor necrosis factor-α (TNF-α) levels were significantly decreased in both the placebo and LcS groups ( < 0.05). In particular, the IL-6 levels were significantly lower in the LcS group than the placebo group after the ingestion period ( < 0.05). In conclusion, the daily consumption of LcS for 9 weeks appeared to relieve constipation and improve the potentially depressive symptoms in patients with depression and significantly decrease the IL-6 levels. In addition, the LcS supplementation also appeared to regulate the intestinal microbiota related to mental illness.
Topics: Adult; Animals; Constipation; Cultured Milk Products; Depression; Double-Blind Method; Feces; Female; Gastrointestinal Microbiome; Humans; Lacticaseibacillus paracasei; Male; Middle Aged; Probiotics; Treatment Outcome
PubMed: 34209804
DOI: 10.3390/nu13072238 -
Journal of Clinical Pathology Jan 1977Three basic histopathological patterns which may be seen in rectal biopsies from patients with pseudomembranous colitis are described, based on a study of 29 cases. The...
Three basic histopathological patterns which may be seen in rectal biopsies from patients with pseudomembranous colitis are described, based on a study of 29 cases. The spectrum of change is illustrated and the problems of differential diagnosis are discussed--from a non-diagnostic proctitis at one extreme to acute ischaemia at the other. In the differential diagnosis of the acute colitic, the importance of urgent rectal biopsy and a carefully taken drug history is stressed. The association of pseudomembranous colitis with pre-existing disease and antibiotic therapy is confirmed. It is suggested that these cause local mucosal damage and may trigger the first part of a local Shwartzman reaction. Capillary microthrombosis may then paly a part in producing the mucosal necrosis seen later in the disease.
Topics: Adolescent; Adult; Aged; Anti-Bacterial Agents; Child; Colitis, Ulcerative; Colon; Diagnosis, Differential; Diarrhea; Enterocolitis, Pseudomembranous; Female; Humans; Ischemia; Male; Middle Aged; Necrosis
PubMed: 838865
DOI: 10.1136/jcp.30.1.1 -
World Journal of Gastrointestinal... Jun 2016Sigmoid volvulus (SV) is extremely uncommon in children and is usually associated with a long-standing history of constipation or pseudo-obstruction. An early diagnosis... (Review)
Review
Sigmoid volvulus (SV) is extremely uncommon in children and is usually associated with a long-standing history of constipation or pseudo-obstruction. An early diagnosis and management are crucial in order to prevent the appearance of hemorrhagic infarction of the twisted loop, avoiding further complications such as necrosis, perforation and sepsis. In patients with no evidence of peritonitis or ischemic bowel, treatment starts with resuscitation and detorsion of the SV, accomplished by means of sigmoidoscopy and concomitant rectal tube placement. The bowel is then prepared and surgery is undertaken electively during the same hospitalization. We report a detailed review of the literature focusing on technical details, risks and benefits of endoscopic management of SV in childhood.
PubMed: 27358669
DOI: 10.4253/wjge.v8.i12.439