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The same drugs are used to treat hemorrhagic rectocolitis (HRC) and Crohn's disease (CD), although the aims are very different. Aminosalicylates are highly beneficial in HRC but virtually ineffective in CD, a disease in which immunosuppressants are more useful. Aminosalicylates exert their antiinflammatory effect directly on the lesions. Various oral and rectal preparations have been developed in order to deliver the active molecule to the intestinal target segment. These drugs are now known to act by stimulating the nuclear receptor PPAR-gamma, and this knowledge should help with the development of new agents. Chronic aminosalicylate treatment appears to diminish the risk of malignant transformation. Systemic steroids are still the mainstay of treatment for exacerbations of HRC and CD, yielding remissions in 60 to 90% of cases. In contrast, systemic steroids should not be used for maintenance therapy. Budesonide is a preparation that selectively releases steroids in the ileocolonic region, thereby reducing systemic adverse effects. Immunosuppressants such as azathioprine and 6-mercaptopurine, and also methotrexate in some cases, are used for maintenance therapy of steroid-dependent and highly recurrent forms. These drugs stabilize the disease in about half the patients who receive them. Treatment typically lasts several years and necessitates regular monitoring, especially of hematological status. Cyclosporine is used intravenously in severe HRC. Infliximab (RemicadeR), a chimeric monoclonal antibody targeting TNF is effective in acute forms and as maintenance therapy for CD. It was also recently shown to be effective in HRC. Infliximab is indicated in steroid-resistant forms and contraindicated in patients with latent systemic infections (tuberculosis, hepatitis B) and heart failure. Artificial nutrition is now only used in children with acute forms, in order to avoid the need for steroids. Probiotics might have a place in maintenance treatment of HRC. Surgical treatment of HRC consists of colectomy or, more radically, ileoprotectomy followed by ileoanal anastomosis with resection: however, the likely benefits and potential complications (especially nocturnal diarrhea) must be carefully weighed up. Surgical treatment of CD consists of resecting the worst-affected segments. As available medical and surgical treatments can only control these diseases, without curing them, patient management must be planned on a long-term basis. Control of exacerbations is judged on the basis of clinical parameters and biological markers of inflammation, rather than on lesion healing. The choice of maintenance therapy depends on the nature of the disease (HRC or CD) and its progressive nature. Surgery is reserved for patients with complicated and drug-resistant forms.

Diffuse and primitive fat replacement of the exocrine pancreas is a rare cause of exocrine pancreatic insufficiency in adults. We report two adult patients with chronic diarrhoea and steatorrhea whose morphologic abnormalities revealed diffuse fat replacement of the pancreas. Tomodensitometry detected diffuse characteristic abnormalities with fat intermixed with normal pancreatic lobules or a "vanishing pancreas". In one patient, magnetic resonance imaging and echo-endoscopy suggested abnormalities. Administration of pancreatic extracts improved symptoms.

In patients with active inflammatory bowel disease (IBD), the objective is to achieve clinical remission. For ulcerative colitis (UC), oral or rectal aminosalycilates are widely used, and in more severe flares, corticoids and occasionally ciclosporine. In active Crohn's disease, corticosteroids represent the main treatment; budesonide must be preferred, as this steroid is better tolerated than prednisone. In patients refractory or intolerant to steroids, infliximab or artificial nutrition can be considered. Maintenance treatment is indicated in most of IBD patients. 5-ASA derivates are preferred in UC; in case of failure, azathioprine can be used. In Crohn's disease, azathioprine or methotrexate are more widely used; maintenance with infliximab is an option in case of failure. Surgery is mainly indicated for complications or in patients resistant to medical treatment.

Failure or intolerance of treatments by azathioprine (AZA) or methotrexate (MTX) is an important problem in the maintenance treatment of refractory CD. Results of the alternative use of mycophenolate mofetil (MMF) are conflicting.To assess the efficacy and tolerance of MMF in patients with refractory CD included in a multicentre and retrospective study.Twenty patients (5 men, 15 women, median age 33 years) have been enrolled. The disease was located in the small intestine (n=7), colon (n=5) or in both ileon and colon (n=8). Five patients had perineal disease. Neighteen patients had an active CD and 13 of them received steroids (30 mg daily). All of them had been treated by AZA (failure, n=5; intolerance, n=15) and/or MTX (failure, n=12; intolerance, n=6). The dose of MMF was 750 mg to 2 g daily for a median of 4 months (range: 4 days-21 months). Response to MMF was determined according to an Harvey-Bradshaw index4 and the possibility to taper steroids.Four patients (AZA: failure, n=2; intolerance, n=2; MTX: failure, n=2; intolerance, n=1) achieved remission under MMF. Three of them had an active CD before start of MMF, 1 patient was already in remission. Those 4 patients remained in remission during follow up (10-18 months). One of the 5 patients with perineal involvement achieved a complete closure of perineal fistula. Ten patients had to stop the medication for a median of 4 months (range: 2-12 months) because of inefficiency. Eleven patients had early adverse reactions and 5 of them had to stop the medication within 4 days to 3 months: pancreatitis (n=2), toxidermia (n=2), diarrhea and abdominal pain (n=1).In this short cohort of 20 patients with refractory CD, either intolerant or non responder to AZA or MTX, treatment with MMF resulted in only 20% of success. Intolerance to MMF was observed in 25% of patients.