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Les lesions anoperineales de la maladie de Crohn sont frequentes. Un bilan clinique et morphologique precis associant examen clinique au besoin sous anesthesie generale et une technique d’imagerie est necessaire dans la prise en charge des lesions complexes. Le controle de la maladie intestinale d’amont est imperatif. La prise en charge therapeutique doit prendre en compte les symptomes du patient et les risques d’hypocontinence. Les lesions primaires doivent etre chirurgicalement respectees. Le traitement medicochirurgical est necessaire pour la prise en charge des fistules complexes. Les molecules anti-TNF representent un progres notable dans le traitement des fistules anoperineales. Les echecs therapeutiques sont sanctionnes par une chirurgie mutilante.

Summary Aims Inflammatory bowel diseases (IBD) have a negative impact on patients’ quality of life. The aims of this survey were to learn more about patients’ concerns, and to compare their feelings with the beliefs of their close relations and physicians. Patients and methods A specific questionnaire, including the RFIPC and the MFI-20, was used. Patients’ answers were compared with those given by their close relations and attending physicians. Results This national survey included 2424 French patients. At the time of diagnosis, 73% of patients expressed having fears, but were also relieved to understand their symptoms. IBD was responsible for fatigue and weariness, and had a negative impact on daily, occupational, leisure, family and personal life. The main fears concerned unpredictable flare-ups followed by need for an ostomy bag and risk of surgery. The answers provided by close relations and physicians matched those of the patients, but physicians overestimated the patient's knowledge and underestimated disease impact. Conclusion IBD has a deleterious effect on quality of life. Close relations of the patient realize the impact the disease has on the patients’ life, but attending physicians still tend to minimize patients’ symptoms.

Previous data have indicated low bone formation as a mechanism of osteoporosis in inflammatory bowel disease. Fluoride can stimulate bone formation.To assess the effect of fluoride supplementation on lumbar spine bone mineral density in osteoporotic patients with inflammatory bowel disease treated in parallel with calcium and vitamin D.In this prospective, randomized, double-blind, parallel and placebo-controlled study, 94 patients with inflammatory bowel disease (lumbar spine T score below - 2 standard deviations, normal serum 25OH vitamin D), with a median age of 35 years, were included. Bone mineral density was measured by dual-energy X-ray absorptiometry. Patients were randomized to receive daily either sodium monofluorophosphate (150 mg, n=45) or placebo (n=49) for 1 year, and all received calcium (1 g) and vitamin D (800 IU). The relative change in bone mineral density from 0 to 12 months was tested in each group (fluoride or placebo) and compared between the groups.Lumbar spine bone mineral density increased significantly in both groups after 1 year: 4.8 +/- 5.6% (n=29) and 3.2 +/- 3.8% (n=31) in the calcium-vitamin D-fluoride and calcium-vitamin D-placebo groups, respectively (P0.001 for each group). There was no difference between the groups (P=0.403). Similar results were observed according to corticosteroid intake or disease activity.Calcium and vitamin D seem to increase lumbar spine density in osteoporotic patients with inflammatory bowel disease; fluoride does not provide further benefit.

To retrospectively evaluate the efficacy, the duration of response, and the tolerance of Remicade in anoperineal Crohn's disease.Fifty patients with severe symptomatic and refractory anoperineal Crohn's lesions (38 fistulae and 29 cavitating ulcers and superficial fissures) were treated with 3 intravenous infusions of Remicade (5 mg/kg) at weeks 0, 2 and 6. Efficacy was assessed using Allan's functional score and proctologic examination at 8 weeks (W8) and 24 weeks (W24) after the first infusion.At W8, a response was noted for 71% (27/38) of fistulae and 79% (23/29) of ulcers and fissures. Healing rates were 39% and 49%, respectively. Efficacy of Remicade at W8 did not vary according to sex, number and type of fistulae and other treatments. At W24, 58% (15/26) of patients with fistulae and 63% (10/16) of patients with ulcers or fissures had a response. The response rate at W24 was higher in patients having anoperineal Crohn's lesions for less than one year: 77% vs 32% (P=0.004). Median Allan's score significantly decreased from 3.9 before treatment to 1.7 at W2 (P0.001), 1.3 at W6 and 0.8 at W8. Median duration of response was 9.5 months (range: 0.5-12.5) after last infusion and was not influenced by associated treatments including immunomodulators. The relapse rate at 1 year was 64% for the responders followed at least one year (n=21). Minor adverse events occurred during 12% of all infusions. Eight patients had an infection, including one pneumonia. Eight patients developed a perineal abscess 16 weeks (range: 4-32) after the first infusion.Remicade is rapidly effective and well tolerated in anoperineal Crohn's lesions, but the high relapse rate stresses the need for long term therapeutic strategies in these patients.

The aim of this work was to assess the quality of life (QoL) of patients with Crohn's disease (CD) prospectively over 1 yr and to determine factors of influence.A total of 231 CD patients were included. At month 0 (M0), M3, M6, M9, and M12, patients were given a validated QoL questionnaire (self-administered) to fill in and a clinical form referring to the period of 3 months before the visit. The QoL questionnaire was made up of the Short-Form-36 and the Rating Form of Inflammatory Bowel Disease Patients Concerns. The impact on QoL of the following factors was analyzed: age, gender, CD duration and localization, presence of extradigestive manifestations or concomitant disease, disease course, medical treatments, and surgery. We studied the correlations between QoL and disease activity assessed by both patients and investigators by a visual analog scale.At M0, all the scores of the Short-Form-36 were significantly lower than those of a standard population, nevertheless improving between M0 and M12. Patients' main worries were first "having an ostomy bag" followed by "uncertain nature of the disease," "energy level." and finally "having surgery." QoL was better correlated with assessment of disease course by the patient than by the investigator. Significant factors of impairment in QoL were female gender, tobacco, active CD, involvement of the colon, hospitalization, corticoid treatment, and surgery in the past 3 months. Conversely, intake of immunosuppressors improved QoL.Patients' QoL is impaired by CD and is underestimated by doctors. Tobacco, hospitalization, and use of corticoids have a negative impact on QoL. Conversely, the use of immunosuppressors is associated with a better QoL.

The incidence of thromboembolic disease is increased in patients with inflammatory bowel disease. Hyperhomocysteinemia is one of the risk factors for thrombosis. The aims were: 1) to assess the prevalence of hyperhomocysteinemia in a large series of patients with Crohn's disease; 2) to search for clinical and biological factors associated with hyperhomocysteinemia.One hundred seventy-one patients with Crohn's disease (64 males, 107 females), median age 31 years (range: 16-82), were studied. The median duration of the disease was 7 years. The concentrations of homocysteine, folate, cobalamin and C-reactive protein were measured in serum from blood sample of each patient.The mean concentration of seric homocysteine was 14.8 micromol/L (N: 4.4 - 12.4 micromol/L). Hyperhomocysteinemia was observed in 89 patients (52%). It was significantly associated with age, sex, smoking habit, serum cobalamin level and history of ileal surgical resection (P0.05). In the group of operated patients, there was a statistically significant association between hyperhomocysteinemia and the length of small bowel resected. In multivariate analysis, sex and smoking were associated with hyperhomocysteinemia.More than half of the patients with Crohn's disease have hyperhomocysteinemia. This result stresses the need for preventing reversible factors associated with hyperhomocysteinemia, such as smoking and cobalamin deficiency, in order to lower the thrombotic risk of patients with Crohn's disease.

Several types of colitis can be NSAID-induced, but whether chronic use of NSAIDs alters colonic mucosa in patients without diarrhoea is not known.Biopsy specimens of rectal mucosa were taken in six patients with rheumatoid arthritis without diarrhoea receiving NSAIDs (group 1, n=6). Patients with rheumatoid arthritis without diarrhoea not receiving NSAIDs (group 2, n=9), and patients undergoing surveillance colonoscopy (group 3, n=23) served as controls. In all patients from the three study groups, intraepithelial lymphocyte count and apoptotic cell count were assessed, and sub-epithelial collagen band thickness was measured. Leucocyte population of lamina propria was evaluated semi-quantitatively. HLA-DR and CD25 expression of mucosal cells was appreciated by immunohistochemistry.Intraepithelial lymphocyte count was in the normal range in all three group patients, and not statistically different between groups. Apoptotic epithelial cell count was not different between groups. Sub-epithelial collagen band thickness was normal in all the patients. No patient had a marked infiltration of lamina propria by leucocytes, and HLA-DR and CD25 were normally expressed in all patients.These results from a small sample of patients suggest that patients without diarrhoea receiving NSAIDs on a long-term basis do not develop microscopic or inflammatory colitis.

Intensive intravenous treatment remains the first line therapy of severe, uncomplicated attacks of ulcerative colitis.To predict the failure of intensive intravenous treatment by combining clinical and laboratory parameters with endoscopy findings.Retrospective study conducted in a tertiary care referral centre. Failure of intensive intravenous treatment was defined as colectomy before day 30, intravenous cyclosporin, or death. Predictive factors of outcome were assessed using univariate and multivariate prognostic analysis.Between January 1990 and May 1997, 85 consecutive patients were treated with intensive intravenous treatment for non-response to oral corticosteroids (n=59) and/or severe attack of ulcerative colitis (n=26). There were 41 successes and 44 failures (including 1 death, 13 cyclosporin and 30 colectomies before day 30). Multivariate prognostic analysis found that the presence of Truelove and Witts' criteria (P=0.018), an attack that had lasted more than 6 weeks (P=0.001), and severe endoscopic lesions (P=0.007) were associated with an increased risk of failure. Patients with severe endoscopic lesions and Truelove and Witts' criteria, or an attack of more than 6 weeks had a failure rate of 85-86%.Clinical, laboratory and endoscopic findings can predict the risk of failure of intensive intravenous treatment. A prospective study is required to confirm these results.

To assess pregnancy outcome in relation to disease activity and maintenance therapy in patients with inflammatory bowel disease.A postal questionnaire was sent to every woman of child-bearing age followed for inflammatory bowel disease in three referral centers (Rothschild, Saint-Lazare, Saint-Louis). Response rate was 65%.One hundred and forty-four pregnancies (153 fetuses) in 138 women (122 had Crohn's disease) were reported. Outcome of pregnancy was normal (baby2500 g, without malformation) in 115 cases (77%). There were 17 cases of preterm birth (11.5%), 3 cases of hypotrophy, and 14 pregnancy losses (9 miscarriages (6%), 4 therapeutic abortions for major malformation (2.8%)). Percentages of normal pregnancy outcome were not different between patients who continued maintenance therapy and those who stopped: respective percentages were 75 vs 73% in patients receiving mesalamine or olsalazine (n = 30), and 60 vs 75% in patients receiving azathioprine (n = 22).In a selected series of women with inflammatory bowel disease, pregnancy outcome is approaching that observed in a normal population, except for an elevated rate of preterm births. There is no need to stop maintenance therapy with 5-aminosalicylates or azathioprine during pregnancy.

To evaluate the effects of smoking on the long term clinical course in patients with ulcerative colitis.The medical charts of 556 patients with ulcerative colitis were reviewed retrospectively. Patients were classified as smokers (n = 85) or nonsmokers (n = 471) according to their smoking status during the course of the disease. Extent of colonic lesions, complications, medical requirements, and actuarial rate of colectomy were compared in smokers and nonsmokers.Mean follow-up (+/- SD) was longer in smokers than in nonsmokers (116 +/- 107 mo, vs 87 +/- 94 mo.). Less smokers than nonsmokers required oral steroids (52 vs 63%, P = 0.05). No difference between the groups was observed regarding the use of salicylates, the need for intravenous steroids, for immunosuppressive drugs, for colectomy, and the occurrence of complications. The actuarial rate of colectomy was less in smokers than in nonsmokers (32 +/- 12% and 42 +/- 6% at 10 years respectively. P = 0.04). Initial and cumulative extent of the disease process did not differ between the groups. However, in the subgroup of patients with limited disease at onset, development of pancolitis was less frequent in smokers than in nonsmokers (14 and 26%, respectively, P = 0.04).The lesser need for oral steroids and the lower actuarial rate of colectomy in smokers suggest that ulcerative colitis in smokers is characterized by a less severe clinical presentation and a better long term prognosis than in nonsmokers.

The etiology of Crohn's disease remains unknown. A putative mycobacterial cause of the disease is still controversial.To assess the mycobacterial hypothesis in Crohn's disease using a polymerase chain reaction technique.Nested polymerase chain reaction with primers on the 16S-rRNA coding region (16S-rDNA) and with primers specific both to the insertion sequences (IS) 900, and IS 901/902 were used to amplify Mycobacterium paratuberculosis or Mycobacterium avium subsp. silvaticum DNA in frozen endoscopic intestinal biopsies or surgical resection specimens from patients with Crohn's disease (n = 47: 25 endoscopic biopsies and 22 surgical resection samples, +/- lymph nodes), ulcerative colitis (n = 27), and non inflammatory bowel diseases (n = 20: colonic tumors and diverticulitis). Positive as well as negative controls were used throughout the study.All strains of Mycobacterium paratuberculosis and Mycobacterium avium subsp. silvaticum tested were positive for both primer systems. Of the 94 biopsies tested, 5 (2 Crohn's disease, 1 ulcerative colitis and 2 controls) were positive with the 16S-rDNA primers but did not correspond to Mycobacterium paratuberculosis or Mycobacterium avium subsp. silvaticum. None of the specimens was positive with the IS primers.These results do not support the hypothesis that Mycobacterium paratuberculosis, or Mycobacterium avium subsp. silvaticum play a role in Crohn's disease.

To evaluate the influence of the indication of the first surgical procedure on the prognosis of Crohn's disease.We compared retrospectively the long-term course of 179 patients operated on for a perforating disease and 322 patients operated on for a nonperforating disease. Mean follow-up was 11 years and 2 months in the two groups.Forty of 179 (25%) and 106 of 322 (33%) patients with perforating and nonperforating diseases underwent a second intestinal resection, respectively. The patients who had been operated on for a perforating disease were significantly more often reoperated on for the same indication, and conversely. Patients with perforating diseases experienced less second resections (actuarial rates: 37 +/- 11% vs 51 +/- 8% at ten years respectively), less post-surgical handicaps (mean index 24.9 vs 27.9), and fewer patients required immunosuppressive drugs (25 vs 35%).Long-term prognosis of perforating Crohn's disease does not appear to be more severe than that of nonperforating disease.

Depending its frequency, the association in the same subject of Crohn's disease and another pathology can be fortuitous or the expression of genetic or environmental interrelationships. The aim of our study was to identify among a series of patients with Crohn's disease preliminary data which would be suggestive of a significant association between Crohn's disease and other pathologies.Personal and familial histories were collected in 832 patients with Crohn's disease who were seen consecutively in the same hospital clinic from 1974 to 1994.We found 4 cases (0.5%) of associated Crohn's disease-multiple sclerosis and Crohn's disease-rheumatoid purpura in the same patient. Each of the following genetic diseases was associated with Crohn's disease in one patient (0.1%): Charcot-Marie-Tooth disease, deuteroanopia, multiple exostosis, familial ichthyosis, periodic disease.We describe for the first time sporadic cases of associated Crohn's disease and another rare disease, Charcot-Marie-Tooth disease, familial ichthyosis and periodic disease. We suggest that there is a significant interrelationship between personal and familial histories of Crohn's disease and multiple sclerosis which should be verified in prospective studies.

To assess the prognosis of pancolitis in ulcerative colitis including survival, colectomy rate, colon cancer risk, activity of disease, functional and socioprofessional impact.Retrospective study of 130 cases of ulcerative pancolitis referred consecutively to Rothschild Hospital from 1962 to 1993. They were 58 men and 72 women. The mean age at onset of ulcerative colitis was 30 years (range: 5-77). The extension to the right colon was secondary in 68% of patients. The period of observation ranged from 0.8 year to 46 years from the onset, with a median of 10.6 years. Three patients were lost to follow up.Eight patients died, the survival rate being 93% at 10 years. Surgical treatment was performed in 85 patients. The cumulative colectomy rates were 61% and 77% at 10 and 20 years respectively. Colonic cancer developed in three patients, corresponding to a cumulative risk after 25 years of 6% in unoperated patients and 1.9% in the whole series. No cancer occurred after colectomy and ileorectal anastomosis. In the group of unoperated patients there was a decrease of activity of the disease during the first fifteen years. The quality of life of colectomized patients with reestablishment of intestinal continuity and of those treated conservatively did not differ significantly.In this series, long term prognosis of ulcerative pancolitis was favourable. The high colectomy rate was balanced by a very low risk of colorectal cancer.

Endoscopic postoperative recurrences occur early after 'curative' surgery for Crohn's disease. Pentasa has been shown to be effective in the maintenance treatment of quiescent Crohn's disease. The aim of this study was to test the efficacy of a 12-week oral intake of Claversal in the prevention of endoscopic recurrences after 'curative' resection for ileal, colonic or ileocolonic Crohn's disease. We conducted a multicentre double-blind controlled trial comparing Claversal (1g tid) with placebo, starting within 15 days after surgery. The macroscopic normality of the two anastomotic segments was assessed at surgery. Patients were clinically and biologically evaluated twice (6-week interval), and colonoscopy was performed at 12 weeks. Endoscopic relapse was defined by any anastomotic ulcerations or stenosis and staged according to a four-grade score.Between May 1989 and May 1991 12 centres included 126 patients, 70 women and 56 men, aged 33 +/- 12 years (range 16-70) in the study. Disease locations were ileal, colonic and ileocolonic in 45, 6 and 49%, respectively. Claversal and placebo groups were similar at inclusion, except for ESR (37 +/- 26 vs. 27 +/- 23 mm/h in the Claversal and placebo groups, respectively; P0.05). Nine patients were withdrawn from the study. Adverse reactions occurred only in six patients. Five patients were excluded for protocol violation. Finally, 106 patients could be evaluated at 12 weeks (55 Claversal and 51 placebo). An endoscopic relapse was observed in 50% and 63% of the Claversal and placebo groups, respectively (P = 0.16), with a similar grade distribution. Claversal was well tolerated.Our study confirms that a large proportion of endoscopic recurrences occur within 3 months of resection in Crohn's disease. There was a slight trend towards greater efficacy of Claversal; it could be worthwhile trying higher dosages and/or 5-ASA compounds with different intestinal release profiles.

International audience; AIM: The aim of the study was to test the hypothesis that some patients with functional diarrhea could actually suffer from a mild clinical pattern of collagenous or lymphocytic colitis. PATIENTS AND METHODS: Twenty consecutive patients with chronic diarrhea were included in the study if the colonic mucosa appeared normal during colonoscopy. From multiple colonic biopsies were established a conventional histological diagnosis and a quantitative histological diagnosis. This latter diagnosis was based on the semiquantitative evaluation of epithelial morphological alterations and lamina propria monocellular infiltration, and on the determination of both intraepithelial lymphocyte count and subepithelial collagen layer thickness. Multiple colonic biopsies from 12 control patients without diarrhea were analyzed according to the same protocol. RESULTS: Among the 20 patients with diarrhea, the quantitative diagnosis of collagenous colitis was made in 3 patients (thickness of the collagen band between 11 and 26 microns) and the diagnosis of lymphocytic colitis in one (21% of intraepithelial lymphocytes). The percentage of intraepithelial lymphocytes did not differ between the 16 remaining patients and the controls (12 +/- 5% and 9 +/- 4%, respectively). Similarly, the score of surface epithelial damage and the score of lamina propria infiltration in patients with diarrhea (1.2 +/- 1.0 et 1.7 +/- 1.5) were not different from the values in the control group (1.3 +/- 1.3 et 1.5 +/- 1.2). The mean fecal weight in patients with diarrhea but without colitis was 161 +/- 130 g/d. All the values of fecal weight were below 300 g/d, except in one patient with a past history of truncular vagotomy. CONCLUSIONS: These results suggest that most of the patients with functional diarrhea do not suffer from mild clinical patterns of collagenous or lymphocytic colitis.

International audience; Corticosteroids are an efficient treatment for active Crohn's disease. The treatment has to be undertaken with a daily intake equivalent to 1 mg/kg per day of prednisolone for a 3 to 7 week period. Immunosuppressive agents are indicated in case of corticodependency or in case of large intestinal resection. Artificial nutrition (enteral or parenteral) is proposed in corticoresistant forms, and is usually followed by an immunosuppressive therapy. Surgical management is reserved for complications, including resistance to all medical therapy. Surgical resection has to be limited in order to avoid a short bowel syndrome. Surgery should not be considered as the ideal therapy as it has been demonstrated that recurrence after surgery increases at distance. 5-aminosalycilates compounds are an alternative therapy in mild attacks. Mesalazine may reduce the recurrence and could be considered as a possible maintenance treatment.

Mesalamine provides a new therapeutic approach in treating Crohn's disease.To assess the efficacy and safety of slow-release mesalamine (Pentasa) in maintaining remission in Crohn's disease, 161 patients with inactive disease were randomized to receive either Pentasa (2 g/day) or placebo in a 2-year double-blind, multicenter trial. Two strata were defined according to the duration of their remission:3 months (n = 64) or 3-24 months (n = 97), presumed to be high and low relapse risk strata, respectively.The probability of relapse was higher in the short-remission placebo group than in the three other groups (p0.003), showing there was a significant benefit from Pentasa in the high relapse risk stratum. In this stratum, the 2-year on-going remission rate was of 29% +/- 9% and 45% +/- 11% (mean +/- SD) in the placebo and Pentasa groups, respectively. The incidences of side effects were similar in both groups.Pentasa (2 g/day for 2 years) is a safe and effective maintenance treatment for Crohn's disease when given within 3 months of achieving remission.

Mesalamine provides a new therapeutic approach in treating Crohn's disease.To assess the efficacy and safety of slow-release mesalamine (Pentasa; Ferring AS, Vanløse, Denmark) in maintaining remission in Crohn's disease, 161 patients with inactive disease were randomized to receive either Pentasa (2 g/day) or placebo in a 2-year double-blind, multicenter trial. Two strata were defined according to the duration of their remission:3 months (n = 64) or 3-24 months (n = 97), presumed to be high and a low relapse risk strata, respectively.The probability of relapse was higher in the short-remission placebo group than in the three other groups (P0.003), showing there was a significant benefit from Pentasa in the high relapse risk stratum. In this stratum, the 2-year ongoing remission rate was of 29% +/- 9% and 45% +/- 11% (mean +/- SD) in the placebo and Pentasa groups, respectively. The incidences of side effects were similar in both groups.Pentasa (2 g/day for 2 years) is a safe and effective maintenance treatment for Crohn's disease when given within 3 months of achieving remission.

A randomized clinical trial was conducted to determine whether colonoscopy is useful in deciding how long to maintain steroid treatment in attacks of Crohn's disease involving the colon. One hundred forty-seven patients with acute attacks of colonic or ileocolonic Crohn's disease were treated by oral prednisolone, 1 mg.kg-1.day-1; 136 achieved clinical remission, but 96 of them still had active endoscopic lesions and were randomized either to immediate start of steroid tapering (group A; n = 46) or to continued prednisolone treatment at the same dosage for 5 more weeks before steroid tapering was begun (group B; n = 50). In the remaining 40 patients (already in endoscopic remission, group C), steroid tapering was begun immediately. After prednisolone discontinuation, patients were followed up for 18 months or until clinical relapse. Prolongation of prednisolone therapy significantly improved the endoscopic scores in group B (30% of endoscopic remission). The frequency of successful steroid weaning was almost identical in groups A and B (82% and 80%, respectively), as was the actuarially calculated relapse clinical rate after steroid withdrawal (P = 0.22). No factor predictive of clinical relapse could be found. The clinical course of patients in group C was similar to that of those in groups A and B. Overall, only 22% of the 147 patients were still in clinical remission and off steroids 18 months after prednisolone discontinuation, outlining the need for maintenance therapy. In conclusion, for patients who have achieved clinical remission, adjustment of steroid treatment duration on the basis of endoscopy results is of no benefit, and the endoscopic aspect has no prognostic value; thus, it appears unnecessary to repeat colonoscopy in such patients before steroid tapering is begun.

International audience; Nutritional recovery was studied during continuous enteral nutrition in 29 patients who had developed malnutrition after gastric surgery. Patients were divided into three groups according to the type of surgery involved: total gastrectomy (n = 10), partial gastrectomy (n = 12), or cephalic pancreaticoduodenectomy (n = 7). The evolution of anthropometric and biological nutritional parameters in each group was compared with that observed in a control group of 10 nonoperated anorectic patients. Significant gains in body weight, arm muscle circumference, triceps skinfold, serum transferrin and global nutritional status were observed after 3 to 4 weeks of enteral nutrition in each group, while serum albumin, serum cholesterol, hemoglobin, and total lymphocyte count did not change significantly. No significant difference was observed between the groups. However, weight gain tended to be slower in patients with cephalic pancreaticoduodenectomy. This study confirms that enteral nutrition is an effective method of nutritional repletion after gastrectomy. Enteral nutrition can be used in undernourished gastrectomized patients when dietary measures alone have proven inadequate.

We report 7 prospectively followed cases of lymphomatous polyposis of the gastrointestinal tract. They were characterized by multiple polypoid lesions affecting several segments of the gastrointestinal tract always involving the colon and the rectum. An ileocecal mass was present in 4 cases. Regional lymph node involvement was constant. Peripheral lymphadenopathy was frequent (5 cases out of 7), as was other extra-digestive extension to the bone marrow (4 cases out of 7) and cavum (3 cases out of 7). The histopathological aspect was that of a small cleaved cells (working formulation) or centrocytic (Kiel classification) non-Hodgkin's lymphoma. The peculiar morphology and phenotype of the tumoral B-lymphocytes suggest their possible follicle marginal zone origin. Lymphomatous polyposis bore a rapidly fatal prognosis in every case (mean survival 20 months). This study of seven patients together with the 20 well-documented cases of the literature confirms the existence of lymphomatous polyposis as a distinctive clinicopathological entity among gastrointestinal non-Hodgkin's lymphoma.

We describe an unusual intestinal bypass arthritis in a 37-year-old man. The intestinal bypass was unusual because the intestinal blind loop was entirely composed of colon. The arthritis was first a typical bypass arthritis but later resembled rheumatoid arthritis. In spite of this resemblance, all rheumatic symptoms disappeared after jejunocaecal reanastomosis.

There are no absolute diagnostic criteria of ulcerative colitis or Crohn's disease, and the diagnosis rests on convergent clinical, laboratory and morphological findings, the most useful being radiological endoscopic and histological data. The diagnosis is often easy, but at the first acute episode all infectious and parasitic causes must be excluded as they may mimic the cryptogenetic diseases. It may be very difficult to distinguish between ulcerative colitis and Crohn's disease when they are restricted to the colon and rectum. In this respect, diagnostic score systems can be very helpful.

International audience; One hundred and two patients with Crohn's colitis present on average for 8 years, were studied retrospectively in order to determine whether or not a group of patients existed in whom the disease remained limited to the colon, and if such a group could be identified early on in the course of the disorder. At the time of the diagnosis of Crohn's disease, 34 patients had a concomitant anoperineal lesion, while 68 had disease affecting the colon only. In the latter, at the end of the follow-up period, the disease remained exclusively limited to the colon in 39 cases (57 p. cent). The actuarial rate of non-extra-colonic spread was 75, 40 and 35 p. cent at 5, 10 and 15 years respectively. Spread involved above all the anoperineal region (55 p. cent at 10 years), and less often the ileum (20 p. cent at 10 years). In patients monitored for at least 6 years, there was no significant difference between those in whom disease had spread and those in whom it remained limited to the colon, regarding the main initial clinical findings by history and examination, the same applying after the disease had been present for 3 years. These results would go against the existence of a specific entity of "Crohn's disease affecting the colon as an organ" and support the opinion that coloproctectomy with a pouch should be avoided in colitis due to Crohn's disease.

International audience; Patients who have an interruption of the small bowel with a high enterostomy usually need parenteral supply or reinfusion of chyme to maintain nutritional and electrolytic balances before restoring intestinal continuity. Ten patients (aged 28-76 years) with a terminal jejunostomy located within the first meter of jejunum were treated by infusion of an elemental diet into the distal small bowel (IEDDSB). In addition, five of these patients had an extensive small bowel resection. IEDDSB was started 32 days after operation and lasted 4 to 8 weeks. Mean daily caloric infusion was 1,732 +/- 666 kcal diluted in 2,860 +/- 808 ml; mean associated oral intake was 1,187 +/- 480 kcal/24 hr, and jejunal fecal losses averaged 3 kg per day. IEDDSB was well tolerated in 4 patients; 5 experienced transient abdominal pain or diarrhea; 1 developed severe and protracted diarrhea. Biological cholestasis was seen before IEDDSB and persisted in most patients; 1 patient developed biliary sludge. Through IEDDSB, nutritional status improved or remained satisfactory in 9 patients, and worsened in 1 patient with sepsis and a short lower intestine. Mean body weight, triceps skin fold, muscle circumference, serum albumin, serum transferrin did not change significantly. Digestive nitrogen balance performed in 6 patients showed a net absorption between 5 and 15 g/24 hr. Fluid and electrolyte balance was maintained in 9 patients and 1 received iterative intravenous saline. Digestive sodium balance showed a net absorption rate greater than 60 mmol/24 hr. in all patients, except the one who required intravenous supply. Postoperative recovery was uneventful in all patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Urinary stones are much more common in subjects with intestinal diseases than in the general population. The chemical composition of the stones depends on the type of intestinal disease. In diarrhoeas with loss of water and electrolytes (inflammatory colitis and, chiefly, ileostomy), the urine is acid and concentrated and the stones are composed of uric acid. Extensive lesions of the ileum or wide resections of the small bowel increase the intestinal absorption of oxalates and expose the patients to oxalate stones. Treatment, which must be preventive, is based upon a knowledge of the pathophysiology of urolithiasis.

In CRST syndrome, latent oesophageal involvement is common but not usually associated with any clinical manifestations. Involvement of the small intestine is rare. In three patients there occurred severe complications related to digestive involvement in the condition. In one case, involvement of the small intestine was associated with functional obstruction. In the other two patients, oesophageal involvement progressed to very tight stenosis of the lower end of the eosophagus. The generally accepted bening nature of this form of scleroderma must therefore be questioned.

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International audience; Intestinal malabsorption was studied in 51 cases (46 patients) with radiological and/or operative evidence of small bowel radiation injury. At the time of the study, 23 patients had not been operated on (MED patients), and 28 had undergone previous small-intestinal by-pass or resection (BP/R patients). Fecal analysis data (n = 51), and results of alpha-1-antitrypsin clearance (n = 24), and of D-xylose (n = 37), folic acid (n = 20) and Schilling (n = 27) absorption tests were compared to the extent and severity of small-intestinal damage assessed radiologically and/or operatively. Mean fecal weight was 311 g/24 h in MED patients and 1,190 g/24 h in BP/R patients. Sixty-five, 43, 86, and 82 p. 100 of MED patients, and 93, 77, 93, and 85 p. 100 of BP/R patients, respectively presented increased fecal weight, sodium, lipid, and nitrogen. In MED patients, there was a significant relationship between the extent and severity of small-intestinal damage and fecal weight, lipid, and nitrogen. In BP/R patients, fecal data were related to those calculated from the site and the extent of the intestinal resection. Fecal losses tended to be more abundant when the residual intestine was severely damaged. Alpha-1-antitrypsin clearance (mean 37 ml/24 h) was increased in 8 out of 9 MED patients and in 11 out of 15 BP/R patients. Its value was not related to the extent and severity of small-intestinal damage.(ABSTRACT TRUNCATED AT 250 WORDS)

International audience; The development of nutritional parameters, anthropometric and biologic, under polymeric continuous gastro-intestinal feeding, was followed during 3 to 7 weeks in a group of 10 gastrectomised patients with malnutrition and compared with a group of 10 patients with malnutrition secondary to intake deficiencies and receiving the same treatment. Body weight, mid-arm muscle circumference, triceps skinfold and serum transferrin increased significantly from the beginning to the end of the gastro-intestinal feeding in both groups, and in a comparable fashion. Continuous gastro-intestinal feeding is therefore an effective treatment of malnutrition in the gastrectomised patient. The response obtained, as far as nutrition is concerned, may be compared to that of the patient with malnutrition secondary to intake deficiencies.

Rectocolitis remains, at the present time, in spite of the large amount of work carried out, a condition of which the cause and the physiopathological mechanism are unknown: none of the theories proposed has been confirmed by the facts; none has made it possible to propose an effective therapeutic regimen. The diagnosis of haemorrhagic rectocolitis rests solely on an assembly of clinical, radiological, and anatomological findings, together with findings on progress of the disease; none of these findings taken separately being pathognomonic. Because of this it is essential in cases of inflammatory colic disorders to analyse critically these different elements before affirming the diagnosis that is often arrived at too easily. Different affections, even apart from Crohn's disease (parasitic, microbial, and iatrogenic affections, etc) may, in fact, give rise to radiological and clinical pictures close to those of haemorrhagic rectocolitis.

This paper reports a rare case of a patient with biclonal gammopathy IGM kappa and IgG lambda corresponding to the simultaneous occurrence of the clinical manifestations of Waldenstrom's macroglobulinemia and multiple myeloma. Two cellular populations derived from the B lymphocyte cell line can be observed in this patient. Bone marrow aspiration revealed abnormal plasma cells with inclusions and lymph node aspiration showed immature lymphoid cells containing mu heavy chains.