Introduction

It is well known that cutaneous lesions may be frequent extraintestinal manifestations of inflammatory bowel diseases (IBD) [1,2]. During literature analysis we found out that there is an obvious lack of epidemiological data regarding this issue.

Aims & Methods

Aim: To establish the prevalence of cutaneous lesions among IBD patients in the university hospital.
Methods: Prospective study included patients with IBD who were managed in the hospital of Lithuanian University of Health Sciences. Patients completed questionnaires including the demographic and IBD data and history or present state of cutaneous lesions. Cutaneous lesions were considered as related to IBD if they were diagnosed following the diagnosis of IBD. Skin lesions which were reported before the diagnosis of IBD were considered as not related to IBD.

Results

162 patients were included in the study, mean age (MA) – 42.5±14.2 years. There were 93 (57.4%) males and 69 (42.6%) females. MA of men – 42.1±14.4, women – 42.9±14.0 years, p>0.05. Ulcerative colitis (UC) was diagnosed in 117 (72.2%) patients, Crohn’s disease (CD) – in 45 (27.8%) patients. MA of UC patients was 43.1±14.0, CD – 40.9±14.9, p>0.05.
In total, skin lesions were indicated by 66 (40.7%) subjects. According to our criteria, in 47 (29%; 95% CI: 22.0-36.1%) cases, cutaneous lesions were considered as obviously related to IBD. We further analyzed the latter cases.
Among UC patients, 35 (29.9%; 95% CI: 21.5-38.3%) had skin lesions related to IBD, among CD patients – 12 (26.7%; 95% CI: 13.2-40.1%), p>0.05.
Erythema nodosum was reported by 6 (3.7%) patients, pyoderma gangrenosum – 6 (3.7%), acne – 2 (1.2%), psoriasis – 10 (6.2%), vitiligo – 2 (1.2%), epidermolysis bullosa acquisita – 1 (0.6%), hemorrhagic vasculitis – 1 (0.6%), eczema – 11 (6.8%), allergic rash – 5 (3.1%), other (unspecified) – 8 (4.9%).
The detailed comparison of different skin lesions among UC and CD patients is presented in table 1.

Table 1. Prevalence of cutaneous lesions among patients with ulcerative colitis and Crohn’s disease

Cutaneous lesions	Ulcerative colitis (N=117) n (%)	Crohn’s disease (N=45) n (%)	p-value
Erythema nodosum	3 (2.6%)	3 (6.7%)	>0.05
Pyoderma gangrenosum	5 (4.3%)	1 (2.2%)	>0.05
Acne	1 (0.9%)	1 (2.2%)	>0.05
Psoriasis	8 (6.8%)	2 (4.4%)	>0.05
Vitiligo	2 (1.7%)	0 (0%)	>0.05
Epidermolysis bullosa acquisita	1 (0.9%)	0 (0%)	>0.05
Vasculitis	1 (0.9%)	0 (0%)	>0.05
Eczema	9 (7.7%)	2 (4.4%)	>0.05
Allergic rash	4 (3.4%)	1 (2.2%)	>0.05

Among UC patients, cutaneous lesions were reported by 2 out of 17 (11.8%) subjects with proctitis, 7 out of 30 (23.3%) subjects with left-sided colitis and 27 out of 70 (38.6%) subjects with pancolitis, p<0.05 between proctitis and pancolitis.
Comparing different types of CD, skin lesions were indicated by 2 out of 17 (11.8%) patients with ileitis, 4 out of 11 (36.4%) patients with colitis and 6 out of 17 (35.3%) patients with ileocolitis; p>0.05.

Conclusion

In our study the prevalence of cutaneous lesions among IBD patients is 29%. There were no differences in the prevalence of skin lesions between the UC and CD patients. The most common cutaneous lesions in UC were skin eczema and psoriasis, in CD – erythema nodosum, psoriasis and eczema. We observed the obvious trend of more frequent skin lesions in patients with more extensive UC. There is also the trend for more frequent skin lesions in Crohn's disease patients with colonic damage.

References

1. Greuter T, Navarini A, Vavricka SR. Skin Manifestations of Inflammatory Bowel Disease. Clin Rev Allergy Immunol. 2017 Dec;53(3):413-427.
2. Iida T, Hida T, Matsuura M, Uhara H, Nakase H. Current clinical issue of skin lesions in patients with inflammatory bowel disease. Clin J Gastroenterol. 2019 Dec;12(6):501-510.

Introduction

Crohn's disease (CD) is a chronic inflammatory disease of the gastrointestinal tract with recurrent nature of the flow. The frequency of exacerbations is approximately 20-25% at 1 year and 75% for 3 years. If the remission lasted less than 12 months, there is a 65% chance that the aggravation comes in the next 18 months. For the duration of remission for 12 months or more the likelihood of an explosion in the next 18 months is reduced to 20%.

Aims & Methods

To evaluate the influence of culture of allogeneic mesenchymal stromal cells (MSCs) of bone marrow for the duration of remission in patients with refractory CD.
Materials and Methods. The first group of patients with CD (n=30) received MSCs, the dose of prednisone was not more than 20 mg/day. The second group of patients (n=30) received standard anti-inflammatory drug therapy of 5-aminosalicylic acid (5-ASA) and glucocorticosteroids (GCS). Age of patients ranged from 19 to 49 years (Me-36 years). The disease was of moderate and high activity, length of damage - ileokolit, ileitis and colitis, the observation time ranged from 68 to 118 months. Clinical activity was assessed by the Crohn's disease activity index (CDAI). The culture of allogeneic MSCs injected drip at 2.5 million per 1 kg of body weight (0-1-26-52 weeks and twice a year).

Results

CDAI in the 1-st group was 242,6±11,7 points, in the 2-nd 240,9±12,9 points (p=0,83), CRP levels in 1-st group was 29,3±6.4 mg/l, the 2-nd - 27,8±4,8 (p=0,47). After 1 year of follow-CDAI in 1-st group was 70,0±11,0 points, in the 2-nd - 133,8±22,2 points (p<0,001), CRP levels in 1-st group was 6,36±1,5 mg/l, in the 2-nd - 12,2±2,9 (p<0,001). After 5 years - the CDAI in 1-st group - 120,0±22,3 points, in the 2-nd - 208,7±17,6 points (p<0,001), CRP levels in 1-st group - 11,3±2,6 mg/l, in the 2-nd - 15,5±2,4 (p<0,001). After 10 years - the CDAI in 1-st group - 126,0±23,8 points, in the 2-nd - 248,7±14,6 points (p<0,001), CRP levels in 1-st group was 12, 3±2,8 mg/l, in the 2-nd - 19,5±3,1 (p <0,001). In the first group of patients in remission after 1, 5 and 10 years was kept at 70%, 46.7% and 43.3%, respectively. In the second group of patients at 1, 5 and 10 year remission was maintained at 36.6%, 6.67% and 6.67%, respectively.

Conclusion

Transplantation of MSCs contributes to longer-term clinical and endoscopic remission in patients with refractory Crohn's disease compared with therapy with corticosteroids.

Clinical Case Summary

Introduction: Cronkhite-Canada syndrome (CCS) is a rare non-hereditary gastrointestinal polyposis syndrome. We illustrate a case with clinical presentation of dysgeusia, chronic diarrhoea and weight loss, and endoscopic features mimicking inflammatory bowel disease (IBD).
Case: Our patient is a 58-year-old Chinese lady who presented with dysgeusia, vomiting, loose stools, hair loss, peripheral numbness and weight loss. Examination revealed xerosis, onycholysis, periorbital hyperpigmentation and alopecia. (Fig. 1) Gastroscopy showed diffuse gastric mucosal hyperaemia, oedema and nodular changes (Fig. 2A). Helicobacter pylori was negative. Colonoscopy revealed a confluent pan-colonic circumferential nodular colitis (Fig. 3A) Histology showed features reminiscent of IBD with mild ileitis and continuous diffuse crypt architectural changes, cryptitis and crypt abscess formation (Fig. 4A-C). The final diagnosis was CCS based on the constellation of clinical and endoscopic features. She received high dose steroid therapy and mesalamine with significant improvement. However, upon tapering of her prednisolone to 15mg once daily, recrudescence occurred. Prednisolone was escalated with a more gradual taper with resultant improvement. At 4 months of treatment, the patient achieved clinical response with improvement of appetite, weight gain, diarrhoea and normalization of serum albumin. Repeat OGD showed gastric hyperplastic polyps (Fig. 4C) and colonoscopy showed improvement of confluent nodular and circumferential colitis (Fig. 2B and 3B). The severity of activity improved but features of chronicity remained on her colonic biopsies histologically (Fig. 5A-C).
Conclusion: The optimum treatment of CCS is currently unknown with no consensus guidelines. The mainstay of treatment remains as steroid therapy and nutritional support with clinical and endoscopic remission as therapeutic goals. Recurrences are not uncommon but often respond to corticosteroid retreatment as in our patient.

References

1. Kopáčová M, Urban O, Cyrany J, et al. Cronkhite-Canada Syndrome: Review of the Literature. Gastroenterology Research and Practice. 2013;2013:e856873. doi:10.1155/2013/856873
2. Watanabe C, Komoto S, Tomita K, et al. Endoscopic and clinical evaluation of treatment and prognosis of Cronkhite–Canada syndrome: a Japanese nationwide survey. J Gastroenterol. 2016;51:327-336. doi:10.1007/s00535-015-1107-7
3. Goto. Cronkhite-Canada syndrome: epidemiological study of 110 cases reported in Japan. Nihon Geka Hokan, vol. 64, no. 1, pp. 3–14, 1995
4. Mao E, Hyder S, Laskiewicz L, Taliano R, DeNucci T. A Rare Case of Cronkhite-Canada Syndrome: 1558. Official journal of the American College of Gastroenterology | ACG. 2017;112:S851.
5. Mao EJ, Hyder SM, DeNucci TD, Fine S. A Successful Steroid-Sparing Approach in Cronkhite-Canada Syndrome. ACG Case Rep J. 2019;6(3):e00055. doi:10.14309/crj.0000000000000055
6. Hewett DG, Kaltenbach T, Sano Y et al. Validation of a simple classification system for endoscopic diagnosis of small colorectal polyps using narrow-band imaging. Gastroenterology. 2012 Sep;143(3):599-607.e1. doi: 10.1053/j.gastro.2012.05.006. Epub 2012 May 15.
7. Schulte S, Kütting F, Mertens J, et al. Case report of patient with a Cronkhite-Canada syndrome: sustained remission after treatment with corticosteroids and mesalazine. BMC Gastroenterology. 2019;19(1):36. doi:10.1186/s12876-019-0944-x

Introduction

The undetermined pancreatic cystic neoplasms represent 20-30% of the total number of pancreatic cystic lesions(PCL). The diagnostic accuracy of endoscopic ultrasound (EUS) morphology is 51%. Endoscopic ultrasound-guided fine-needle aspiration(EUS-FNA) should be performed for differentiating between mucinous and non-mucinous pancreatic cysts when the characterization of the cyst cannot be made on the basis of non invasive imaging techniques.

Aims & Methods

Our aim was to assess the utility of the Neutrophil gelatinase-associated lipocalin(Ngal) concentration alone or combined with glucose level in cyst fluid obtained by EUS with EUS-FNA for discriminating between mucinous and non-mucinous PCL's.
This prospective study was performed between april 2018 and may 2020 at one tertiary referral hospital and included 63 patients , 30 with undetermined pancreatic cysts (group A) and the controlled group was represented by 33 patients with pancreatic pseudocysts after acute pancreatitis drained by EUS (group B). The patients from group A underwent EUS-FNA for liquid analysis and the patients from group B had liquid collection during the drainage of pseudocysts. The final diagnosis was based on surgery or EUS results (morphology, cytology, glucose and carcinoembryonic antigen(CEA) intracystic level) or on imaging during follow-up (24 month). We performed sandwich enzyme-linked immunosorbent assays (ELISA) for cystic and serum Ngal determination and measured glucose levels by a hand glucometer.

Results

The final diagnosis was pseudocyst in 33 patients, serous cystadenoma in 6, mucinous cystadenoma in 3, intraductal papillary mucinous neoplasms in 19 patients, and ductal adenocarcinoma in 2 patients. The cystic fluid analysis of these patients showed that the mean Ngal value for the serous cystic adenomas was 336ng/dl, 728ng/dl for the mucinous lesions and 1116ng/dl for the pseudocysts. The intracystic Ngal concentration (cut-off ≥ 500 and ≤ 800ng/dl) had diagnsotic sensitivity 70.8%, and specificity 92.3% for mucinous cysts. Serum Ngal concentration had no diagnostic contribution. The cystic glucose levels (cut-off ≤ 22mg/dl) had sensitivity 83.3% and specificity 82.1% for mucinous lesions. Combined glucose(cut-off ≤ 22mg/dl) and Ngal(cut-off ≥ 500 and ≤ 800ng/dl ) testing showed sensitivity of 58,3 and specificity 100% for mucinous cysts. Wheras either positive Ngal (cut-off ≥ 500 and ≤ 800ng/dl) or glucose (cut-off ≤ 22mg/dl) testing showed sensitivity 95.8% and specificity 74.4%.

Conclusion

Pancreatic cyst fluid NGAL concentration alone and combined with glucose level appeared to be useful in discriminating mucinous cysts.

References

State‑of‑the‑Art Update of Pancreatic Cysts -Andrew Canakis · Linda S. Lee2 Digestive Diseases and Sciences (2022) 67:1573–1587

Disclosure

Nothing to disclouse

Introduction

Previous observational studies reported a higher effectiveness of colonoscopy in preventing distal vs. proximal colorectal cancer (CRC) which we could not reproduce in a recently published observational study using target trial emulation (TTE). The design of the previous studies suffered from “time zero violation”, i.e. eligibility check, treatment assignment (screening vs. no screening) and start of follow-up were not synchronized.

Aims & Methods

We aimed to assess whether this “time zero violation” falsely induces a site-specific difference in the effect of colonoscopy. We used the same dataset underlying our recently published analysis (Braitmaier et al. 2022) based on German claims data (20% population coverage). We assessed the effect of screening colonoscopy in preventing distal and proximal CRC over 11 years of follow-up in 55–69-year-old persons at average CRC risk. Unlike in our recently published analysis, we used the design of previous observational studies with “time zero violation”. We compared the findings of both analyses.

Results

While in the recently published analysis using TTE, the relative risk (RR) of distal and proximal CRC in the screening colonoscopy vs. control group was similar (RR: 0.67 for distal, 0.70 for proximal), the analysis with “time zero violation” indicated a difference in site-specific performance. In this latter analysis, the RR was 0.41 for distal CRC and 0.66 for proximal CRC.

Conclusion

Our study demonstrates that “time zero violation” can substantially bias the results of observational studies. In our example, it falsely suggested an almost double preventive effect of colonoscopy in the distal vs. the proximal colon. The difference disappeared when the same data were analyzed using a TTE approach, which is known to avoid design-induced biases.

References

Braitmaier M, Schwarz S, Kollhorst B, Senore C, Didelez V, Haug U (2022) Screening colonoscopy similarly prevented distal and proximal colorectal cancer: a prospective study among 55-69-year-olds; Journal of Clinical Epidemiology; 149: 118-126