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RESUMEN: La enfermedad hepática metabólica es la hepatopatía más frecuente. Se asocia clásicamente a factores metabólicos aunque parecen existir otros factores de riesgo menos conocidos. En el presente trabajo se analiza el papel de las enfermedades inmunomediadas, en este caso la enfermedad inflamatoria intestinal, como factor de riesgo independiente de los clásicos metabólicos para la aparición de hepatopatía metabólica. Para ello se desarrolló un estudio de casos y controles que confirmó nuestra hipótesis, confirmando la presencia de enfermedad inflamatoria intestinal como el principal factor de riesgo para presentar enfermedad hepática grasa metabólica y fibrosis avanzada. Finalmente proponemos un algoritmo para el diagnóstico de esta hepatopatía en pacientes con enfermedad inflamatoria intestinal. ABSTRACT: Metabolic fatty liver disease is the most common liver disease. It has been classically associated with metabolic factors, although there seem to be other less well-known risk factors. This paper analyzes the role of immune-mediated diseases, in this case inflammatory bowel disease, as a risk factor independent of the clasic metabolic factors for the appearance of metabolic liver disease. For this, a case-control study was developed that confirmed our hypothesis, confirming the presence of inflammatory bowel disease as the main risk factor for presenting fatty liver disease and advanced fibrosis. Finally, we propose an algorithm for the diagnosis of this liver disease in patients with inflammatory bowel disease.

Introduction. The development of inflammatory bowel disease during the treatment with tumor necrosis factor-? inhibitors is seen in patients with ankylosing spondylitis. Crohn?s disease is the mainly developing form, and etanercept is the most frequently associated agent. Although thrombocytosis in patients with ankylosing spondylitis and inflammatory bowel diseases is often seen due to chronic inflammation, iron deficiency anemia or drug administration, presence of essential thrombocythemia is not common. To our knowledge, there is no published data of coexistence of these three diseases in one patient. Case report. We reported a 35-year-patient with simultaneous presentation of ankylosing spondylitis and essential thrombocythemia. Due to hepatotoxicity of initial treatment with sulfasalazine and metotrexate, tumor necrosis factor-? inhibitor (etanercept) was introduced. Both diseases were well controlled until Crohn?s disease emerged. Two years after switching from etanercept to adalimumab all three coexisting diseases were in remission. Conclusion. Treatment with tumor necrosis factor-? inhibitors significantly improved clinical outcome of patients with chronic inflammatory diseases. However, the appearance of adverse effects may cause a discontinuation or change of a drug. The existence of comorbidities additionally complicates the treatment of such patients.

Introduction: Diabetes mellitus and colorectal cancer are diseases with an increasing impact on the population. Colorectal cancer is a well-recognized complication of inflammatory bowel diseases, such as ulcerative colitis and Crohn’s colitis. Here we describe an unusual case of diabetes mellitus, Crohn`s colitis-associated cancer. Case report: We report the case of a 49-year-old woman, known with Crohn's disease and diabetes, who developed a transverse colon adenocarcinoma associated with multiple outbreaks of high-grade or low-grade intraepithelial dysplasia/neoplasia, for which a subtotal proctocolectomy with ileorecto-anastomosis with “J” pouch it was made. Conclusions: The risk of colonic carcinoma in Crohn's disease is increasing. An association of colorectal cancer with diabet mellitus and inflammatory bowel disease has been established. From diagnosis to treatment the management of these cases can be difficult and challenging.

The aim: to review and analyze scientific literature data about using magnetic resonance enterocolonography in diagnosing Crohn`s disease. Objectives: to select literature describing significance of using magnetic resonance enterocolonography in diagnosing Crohn`s disease, evaluate magnetic resonance eneterocolonography advantages and disadvantages, to compare magnetic resonance enterocolonography with other diagnostic possibilities, review typical for Crohn`s disease lesions, seen during magnetic resonance enterocolonography, to review Crohn`s disease indexes of activity. Methods: scientific literature for literature review was selected from „The Cochrane library“, PubMed data base and Lithuanian University of Health Science Aleph data base catalog. Keywords used in reasearch: „Crohn disease“, „MRI enterography“, ”MRI colonography”, “endoscopy”, “CT enterography”, „inflammatory bowel disease“, „IBD“, “bowel MRI”, „diagnosis“, „Krono liga”, “magnetinis rezonansas“. Criteria selected for literature search: reaserches included only people with Crohn`s disease or inflammatory bowel disease, magnetic resonance enterocolonography performed using specific protocols, literature analyzing other diagnostic possibilities, used for Crohn`s diesease or inflammatory bowel disease, comparing their affinities and differences with magnetic resonance enterocolonography. There were more than eleven participants in selected studies. Retrospective, perspecitve studies, literature reviews and meta- analyzes, publicated between 2001 and 2018 were included. Conclusions: according to the criteria 36 publication were selected. Magnetic resonance enterocolonography is reliable, specific and sensitive diagnostic method which lacks radiation. Its efficiency does not differ from other diagnostic methods used for diagnosing Crohn`s disease. Advantages: high soft tissue evaluation, high complication detecting efficiency, using various sequences to detect lesions, lack of ionizing radiation. Disadvantages: high cost, access to magnetic resonance enterography is limited, it’s time consuming and in the early stages of disease lesions can’t be seen. Indexes of activity can be used to prognose disease course, standardize disease activity and treatment efficiency evaluation and to select best individual treatment.

A doença de Crohn (DC) é uma doença crónica de etiologia complexa, envolvendo fatores ambientais, genéticos e imunológicos. A DC apresenta um quadro clínico complexo que inclui alterações intestinais e extra-intestinais e, entre estas últimas, estão as manifestações orais que são classificados em lesões específicas e não específicas. Estas lesões são variadas incluindo úlceras, hiperplasia gengival, aftas, entre outras e afetam essencialmente a mucosa, gengiva, lábios, área vestibular e retromolar. As lesões orais podem não ser derivadas da própria patologia mas, também, do uso prolongado de fármacos por estes pacientes e pela sua deficiente absorção de nutrientes. Por estas razões, o paciente com DC necessita de uma atenção própria do médico dentista, especialmente durante os períodos de exacerbação da doença. A terapia farmacológica da DC inclui imunossupressores, corticosteróides, e aminossalicilatos, que são utilizados para o controlo dos sintomas intestinais, o que, regra geral, é também suficiente para o tratamento das manifestações orais. Crohn's disease (CD) is a chronic disease of complex etiology, involving environmental, genetic and immunological factors. CD presents a complex clinical picture that includes intestinal and extra-intestinal manifestations, and these last ones include oral manifestations that are classified into specific and non-specific lesions. The oral lesions are several including ulcers, gingival hyperplasia, aphtha’s, between others affecting mainly the mucosa, gingiva, lips, vestibular and retromolar areas. Other oral lesions are those caused by the prolonged use of drugs by this patients and nutrients malabsorption. For these reasons the patient with CD needs more attention from the medical dentist, especially during periods of exacerbation of the disease. Pharmacological therapy of Crohn Disease includes immunosuppressant’s, corticosteroids and aminosalicylates, which are used to control intestinal symptoms and also are generally sufficient for the treatment of oral manifestations.

Background Inflammatory Bowel Disease (IBD) patients often present with nutritional disorders that affect both macronutrient and micronutrient levels. Vitamin and mineral deficiencies are typically more frequent in Crohn's disease (CD) patients than other IBD patients. However, some studies have shown that these deficiencies can also be present in ulcerative colitis (UC) patients, even in those in remission. Aims To describe the prevalence of micronutrient deficiencies in patients diagnosed with IBD and to correlate these micronutrient deficiencies with demographic, clinical and disease characteristics. Methods A cross-sectional study of patients in the IBD program who were 18 years and older was completed. Clinical characteristics and disease activity indexes were assessed. Body Mass Index (BMI), haematocrit, serum albumin, serum iron profile, serum 25(OH) D, vitamin B12, folate, zinc and copper were measured. Results Ninety-one patients with IBD were included: 46 patients (50.5 per cent) with UC and 45 patients (49.5 per cent) with CD. At least one micronutrient deficiency was found in 39.5 per cent of patients, 35.1 per cent had two deficiencies, and 12 per cent had three or more deficiencies. Iron, zinc, copper, and vitamin B12 deficiencies were found in 33 per cent, 22 per cent, 11 per cent and 10 per cent of patients, respectively. No folate deficiencies were found. Low levels of serum 25(OH) D were detected in 76 per cent of patients. The mean BMI was 24.3 (SD 3.4), and the mean serum albumin level was 4.0g/l (SD 0.4). Conclusion Micronutrient deficiencies were frequent in our study cohort and did not correlate with macronutrient status. Measurement of macronutrients and micronutrients should become a routine assessment in IBD patients to improve patient care and to avoid negative repercussions on disease activity.

Results of the retrospective, population-based study, 2000–2010, on inflammatory bowel disease, ulceratice colitis (UC) and Crohn's disease (CD), from Zadar County, have been presented and compared with world experience and com- parative data from Primorsko-Goranska and Vukovarsko-Srijemska Counties. The average incidence rates (per 100 000) were 8.2 and 8.4, for UC and CD, respectively. Prevalence rates, at the end of the follow up, were 133.9 for UC and 111 for CD. Constant increase in the incidence rates for both, UC and CD, have been recorded, for CD more prominently in the second part of the follow up, 2006–2010. Prevalence rates have being continuosly rased for both diseases, data for UC ex- ceeding that for CD. Results of data comparison among the counties contribute in favour to the hypothesis of Zadar County as a rapidly developing area and strongly argue against the existence of the North-South gradient between Vukovarsko-Srijemska and Zadar Counties.

Inflammatory bowel diseases (IBD), Crohn's disease (CD) and ulcerative colitis (UC), were retrospectively assessed on the incidence and prevalence in Vukovarsko-Srijemska County, continental Croatia. There were a total number of 150 patients, 119 with UC and 31 with CD. Of them, 79.3% were patients with UC, indicating a predominant participation of UC in the sample. Comparisons between the period of surveillance, 2001-2010, and the decade before, 1991-2000, showed a significant increase in the incidence rates of both, UC and CD (UC 3.5, CD 0.95, 2001-2010, and UC 1.0, CD 0.45, 1991-2000). Comparison of this study with that performed in Primorsko-Goranska County, coastal Croatia, revealed different distribution patterns of IBD. In Primorsko-Goranska County, significantly higher incidence and prevalence rates of UC and CD and rather equal ratios between two diseases, were observed. The results are indicative of the differences between more developed Western and less developed Eastern parts of Croatia.

Clinical characteristics of the cohort of 150 patients with inflammatory bowel diseases, ulcerative colitis (UC) and Crohn's disease (CD), Vukovarsko-Srijemska County, Croatia, were retrospectively assessed. UC was clinically presented with frequent passage of bloody, slimy stools, while preferential symptoms of CD were fever, anemia and severe weight loss, differences reflecting longer duration of symptoms prior to the diagnosis, in patients with CD. The prevalent disease localisations, in patients with UC, were the rectum and the left colon and the anorectum, while the prevailing phenotype, in patients with CD, corresponded with younger adult age at disease onset, ileocolonic localization and stricturing disease behavior Intestinal complications, including perforation, fistula, abscess and ileus, were more prevalent in patients with CD. Of extraintestinal complications, only ankylosing spondylitis and erythema nodosum, reached marginally significant differences, in favor to patients with CD. Shortcomings of this study include the lack of associations and the time-dependent disease projections.

Background The conventional ileostomy can be avoided. Many attempts have been performed. The first successful solution was the continent ileostomy- Kock pouch. The high rate of complications and revisions some experienced forced surgeon to try to restore the continence by the mechanism of the anus involving an ileal pouch. Both procedures afterwards documented excellent functional outcome, but the complication rates were not negligible and the long-term failure rate were increasing. Different surgical refinements were done and the risk factors for complications and failures were investigated as experience and materials increased. Restoring of the integrity of anal function and the succsess of the ileal pouch-anal anastomosis shadowed the practise of the forerunner: the continent ileostomy reservoir. This latter procedure was more demanding and seemed in the first year of ileal pouchanal anastomosis era to have significant more complications and revisional surgery. The worldwide adoption of the pelvic pouch decreased the need for the continent ileostomy and a vicious circle evolved. Today only few centres perform the procedure. Patients who are not suitable for ileal anal-pouch anastomosis are seldom offered the possibility of having a continent ileostomy. Aims The aims of the study was to investigate surgical load, complications and long-term functional outcome and to define factors which affect these subjects in patients operated with ileal pouch-anal anastomosis, continent ileostomy or both in one single surgical department during the same period and without any institutional learning curve, and furthermore, to compare and contrast the two options. Material and methods From 1984 to 2005(7) 304 (315) patients were operated with IPAA at St. Olavs Hospital (earlier: Regional Hospital of Trondheim). From 1983 to 2002(7) 50 (65) patients had a continent ileostomy constructed. This was an observational study in the scope of surveillance and quality assurance. All patients were offered a planed regularly annual outpatient clinic follow up programme including a prospective standardised interview on clinical outcome. This was a supplement to clinical investigation with endoscopy and consecutive documentation of complications and other factors affecting the patients’ health. Data were recorded in the medical chart. In this system, all patients had recorded dataset. However, the intervals between data recordings differ and the intervals increased by time. All inpatients data were included. Standard descriptive statistical analysis and simple associations were undertaken. Handling longitudinal data with limited cases, varying time intervals was done in a Times Series Cross Sectional data model, analysed, and adjusted for several factors affecting functional outcome. Multivariable analysis was done. Results The estimated failure rate at 20 years was 11.4% for ileal pouch-anal anastomosis and 11.6% for continent ileostomy. Salvage procedures rates were 31% vs. 38%, respectively (p=0.06). The salvage procedures in IPAA included local procedures and redoes with laparotomy. Salvage procedures in CI were related to the function of the nipple valve, mainly nipple valve sliding and less frequent stenosis or fistulas. Complications rates were high. In pelvic pouch surgery, half of the patients would need re-operations in 20 years. Ten percentages had early anastomotic separation without septic complications. Four percentages had early pelvic septic complications. Fistulas and sepsis at the anastomotic site were the main severe complications, often leading to pouch failure. Closing of the loop ileostomy was accompanied with complications in six percentages. In the patients (48) who did not have a covering stoma the overall complications rate did not differ from those with a loop ileostomy, although nine needed a secondary stoma. Covering stoma seems to postpone anastomotic complications. Handsewn anastomosis had more strictures, but otherwise the complications rates were similar to stapled anastomosis. Patients having the diagnosis changed to Crohn`s diseases had more complications and higher failure rate. Early anastomotic complications were associated with long-term complications. In patients with continent ileostomy the nipple valve sliding is the main cause of revision. One third needed revision once or several times. At 20 years follow-up, half of the patients would need surgery due to complications. Although many patients with CI need several revisions, all patients were continent at the last follow up with a stable intubation frequency of 3 – 5 per 24 hour. The failure of the pelvic pouch is the end of severe complications. Two third of the failures had the pouch excision or permanent ileostomy with the pouch in situ. One third underwent a conversion to CI, with equal surgical and functional outcome as other patients with CI. In IPAA, bowel movements at day were between 5-6 at day and 0-1 at night. The rates of more or less frequent incontinence were about 10%, and 41% and 55% had reported soling at day and night respectively. The long-term functional outcome did not deteriorate with time: ie. observational time, as an independent factor did not influence outcome. Factors influencing the outcome were found but the impact of gender, age, protective stoma, hand-sewn anastomosis and early complications were negligible. Pouchitis did significantly influence functional outcome negatively, but did not create deterioration over time. Estimated pouchitis rate in IPAA was 43% for more than 20 years. The onset of the first pouchitis appears mostly in the 5-6 first years after surgery. The crude rate was 35% and 6% of the patients had chronic pouchitis. Severe/chronic pouchitis was associated with primary sclerosing cholangitis, but not with pyoderma gangrenousum or diagnosed joint affections. Idiopathic pouchitis were absent among patients with familial adenomatous polyposis. In continent ileostomy the rate of pouchitis was 26%. Conclusion The complications in both the pelvic pouch surgery and the surgery of continent ileostomy are considerable. Although not similar the surgical load are in the same order of magnitude. For the continent ileostomy revisional surgery are to be expected. The failure rate of both procedures are high and in long-term similar. The long-term functional outcome are however stabile and excellent. The failed pelvic pouch can be converted to a continent ileostomy in selected and motivated patients. The entity of pouchitis is conflicting and has to be divided into several different entities both on clinical, constitutional and other differentiating features. Patients with PSC should be informed of a possible higher risk of severe and chronic pouchitis after IPAA.

Ziel der Studie war die Erfassung der Morbidität und Mortalität nach operativer Therapie von Patienten mit Chronisch Entzündlichen Darmerkrankungen mit speziellem Fokus auf die Anwendbarkeit eines Risiko-Score-Systems, dem POSSUM score (Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity) zur präoperativen Risikoabschätzung und Prognose der postoperativen Morbidität The aim of this study was to assess the morbidity and mortality of patients undergoing surgery for infIammatory bowel disease (IBD) with special focus of the predictive value of the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) scoring system for preoperative risk adjustment of postoperative morbidity.

Der progrediente Verlauf einer chronisch entzündlichen Darmerkrankung (CED) bleibt eine therapeutische Herausforderung. Kontrovers diskutiert werden immunsuppressive, immunmodu-latorische und immunstimulierende Therapiemodelle. Vor diesem Hintergrund interessierten die Auswirkungen der chronisch immunsuppressiven Therapie im Vergleich zur konventionell antientzündlichen Therapie. Der Erkrankungsverlauf von 41 CED-Patienten (CU 30, MC 6, CI 5), die sich überwiegend auf-grund einer fortgeschrittenen PSC einer Lebertransplantation unterzogen hatten, wurde mit einer Kontrollgruppe von 42 (CU 29, MC 11, CI 2) nicht-transplantierten CED-Patienten mittels retrospektiver Datenerhebung, standardisiertem Fragebogen und aktualisierender telefonischer Befragung verglichen. Posttransplantär kamen die oralen immunsuppressiven Medikamente Ciclosporin A, Tacrolimus und Mycophenolat Mofetil (MMF) zur Anwendung. Analysiert wurde einerseits entsprechend kurzzeitiger Therapieschemata mit patienten-unabhängigen Zeit-abschnitten (6 Monats-Intervalle) mittels nichtparametrischer Testverfahren, andererseits, bei Zeiträumen von mehr als 6 Monaten (Langzeittherapie), fand die Kaplan- Meier-Methode Anwendung. In der Längsschnittanalyse waren in der Transplantiertengruppe nach 14,5 Jahren 22 von 41 der Patienten versus 14 von 42 der Kontrollpatienten dauerhaft in Remission (p=0,0295). Alle drei immunsuppressiven Medikamente standen im Zusammenhang mit Remissionsinduktionen (Ciclosporin: p=0,000, Tacrolimus: p=0,000, MMF: p=0,001), eine stabile Remission nach 14,5 Jahren war aber nur während einer MMF-Therapie (p=0,000) zu beobachten. In der Immunsuppressivagruppe wurden im Verlauf 3 Kolektomien (CU-Patienten) versus 7 innerhalb der Kontrollgruppe (3 CU-, 4 MC-Patienten) notwendig. Weiterhin kam es im gesamten Verlauf in der Immunsuppressivagruppe zu 5 Carzinomen, davon zu einem kolo-rektalen Carzinom bei CU (2,4%) und 2 Cholangiocellulären Carzinomen, in der Kontrollgruppe zu 4 Carzinomen, darunter ebenfalls einem kolorektalen Carzinom bei CU (2,4%) und 1 Cholangiocellulären Carzinomen. Extraintestinale Manifestationen traten als Arthropathien während Ciclosporin- (p=0,000) und Tacrolimus-Therapie (p=0,000) auf, Nebenwirkungen waren unter Ciclosporin dermatologischer (p=0,005), unter Tacrolimus kardiovaskulärer (p=0,000) und während MMF dermatologischer (p=0,011) und pulmonologischer (p=0,006) Klassifikation zu beobachten. Bei 16 Patienten dominierte direkt nach der Transplantation eine völlige CED- Symptomfreiheit, später als 1 Jahr nach der Transplantation noch bei 9 Patienten. Eine Progredienz der CED-Symptome nach Lebertransplantation fiel ausschließlich unter CI-Patienten auf (4 Patienten bei zuvor 1 Patient). Schlussfolgernd war zum einen im Vergleich zu anderen Arbeiten die Inzidenz kolorektaler Karzinome unter Langzeitimmunsuppression im Vergleich zur Kontrollgruppe nicht erhöht, zum anderen die Kolektomierate in der Transplantiertengruppe nur halb so hoch wie in den Kontrollen, und letztendlich ließ sich bei Beobachtungseinheiten von bis zu 14,5 Jahren ein Vorteil im rezidivfreien Überleben für die Patienten mit chronischer Immunsuppression gegenüber den Kontroll-Patienten in Bezug auf einen stabilen Remissionserhalt erkennen, wobei im Einzelnen im Zusammenhang mit dem Immunsuppressivum MMF relevante Ergebnisse zu beobachten waren., The progressive course of chronic inflammatory bowel disease (IBD) remains a challenge to treat. Immunosuppressive, immunomodulatory and immunostimulatory therapy models are the subject of controversial debate. Against this background, the effects of chronic immunosuppressive therapy as compared with conventional anti-inflammatory therapy were of interest. The disease progression of 41 IBD patients ulcerative colitis (UC) 30, crohn`s disease (CD) 6, indeterminate colitis (CI) 5, who, on account of advanced primary sclerosing cholangitis (PSC), had predominantly undergone a liver transplant, was compared with a control group consisting of 42 (UC 29, CD 11, CI 2) IBD patients, who did not undergo a transplant, assessed by means of retrospective data collection, standardised surveys and updated telephone interviews. After the transplant, oral types of immunosuppressive medication, such as cyclosporine A, tacrolimus, and mycophenolate mofetil (MMF), were applied. On the one hand, analyses were carried out by means of non-parametric test procedures, according to short-term schemes of treatment at time intervals (6 month-intervals) irrespective of the patient; on the other hand, the Kaplan- Meier method was applied at time intervals of more than 6 months (long-term therapy). In the longitudinal analysis, after 14.5 years, 22 out of 41 patients in the transplant group remained permanently in remission (p = 0.0295) in comparison with 14 out of 42 of the control group patients. All three types of immunosuppressive medication were associated with remission inductions (cyclosporine: p =0.000, tacrolimus: p =0.000, MMF: p =0.001). However, stable remission after 14.5 years was observed only during MMF therapy (p =0.000). In the immunosuppressive group, over the course, 3 colectomies (UC patients) were necessary, compared with 7 within the control group (3 UC, 4 CD patients). Furthermore, in the immunosuppressive group, over the entire course, 5 cases of carcinoma arose, consisting of one case of colorectal carcinoma in those with UC (2.4%) and 2 cases of cholangiocellular carcinoma. In the control group, 4 cases of carcinoma occurred, among which there was also one case of colorectal carcinoma in those with UC (2.4%) and one case of cholangiocellular carcinoma. Extra intestinal symptoms occurred as arthropathies during cyclosporine (p=0.000) and tacrolimus therapy (p=0.000). Side effects observed in cyclosporine were attributed to dermatological (p=0.005) classification, in tacrolimus to cardiovascular (p=0.000) classification and during MMF medication, to dermatological (p=0.011) and pulmonological (p=0.006) classification. 16 patients were completely free from IBD symptoms immediately after the transplant; more than a year after the transplant there were only 9 patients. Progression of the IBD symptoms following liver transplant was only evident in CI patients (4 patients, while initially 1 patient). By deduction, on the one hand, in comparison with other studies, the incidence of colorectal carcinoma in long-term immunosuppression, as compared with the control group, did not increase. On the other hand, the colectomy rate in the transplant group was only half as high as in the control group. Finally, in the observation periods of up to 14.5 years, an advantage with reference to stable retention of remission was identified in relapse-free survival for patients with chronic immunosuppression, compared with control group patients, in the course of which relevant results associated with immunosuppressive MMF were observed in detail.

La mesalazina es un farmaco de la familia de los amino salicilatos con caracteristicas antiinflamatorias e imunomoduladoras. En el 2008 el consumo de mesalazina en el Hospital Mexico se triplico con respecto a los anos anteriores. El objetivo del presente estudio es evaluar la prescripcion de mesalazina por el Servicio de Gastroenterologia del Hospital Mexico, con base en los criterios establecidos por el Comite Central de Farmacoterapia de enero a diciembre del 2008. De una muestra de 75 pacientes a los cuales se les prescribio mesalazina durante el 2008, se procedio a revisar los expedientes clinicos de 53 de ellos tras la aplicacion de los criterios de inclusion y exclusion. Se observo que un 83% de los pacientes en tratamiento con mesalazina fueron diagnosticados con Colitis Ulcerativa Cronica Intestinal (CUCI) y un 15% con Enfermedad de Crohn (EC) en el 2% restante no se indico el diagnostico en el expediente. El 58% de los pacientes tuvieron tratamiento previo con sulfasalazina antes de cambiar a mesalazina y un 42% inicio tratamiento con mesalazina; sin embargo, solamente en el 13% de los expedientes se indico el motivo del cambio. La dosis mas utilizada de mesalazina es la de 1g TID para el tratamiento del CUCI y 1g BID para el tratamiento de EC. Se concluye que el aumento en el consumo de mesalazina durante el 2008 no se debe al uso del medicamento en otras patologias; sin embargo, la ausencia de una justificacion en el expediente para el uso de mesalazina sugiere que no se esta siguiendo la linea de prescripcion establecida por la institucion.

A doença de Crohn é uma afecção intestinal inflamatória crônica, multissistêmica e de caráter recorrente. Sua etiopatogênese permanece ainda desconhecida, mas considera-se haver um cenário fisiopatológico caracterizado, principalmente, pela inibição da imunidade inata com exacerbação da imunidade adaptativa, com atividade inflamatória mucosa intensificada. Por isso, os corticosteróides constituem a base fundamental do tratamento farmacológico na indução da remissão clínica na doença, graças às suas potentes ações como supressores do processo inflamatório. Entretanto, os proibitivos efeitos colaterais da corticoterapia prolongada associados à alta freqüência da cortico-dependencia na doença estimulou a busca de alternativas terapêuticas para manutenção da remissão no longo prazo. Nesse contexto, os imunossupressores, particularmente, os análogos da purina, azatioprina (AZA) ou 6mercaptopurina ocupam um papel central no tratamento de manutenção na doença, com efeitos “poupadores de esteróides”. A utilização desses agentes para manter a remissão clínica na doença é apoiada por evidências de estudos clínicos controlados e randomizados. No entanto, a maioria desses estudos não avaliou especificamente os doentes corticodependentes, não sendo claramente conhecida a ação dos análogos da purina nesse grupo de pacientes. Portanto, os objetivos do nosso estudo foram verificar a eficácia no longo prazo, da AZA em uma população exclusivamente portadora de doença de Crohn dependente de esteróides, assim como identificar os possíveis fatores preditivos associados à resposta clínica sustentada. Além disso foi verificada também a segurança dessa terapia, através da análise da incidência de eventos adversos. Para tanto, um total de 106 indivíduos adultos com doença de Crohn cortico-dependente foram prospectivamente incluídos para tratamento com AZA (2-3 mg/Kg/dia), durante o período de acompanhamento de até 10 anos. A proporção de doentes em remissão sustentada livre de esteróides ao final de 12, 24, 36, 48 e 60 meses foi de 0.61, 0.73, 0.72, 0,70 e 0.70 respectivamente. Depois disso, essa taxa anual foi sendo gradualmente reduzida, alcançando um nadir aos 108 meses de acompanhamento. O tempo médio de retirada completa dos esteróides foi de seis meses. Características demográficas, aquelas relacionadas à doença e a dose de AZA não se correlacionaram com remissão sustentada. Apenas a reduzida contagem leucocitária média durante o acompanhamento foi associada com a remissão livre de corticóides (P=0.01). Efeitos adversos graves relacionados à terapia com AZA foram incomuns. The Crohn´s disease is a chronic, inflammatory, multisystem bowel disorder with a relapsing course. Her etiology remains unknown but probably there´s a scenario characterized by inibition of innate immunity and exacerbation of the adaptative immunity with exacerbated mucosal inflammatory activity. Then, the corticosteroids have been the mainstay of pharmacologic treatment for inducing clinical remission in the disease. However, the prohibitive side effects of prolonged corticosteroid therapy associated with high frequency of the corticosteroid- dependency in the disease taken to alternative treatments for long- term maintenance of clinical remission. The immunomodulators, especially, the purine analogs, azathioprine(AZA) or 6- mercaptopurine are the major option for this indication, with corticosteroid- sparing proprieties. The use of these agents is supported by randomized, controlled clinical studies. However, these trials have not evaluated the specific issue of the steroid dependence. Thus, our objectives in this study were to asses the efficacy and safety of AZA therapy in patients strictly with steroid-dependent Crohn`s disease and possibly, factors associated with sustained clinical remission. Therefore, 106 adults patients with steroiddependent Crohn`s disease were prospectively included for treatment with AZA (23mg/Kg/day) during the period of follow up as long as 10 years. The proportion of patients remaining in sustained steroid-free remission at 12, 24, 36, 48 and 60 months was 0.61, 0.73, 0.72, 0.70 and 0.70, respectively. Thereafter, the annual rate of weaning from steroids decreased gradually, reaching a nadir of 0.41 at 108 months. Median time to complete steroid withdrawal was 6 months. Demographics, disease-related data and the AZA dose did not correlate with sustained remission. Only the reduced mean leukocyte count during the follow up was associated with remission free steroids (P= 0.01). Serious adverse effects related to AZA therapy were uncommon.

Crohn's disease is a chronic, relapsing, inflammatory disorder which may involve any segment of the bowel from mouth to anus. The mucocutaneous manifestations of Crohn's disease in the orofacial region are multiple, including oral Crohn's disease, metastatic Crohn's disease in sites noncontiguous with the bowel system, and reactive disorders such as pyoderma gangrenosum. Clinicians should be familiar with these extraintestinal manifestations and include this important and often serious disease in the evaluation of patients with selected orofacial disorders. The recognition of these manifestations may help prevent misdiagnosis and unnecessary treatment, and facilitates timely diagnosis, palliation and definitive therapy.

La enfermedad Inflamatoria Intestinal: (Rectocolitis Ulcerosa Idiopática y Enfermedad de Crohn) presenta diferentes características epidemiológicas, endoscópicas e histológicas. Materiales y Métodos: Estudio descriptivo, transversal retrospectivo ? prospectivo, donde se aplicó un formulario desde enero hasta noviembre 2006 para determinar las características epidemiológicas, endoscópicas, e histológicas de los pacientes. Resultados: Se encontró 28 pacientes con Rectocolitis Ulcerosa Idiopatica y 6 pacientes con Enfermedad de Crohn. En RCUI predominó el sexo femenino (53.6%), raza mezclada (92.9%), antecedentes familiares ausentes (78.6%) sin antecedentes personales de importancia (82.1%), con Pancolitis (53.6%) y duración de la enfermedad entre 6 meses y 5 años el (60.8%). En Crohn se presentó similar distribución de sexo, la raza predominante fue la mezclada (83.3%), ningun antecedente familiar, habito tabáquico y localización solo en Colon (50%) y 66.6% tenían menos de 1 año del diagnostico. En Rectocolitis el grupo etáreo mas frecuente (35.7%) de 30 ? 39 años, en Crohn 33.3% en grupos etáreos de 30-39 y 40-49 años. Los síntomas mas frecuentes fueron similares en ambas dolor abdominal y diarrea con o sin sangre. Los hallazgos endoscopicos 53.6% enfermedad moderada con reporte histológico de ulceras, abscesos o distorsión de las criptas 82.4% en rectocolitis y Ulceraciones lineales o serpenginosas en segmentos efectuando recto en 100%, histología de conglomerado de macrófagos (83.3%) y granulomas no caseosos o epiteloides en 66.7% en Crohn. Conclusiones: Los resultados coinciden en su mayoría con los reportados en la literatura internacional y deben servir como base de datos para la realización de estudios prospectivos. The aim of this study was to determine epidemiologic characteristics, endoscopic and histologic findings of Inflamatory Bowel Disease (IBD): Ulcerative Colitis (UC) and Crohn`s disease (CD) performed in outpatients in the Hospital Universitario de Maracaibo between January and November 2006. Through a descriptive, retrospective-prospective, transversal. study the information was recorded with a cuestionary, 28 pacients had UC and 6 CD, female was most frequent in 53.6%, Hispanic race (92.9%), without any family(78.6%) or personal past history (82.1%). Pancolitis was present in 53.6%. The time of illness was between 6 months to 5 years (60.8%). CD had similar sex distribution, Hispanic race was predominant in 83.3%, no tabaco habit and colon only presentation in 50%. 66.6% had one year or less with the diagnosis. UC was more frequent between 30-39 years of age (35.7%), CD more frequent between 30-39 and 40-49 years of age (33.3%). The most frequent clinical feature was abdominal pain, diarrhea with/ without blood. Endoscopic features were moderate illness 53.6%, with crypt architectural distortion, abscess, and ulcers (82.4%) in UC. CD segmental involment with skip areas, deep linear ulcerations rectum spared 100% and epitheloid granulomas 66.7% and infiltration of macrophages 83.3%. This report was similar in current issue and could be used in prospective studies.