Immunosuppressive drugs in the treatment of inflammatory bowel disease.
Aranda R. Horgan K.
Inflammatory Bowel Disease Clinical and Research Center, UCLA School of Medicine 90095-7019, USA.
Immunosuppressive (IS) drugs are an important option in the management of both forms of inflammatory bowel disease (IBD): Crohn's disease and ulcerative colitis. As the experience of using these agents in the treatment of IBD has increased and more data have become available on their efficacy, these drugs are being used more extensively. The principle drugs used in clinical practice at this time include: azathioprine (AZA) and its metabolite 6-mercaptopurine (6-MP), methotrexate, and cyclosporin A. AZA and 6-MP are generally considered the first line immunosuppressive agents. These drugs are effective and generally well tolerated by the majority of patients started on them, enabling many patients to avoid the predictable side effects of steroid therapy. Because of their extensive use, it is important that clinicians involved in the care of IBD patients are familiar with the IS drugs used to treat IBD, especially AZA and 6-MP.
Medical management of perianal Crohns disease.
Winter AM. Hanauer SB.
Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Hospitals, IL 60637, USA.
Perianal disease is a frequent complication necessitating both medical and surgical management in Crohn's disease. Fissures, fistulae, or abscesses are found in approximately 36% of patients; occur more often in the ileocolonic and colonic disease; and may precede the onset of intestinal symptoms (Farmer et al, Gastroenterology 68:627-635, 1975; Rankin et al, Gastroenterology 77:914-920, 1979; Gray et al, Gut 6:515-524, 1965; and Homan et al, Arch Surg 111:1333-1335, 1976). To approach perianal manifestations, the physician must identify the anatomic location of the disease, treat the suppurative complications, and consider a long-term approach to palliation of chronic inflammatory sequelae. This article will review the medical management of perianal Crohn's disease and indications for surgery.
Surgical options in the management of perianal Crohns disease.
Kosinski L. Welton ML.
Department of Surgery, University of California, San Francisco 94143-0144, USA.
Perianal complications of Crohn's disease are common, and surgical management has been controversial. Over the last 10 years, improved outcomes have defined a more prominent role for operative interventions, especially with respect to management of focal perineal sepsis and fistulas. Liberal placement of drainage catheters and noncutting setons, advancement flap closure of perineal fistulas, and selective construction of diverting stomas have good results when combined with optimal medical therapy to induce remission of inflammation. Proctectomy, which is infrequently required, can often be postponed for several years when complementary surgical and medical treatments are provided.
Nutritional issues and therapy in inflammatory bowel disease.
Husain A. Korzenik JR.
Department of Internal Medicine, Washington University School of Medicine, St Louis, MO 63110, USA.
Nutritional issues in inflammatory bowel disease (IBD) often receive inadequate attention both in regard to therapy and nutritionally related complications of IBD. This article reviews much of the research that has evaluated the role of diet in the causation, primary treatment, and adjunctive therapy of both ulcerative colitis (UC) and Crohn's disease (CD). Benefits have been demonstrated in the use of elemental diets or polymeric diets in CD in both acute flare up or maintenance of IBD. A careful team approach can overcome problems in implementing nutritional therapy. Nutrition also has a critical benefit in postoperative CD and perioperative UC. Numerous easily corrected, nutritional abnormalities are often overlooked in patients with IBD, which may have significant consequences. Nutritional therapy may have a central place in the hierarchy of treatment in IBD and further research is critical in this area to better define the benefits of nutrition in IBD.
Practical imaging in acute pancreatitis.
Morgan DE. Baron TH.
Department of Radiology, University of Alabama at Birmingham, 35233, USA.
Pancreatitis may be acute or chronic, mild or severe. In patients with acute pancreatitis the optimal imaging test is dynamic intravenous and oral contrast enhanced computed tomography (CECT). Serial CECTs are useful to monitor disease progression and to assess intraabdominal complications in patients with severe acute pancreatitis. CECT is helpful in planning the approach (endoscopic transmural versus percutaneous) for pancreatic drainage. Computed tomography or ultrasound-guided aspiration of pancreatic collections is safe, sensitive, and specific and has become a routine procedure used to screen for infected necrosis. When pancreatic drainage is contemplated, magnetic resonance imaging is useful for identifying residual necrotic debris within the collection. Patients with mild acute pancreatitis usually require no cross-sectional imaging study other than ultrasound screening for gallstones, if gallstone pancreatitis is suspected clinically. In patients with chronic pancreatitis, screening for complications such as superimposed acute pancreatitis or development of pancreatic pseudocysts may be performed with CECT or ultrasound.
Endoscopic ultrasonography in pancreatic disease.
Program for Endoscopic Ultrasound, Diagnosis, Study and Research, Veterans Affairs Medical Center and Wright State University School of Medicine, Dayton, OH 45401-0927, USA.
Endoscopic ultrasound has emerged as an important modality for management of pancreatic disease because of its ability to provide high frequency images of the pancreatic ducts and the parenchyma. Development of interventional techniques under endosonographic guidance has further advanced the potential use of this technique in pancreatic disorders. This paper shows and reviews the current knowledge on endoscopic ultrasound in pancreatic imaging.
Pancreatic fluid collections: diagnosis and endoscopic management.
Adkisson KW. Baron TH. Morgan DE.
Department of Medicine, University of Alabama at Birmingham, 35294-0007, USA.
Pancreatitis may be acute or chronic, mild or severe. Acute necrotizing pancreatitis remains the most serious form of acute pancreatitis and accounts for the majority of complications. Although there is an established nomenclature for pancreatitis and pancreatic fluid collections, such as pancreatic pseudocysts, it is not widely understood or recognized by gastroenterologists. Because the management options for the treatment of pancreatic fluid collections continues to evolve with an increased use of endoscopic therapy, gastroenterologists will be increasingly called on to treat patients with pancreatitis and its complications. This article addresses and summarizes pancreatic fluid collections and their management, with an emphasis on endoscopic drainage.
Pancreatic duct stenting in benign pancreatic disease.
Somogyi L. Forsmark CE.
Division of Gastroenterology, Hepatology, and Nutrition, University of Florida College of Medicine, Gainesville 32610-0214, USA.
The ability to place endoscopic stents into the pancreatic duct has led to a dramatic increase in stent therapy for benign pancreatic diseases, particularly chronic pancreatitis and pancreas divisum. The overall effectiveness of this therapy remains unknown. This article critically reviews the available literature with a focus on patient selection, efficacy, and risk. The risk of pancreatic duct stenting is only now beginning to be appreciated, and clinicians must understand not only the potential effectiveness of pancreatic duct stenting but also the magnitude of the potential risk when considering this therapy.
The surgical management of chronic pancreatitis (ductal strictures).
Pederson LC. Vickers SM.
Department of Surgery, University of Alabama at Birmingham, 35294-0007, USA.
Chronic pancreatitis is a lifelong illness for patients and a persistent medical challenge for the gastrointestinal physician. Most cases are induced by alcohol abuse. This leads to a process of recurrent injury, chronic fibrosis and subsequent pain, pancreatic ductal scarring, and dilatation. The surgical management of these associated complications as seen in the patient presented in this report will be discussed in the context of the current surgical literature.