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Endoscopie de l 'enfant

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  • 1. Prophylaxis in Crohn’s disease after surgical intervention Dr. ALI KHALIL
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  • 2. Surgical indications
    • > 50 % of Patients with ileal or ileocolonic crohn’s disease undergo resection of the diseased bowel because of complications including:
    • Stenosis
    • Abcess
    • Fistula
    • Intractable disease
  • 3. Complications of Crohn’s Disease Crohn’s Strictures
  • 4. Complications of Crohn’s Disease Crohn’s Fistulae
  • 5. Recurrence of the disease
    • Recurrence can be demonstrated endoscopically in 73% - 93% of patients at 1 year
    • at the site of resection
    • Approximately 50% of patients requierd repeat surgery within 10 years
    • Risk factors: - age > 30 years
    • - duration of disease > 5 years
    • - use of corticosteroids > 6 months
    • - smoking habits
    • - chronic activity
  • 6. Crohn’s disease Treatment Goals
    • Diagnosis and prompt therapeutic response
    • Induction of complete remission
    • Maintenance of clinical remission
    • Prevent recurrence of disesase in disease-free segments of the bowel after surgery
    • Low side-effect profile to enhance compliance
  • 7. Crohn’s Disease - Treatment
    • Conventional therapies :
    • Aminosalicylates
    • Corticosteroids/Budesonide
    • Immunomodulators
    • Antibiotics
    • Anti-metabolites
    • Biologic Modifiers
  • 8. Aminosalicylates Mesalamine (1)
    • A meta-analysis of 15 randomised controlled trials
    • 2097 patients
    • The mesalamine significantly reduced the risk of symptomatic relapse
    • The benefits are mainly observed in the post surgical setting « confidence interval (–21,8% to 4,5% )
    Camma C et al, gastroenterology 2001
  • 9. Aminosalicylates Mesalamine (2)
    • Randomisad controled trial
    • 163 patients
    • 1,5 g of (Rowasa and salofalk) twice a day for 8 weeks
    • Mesalamine is effective in decreasing the risk of reccurent crohn’s disease after surgical resection
    • The symptomatic reccurence rate in the treatment group was 31 % compared with 41 % in the placebo group ( p=0,031)
    Mcleod et al, gastroenterology 1995
  • 10. Aminosalicylates Mesalamine (3)
    • Double-blind multicenter clinical trial
    • 3g/day of Pentasa , 12 months of treatment
    • 67 patients
    • The overall rate of severe endoscopic reccurence was 24% in the mesalamine group and 56% int the placebo group after 1 year
    Brignola et al, gastroenterology 1995
  • 11. Aminosalicylates Mesalamine (4)
    • Prospective, double-blind, multicenter study
    • 4g/day Pentasa vs placebo continued for 18 months
    • 318 patients
    • 10 days after resection
    • Relapse after 18 months: 24,5% in group mesalamine
    • 31,4% in placebo group
    • Some relapse-preventing effect was found in patients was isolated small bowel disease
    Lochts et al, gastroenterology 2000
  • 12. Aminosalicylates Mesalazine
    • A multicenter randomized control trial
    • 110 patients
    • 2,4 g Asacol/day vs no treatment at all
    • Colonoscopy and ileoscopy at 6 months and yearly therafter
    • Over 2 year period: prevent 39 % of all reccurences and 55% of the severe reccurences
    Caprilli et al, aliment pharmacol ther 1995
  • 13. Aminosalicylates Conclusion
    • 3 studies showed that mesalamine is effective in decreasing the risk of reccurence
    • One study showed that mesalamine did not significantly affect the postoperative course of crohn’s disease
  • 14. Corticoïdes Budesonide
    • A double-blind randomized trial
    • 129 patients
    • 6 mg/day or placebo within two weeks from surgery
    • The frequency of endoscopic reccurrence did not differ between the groups at 3 and 12 months
    • In patients with disease activity as indication for surgery, the endoscopic reccurrence rate at the anastomosis was lower in the budesonide group
    • But not in patients with fibrostenosis as indication for surgery
    Hellers et al, gastroenterology 1999
  • 15. percentage of patients with macroscopic recurrence of inflammation in the neoterminal ileum Budesonide Placebo Patients with recurence
  • 16. Patients with recurence percentage of patients with macroscopic recurrence of inflammation of anastomosis Placebo Budesonide
  • 17. Endoscopy score Budesonide Placebo Endoscopy score in the neoterminal ileum
  • 18. Endoscopy score Endoscopy score at anastomosis Budesonide Placebo
  • 19. Immunomodulators 6-Mercaptopurine (6-MP)
    • Randomized study, double-blind
    • 131 patients
    • 6-MP (50mg), mesalamine (3g) or placebo daily
    Stephen et al, gastroenterology 2004 49% 46% 33% Radiographic recurrence 64% 63% 43% Endoscopic recurrence 77% 58% 50% Clinical recurrence Placebo Mesalamine 6-MP
  • 20. Clinical recurrence
  • 21. Endoscopic recurrence
  • 22. Radiographic recurrence
  • 23. Immunomodulators Azathioprine
    • Comparative trial
    • 142 patients
    • Azathioprine (2 mg/kg/day) and mesalamine (3 g/day) for 24 months
    • Relapse was experienced in 17 patients (34%) receiving azathioprine and 28 (46%) receiving mesalamine but the difference was not significant
    Ardizzone et al, gastroenterology 2004
  • 24. Immunomodulators Conclusion
    •  6-MP, 50mg daily was more effective than placebo at preventing post-operative recurrence of crohn’s disease and should be considered as a maintenance therapy after ileocolic resection
    •  The difference was not significant between azathioprine and mesalamine
    •  More placebo-controlled studies of recurrence prevention with immunosuppressives are necessary
    •  Higher risk of toxicity
  • 25. Antibiotics Metronidazole
    • A double-blind controlled trial
    • 60 patients
    • Metrornidazole 20mg/kg/day or placebo continued for 3months
    • At 12 weeks, 75 % of patients in the placebo group had recurrent lesions in the neoterminal ileum as compared with 52% in the metronidazole group
    • The incidence of endoscopic recurrence was significantly reduced by metronidazole as compared with placebo
    Rutilements et al, gastroenterology 2005
  • 26. Antibiotics Ornidazole
    • A double-blind randomized trial
    • 80 patients
    • Ornidazole 1 g/day or placebo continued for 1 year within 1week of resection
    • Clinical recurrence rate at 1 year from 37.5% in placebo group to 7.9% in the ornidazole group
    • Endoscopic recurrence was reduced from 79% in Placebo to 53.6% in the ornidazole group
    Rutgeerts et al, gastroenterology 2005
  • 27. Antibiotics Conclusions
    •  Metronidazole therapy for 3 months decreased the severity of early recurrence of crohn’s disease after resection and seems to delay symptomatic recurrence
    • Ornidazole 1g/day is effective for the prevention of recurrence of Crohn’s disease after ileocolonic resection
    • Ornidazole have a better safety profile
  • 28. Summary
    • Mesalamine 3g/day, 12 months of treatment within two weeks from surgery is considered as first choice treatment
    • Immunomodulators should be considered as a maintenance therapy after ileocolic resection
    • Ornidazole 1g/day, 3-6 months of treatment, is effective to prevent posoperative recurrence of crohn’s disease
    • Budesonide 6mg/ day, may be more effective in patients with high disease activity as a primary indication for surgery