Endoscopie de l 'enfant

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Endoscopie de l 'enfant

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