This document discusses Behcet's disease (BD), including its epidemiology, clinical manifestations, and gastrointestinal involvement. Some key points:
1) BD prevalence is highest in Turkey (80-370 per 100,000), the Middle East, and Far East, and lowest in North America and Europe (0.2-6.6 per 100,000).
2) Common clinical manifestations include oral and genital ulcers, skin lesions, and ocular disease. Gastrointestinal involvement (entero-BD) can cause abdominal pain, diarrhea and intestinal perforation.
3) Diagnosis of entero-BD can be challenging and requires evaluating clinical features, imaging, endoscopy, histology
1. Behcet's disease is a systemic autoimmune vasculitis characterized by recurrent oral and genital ulcers. It can affect multiple organ systems including eyes, skin, joints, gastrointestinal tract, and nervous system.
2. The disease is named after Turkish dermatologist Hulusi Behcet who first described the triple symptom complex in 1937. It is more common in countries along the Silk Road. Genetic factors like HLA-B51 are associated with increased risk.
3. Pathogenesis involves inflammation of blood vessels due to immune dysregulation. Diagnosis is based on clinical criteria including oral/genital ulcers, skin lesions, eye inflammation, and positive pathergy test. Treatment focuses on
Predictors of the outcome of diabetic foot ulcer at Assiut university hospitalmhrsrs2011
This study aimed to identify predictors of poor outcome (non-healing) of diabetic foot ulcers at Assiut University Hospital. 100 patients with diabetic foot ulcers were prospectively followed for 1 year. Male sex, diabetes duration over 10 years, severe peripheral neuropathy, ulcer duration over 3 months, Wagner grade 3 ulcers, Texas grade 2D/3D ulcers, and ABI under 0.8 were found to independently predict non-healing of ulcers based on multivariate regression analysis. Baseline characteristics, foot examination findings, ulcer characteristics, and laboratory values of patients with healed versus unhealed ulcers after 1 year were also compared.
Climate change and agriculture - what do we need to do differently?elwyngj
This document discusses climate-smart smallholder agriculture, comparing it to traditional approaches. It makes three key points:
1. Climate-smart smallholder agriculture focuses more on managing climate risks and developing local institutions' ability to deal with uncertainty than traditional approaches. This includes assessing climate impacts and prioritizing risks.
2. It emphasizes long-term development scenarios over short-term gains to build resilience against future climate changes. Scenarios could include rising sea levels and effects on food production.
3. In addition to adaptation measures, it considers emissions from agriculture and food systems, which account for 10-29% of global greenhouse gases. Integrated approaches that provide multiple benefits like conserving biodiversity and liv
1. Thailand relies heavily on imported crude oil for its energy needs, accounting for over 50% of total supply in 2006. Domestic sources provide around 45% of energy, mainly from natural gas, condensate, and lignite.
2. The value of Thailand's imported energy increased significantly from 2001 to 2006 due to high global crude oil prices, reaching 919 billion baht in 2006 or around 15% of GDP.
3. Industry, transportation, and households are the largest consumers of energy in Thailand, using 38%, 36%, and 14% of total energy respectively. Improving energy efficiency across sectors is important for sustainable economic growth.
This document discusses endoscopic therapies for the management of variceal hemorrhage, specifically endoscopic sclerotherapy (EST) and endoscopic variceal ligation (EVL). It provides background on variceal bleeding and survival rates over time. It then describes the modalities and techniques of EST and EVL, including injection methods, sclerosing agents used, risks, and indications. Randomized controlled trials comparing EST and EVL are summarized, showing higher eradication rates with EVL. In conclusion, endoscopic therapies like EST and EVL are effective for controlling acute variceal bleeding and reducing recurrence when used for primary or secondary prophylaxis.
Session 12 - Introduction to Information ToolsMedXellence
This document summarizes tools for gathering performance improvement evidence, including the Template Analysis Tool (TAT). TAT provides clinic and provider-specific templates to analyze appointment categories, statuses, and dates. It summarizes appointment data for specific clinics, providers, and time periods to evaluate access and utilization. The document discusses using TAT and other sources like the Tricare Operations Center to examine metrics like empaneled patients, visits per 1000 patients, and provider availability. The goal is to provide actionable data to support decision making and demonstrate improvement tools for staff.
1. Behcet's disease is a systemic autoimmune vasculitis characterized by recurrent oral and genital ulcers. It can affect multiple organ systems including eyes, skin, joints, gastrointestinal tract, and nervous system.
2. The disease is named after Turkish dermatologist Hulusi Behcet who first described the triple symptom complex in 1937. It is more common in countries along the Silk Road. Genetic factors like HLA-B51 are associated with increased risk.
3. Pathogenesis involves inflammation of blood vessels due to immune dysregulation. Diagnosis is based on clinical criteria including oral/genital ulcers, skin lesions, eye inflammation, and positive pathergy test. Treatment focuses on
Predictors of the outcome of diabetic foot ulcer at Assiut university hospitalmhrsrs2011
This study aimed to identify predictors of poor outcome (non-healing) of diabetic foot ulcers at Assiut University Hospital. 100 patients with diabetic foot ulcers were prospectively followed for 1 year. Male sex, diabetes duration over 10 years, severe peripheral neuropathy, ulcer duration over 3 months, Wagner grade 3 ulcers, Texas grade 2D/3D ulcers, and ABI under 0.8 were found to independently predict non-healing of ulcers based on multivariate regression analysis. Baseline characteristics, foot examination findings, ulcer characteristics, and laboratory values of patients with healed versus unhealed ulcers after 1 year were also compared.
Climate change and agriculture - what do we need to do differently?elwyngj
This document discusses climate-smart smallholder agriculture, comparing it to traditional approaches. It makes three key points:
1. Climate-smart smallholder agriculture focuses more on managing climate risks and developing local institutions' ability to deal with uncertainty than traditional approaches. This includes assessing climate impacts and prioritizing risks.
2. It emphasizes long-term development scenarios over short-term gains to build resilience against future climate changes. Scenarios could include rising sea levels and effects on food production.
3. In addition to adaptation measures, it considers emissions from agriculture and food systems, which account for 10-29% of global greenhouse gases. Integrated approaches that provide multiple benefits like conserving biodiversity and liv
1. Thailand relies heavily on imported crude oil for its energy needs, accounting for over 50% of total supply in 2006. Domestic sources provide around 45% of energy, mainly from natural gas, condensate, and lignite.
2. The value of Thailand's imported energy increased significantly from 2001 to 2006 due to high global crude oil prices, reaching 919 billion baht in 2006 or around 15% of GDP.
3. Industry, transportation, and households are the largest consumers of energy in Thailand, using 38%, 36%, and 14% of total energy respectively. Improving energy efficiency across sectors is important for sustainable economic growth.
This document discusses endoscopic therapies for the management of variceal hemorrhage, specifically endoscopic sclerotherapy (EST) and endoscopic variceal ligation (EVL). It provides background on variceal bleeding and survival rates over time. It then describes the modalities and techniques of EST and EVL, including injection methods, sclerosing agents used, risks, and indications. Randomized controlled trials comparing EST and EVL are summarized, showing higher eradication rates with EVL. In conclusion, endoscopic therapies like EST and EVL are effective for controlling acute variceal bleeding and reducing recurrence when used for primary or secondary prophylaxis.
Session 12 - Introduction to Information ToolsMedXellence
This document summarizes tools for gathering performance improvement evidence, including the Template Analysis Tool (TAT). TAT provides clinic and provider-specific templates to analyze appointment categories, statuses, and dates. It summarizes appointment data for specific clinics, providers, and time periods to evaluate access and utilization. The document discusses using TAT and other sources like the Tricare Operations Center to examine metrics like empaneled patients, visits per 1000 patients, and provider availability. The goal is to provide actionable data to support decision making and demonstrate improvement tools for staff.
The Darzi report identifies the following priorities for primary care in the NHS:
1) Better access through new GP health centers, extended GP hours including weekends, and linking payments to attracting patients.
2) Tackling inequalities by improving access in underserved areas.
3) More choice by making it easier to switch GPs and opening services to non-NHS providers.
Diverticular disease is common in Western nations and involves the formation of pouches or diverticula in the colon wall. Diverticulosis refers to the presence of diverticula without inflammation, while diverticulitis occurs when the diverticula become inflamed. Uncomplicated diverticulitis is typically treated with bowel rest, antibiotics, and lifestyle modifications to promote healing. Complicated diverticulitis involving perforation or abscess requires surgical evaluation. Diverticulitis is diagnosed based on symptoms, physical exam, and imaging studies. Treatment aims to resolve the inflammation and prevent recurrence through diet and follow up screening.
Adapting to a changing climate - Jerry Knox (Cranfield University)Farming Futures
1. The document discusses how climate change is impacting agriculture through changes in temperature, precipitation patterns, and increased evapotranspiration.
2. It provides examples of observed and projected changes in potato yields and irrigation needs in Europe under different climate scenarios by mid-century.
3. Adaptation strategies are needed to address water scarcity issues exacerbated by climate change, such as more efficient irrigation systems, shifting to drought-resistant crops, and cooperative water management.
Microalbuminuria in diabetic and hypertensive patient2A.Salam Sharif
microalbuminuria is early sign of general vasculopathy and hurbinger of ESRD, the significance of microalbuminuria in diabetic and hypertensive patients is risky sign for further cardiovascular diseases, in this discussion I aimed to discuss the therapeutic approach for these patients
Coral diseases, coral bleaching and other health issues affecting Red Sea cor...Amin Mohamed
Research paper presented at the 12th International Coral Reef Symposium (ICRS) Cairns, Australia 9-13 July 2012 in the Climate change and bleaching mini-symposium. The paper has presented the first detailed quantitative data on the distribution and prevalence of coral diseases and other compromised health signs including coral bleaching that affect multiple corals in multiple sites along the Egyptian Red Sea coast.
thymoma diagnosis work up and management final.pptxAminzia3
This presentation on the presentation, work up, management of thymoma focusing on latest guide lines. It enamurates the clinical suspicious, age of presentation, differential diagnosis and treatment.
This document discusses key steps in public health research and decision making for diabetes, including surveillance to identify problems, analytic epidemiology to identify modifiable risk factors, and health services research to examine interventions. It outlines a range of potential priorities for responding to diabetes, from controlling complications to preventing diabetes among high-risk groups. Common study designs in epidemiologic research are described, including observational and intervention studies. The document discusses how risk factors are used to understand disease etiology and guide intervention development. Specific modifiable risk factors for type 2 diabetes are identified, including obesity, physical inactivity, diet, and gestational diabetes. Evidence on risk factors comes from descriptive epidemiology, cohort studies, randomized trials, and natural experiments.
Cattaneo le urgenze in ematologia 21 maggio 2011cmid
This document discusses antiplatelet drugs used to prevent blood clots, including aspirin, clopidogrel, prasugrel, ticagrelor, cangrelor, and elinogrel. It summarizes the mechanisms of action, metabolism, efficacy, and safety profiles of these drugs. Resistance or variable response to certain antiplatelet drugs is also addressed. The ideal properties of an antithrombotic agent are outlined. Later generation drugs like prasugrel, ticagrelor, and cangrelor demonstrate more consistent platelet inhibition compared to clopidogrel. However, some such as ticagrelor and elinogrel are associated with higher rates of dyspnea.
The Darzi report identifies the following priorities for primary care in the NHS:
1) Better access through new GP health centers, extended GP hours including weekends, and linking payments to attracting patients.
2) Tackling inequalities by improving access in underserved areas.
3) More choice by making it easier to switch GPs and opening services to non-NHS providers.
Diverticular disease is common in Western nations and involves the formation of pouches or diverticula in the colon wall. Diverticulosis refers to the presence of diverticula without inflammation, while diverticulitis occurs when the diverticula become inflamed. Uncomplicated diverticulitis is typically treated with bowel rest, antibiotics, and lifestyle modifications to promote healing. Complicated diverticulitis involving perforation or abscess requires surgical evaluation. Diverticulitis is diagnosed based on symptoms, physical exam, and imaging studies. Treatment aims to resolve the inflammation and prevent recurrence through diet and follow up screening.
Adapting to a changing climate - Jerry Knox (Cranfield University)Farming Futures
1. The document discusses how climate change is impacting agriculture through changes in temperature, precipitation patterns, and increased evapotranspiration.
2. It provides examples of observed and projected changes in potato yields and irrigation needs in Europe under different climate scenarios by mid-century.
3. Adaptation strategies are needed to address water scarcity issues exacerbated by climate change, such as more efficient irrigation systems, shifting to drought-resistant crops, and cooperative water management.
Microalbuminuria in diabetic and hypertensive patient2A.Salam Sharif
microalbuminuria is early sign of general vasculopathy and hurbinger of ESRD, the significance of microalbuminuria in diabetic and hypertensive patients is risky sign for further cardiovascular diseases, in this discussion I aimed to discuss the therapeutic approach for these patients
Coral diseases, coral bleaching and other health issues affecting Red Sea cor...Amin Mohamed
Research paper presented at the 12th International Coral Reef Symposium (ICRS) Cairns, Australia 9-13 July 2012 in the Climate change and bleaching mini-symposium. The paper has presented the first detailed quantitative data on the distribution and prevalence of coral diseases and other compromised health signs including coral bleaching that affect multiple corals in multiple sites along the Egyptian Red Sea coast.
thymoma diagnosis work up and management final.pptxAminzia3
This presentation on the presentation, work up, management of thymoma focusing on latest guide lines. It enamurates the clinical suspicious, age of presentation, differential diagnosis and treatment.
This document discusses key steps in public health research and decision making for diabetes, including surveillance to identify problems, analytic epidemiology to identify modifiable risk factors, and health services research to examine interventions. It outlines a range of potential priorities for responding to diabetes, from controlling complications to preventing diabetes among high-risk groups. Common study designs in epidemiologic research are described, including observational and intervention studies. The document discusses how risk factors are used to understand disease etiology and guide intervention development. Specific modifiable risk factors for type 2 diabetes are identified, including obesity, physical inactivity, diet, and gestational diabetes. Evidence on risk factors comes from descriptive epidemiology, cohort studies, randomized trials, and natural experiments.
Cattaneo le urgenze in ematologia 21 maggio 2011cmid
This document discusses antiplatelet drugs used to prevent blood clots, including aspirin, clopidogrel, prasugrel, ticagrelor, cangrelor, and elinogrel. It summarizes the mechanisms of action, metabolism, efficacy, and safety profiles of these drugs. Resistance or variable response to certain antiplatelet drugs is also addressed. The ideal properties of an antithrombotic agent are outlined. Later generation drugs like prasugrel, ticagrelor, and cangrelor demonstrate more consistent platelet inhibition compared to clopidogrel. However, some such as ticagrelor and elinogrel are associated with higher rates of dyspnea.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
One health condition that is becoming more common day by day is diabetes.
According to research conducted by the National Family Health Survey of India, diabetic cases show a projection which might increase to 10.4% by 2030.
Histopathology of Rheumatoid Arthritis: Visual treat
Master Rosina Marzo 09 [2]
1. Patologie Immuni &
Malattie Orfane
Torino – 22-24 Gennaio 2009
22-
Entero Behçet
F. Rosina
PRESIDIO SANITARIO GRADENIGO
TORINO
S.C. Gastroenterologia & Epatologia
2. Behçet disease
Epidemiology of a rare disease
North America & North Europe 0,2 - 6,6 /100.000
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
3. Behçet disease
Epidemiology of a not so rare disease
North America & North Europe 0,2 - 6,6 /100.000
Far & Middle East 13,5 - 20/100.000
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
4. Behçet disease
Epidemiology of a common disease
North America & North Europe 0,2 - 6,6 /100.000
Far & Middle East 13,5 - 20/100.000
Turkey 80 - 370 / 100,000
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
5. Behçet disease
Epidemiology of a common disease
North America & North Europe 0,2-6,6/100.000
Far & Middle East 13,5-20/100.000
Turkey 80-370 / 100,000
Age 20-40 yrs
Sex Men prevalence
(Middle East)
Female prevalence
(Far East & North Europe)
Severity More severe in Young Men
Middle & Far East
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
6. Behçet disease
Definition
Behcet's disease is a chronic,
relapsing vasculitis involving arterial
and venous blood vessels of all sizes
leading to several systemic
manifestations….
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
7. Behçet disease
Clinical manifestations
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100
90
80
75 75 75
70
60
50
50
40
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30
20
20
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10
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12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
8. Behçet disease
Large Vessels Disease
Number of
patients
Arterial disease
Pulmonary artery occlusion or aneurysm 36/728 (5%)
Aortic aneurysm 17/728 (2%)
Extremity arterial occlusion or aneurysm 45/728 (6%)
Other arterial occlusion or aneurysm 42/728 (6%)
Right ventricular thrombus 2/728
Review of 728 cases from Koc, Y, Gullu, I, Akpek, G, et al. J Rheumatol 1992; 19:402.
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
9. Behçet disease
Enteral Arterial disease
• Massive gastrointestinal bleeding due to aneurysmal
rupture of ileo-colic artery. After the failure of hemostasis
with arterial embolization, ileo-right colecctomy was performed.
(Kim SU et al Korean J Gastroenterol. 2007)
• Massive hemorrhage from ruptured small aneurysm on
the right ileocolic artery successfully treated with
superselective arterial embolization using microcoils (Hong
YK, Yoo WH. Rheumatol Int 2008)
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
10. Behçet disease
Large Vessels Disease
Number of
patients
Venous disease
Deep venous thrombosis 221/728 (30%)
Subcutaneous thrombophlebitis 205/728 (28%)
SVC occlusion 122/728 (17%)
IVC occlusion 93/728 (13%)
Cerebral sinus thrombosis 30/728 (4%)
Budd-Chiari syndrome 17/728 (2%)
Other venous occlusion 24/728 (3%)
Review of 728 cases from Koc, Y, Gullu, I, Akpek, G, et al. J Rheumatol 1992; 19:402.
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
11. Behçet disease
Large vessel Disease
Number of patients
Hepatic Vein Thrombosis 14/493 (3%)
Hepatic Vein (HV) Thrombosis Alone 4/14 (29%)
HV + Inferior Vena Cava (IVC) Thrombosis 8/14 (57%)
HV + IVC + Portal Vein Thrombosis 2/14 (16%)
Bayraktar Y et al.. Am J Gastroenterol 1997
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
12. Behçet disease
Budd Chiari
• Acute — 20 % (5% with fulminant hepatic failure)
• Subacute — 40 % (signs or symptoms for less
than six months and no evidence of liver cirrhosis)
• Chronic — 40 % (signs or symptoms for more
than six months with evidence of portal hypertension
and cirrhosis)
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
13.
14. Behçet
Small Vessels Disease: Entero Behçet
Symptoms
• anorexia
• nausea
• abdominal pain
• diarrhea
Lesions
• “punched out” or “flask shaped” ulcers involving both
the submucosa and the muscularis propria, especially
in the ileo-ciecal region, less frequenltly in the
esophagus and rarely in the stomach and duodenum
Griffin JW et al. South Med J 1982
Anti M et al. J Clin Gastroenterol 1986
Powderly WG et al. Ir J Med Sci 1987
Stringer DA et al. Pediatr Radiol 198
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
15. Behçet disease
Clinical manifestations
Italy Turkey China Taiwan Korea Thai
Number of studied pts 137 2313 28 125 1527 23
• Oral ulcerations 99% 100% 95% NR 99% 100%
• Uro-genital lesions
Uro- 63% 85% 50% NR 83% 70%
• Cutaneous lesions 82% 80% 95% NR 84% 61%
• Ocular disease 61% 38% 50% NR 51% 52%
• Neurologic disease NR 3% NR NR NR 9%
• Vascular disease NR 25% NR NR NR 9%
• Arthritis NR 11% 45% NR NR NR
• Renal disease NR NR NR NR NR NR
• Cardiac disease NR NR NR NR NR NR
• Pulmonary disease NR 0,03% NR NR NR NR
Salvarani C et al. Arthritis Rheum 2007
Pipitone N et al. Clin Exp Rheumatol 2004
Tursen U et al. Int J Dermatol 2003
Ning Sheng L et al. Clin Rheumatol 2005
Chou SJ et al J Gastrointest Surg 2007
Ling J et al Yan Ke Xue Bao 2005
Bang D et al. J Korean Med Sci 2001
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
16. Behçet disease
Gastrointestinal
100
* 43% HP/NSAIDs neg.ve
90
Peptic ulcers
80
70 66
60
50
40 35
30
20
9 9
10
1,5 Salvarani C et al. Arthritis Rheum 2007
0
0 Pipitone N et al. Clin Exp Rheumatol 2004
Tursen U et al. Int J Dermatol 2003
Ning Sheng L et al. Clin Rheumatol 2005
ey
a
ly
an
ai
a*
re
Ita
Th
rk
Chou SJ et al J Gastrointest Surg 2007
iw
in
Ko
Tu
Ch
Ta
Ling J et al Yan Ke Xue Bao 2005
Bang D et al. J Korean Med Sci 2001
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
17. Entero Behçet
Natural History
Remitting relapsing disease complicated by
Intestinal perforation
Taiwan
125 Behçet’s disease cases
Follow-up 25 yrs
82/125 (66%) intestinal Behçet’s disease
22/82 (27%) intestinal perforation
Male/female 14/8 - Age 22-65 yrs
Surgery:
• Hemicolectomy 11
• Partial Ileum Resection 8
• Ileocecal Resection 3
Reperforation:3
Chou SJ et al J Gastrointest Surg 2007
Choi IJ et al. Dis Colon Rectum 2000
Kin Js et al. Endoscopy 2000
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
18. Entero Behçet
Treatment
Glucocorticoids plus Azathiopine / 6-mercaptopurine
• Prednisone 0.5 to 1.0 mg/kg daily
• Azathioprine 2.5 – 2.5 mg/k / daily
Infliximab
3 to 5 mg/kg at 0, 2, and 6 weeks, followed by 5 mg/kg every 8 weeks
(Travis SP et al , Gut 2001; Kram MT et al, Dis Colon Rectum. 2003; Naganuma M et al, Inflamm Bowel Dis
2008; Lee JH et al Korean J Intern Med 2007))
Thalidomide
2 mg/kg per day,
(Yasui K et al, J Pediatr 2003; Yasui K et al Inflamm Bowel Dis 2008)
Cyclosporin
Surgery
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
19. Entero Behçet
Diagnosis
……the problem is not to assess the
presence of GI involvement in a patient with
a known Behçet disease, but ……
to make a diagnosis of Behçet syndrome in
a patient with GI ulcers
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
20. Entero Behçet
Diagnosis
• Radiology
• Endoscopy
• Upper GI Endoscopy
• Colonoscopy
• Wireless Capsule Endoscopy
• Histology
• Serology
but ……
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
21. Entero Behçet
Diagnosis
Small Bowel & Colon Barium Studies
• mucosal fold thickening
• discrete ulcers
• poor sensitivity and specificity
CT scans
• bowel wall thickening
• perienteric infiltration
• polipoid bowel involvement
• polipod mass-like lesions
Chung SY et alRadiographics 2001
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
22. Entero Behçet
Diagnosis
Crohn’s
• Endoscopy
• Upper GI Endoscopy
• Colonoscopy
• Small Bowel Capsule Endoscopy
Behçet’s
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
23. Entero Behçet
Wireless Capsule Endoscopy
Barium-CT pos.ve / suspected Behçet (0/11 - 0%)
WCE pos.ve / suspected Behçet (10/11 - 91%)
Thomson M et al. J Pediatr Gastroenterol Nutr 2007
Hamdulay SS et al Rheumatology Oxford 2008
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
24. Entero Behçet
Diagnosis
• Endoscopy
• Upper GI Endoscopy
• Colonoscopy
• Small Bowel Capsule
Endoscopy
• Histology
does not discriminate
between Behçet and other
Gastrointestinal Vasculitis,
specific for IBD only when
early lesions are present
• Serology
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
25. Entero Behçet
Diagnosis
Serology
ASCA IgA & IgG
Crohn Disease 42%
Behçet Disease 4%
Ulcerative Colitis 4%
Ankilosing Spondilitis 15%
Fresko I et al. Clin Exper Rheumatol 2005
Choi CH et al. Dis Colon Rectum 2006
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
26. Entero Behçet
Diagnosis
Serology
ASCA IgA & IgG
Crohn Disease 42%
Behçet Disease 4%
Ulcerative Colitis 4%
Ankilosing Spondilitis 15%
Enteral Behçet 44%
……..severity and relapse rates of intestinal Behçet's disease not associated
with ASCA expression.
ASCA pos.ve pts more likely to receive surgical treatment.
Fresko I et al. Clin Exper Rheumatol 2005
Choi CH et al. Dis Colon Rectum 2006
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
27. Entero Behçet
Diagnosis
• Barium Studies
• Endoscopy
• Upper GI Endoscopy
• Colonoscopy
• Small Bowel Capsule Endoscopy
• Biopsy
• Serology
• International Diagnostic Criteria
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
28. Entero Behçet
International Diagnostic Criteria
Recurrent Oral Aphthae (three times in one year)
plus two of the following in the absence of other systemic diseases:
• Recurrent genital aphthae
• Eye lesions (including anterior or posterior uveitis, cells in vitreous on slit
lamp examination, or retinal vasculitis, observed by an ophthalmologist)
• Skin lesions (including erythema nodosum, pseudo vasculitis, papulopustular
lesions, or acneiform nodules consistent with Behcet's)
• A positive pathergy test (a papule 2 mm or more in size developing 24 to
48 hours after oblique insertion of a 20 to 25 gauge needle 5mm into the skin,
generally performed on the forearm)
International Study Group for Behcet's Disease. Lancet 1990
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
29. Entero Behçet
Sensitivity & specificity of Behçet Diagnostic criteria
Sensitivity Specificity
International 95% 100%
Japanese 100% 95%
Mason & Barnes 100% 94%
International Study Group for Behcet's Disease. Lancet 199
Tunc R etr al. Clin Exp Rheumatol 2001
Chang HK et al Clin Exp Rheumatol 2004
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
30. Entero Behçet
International Diagnostic Criteria
Recurrent Oral Aphthae (three times in one year)
plus two of the following in the absence of other systemic diseases:
• Recurrent genital aphthae
• Eye lesions (including anterior or posterior Uveitis, cells in vitreous on slit
lamp examination, or retinal vasculitis, observed by an ophthalmologist)
• Skin lesions (including Erythema Nodosum, pseudo vasculitis,
papulopustular lesions, or acneiform nodules consistent with Behcet's)
• A positive pathergy test (a papule 2 mm or more in size developing 24 to
48 hours after oblique insertion of a 20 to 25 gauge needle 5mm into the skin,
generally performed on the forearm)
International Study Group for Behcet's Disease. Lancet 1990
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
31. Entero Behçet
Sensitivity & specificity of Behçet Diagnostic criteria
Sensitivity Specificity
International 95% 100%
Japanese 100% 95%
Mason & Barnes 100% 94%
… inclusion of pts with Crohn disease and Ulcerative Colitis did not
substantially change sensitivity & specificity of ISG (International Study
Group) diagnostic score
International Study Group for Behcet's Disease. Lancet 199
Tunc R etr al. Clin Exp Rheumatol 2001
Chang HK et al Clin Exp Rheumatol 2004
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
32. Entero Behçet
Conclusions
.....if you have still some doubt
on your diagnosis…….
…. just rule out infective colitis
and feel comfortable since …….
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
36. Entero Behçet
Conclusions
Crohn’s Behçet’s
Steroids OK OK
Azathioprine OK OK
Infliximab OK OK
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
37. …if you still have some doubt on the diagnosis,
Just rule out infective colitis and fell confortable since …….
Crohn’s Behçet’s
Steroids OK OK
Azathioprine OK OK
Infliximab OK OK
….. Perfectly fitting for both Behçet’s and Crohn’s disease.
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
38. The Mason–Barnes Criteria
Major Symptoms Minor Symptoms
Buccal ulcerations Gastrointestinal lesions
Genital ulcerations Thrombophlebitis
Ocular lesions Cardiovascular lesions
Arthritis
Skin lesions Neurologic lesions
Family history
Three major or two major and two minor criteria are required to establish the
diagnosis of Behçet’s disease
39. Entero Behçet
Sensitivity & specificity of Behçet Diagnostic criteria
Sensitivity Specificity
International 95% 100%
Japanese (Suzuki) 100% 95%
Mason & Barnes 100% 94%
International Study Group for Behcet's Disease. Lancet 199
Tunc R etr al. Clin Exp Rheumatol 2001
Chang HK et al Clin Exp Rheumatol 2004
12° Convegno Patologie Immuni & Malattie Orfane , Torino 22-24 gennaio 2009
40. XIII Congresso Nazionale delle
Malattie Digestive
Corso AIGO-SIGE
AIGO-
“Hot topics in Gastroenterologia”
Palermo – 3 ottobre 2007
“Up date” su ….
Colangite Sclerosante
Primitiva
F. Rosina
Presidio Sanitario Gradenigo
Torino
41. Behçet disease
• Oral ulcerations (95-100%)
• Uro-genital lesions (75%)
Clinical manifestations
• Cutaneous lesions (>75%)
• Ocular disease (25-75%)
• Neurologic disease ( < 20%)
• Vascular disease (33%)
• Arthritis (75%)
• Renal disease (uncommon)
• Cardiac disease (uncommon)
• Pulmonary diasease (uncommon)
• Gastrointestinal Symptoms (common)
• Gastrointestinal disease (more or less frequent depending on the
geographical area: unfrequent in in Italy and middle east – common in far
east (Japan, Korea)
•
Severity is generally greater in men. The greatest morbidity and mortality
occurs with ocular disease (affecting up to two-thirds of patients),
vascular disease (affecting up to one-third of patients), and central
nervous system disease (affecting 10 to 20 percent of patients).
Cutaneous and articular manifestations are common. Renal disease and
peripheral nervous system involvement are less common than in other
vasculitides
20° Congresso Regionale ACOI , 31 ottobre 2008
42. Behçet disease
Epidemiology
Behcet's disease is more common (and often more severe) along the ancient silk
road, which extends from eastern Asia to the Mediterranean [4]. It is most common
in Turkey (80 to 370 cases per 100,000) while the prevalence ranges from 13.5 to
20 per 100,000 in Japan, Korea, China, Iran, Iraq, and Saudi Arabia [4]. By
comparison, the prevalence is from 1:15,000 to 1:500,000 in Northern American
(Olmsted County, Minnesota) and Northern European countries. It is somewhat
more common in men in the eastern Mediterranean area and in women in north
European countries, and typically affects young adults 20 to 40 years of age. The
disease appears to be more severe in young, male, and Middle Eastern or Far
Eastern patients
FARE TABELLA IMPOSTANDOLA TUTTA SU UN RAPPORTO …./100.000
clinical manifestations vary among different patients and populations. Men and
women have different propensities to develop the disease, but this varies among
populations. As an example, Behcet's is more common in men in the Middle East
and in women in Japan and Korea [6].
20° Congresso Regionale ACOI , 31 ottobre 2008
43. Behçet disease
Vascular disease
Most clinical manifestations of
Behcet's disease are due to
vasculitis involving:
• blood vessels of all sizes
• arterial and venous
20° Congresso Regionale ACOI , 31 ottobre 2008
44. Behçet disease
Budd Chiari etiology
Myeloproliferative diseases
Malignancy
Hepatocellular carcinoma
Infections and benign lesions of the liver
Oral contraceptives
Pregnancy
Hypercoagulable states
(Factor V Leiden mutation, Prothrombin gene mutation, Antiphospholipid antibody
syndrome, Antithrombin III deficiency, Protein C deficiency, Protein S deficiency )
Paroxysmal nocturnal hemoglobinuria
JAK2 mutations
Behcet's disease
Membranous webs of the inferior vena cava and/or the hepatic veins
Miscellaneous conditions
Idiopathic
20° Congresso Regionale ACOI , 31 ottobre 2008
45. Behçet disease
Clinical manifestations
• Oral ulcerations (95-100%)
(95-
• Uro-genital lesions (75%)
Uro-
• Cutaneous lesions (>75%)
• Ocular disease (25-75%)
(25-
• Neurologic disease ( < 20%)
• large Vessel Vascular disease (33%)
• Arthritis (75%)
• Renal disease (uncommon)
• Cardiac disease (uncommon)
• Pulmonary disease (uncommon)
• Gastrointestinal Symptoms (common)
• Gastrointestinal Disease (more or less frequent depending on the geographical
area: infrequent in in Italy and middle east – common in far east)
20° Congresso Regionale ACOI , 31 ottobre 2008