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Volume 5, No 4 - Fall 2005

Volume 5, No 4 - Fall 2005

Table of Contents

Antibiotic Prophylaxis in Severe Acute Pancreatitis: The Never-Ending Controversy Therapeutic Challenges
Infections are the most common late cause of morbidity and mortality in severe acute pancreatitis. Between 1993 and 2004, a number of prospective controlled trials, meta-analyses, and guidelines all concluded that antibiotics were indicated for the prophylaxis of infections in severe acute pancreatitis. However, in 2004, the first prospective, double-blind, placebo-controlled trial was published showing no effect of prophylactic antibiotics, thus rekindling the controversy surrounding this subject. For those physicians who choose to use prophylactic antibiotics, their use should be limited to patients with pancreatic necrosis, and the choice of antibiotic should be guided by the drug’s proven ability to penetrate into the pancreas. Evidence supports imipenem, meropenem, or cefepime for this indication. One third of patients will develop infection of pancreatic necrosis despite the use of prophylactic antibiotics. Vigilance must be maintained for evidence of recurrence of markers of inflammation or persistence beyond the first week, which would suggest the need for fine-needle aspiration and culture to detect infection. Physicians who choose not to use prophylactic antibiotics for pancreatic necrosis should be aware that they will need to initiate antibiotics in 54% to 77% of patients for either infection of pancreatic necrosis or extrapancreatic infections. [Rev Gastroenterol Disord. 2005;5(4):183-194]
Role of Liver Biopsy in Management of Chronic Liver Disease: Selective Rather Than Routine Management Review
Liver biopsy has historically played a central role in the diagnosis and management of a variety of chronic liver diseases. However, as the understanding of disease pathology has progressed, and laboratory diagnostics, imaging technology, and clinical algorithms to determine both the etiology and presence of fibrosis have advanced, the role of liver biopsy has become more circumscribed. In chronic liver disease, liver biopsy is now more often used selectively, rather than routinely, for diagnostic purposes. Newer treatment of chronic hepatitis B and C has become more effective and thus reduced the routine need to acquire tissue. Risk factors for nonalcoholic fatty liver disease are readily identified and suggest the diagnosis after exclusion of alternative considerations, and there is no specific treatment for this condition; thus there is little role for the routine use of liver biopsy to guide treatment. Only in select cases of chronic hepatitis C, especially in patients with genotype 1, an indeterminate stage and grade of disease on noninvasive evaluation, or in those with human immunodeficiency virus coinfection, for whom the risks and benefits of treatment are less clear, is there a role for routine pretreatment biopsy. [Rev Gastroenterol Disord. 2005;5(4):195-205]
Endoscopic Therapy of Benign Biliary Strictures Treatment Review
Benign biliary strictures result from many etiologies, including postoperative injuries, anastomotic strictures, and chronic pancreatitis. Therapy is generally required to relieve symptoms of cholestasis or cholangitis and prevent secondary cirrhosis. Surgery has been the traditional method for treatment of benign biliary strictures but is associated with significant morbidity and variable long-term outcomes. More research is needed to define the best methods and materials for various patient populations. Endoscopic management, including stricture dilation and stent placement, is more appealing because it is less invasive and better tolerated, but repeated treatments are required. Outcomes of endoscopic management depend on both the etiology and the location of the stricture. Accumulating data suggest that long-term success is substantially greater when multiple rather than single plastic stents are placed. Uncovered metallic stents are problematic and generally not recommended. Emerging alternatives to plastic stents include the placement of removable covered metallic stents. [Rev Gastroenterol Disord. 2005;5(4):206-214]
Ulcerative Colitis Therapy: Importance of Delivery Mechanisms Treatment Review
Since the initial observation that mesalamine or 5-aminosalicylate (5-ASA) has an anti-inflammatory effect on ulcerative colitis, investigators have been trying to improve on the delivery mechanisms of this compound. As it is believed that the anti-inflammatory effect of 5-ASAs is mediated topically, current formulations are designed to release 5-ASA in the small intestine and colon, or predominantly in the colon. A dose-response curve is seen with some preparations of mesalamine but not all. In general, 5-ASAs are effective in patients with ulcerative colitis and much less effective in Crohn’s disease. Evidence demonstrates that 5-ASAs are effective for induction of remission and maintenance of remission. Preparations that deliver 5-ASA in a pH-dependent manner are most affected by variability in luminal pH, whereas those that depend on bacterial cleavage for release of the active 5-ASA are most affected by transit time. Most studies have not compared different preparations of mesalamine and examined differences in colonic delivery. Depending on the endpoint examined in the studies, efficacy of the various 5-ASA products appears similar at the most optimal doses. For a given patient, however, it may be necessary to experiment with more than one preparation if an initial trial results in a suboptimal response. [Rev Gastroenterol Disord. 2005;5(4):215-222]
Colorectal Disease Reviewing the Literature