A review of immune modifier therapy for inflammatory bowel disease: Azathioprine, 6-mercaptopurine, cyclosporine, and methotrexate

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ABSTRACTS

blinded fashion by a pathologist, The Injury scores for the ammals given corn oil were significantly higher than those fore the casein group. It is concluded that intralummal lipids may augment intestinal ischemic injury in the newborn rat. The same results were not seen m the weanling rat. Although oxygen-free radicals were present durmg injury. lipid peroxidation from oxygen radicals was not responsible for the increase in histological Injury seen.-Kchnrd R. Rlckeffs

A Review of immune Modifier Therapy for Inflammatory Bowel Disease: Azathioprine, 6-Mercaptopurine, Cyclosporine, and Methotrexate. WJ. Saridbonz. Am J Gastroenterol91:423-l33. (March). 1996. This excellent review analyzes the indications and efficacy of the use of immune modifiers, such as azathiopnne (AZA). 6-mercaptopurine (6MP), cyclosporrne (CYA), and methotrexate (MTX). in the treatment of inflammatory bowel disease. Refractory Crohn’s disease. fistulizing Crohn’s disease. and steroid-dependent Crohn’s disease can be treated with AZA or 6MP. Steroid-dependent ulcerative colitis and possibly refractory ulcerative colitis also can be treated with AZA or 6MP. Additionally. AZA/6MP can be used in both Crohn’s disease and ulcerative colitrs for remission maintenance. Low-dose CYA IS not efficacious for inflammatory bowel disease. High-dose CYA therapy can be used for severe steroid-refractory ulcerative colitis and possibly for severe steroid-refractory Crohn’s disease and fistulizing Crohn’s disease. CYA should not be used for remission maintenance in either Crohn’s disease or ulcerative colitis. Monitoring for marrow toxicity is required when using AZA or 6MP: monitoring for nephrotoxicity IS required when using CYA. Indications for use of MTX include refractory Crohn’s disease and steroid-dependent Crohn’s disease. MTX has not been shown to be usefui for refractory ulcerative colitis or for remission maintenance for ulcerative cohtis or Crohn’s disease. Mom tormg for bone mao-ow toxicity and hepatic toxicity is required when using MTX.-Richard R. Ricketts

ABDOMEN Pancreaticobiliary Maljunction Associated With Nondilation or Minimal Dilatation of the Common Bile Duct in Children: Diagnosis and Treatment. L Miynno, K. Alldo, A. Yamamka, ef al. Em J Pediatr Surg 6:334-337. (December), 1997. It is known that the etiology of congenital biliary dilatation (CBD) is closely associated with pancreaticobiliary maljunction (PBMJ). Treatment of CBD today is primary excision of the cyst followed by hepaticoenterostomy. However. PBMJ without dilatation of the bilary tract recently has been reported, and its treatment is still controversial. In adults. simple cholecystectomy without biliary reconstruction is often performed, because it usually presents as an anomaly of the gallbladder. The authors have encountered eight patients with PBMJ without dilatation of the common bile duct among 180 pediatric cases of CBD. The symptoms were those of pancreatitis. ie. abdominal pain associated with elevated of semm amylase levels Five cases presented with jaundice or a history of pale-colored stools. Endoscopic retrograde cholangiopancreatography was performed to confirm the diagnosis. Five of the eight patients were found to have dilatation of the common channel. Three cases had proven protem plugs or debris at the level of the common channel. It is strongly su,,quested that the manifestation of chmcal symptoms in these patlents results from stasis or obstruction at the level of the common channel. In children who present with recurrent pancreatitis. PBMJ must be suspected even if the common bile duct appears normal. It is difficult to resolve these anomalies without operative repair. The authors consider that radical treatment of PBMJ is required for these children to prevent serious long-term complications.Thomas A. Angeupointrzr

Spontaneous Perforation of the Biliary Tract in Infancy: A Series of 11 Cases. C. Chordor, F Isknr~damr~i, 0. De Dreg, et al. Eur J Pediatr Surg 6:341-346. (December). 1996. Eleven patients with spontaneous perforation of the bihary tract are presented. Three groups could be differentiated. each with a different pattern of local presentation: generalized biliary peritonitis (n = 2), localized peritonitis (n = 41. and secondary bihary stenosis (n = 5). In each case, cholestatic jaundice developed after a postnatal symptomfree interval. Ten infants were operated on Perforation was located in the cystic duct (n = 2) the common hepatic duct (n = 1). the junction of the cystic and hepatic ducts (n = 4). and the common bile duct (n = 1). The site of perforation could not be identified in two cases. Cholecystectomy was performed in two cases, simple external biliary drainage in three, and biliary reconstruction in five. Postoperative complications included bile leak (n = 2) ascending cholangitis (n = l), and portal vem thrombosis (n = 2). Five patients required additional surgery. One infant died of postoperative sepsis. Four patients are alive and well; the others were lost to follow-up. Late sequelae are present in four children; portal hypertension (n = 1). mild residual bile duct dilatation (n = 1). and mild to moderate liver fibrosis (n = 2). Prompt diagnosis and treatment should improve the prognosis of this rare condition.--irl?amns A. Angerpointner

Hepatic Trauma in Children: Long-Term R Gudirzchet, and N. Gemon. Eur J Pediatr ber). 1996.

Follow-Up. E Farvorl. Surg 6:347-349. (Decem-

Forty-three children with blunt hepatic trauma were studied prospectively. Four (9%) died. Fouiteen children (52%) were operated on, and 13 (48%) were treated conservatively. Twenty-seven children were examined by long-term ultrasonography (US), with a mean of 6 years followmg the trauma. Results of physical examinations and liver tests were normal for all children. The US aspect was abnormal m 22% of the cases. showmg hypoechogemc areas and anomahes of the biliary tract. Cholelithiasis secondary to hemobilia was demonstrated m two children. Cholecsytectomy had to be performed m one patient because of posttraumatic strictures of the biliary tract. The authors recommend follow-up US for children who sustain blunt hepatic trauma at 6 months followmg the event -Thomas A. Angerpointner

Laparoscopic Evaluation of Contralateral Patent Processus Vaginalis in Children. K. Pellegr-m. D. BelzsalzE, E Karuel; et al. Am J Surg 172:602-606. (November), 1996. Fifty consecutively treated chrldren (up to 8 years of age) referred for treatment of unilateral inguinal hernia were offered diagnostic laparoscopy to evaluate the contralateral mguinal canal for the presence of a hernia. Thirteen of 42 patients with a symptomatic hernia had a contralateral patent processus vagmahs noted by diagnostic laparoscopy. The children who did not have a patent processus did not undergo contralateral exploration. However, all children underwent a supraumbilical Incision, msufflation, and insertion of a laparoscope. Disposable ports were used. The authors concede that this report does not answer the question of the need for repair with the presence of a patent processus vaginalis --T/toinns E Ttzzc); Jr

Traumatic Rupture of Hydatid Cysts. J Surg 39:293-396. (August). 1996. The authors cysts in college blunt abdominal splemc flexure peritomtis was

report students trauma colon]) present,

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four instances of traumatic rupture of hydatid between 1972 and 1956. The sports that caused to the four patients were soccer (3 [2 liver, 1 and wrestling (1 spleen). The cysts were large, some postoperative courses were complicated