Publications by authors named "Giovanni Maconi"

119 Publications

Prevalence and significance of mesentery thickening and lymph nodes enlargement in Crohn's disease.

Dig Liver Dis 2021 Jul 19. Epub 2021 Jul 19.

Department of Biomedical and Clinical Science "Luigi Sacco", University of Milan, Italy.

Background: Mesentery thickening and enlarged lymphnodes are typical findings of Crohn's disease (CD), but their role is unknown. Aim of the present study was to evaluate their prevalence and significance on postoperative complications and long-term surgical recurrence after CD surgery.

Methods: 1272 consecutive, unselected patients were retrospectively reviewed, divided into 4 groups based on the presence or absence of a thickened mesentery and enlarged lymphnodes, and stratified for primary or recurrent surgical procedure. In all patients but those treated with strictureplasty the mesentery and lymphnodes were removed. Patients' characteristics, peri-operative findings, and long-term recurrence were compared by univariate and multivariate analysis.

Results: Thickened mesentery and enlarged lymphnodes were not present in all cases, were typical of ileal location and penetrating behaviour, had a constant decrease over recurrences, were independent of either pre-operative medical therapy or surgical approach, did not increase the duration of surgery and complications, presented similar 20-years recurrence rate to normal mesentery and lymphnodes. Lymphopathy was associated to a worst nutritional status during disease recurrences. At multivariate analysis, age, location, and behaviour, but not mesenteric characteristics, were related to an increased risk of surgical recurrence.

Conclusions: This study provides new information on mesentery and lymphnodes in CD patients. Further studies are needed to clarify the appropriate surgical approach.
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http://dx.doi.org/10.1016/j.dld.2021.06.030DOI Listing
July 2021

Lower incidence of COVID-19 in patients with inflammatory bowel disease treated with non-gut selective biologic therapy.

J Gastroenterol Hepatol 2021 Jun 23. Epub 2021 Jun 23.

Gastroenterology Unit, ASST Fatebenefratelli-Sacco, L. Sacco University Hospital, Department of Biochemical and Clinical Sciences, University of Milan, Milan, Italy.

Background And Aim: Since the outbreak of COVID-19, concerns have been raised as to whether inflammatory bowel disease (IBD) patients under biologic therapy may be more susceptible to the disease. This study aimed to determine the incidence and outcomes of COVID-19 in a large cohort of IBD patients on biologic therapy.

Methods: This observational retrospective multicenter study collected data about COVID-19 in IBD patients on biologic therapy in Italy, between February and May 2020. The main end-points were (i) to assess both the cumulative incidence and clinical outcome of COVID-19, according to different biologic agents and (ii) to compare them with the general population and a cohort IBD patients undergoing non-biologic therapies.

Results: Among 1816 IBD patients, the cumulative incidence of COVID-19 was 3.9 per 1000 (7/1816) with a 57% hospitalization rate and a 29% case-fatality rate. The class of biologic agents was the only risk factor of developing COVID-19 (P = 0.01). Non-gut selective agents were associated with a lower incidence of COVID-19 cases, related symptoms, and hospitalization (P < 0.05). Compared with the general population of Lombardy, an overall lower incidence of COVID-19 was observed (3.9 vs 8.5 per 1000, P = 0.03). Compared with 565 IBD patients on non-biologic therapies, a lower rate of COVID-19 symptoms was observed in our cohort (7.5% vs 18%, P < 0.001).

Conclusions: Compared with the general population, IBD patients on biologic therapy are not exposed to a higher risk of COVID-19. Non-gut selective agents are associated with a lower incidence of symptomatic disease, supporting the decision of maintaining the ongoing treatment.
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http://dx.doi.org/10.1111/jgh.15591DOI Listing
June 2021

Noninvasive Monitoring After Azathioprine Withdrawal in Patients With Inflammatory Bowel Disease in Deep Remission.

Clin Gastroenterol Hepatol 2021 Jun 15. Epub 2021 Jun 15.

Gastroenterology Unit, "L. Sacco" University Hospital, ASST Fatebenefratelli Sacco, Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Milan, Italy.

Background & Aims: There is uncertainty regarding the optimal duration of treatment with azathioprine (AZA) in ulcerative colitis (UC) and Crohn's disease (CD). We analyzed the clinical course and predictors of relapse after AZA withdrawal in patients in sustained deep remission.

Methods: A prospective study was performed on patients who stopped their treatment with AZA while being in steroid-free, extended deep remission (normal clinical, endoscopic, and histologic indexes, C-reactive protein, and fecal calprotectin [FC]). Standard biochemical tests and FC were measured at 3 and 6 months, then every 6 months. Bowel ultrasounds and ileocolonoscopy were performed every 6 and 12 months, respectively. Multivariate analysis for predictors of relapse was performed using a Cox proportional hazards model and hazard ratios were calculated. Spearman nonparametric correlation test was also used. The accuracy of significant predictors was calculated.

Results: Fifty-seven patients with inflammatory bowel disease stopped AZA after median 7 years (range, 5-19) and were followed up for median 50 months (range, 25-85). Twenty-six patients (18/31 UC, 8/26 CD; P = .003) relapsed, within a median 15 months (range, 2-37). FC was the only variable significantly correlated with later relapse of both diseases (UC: hazard ratio, 3.3; 95% confidence interval, 1.2-10; CD: hazard ratio, 4.5; 95% confidence interval, 1.4-12.5). The sensitivity, specificity, and positive and negative predictive values of FC were 50%, 100%, 100%, and 59% in UC and 50%, 94%, 80%, and 81% in CD.

Conclusions: More than half patients with UC and one-third of patients with CD relapse after AZA withdrawal despite previous deep remission. FC positivity is associated with high risk of relapse, allowing early correction of the therapeutic strategy.
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http://dx.doi.org/10.1016/j.cgh.2021.06.014DOI Listing
June 2021

Intestinal metastasis from breast cancer: Presentation, treatment and survival from a systematic literature review.

World J Clin Oncol 2021 May;12(5):382-392

Department of Biomedical and Clinical Sciences, Gastroenterology Unit, "Luigi Sacco" University Hospital, Milano 20157, Italy.

Background: Intestinal metastases from breast cancer (BC) arerare; available data depend mainly on case reports and case series.

Aim: To conduct a review of the literature regarding presentation, diagnosis, treatment and survival of patients with intestinal metastasis from BC.

Methods: We identified all articles that described patients with intestinal metastasis (from duodenum to anum) from BC using MEDLINE (1975 to 2020) and EMBASE (1975 to 2020) electronic databases.

Results: We found 96 cases of intestinal metastasis of BC. Metastasization involved large bowel (cecum, colon, sigmoid, rectum) (51%), small bowel (duodenum, jejunum, ileum) (49%), and anum (< 1%). Median age of patients was 61-years. The most frequent histology was infiltrating lobular carcinoma followed by infiltrating ductal carcinoma. In more than half of patients, the diagnosis was made after the diagnosis of BC (median: 7.2 years) and in many cases of emergency, for bowel obstruction, bleeding or perforation. Diagnosis was achieved through endoscopy, radiological examination or both. In most of the cases, patients underwent surgery with or without systemic therapies. Survival of patients included in this review was available in less than 50% of patients and showed an overall median of 12 mo since diagnosis of the intestinal metastasis.

Conclusion: Although, intestinal metastases of BC are considered a rare condition, clinicians should consider the possibility of intestinal involvement in case of abdominal symptoms even in acute setting and many years after the diagnosis of BC, especially in patients with a histology of lobular carcinoma.
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http://dx.doi.org/10.5306/wjco.v12.i5.382DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8173325PMC
May 2021

Gastrointestinal Ultrasound in Functional Disorders of the Gastrointestinal Tract - EFSUMB Consensus Statement.

Ultrasound Int Open 2021 Apr 28;7(1):E14-E24. Epub 2021 May 28.

Haukeland University Hospital, Haukeland University Hospital, and Department of Clinical Medicine, University of Bergen, Bergen, Norway.

Abdominal ultrasonography and intestinal ultrasonography are widely used as first diagnostic tools for investigating patients with abdominal symptoms, mainly for excluding organic diseases. However, gastrointestinal ultrasound (GIUS), as a real-time diagnostic imaging method, can also provide information on motility, flow, perfusion, peristalsis, and organ filling and emptying, with high temporal and spatial resolution. Thanks to its noninvasiveness and high repeatability, GIUS can investigate functional gastrointestinal processes and functional gastrointestinal diseases (FGID) by studying their behavior over time and their response to therapy and providing insight into their pathophysiologic mechanisms. The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) has established a Task Force Group consisting of GIUS experts, which developed clinical recommendations and guidelines on the role of GIUS in several acute and chronic gastrointestinal diseases. This review is dedicated to the role of GIUS in assisting the diagnosis of FGID and particularly in investigating patients with symptoms of functional disorders, such as dysphagia, reflux disorders, dyspepsia, abdominal pain, bloating, and altered bowel habits. The available scientific evidence of GIUS in detecting, assessing, and investigating FGID are reported here, while highlighting sonographic findings and its usefulness in a clinical setting, defining the actual and potential role of GIUS in the management of patients, and providing information regarding future applications and research.
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http://dx.doi.org/10.1055/a-1474-8013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8163523PMC
April 2021

Ultrasonographic Evaluation of Intestinal Fibrosis and Inflammation in Crohn's Disease. The State of the Art.

Front Pharmacol 2021 26;12:679924. Epub 2021 Apr 26.

Gastroenterology Unit-ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences (DIBIC) L. Sacco, Università degli Studi di Milano, Milan, Italy.

The evaluation of the degree of inflammation and fibrosis, intrinsic elements in intestinal wall damage of Crohn's disease, is essential to individuate the extent of the lesions and the presence of strictures. This information will contribute to the choice of the appropriate therapeutic approach, the prediction of the response to therapy and the course of the disease. The accurate evaluation of the extent and severity of inflammation and/or fibrosis in Crohn's disease currently requires histopathological analysis of the intestinal wall. However, in clinical practice and research, transmural assessment of the intestinal wall with cross sectional imaging is increasingly used for this purpose. The B-mode ultrasonograhic characteristics of the intestinal wall, the assessment of its vascularization by color Doppler and I.V. contrast agents, and the evaluation of the mechanical and elastic properties by sonoelastography, may provide useful and accurate information on the severity and extent of inflammation and intestinal fibrosis in Crohn's disease. The purpose of this review is to provide an update on current sonographic methods to discriminate inflammation and fibrosis in Crohn's disease.
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http://dx.doi.org/10.3389/fphar.2021.679924DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8107820PMC
April 2021

How to Manage COVID-19 Vaccination in Immune-Mediated Inflammatory Diseases: An Expert Opinion by IMIDs Study Group.

Front Immunol 2021;12:656362. Epub 2021 Apr 15.

Gastroenterology Unit, ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences (DIBIC) L. Sacco, Università degli Studi di Milano, Milan, Italy.

Since March 2020, the outbreak of Sars-CoV-2 pandemic has changed medical practice and daily routine around the world. Huge efforts from pharmacological industries have led to the development of COVID-19 vaccines. In particular two mRNA vaccines, namely the BNT162b2 (Pfizer-BioNTech) and the mRNA-1273 (Moderna), and a viral-vectored vaccine, i.e. ChAdOx1 nCoV-19 (AstraZeneca), have recently been approved in Europe. Clinical trials on these vaccines have been published on the general population showing a high efficacy with minor adverse events. However, specific data about the efficacy and safety of these vaccines in patients with immune-mediated inflammatory diseases (IMIDs) are still lacking. Moreover, the limited availability of these vaccines requires prioritizing some vulnerable categories of patients compared to others. In this position paper, we propose the point of view about the management of COVID-19 vaccination from Italian experts on IMIDs and the identification of high-risk groups according to the different diseases and their chronic therapy.
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http://dx.doi.org/10.3389/fimmu.2021.656362DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8082137PMC
May 2021

Budesonide MMX in the Treatment of Ulcerative Colitis: Current Perspectives on Efficacy and Safety.

Ther Clin Risk Manag 2021 7;17:285-292. Epub 2021 Apr 7.

Gastroenterology Unit, Department of Biomedical and Clinical Sciences FBF - L.Sacco, University Hospital, Milan, Italy.

Budesonide MMX is a low bioavailability corticosteroid oral once-daily formulation, which has a controlled rate of release throughout the colon, thanks to the multimatrix (MMX) formulation. It has been available for a decade in the USA and Europe for the induction of remission in patients with active, mild to moderate ulcerative colitis, particularly for those not responsive to mesalamine. The efficacy of budesonide MMX in this setting has been assessed by registrative randomized controlled trials showing a higher rate of clinical and endoscopic remission at 8 weeks compared with placebo, mostly in patients with proctosigmoiditis and left-side colitis. Since it is available in our therapeutic armamentarium, a few studies have confirmed the effectiveness of budesonide MMX also in real-life, highlighting the high rate of clinical response and remission and the high safety profile. In the present review, we summarise clinical trials and real-life results of budesonide MMX, assessing its use and predictors of response and non-response in real-life.
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http://dx.doi.org/10.2147/TCRM.S263835DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8039041PMC
April 2021

Ultrasonography Tight Control and Monitoring in Crohn's Disease During Different Biological Therapies: A Multicenter Study.

Clin Gastroenterol Hepatol 2021 Mar 26. Epub 2021 Mar 26.

Gastroenterology, Department of Clinical Medicine and Surgery, Federico II, School of Medicine, Naples.

Background & Aims: Bowel ultrasonography (BUS) is a noninvasive tool for evaluating bowel activity in Crohn's disease (CD) patients. Aim of our multicenter study was to assess whether BUS helps to monitor intestinal activity improvement/resolution following different biological therapies.

Methods: Adult CD patients were prospectively enrolled at 16 sites in Italy. Changes in BUS parameters [i.e. bowel wall thickening (BWT), lesion length, echo pattern, blood flow changes and transmural healing (TH: normalization of all BUS parameters)] were analyzed at baseline and after 3, 6 and 12 months of different biological therapies.

Results: One hundred eighty-eight out of 201 CD patients were enrolled and analyzed (116 males [62%]; median age 36 years). Fifty-five percent of patients were treated with adalimumab, 16% with infliximab, 13% with vedolizumab and 16% with ustekinumab. TH rates at 12 months were 27.5% with an NNT of 3.6. TH at 12 months after adalimumab was 26.8%, 37% after infliximab, 27.2% after vedolizumab and 20% after ustekinumab. Mean BWT improvement from baseline was statistically significant at 3 and 12 months (P < .0001). Median Harvey-Bradshaw index, C-reactive protein and fecal calprotectin decreased after 12 months from baseline (P < .0001). Logistic regression analysis showed colonic lesion was associated with a higher risk of TH at 3 months and a greater BWT at baseline was associated with a lower risk of TH at 3 months [P = .03 (OR 0.70, 95% CI 0.50-0.97)] and 12 months [P = .01 (OR 0.58, 95% CI 0.38-0.89)]. At 3 months therapy optimization during the study was the only independent factor associated with a higher risk of no ultrasonographic response [P = .02 (OR 3.34, 95% CI 1.18-9.47)] and at 12 months disease duration [P = .02 (OR 3.03, 95% CI 1.15-7.94)].

Conclusions: Data indicate that BUS is useful to monitor biologics-induced bowel activity improvement/resolution in CD.
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http://dx.doi.org/10.1016/j.cgh.2021.03.030DOI Listing
March 2021

Letter: ustekinumab for the treatment of post-surgical and refractory Crohn's disease.

Aliment Pharmacol Ther 2021 04;53(7):859-860

Division of Gastroenterology, "L. Sacco" University Hospital, Milan, Italy.

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http://dx.doi.org/10.1111/apt.16281DOI Listing
April 2021

Strictureplasties performed by laparoscopic approach for complicated Crohn's disease. A prospective, observational, cohort study.

Dig Liver Dis 2021 Feb 21. Epub 2021 Feb 21.

Department of Biomedical and Clinical Science "Luigi Sacco", University of Milan, Italy.

Background: Laparoscopy is considered the best surgical approach for Crohn's Disease (CD), and strictureplasty a reliable alternative to intestinal resection. Nevertheless, their association has never been evaluated.

Aim: To investigate feasibility and safety of conventional (SP) and non-conventional (NCSP) strictureplasties, using laparoscopy, for complicated CD.

Methods: Starting January 2008, a prospective cohort study was performed, in consecutive, unselected patients, undergoing primary surgery for CD (Group-A). The residential database (CD-CARD) was used for the retrospective extraction of control patients (Group-B). Univariate and multi-variate analysis of pre-operative characteristics, intra-operative findings, morbidity, and intra-abdominal septic complications (IASCs) was performed.

Results: Between January 2008 and December 2019, 331 patients received 162 SPs, 138 NCSPs, and 373 resections (Group-A). From the CD-CARD, 227 control patients received 159 SPs, 117 NCSPs, and 271 resections (Group-B) (ns). Preoperatively, Group-A presented batter nutritional status and received more biological therapies, Group-B more steroids. Group-A presented less abdominal abscesses, planned ostomies, minor complications, shorter operating time and hospitalization than Group-B, but similar major complications, IASCs and anastomotic leaks. IASCs were related to older age, elevated inflammatory indices, and preoperative treatment with high-risk drugs.

Conclusions: SP and NCSP are feasible by laparoscopy, with low morbidity rate, confirming the advantages of both minimally invasive and conservative surgery.
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http://dx.doi.org/10.1016/j.dld.2021.01.023DOI Listing
February 2021

Effect of Ustekinumab on Extraintestinal Diseases in Refractory Crohn's Disease.

J Crohns Colitis 2021 Aug;15(8):1399-1400

Division of Gastroenterology, 'L. Sacco' University Hospital, Milan, Italy.

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http://dx.doi.org/10.1093/ecco-jcc/jjab028DOI Listing
August 2021

Risk of COVID 19 in patients with inflammatory bowel diseases compared to a control population.

Dig Liver Dis 2021 03 26;53(3):263-270. Epub 2020 Dec 26.

Gastroenterology Unit, ASST Fatebenefratelli Sacco, Department of Biomedical and Clinical Sciences "L.Sacco" University of Milan, Italy.

Background: It is unclear whether patients with inflammatory bowel disease (IBD) are at increased risk of COVID-19.

Objectives: This observational study compared the prevalence of COVID-19 symptoms, diagnosis and hospitalization in IBD patients with a control population with non-inflammatory bowel disorders.

Methods: This multicentre study, included 2733 outpatients (1397 IBD patients and 1336 controls), from eight major gastrointestinal centres in Lombardy, Italy. Patients were invited to complete a web-based questionnaire regarding demographic, historical and clinical features over the previous 6 weeks. The prevalence of COVID-19 symptoms, diagnosis and hospitalization for COVID-19 was assessed.

Results: 1810 patients (64%) responded to the questionnaire (941 IBD patients and 869 controls). IBD patients were significantly younger and of male sex than controls. NSAID use and smoking were more frequent in controls. IBD patients were more likely treated with vitamin-D and vaccinated for influenza. Highly probable COVID-19 on the basis of symptoms and signs was less frequent in the IBD group (3.8% vs 6.3%; OR:0.45, 95%CI:0.28-0.75). IBD patients had a lower rate of nasopharyngeal swab-PCR confirmed diagnosis (0.2% vs 1.2%; OR:0.14, 95%CI:0.03-0.67). There was no difference in hospitalization between the groups (0.1% vs 0.6%; OR:0.14, 95%CI:0.02-1.17).

Conclusion: IBD patients do not have an increased risk of COVID-19 specific symptoms or more severe disease compared with a control group of gastroenterology patients.
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http://dx.doi.org/10.1016/j.dld.2020.12.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7762705PMC
March 2021

Dermatological Manifestations in Inflammatory Bowel Diseases.

J Clin Med 2021 Jan 19;10(2). Epub 2021 Jan 19.

Gastroenterology Unit, Department of Biomedical and Clinical Sciences, "L.Sacco" Hospital, 20157 Milano, Italy.

Inflammatory bowel diseases (IBDs) may be associated with extra-intestinal manifestations. Among these, mucocutaneous manifestations are relatively frequent, often difficult to diagnose and treat, and may complicate the course of the underlying disease. In the present review, a summary of the most relevant literature on the dermatologic manifestations occurring in patients with inflammatory bowel diseases has been reviewed. The following dermatological manifestations associated with IBDs have been identified: (i) specific manifestations with the same histological features of the underlying IBD (occurring only in Crohn's disease); (ii) cutaneous disorders associated with IBDs (such as aphthous stomatitis, erythema nodosum, psoriasis, epidermolysis bullosa acquisita); (iii) reactive mucocutaneous manifestations of IBDs (such as pyoderma gangrenosum, Sweet's syndrome, bowel-associated dermatosis-arthritis syndrome, aseptic abscess ulcers, pyodermatitis-pyostomatitis vegetans, etc.); (iv) mucocutaneous conditions secondary to treatment (including injection site reactions, infusion reactions, paradoxical reactions, eczematous and psoriasis-like reactions, cutaneous infections, and cutaneous malignancies); (v) manifestations due to nutritional malabsorption (such as stomatitis, glossitis, angular cheilitis, pellagra, scurvy, purpura, acrodermatitis enteropathica, phrynoderma, seborrheic-type dermatitis, hair and nail abnormalities). An accurate dermatological examination is essential in all IBD patients, especially in candidates to biologic therapies, in whom drug-induced cutaneous reactions may assume marked clinical relevance.
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http://dx.doi.org/10.3390/jcm10020364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7835974PMC
January 2021

A Simple Intestinal Ultrasound Score in Crohn's Disease: First Big Step Towards New Paradigms.

J Crohns Colitis 2021 Jan;15(1):3-4

L Sacco University Hospital, Department of Gastroenterology, Via GB Grassi 74, Milano, Italy.

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http://dx.doi.org/10.1093/ecco-jcc/jjaa167DOI Listing
January 2021

Expert Consensus on Optimal Acquisition and Development of the International Bowel Ultrasound Segmental Activity Score [IBUS-SAS]: A Reliability and Inter-rater Variability Study on Intestinal Ultrasonography in Crohn's Disease.

J Crohns Colitis 2021 Apr;15(4):609-616

Gastrounit, Division of Medicine, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark.

Background And Aims: Intestinal ultrasound [IUS] is an accurate, patient-centreed monitoring tool that objectively evaluates Crohn's disease [CD] activity. However no current, widely accepted, reproducible activity index exists to facilitate consistent IUS identification of inflammatory activity. The aim of this study is to identify key parameters of CD inflammation on IUS, evaluate their reliability, and develop an IUS index reflecting segmental activity.

Methods: There were three phases: [1] expert consensus Delphi method to derive measures of IUS activity; [2] an initial, multi-expert case acquisition and expert interpretation of 20 blinded cases, to measure inter-rater reliability for individual measures; [3] refinement of case acquisition and interpretation by 12 international experts, with 30 blinded case reads with reliability assessment and development of a segmental activity score.

Results: Delphi consensus: 11 experts representing seven countries identified four key parameters including: [1] bowel wall thickness [BWT]; [2] bowel wall stratification; [3] hyperaemia of the wall [colour Doppler imaging]; and [4] inflammatory mesenteric fat. Blind read: each variable exhibited moderate to substantial reliability. Optimal, standardised image and cineloop acquisition were established. Second blind read and score development: intra-class correlation coefficient [ICC] for BWT was almost perfect at 0.96 [0.94-0.98]. All four parameters correlated with the global disease activity assessment and were included in the final International Bowel Ultrasound Segmental Activity Score with almost perfect ICC (0.97 [0.95-0.99, p <0.001]).

Conclusions: Using expert consensus and standardised approaches, identification of key activity measurements on IUS has been achieved and a segmental activity score has been proposed, demonstrating excellent reliability.
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http://dx.doi.org/10.1093/ecco-jcc/jjaa216DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8023841PMC
April 2021

Modified Kudo classification can improve accuracy of virtual chromoendoscopy with FICE in endoscopic surveillance of ulcerative colitis.

Endosc Int Open 2020 Oct 22;8(10):E1414-E1422. Epub 2020 Sep 22.

Gastroenterology Unit, ASST Fatebenefratelli Sacco, Milan, Italy.

 Virtual chromoendoscopy with Fuji Intelligent Color Enhancement (FICE) has never been studied in prospective trials of endoscopic surveillance for ulcerative colitis (UC). We compared FICE and white light endoscopy (WLE) in differentiation of visible lesions in UC.  In a prospective parallel study, we compared consecutive outpatients with UC submitted to surveillance colonoscopy with FICE or WLE. At least one visible polypoid or non-polypoid lesion for each patient was required. Random biopsies from normal mucosa, targeted biopsies or removal of suspected neoplastic lesions and targeted biopsies of unsuspected lesions were performed. In the FICE arm, neoplasia was suspected according to a modified Kudo classification (FICE-KUDO/inflammatory bowel disease [IBD]). Sensitivity (SE), specificity (SP), positive and negative likelihood ratios (LR) and negative predictive value (NPV) were analyzed.  One hundred patients were submitted to FICE (n = 46) or WLE (n = 54). Twenty-two patients (11 in WLE, 11 in FICE) had a least one neoplastic lesion. No neoplasia was found in random biopsies. Among 275 lesions, 17 of 136 by FICE and 27 of 139 by WLE were suspected neoplasia, but 28 (14 in each arm) were true neoplastic lesions. The accuracy of FICE-KUDO/IBD vs WLE (per lesion) was: SE 93 % vs 64 % (  = 0.065), SP 97 % vs 86 % (  = 0.002), positive-LR 28.3 vs 4.5 (  = 0.001), negative-LR 0.07 vs 0.42 (  = 0.092), NPV 99 % vs 96 % (  = 0.083). FICE-KUDO/IBD detected more non-polypoid lesions than WLE (  = 0.016).  Targeted biopsies of polypoid and non-polypoid lesions, using the modified Kudo classification with FICE are more accurate than WLE in UC surveillance.
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http://dx.doi.org/10.1055/a-1165-0169DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7508663PMC
October 2020

Abdominal Symptoms and Colonic Diverticula in Marfan's Syndrome: A Clinical and Ultrasonographic Case Control Study.

J Clin Med 2020 Sep 28;9(10). Epub 2020 Sep 28.

Gastroenterology & Hepatology Section, Department of Medicine, University of Perugia Medical School, 06122 Perugia, Italy.

Background: Marfan's syndrome (MFS) seems to be frequently associated with colonic diverticulosis, but the prevalence of diverticula and symptoms evocative of diverticular disease in this population are still unknown.

Methods: This prospective case control study included 90 consecutive patients with MFS, 90 unselected controls, and 90 asymptomatic subjects. The clinical characteristics, including lower gastrointestinal symptoms, and ultrasonographic features of the bowel, including diverticula and thickening of the muscularis propria of the sigmoid colon, were investigated. In addition, the genotype of MFS patients was assessed. The characteristics of patients and controls were compared using parametric tests.

Results: Complaints of abdominal symptoms were made by 23 (25.6%) patients with MFS and 48 (53%) control subjects ( < 0.01). Constipation and bloating were reported less frequently by MFS patients than controls (constipation: 13.3% vs. 26.6%, = 0.039; bloating: 3.3% vs. 41.1%, < 0.0001), while other symptoms were not significantly different. Sigmoid diverticulosis was detected in 12 (12.3%) patients with MFS, as well as in 3 (3.3%) asymptomatic healthy subjects and 4 (4.4%) random controls ( = 0.0310). The genetic variants of MFS were not correlated with symptoms or diverticula.

Conclusion: Patients with MFS have a greater prevalence of diverticula, although less abdominal symptoms, compared to the general population. Symptoms and diverticula in MFS are not correlated with any genetic variant.
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http://dx.doi.org/10.3390/jcm9103141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7599469PMC
September 2020

CT colonography evaluation of the relationship between colon anatomy and diverticula.

Br J Radiol 2020 Dec 17;93(1116):20200670. Epub 2020 Sep 17.

Postgraduation School in Radiodiagnostics, Facoltà di Medicina e Chirurgia, Università degli Studi di Milano, Via Festa del Perdono 7, 20122, Milan, Italy.

Objectives: In this study, we aimed at investigating the relationship between diverticula and colonic features such as total colon length (TCL), using CTC. We also evaluated polyps, neoplastic lesions and the correlation among them.

Methods: This retrospective study considered a series of patients who underwent CTC in our Hospital from 2010 to 2018. We evaluated TCL, the length of each colon segments and sigmoid colon diameter using dedicated software. We verified the presence of diverticula, polyps and neoplasm and measured the number of diverticula using a five-point class scale, evaluating the colonic segments involved by the disease and the number of diverticula for each segment. A logistic regression model was used to analyse the relationship between diverticula and the patients' age, sigmoid colonic diameter and the length of each colonic segments.

Results: The population finally included 467 patients, 177 males and 290 females (average age of 67 ± 12; range 45-96). The mean TCL was 169 ± 25 cm (range 115-241 cm). Out of the 467, 323 patients (69%) had at least one analyse. The patients with diverticula had a mean TCL significantly shorter than patients without diverticula (164 ± 22 vs 181 ± 27 cm; = 0.001). Among the different variables, sigmoid colon length, sigmoid colon diameter and patient's age were correlated with diverticula ( < 0.01). Otherwise there is no association among diverticula, polyps and neoplasm.

Conclusions: The presence of colonic diverticula was significantly inversely correlated with TCL.The TCL was not significantly correlated with polyps and cancers.

Advances In Knowledge: The presence of colonic diverticula was significantly inversely correlated with total colon length, and in particular they significantly decreased with increasing colon length; our observation could contribute to the comprehension of diverticula pathogenesis.
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http://dx.doi.org/10.1259/bjr.20200670DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7716006PMC
December 2020

CT colonography followed by elective surgery in patients with acute diverticulitis: a radiological-pathological correlation study.

Abdom Radiol (NY) 2021 02 3;46(2):491-497. Epub 2020 Aug 3.

Unità di Radiologia, IRCCS Policlinico San Donato, San Donato Milanese, Italy.

Purpose: To perform a radiologic-pathologic correlation analysis of sigmoid colon in patients undergoing pre-operative CT Colonography (CTC) after an episode of acute diverticulitis (AD).

Methods: Fifty-nine consecutive patients (31/28 M/F; 58 ± 13 years) underwent CTC 55 ± 18 days after AD, 8 ± 4 weeks before surgery. Thirty-seven patients (63%) underwent conventional abdominal CT at time of AD. An experienced blinded radiologist retrospectively analyzed all images: disease severity was graded according to the Ambrosetti classification on conventional CT and according to the diverticular disease severity score (DDSS) on CTC. A GI pathologist performed a dedicated analysis, evaluating the presence of acute and chronic inflammation, and fibrosis, using 0-3 point scale for each variable.

Results: Of 59 patients, 41 (69%) had at least one previous AD episode; twenty-six patients (44%) had a complicated AD. DDSS was mild-moderate in 34/59 (58%), and severe in 25/59 (42%). All patients had chronic inflammation, while 90% had low-to-severe fibrosis. Patients with moderate/severe fibrosis were older than those with no/mild fibrosis (61 ± 13 versus 54 ± 13). We found a significant correlation between DDSS and chronic inflammation (p = 0.004), as well as DDSS and fibrosis (p = 0.005). Furthermore, fibrosis was correlated with complicated acute diverticulitis (p = 0.0.27), and with age (p = 0.067). At multivariate analysis, complicated diverticulitis was the best predictor of fibrosis (odds ratio 4.4). Patient age and DDSS were other independent predictors.

Conclusion: DDSS-based assessment on preoperative CTC was a good predictor of chronic colonic inflammation and fibrosis. In addition, the presence of complicated diverticulitis on CT during the acute episode was most predictive of fibrosis.
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http://dx.doi.org/10.1007/s00261-020-02690-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7897191PMC
February 2021

The effect of a multidisciplinary approach for smoking cessation in patients with Crohn's disease: Results from an observational cohort study.

Tob Induc Dis 2020 2;18:29. Epub 2020 Apr 2.

Division of Pulmonary Diseases, Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milan, Italy.

Introduction: Cigarette smoking is the most important risk factor for Crohn's disease (CD). The effectiveness of smoking cessation programs (SCPs) in patients with CD is still poorly understood.

Methods: This was a retrospective, observational, single-centre, cohort study of 136 active smokers with mean age 55 years (SD=11), 58% males, including 27 (19.8%) patients with CD who entered the multidisciplinary SCP of the Luigi Sacco University Hospital of Milan from January 2017 through January 2019. A pulmonologist was responsible for the clinical and pharmacological management, while a psychiatrist and a psychologist conducted the counselling and assessed the motivation to quit, anxiety and depression using the Brief Psychiatric Rating Scale (BPRS) and the nicotine dependence with the Fagerström test. Patients were defined as quitters after 12 months.

Results: Demographic and clinical characteristics, and Fagerström score, did not differ in patients with and without CD. At baseline, patients with CD had a higher BPRS (median: 27, IQR: 22-32; vs 25 and 22-28.5; p=0.03), and a lower motivation to quit score (median: 10, IQR: 9-13; vs 14 and 12-15; p<0.001). After 12 months, the quitting rate of smokers with CD was significantly lower (14.8% vs 36.7%; p<0.022) and the chance of quitting was negatively associated with the baseline BPRS (r=-0.256; p<0.003). Varenicline and nicotine replacement therapy tended to be less effective in patients with CD.

Conclusions: The lower efficacy of SCPs in patients with CD might be secondary to a higher prevalence of anxiety and depression. Psychological issue recognition and support should be enhanced to increase SCP effectiveness in CD.
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http://dx.doi.org/10.18332/tid/119161DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7177387PMC
April 2020

Gastrointestinal Ultrasound (GIUS) in Intestinal Emergencies - An EFSUMB Position Paper.

Ultraschall Med 2020 Dec 20;41(6):646-657. Epub 2020 Apr 20.

Haukeland University Hospital, National Centre for Ultrasound in Gastroenterology, Bergen, Norway.

An interdisciplinary group of European experts summarizes the value of gastrointestinal ultrasound (GIUS) in the management of three time-critical causes of acute abdomen: bowel obstruction, gastrointestinal perforation and acute ischemic bowel disease. Based on an extensive literature review, statements for a targeted diagnostic strategy in these intestinal emergencies are presented. GIUS is best established in case of small bowel obstruction. Metanalyses and prospective studies showed a sensitivity and specificity comparable to that of computed tomography (CT) and superior to plain X-ray. GIUS may save time and radiation exposure and has the advantage of displaying bowel function directly. Gastrointestinal perforation is more challenging for less experienced investigators. Although GIUS in experienced hands has a relatively high sensitivity to establish a correct diagnosis, CT is the most sensitive method in this situation. The spectrum of intestinal ischemia ranges from self-limited ischemic colitis to fatal intestinal infarction. In acute arterial mesenteric ischemia, GIUS may provide information, but prompt CT angiography is the gold standard. On the other end of the spectrum, ischemic colitis shows typical ultrasound features that allow correct diagnosis. GIUS here has a diagnostic performance similar to CT and helps to differentiate mild from severe ischemic colitis.
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http://dx.doi.org/10.1055/a-1147-1295DOI Listing
December 2020

State of the art in the teaching of digestive ultrasound.

Med Ultrason 2020 03;22(1):71-74

Gastroenterology Unit. Centro Hospitalar de Vila Nova de Gaia e Espinho.

Gastrointestinal ultrasound (GIUS) has been increasingly used for the management of gastrointestinal disorders due to its potentialities as a cheap, widely available and safe examination with comparable accuracy to other techniques such as Computed Tomography or Magnetic Resonance Imaging. However, some limitations have been stated to justify its underuse such as its dependency on the operator, small field of view and penetration and need of expertise. However, most of these limitations are inherent to any technique. The main problems with GIUS are lack of standardized definitions, adequate training programs and measures to assess the quality. The definition of universally applicable standardized measurements, the implementation of an internationally recognized curriculum as well as an agreed set of core competencies and the assessment of performance will hopefully overcome its potential limitations and implement its utilization universally in clinical practice.
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http://dx.doi.org/10.11152/mu-2273DOI Listing
March 2020

What's New in Diagnosing Diverticular Disease.

J Gastrointestin Liver Dis 2019 Dec 19;28(suppl. 4):17-22. Epub 2019 Dec 19.

Gastrointestinal Unit, Department of Medical and Surgical Sciences, "Maggiore" University Hospital, Parma, Italy.

In this session different issues for the diagnosis of diverticular disease (DD) were considered including "Biomarkers", "Computer tomography", "Ultrasonography in detecting acute diverticulitis", "Endoscopy" and "The DICA classification: a new predictive tool in managing diverticular disease". Most patients affected by DD suffer from recurrent attacks of abdominal pain without evidence of an active inflammatory process, causing a difficult differential diagnosis with other intestinal conditions. Several biomarkers, serological, fecal, urinary and genetic were considered, but recent studies confirmed that only CRP and fecal calprotectin are matching with the criteria for an ideal biomarker for DD. Colonoscopy still remains the gold standard for the diagnosis of DD, playing a key role in many clinical settings, such as colonic diverticular bleeding, or to differentiate inflammatory bowel disease (IBD) and segmental colitis associated with diverticulosis (SCAD); Moreover, in 2015 has been developed the DICA (Diverticular Inflammation and Complication Assessment) endoscopic classification that considers 10 different parameters, each one with a score, and the sum of items scores represents the severity of the disease; in this way the endoscopic exam would be able to predict the outcome of DD for each patient. On the other hand, computer tomography (CT) is the gold standard for acute diverticulitis (AD) with an excellent sensitivity and specificity; recently, metanalysis of prospective studies have shown that intestinal ultrasonography (IUS) and CT have the same sensitivity for the diagnosis of an AD and the advantage is that IUS is less expensive, non-invasive and easily accessible.
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http://dx.doi.org/10.15403/jgld-553DOI Listing
December 2019

The DICA Endoscopic Classification for Diverticular Disease of the Colon Shows a Significant Interobserver Agreement among Community Endoscopists: an International Study.

J Gastrointestin Liver Dis 2019 Dec 19;28(suppl. 4):39-44. Epub 2019 Dec 19.

Department of Colorectal Surgery, King's College Hospital, London, United Kingdom.

Background And Aims: The Diverticular Inflammation and Complication Assessment (DICA) endoscopic classification of diverticulosis and diverticular disease (DD) is currently available. It scores severity of the disease as DICA 1, DICA 2 and DICA 3. Our aim was to assess the agreement on this classification in an international endoscopists community setting.

Methods: A total of 96 doctors (82.9% endoscopists) independently scored a set of DD endoscopic videos. The percentages of overall agreement on DICA score and a free-marginal multirater kappa (κ) coefficient were reported as statistical measures of interrater agreement.

Results: Overall agreement in using DICA was 91.8% with a free-marginal kappa of 88% (95% CI 80-95). The overall agreement levels were: DICA 1, 85.2%; DICA 2, 96.5%; DICA 3, 99.5%. The free marginal κ was: DICA 1 = 0.753, DICA 2 = 0.958, DICA 3 = 0.919. The agreement about the main endoscopic items was 83.4% (k 67%) for diverticular extension, 62.6% (k 65%) for number of diverticula for each district, 86.8% (k 82%) for presence of inflammation, and 98.5 (k 98%) for presence of complications.

Conclusions: The overall interrater agreement in this study ranges from good to very good. DICA score is a simple and reproducible endoscopic scoring system for diverticulosis and DD.
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http://dx.doi.org/10.15403/jgld-558DOI Listing
December 2019

International Consensus on Diverticulosis and Diverticular Disease. Statements from the 3rd International Symposium on Diverticular Disease.

J Gastrointestin Liver Dis 2019 Dec 19;28(suppl. 4):57-66. Epub 2019 Dec 19.

Division of Internal Medicine and Gastroenterology, CIC "Columbus", Catholic University - "A. Gemelli" University Hospital, Rome, Italy.

The statements produced by the Chairmen and Speakers of the 3rd International Symposium on Diverticular Disease, held in Madrid on April 11th-13th 2019, are reported. Topics such as current and evolving concepts on the pathogenesis, the course of the disease, the news in diagnosing, hot topics in medical and surgical treatments, and finally, critical issues on the disease were reviewed by the Chairmen who proposed 39 statements graded according to level of evidence and strength of recommendation. Each topic was explored focusing on the more relevant clinical questions. The vote was conducted on a 6-point scale and consensus was defined a priori as 67% agreement of the participants. The voting group consisted of 124 physicians from 18 countries, and agreement with all statements was provided. Comments were added explaining some controversial areas.
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http://dx.doi.org/10.15403/jgld-562DOI Listing
December 2019

Impact of intestinal ultrasound on the management of patients with inflammatory bowel disease: how to apply scientific evidence to clinical practice.

Dig Liver Dis 2020 01 13;52(1):9-18. Epub 2019 Nov 13.

Gastroenterology Unit, Department of Biomedical and Clinical Sciences, ASST Fatebenefratelli Sacco, "Luigi Sacco" Hospital, University of Milan, Italy.

Technological improvements and growing sonographers' expertise boost the role of intestinal ultrasound (IUS) in assessing patients with inflammatory bowel diseases (IBD). Non-invasiveness, low cost and good reproducibility make IUS attractive. Leveraging on the Authors' long-term field experience, this review focuses on the IUS role in IBD patients' clinical management. For detecting IBD, particularly Crohn's disease, the IUS parameters - above all the evidence of a thickened bowel wall (BWT) - show very good diagnostic accuracy similar to that of MRI or CT scan. The standard IUS parameters are not accurate enough to detect inflammatory activity, but intravenous contrast-enhanced US (CEUS) is highly accurate in ruling active inflammation out. However, its routinely use remains limited in clinical practice and its parameters need standardization. IUS is accurate in detecting IBD main complications: in particular, fistulae and abscesses. As to stenosis the recent introduction of IUS-based elastographic techniques allows to differentiate prevalently inflammatory from highly fibrotic strictures. IUS proves valid also for monitoring IBD patients. In particular, the evidence of transmural healing, defined as BWT normalization, has got an important prognostic meaning, as associated with better long-term clinical outcomes. Post-surgery CD recurrence can be suggested by early IUS assessment.
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http://dx.doi.org/10.1016/j.dld.2019.10.004DOI Listing
January 2020

Use, effectiveness and tolerability of budesonide-MMX in ulcerative colitis: A real-life experience.

United European Gastroenterol J 2019 11 17;7(9):1164-1170. Epub 2019 Jul 17.

Gastroenterology Unit, University of Milan, Milan, Italy.

Background: Budesonide-MMX has an established role in the management of relapsing mild-to-moderate ulcerative colitis. Data regarding effectiveness and tolerability in real-life clinical practice are limited.

Aim: The aim of this study was to assess the use of budesonide-MMX in ulcerative colitis, as well as short-term effectiveness and tolerability in real-life practice.

Methods: We conducted a retrospective study of adult patients with mild-to-moderate ulcerative colitis treated with budesonide-MMX at four tertiary inflammatory bowel disease centres in Italy from June 2016 to February 2018. Demographic and clinical features of patients, the use of budesonide-MMX, disease course and concomitant therapy were recorded. The primary outcome assessed was clinical remission at 2 months.

Results: A total of 82 patients with active mild-to-moderate ulcerative colitis were included in the study with a mean age of 45.9 years and a median partial Mayo Score of 4 (interquartile range 3-5). A total of 41 patients were male. Overall, 36 had extensive colitis, 38 left-sided colitis and eight proctitis. Treatments at the time of inclusion included 10 patients receiving biologic therapy, seven azathioprine and 54 mesalazine or salazopyrin. The main reasons for the addition of budesonide-MMX were clinical relapse (47.5%) or inadequate response to current therapy (39.0%). In total, 50% of patients achieved clinical remission, whereas 9.8% had clinical improvement. No response was noted in 40.2% of subjects. Using multivariate binary logistic regression, a moderate degree of activity was the main independent predictor of non-response. Eight significant adverse effects were reported in six patients with three discontinuing treatment.

Conclusion: In real-life clinical practice, budesonide-MMX is commonly used in combination with other therapies, both for acute disease flares and for partial response to therapy.
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http://dx.doi.org/10.1177/2050640619864257DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6826517PMC
November 2019

EFSUMB Gastrointestinal Ultrasound (GIUS) Task Force Group: Celiac sprue and other rare gastrointestinal diseases ultrasound features.

Med Ultrason 2019 Aug;21(3):299-315

National Centre for Ultrasound in Gastroenterology, Department of Medicine, Haukeland University Hospital, Bergen, and Department of Clinical Medicine, University of Bergen, Norway.

Transabdominal gastrointestinal ultrasound (GIUS) is unique in its capacity to examine the bowel non-invasively and in its physiological condition, including extra-intestinal features such as the splanchnic vessels, mesentery, omentum and lymph nodes- even at the bedside. Despite this, and its extensive documentation for its usefulness, it has only been fully implemented in a few European countries and expert centres. Therefore, the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) established a GIUS Task Force Group in 2014 consisting of international experts from 9 European countries with the objectives to standardize and promote the use of GIUS in a clinical setting. This is achieved by publishing clinical guidelines and recommendations on indications and use of GIUS and so far,4 guidelines have been published: first on "examination techniques and normal findings", second on "inflammatory bowel disease", third on "acute appendicitis and diverticulitis" and fourth on "transrectal and perineal ultrasound".This paper describes the ultrasound features of miscellaneous disorders such as celiac disease, cystic fibrosis, omental infarction, Meckel's diverticle, endometriosis, intestinal neoplasia, mucocele, amyloidosis, GVHD, foreign bodies, vasculitis, and pneumatosis cystoides intestinalis. Bowel ultrasound can be indicated in most of these conditions to investigate intestinal symptoms but in other cases the alterations of the bowel can be also an incidental finding that suggest other examinations which finally help to discover an unknown pathological condition.
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http://dx.doi.org/10.11152/mu-2162DOI Listing
August 2019
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