Biosimilars monoclonal antibodies in the therapy of inflammatory bowel diseases An important milestone in the development of Crohn’s disease and ulcerative colitis therapy, or just a sophisticated generic?

Summary: In 2013, EMA approved the fi rst biosimilar infl iximab CT-P13 for clinical practice in all indications of the original infl iximab. Since 2015, biosimilar infl iximab has been extensively used in patients with Crohn‘s disease and ulcerative colitis also in the Czech Republic. Biosimilar infl iximab is very similar to the original infl iximab in terms of its macromolecular structure, and its clinical eff ects, adverse events and immunogenicity are identical to those of the original infl iximab. Biosimilar biologics which have been introduced in clinical practice signifi cantly reduced therapeutic costs and improved access to an innovative therapy and facilitated a new therapeutic strategy, with pro-active drug monitoring and fl exibility in dosing. Biosimilars are associated with a signifi cant improvement in the therapeutic armamentarium, which makes them one of the important therapeutic milestones in the treatment of infl ammatory bowel disease. Key words: bio similars – bio logic therapy – Crohn’s disease – ulcerative colitis

Diet after bariatric surgery in practice

Summary: Bariatric-metabolic surgery is associated with many health benefi ts and improved quality of life. However, the resulting eff ect largely depends on the patient’s compliance and willingness and ability to adopt a new diet, which is associated with bariatric procedures. A whole team of experts plays an important role in preparing the patient for this change. Appropriately composed diet and adherence to the frequency and size of portions is essential in the prevention of nutritional defi ciencies. The bariatric food pyramid is a suitable helper for the implementation of nutritional recommendations. Key words: main nutrients – energy intake – bariatric food pyramid – bariatric plate

Azathioprine in the therapy of paediatric inflammatory bowel disease – part II: pharmacodynamics, pharmacokinetics, and the possibilities of measuring its metabolites in clinical practice

Summary Background: Thiopurines (predominantly azathioprine and mercaptopurine) are widely used in paediatrics to maintain remission in the treatment of inflammatory bowel disease. After its absorption from the gastrointestinal tract, azathioprine is converted into 6 mercaptopurine in approximately 90%. Several enzymes (such as thiopurine methyltransferase, xanthine oxidase and hypoxanthine-guanine phosphoribosyl transferase) participate in its further metabolism, producing non-active methylated metabolites (6 methylmercaptopurine) and thiouric acid and active 6-thioguanine nucleotide. The concentration of these metabolites can be measured in red blood cells. Aim: To map the benefits and possibilities of thiopurine metabolites measurements in patients suffering from inflammatory bowel disease. Conclusion: The measurement of active and non-active metabolites can help evaluate the bioavailability of those drugs, identify some causes of adverse effects and reveal non-adherence. Keywords Crohn’s disease, merkaptopurin, pediatrie, thiopuriny, ulcerative colitis

The indications for performing colonoscopy in Iranian children – a cross-sectional study

Background: Colonoscopy is the gold standard dia­gnostic method for colon diseases providing an excellent view of the mucosal surface of the colon and terminal ileum. Colonoscopy in children is indicated for dia­gnosis and treatment of gastrointestinal diseases. In this study, we evaluated the reasons for performing colonoscopy in children. Methods: This was a descriptive cross-sectional study including all children referred for colonoscopy to the Gastroenterology clinic affiliated with the Shiraz University of Medical Sciences. The children were selected by a convenient sampling method. Statistical analysis was conducted in the SPSS 22 software. Results: From 389 children referred for colonoscopy, 203 were boys and 186 were girls. The mean age was 8.36 ±4.8 years. The most common reason for colonoscopy was rectal bleeding (63.5%) with the most prevalent dia­gnoses being juvenile polyp and inflammatory bowel disease, each accounting for 11.3% patients. Conclusions: The most common findings of colonoscopy were polyp, IBD and colon inflammation, and the most prevalent symptoms leading to colonoscopy were rectal bleeding, chronic diarrhea, IBD treatment follow-up, suspected IBD and abdominal pain. The high prevalence of pediatric patients presenting with these symptoms indicates the increasing importance of colonoscopy in these patients. Keywords colonoscopy, gastrointestinal bleeding, inflammatory bowel disease, gastrointestinální onemocnění

Gluten-related immunogenic peptides in stool as means to monitor compliance with gluten-free diet in children with newly dia gnosed coeliac disease

Objectives and study: To compare the values of gluten-related immunogenic peptides (GIP) in stool and anti-tissue transglutaminase IgA antibodies (anti-tTG IgA) in blood in children newly diagnosed with coeliac disease (CD). Methods: All children (2–15 y) newly diagnosed with CD between May 2018 and May 2020 at our clinic who complied with the inclusion criteria were invited to join the prospective study. During workup for CD, a stool sample to measure GIP was taken together with a blood sample to measure anti-tTG IgA. All newly diagnosed children were invited 4 months later for a check-up. Children and their caregivers were asked about known non-compliance with the gluten-free diet (GFD), a blood sample was taken to measure the anti-tTG IgA, and a stool sample was collected to measure GIP. Blood was evaluated for anti-tTG IgA by ELISA, and the stool was tested by quantitative Sandwich ELISA designed to detect and quantify GIP using the G12 antibody. Values of GIP and anti-tTG IgA were compared in terms of their relation to the upper limit of normal (ULN) of the particular method. Results: 29 children (18 girls) were enrolled in the study. The values of GIP in stool at the time of diagnosis were above the ULN (0.15 µg/g) in all children. Average 4.21, median 3.29, standard deviation (SD) 3.7. After the four months, all but three (89.7%) had values of GIP in the reference range. Average 0.29, median 0.12, SD 0.73. Similarly, anti-tTG IgA values were above the ULN (9.9 U/mL) at the time of diagnosis in all children. Average 164, median 195, SD 49. Although the anti-tTG IgA levels were lower at check-up in all but one child, only 10 (34.5%) showed values within the normal range, with an average of 27.9, median 12.0, and SD 38.9. All children declared strict adherence to GFD. Discussion: Using the GIP concentration in stool, adherence to GFD in our cohort of children is very good, better than that described in literature. Conclusion: Measuring GIP in stool could prove a more sensitive indicator of adherence to GFD in the early months after the diagnosis of CD when anti-tTG IgA are still elevated above the ULN due to their well-described gradual decrease after GFD initiation.

Azathioprine in the therapy of paediatric inflammatory bowel disease – part I: treatment indications, dosing and thiopurine-related adverse events

Background: Thiopurines (in Europe mainly azathioprine) are widely used in the treatment of inflammatory bowel diseases in children. Due to a prolonged time until the onset of therapeutic effect, those drugs are aimed to be used in the maintenance phase of the therapy rather than for induction of remission. Thiopurines are sometimes used in combination therapy (with aminosalicylates or biological treatment agents). The adverse events of these drugs occur as often as in 15–40% cases and may lead to treatment cessation in a significant number of patients. Aims: To overview available information on (mainly) children suffering from inflammatory bowel disease. Conclusion: Genetic examination accompanied with laboratory monitoring of blood count parameters (specifically at the beginning of therapy) and biochemistry can help prevent some of the severe adverse events. Keywords Crohn’s disease, ulcerative colitis, pediatrie, merkaptopurin, thiopuriny

Eff ect of ursodeoxycholic acid in postcholecystectomy cholestatic hepatopathy verified by ultrasonography

Summary: Cholestasis syndrome is accompanied by a large number of diverse liver and biliary tract diseases. Many cholestatic changes are fully reversible in the fi rst phase. However, with long-term cholestasis, extensive hepatocyte dysfunction occurs, the disease progresses, and many cholestatic syndromes result in irreversible liver damage and failure. Cholestatic liver diseases represent an important group of liver diseases that are an indication for liver transplantation. Postcholecystectomy syndrome is an imprecisely defi ned term, which includes a set of ongoing or recurrent or new diffi culties of patients after gallbladder surgery. We distinguish between early postcholecystectomy syndrome immediately in the postoperative period, or late postcholecystectomy syndrome, which occurs months or even years later. Ultrasonography is the fi rst imaging examination method for diseases of the liver and hepatobiliary system. It is a non-invasive method, available, relatively cheap, easily repeatable, and it does not represent a burden for the patient. Common bile duct dilatation after cholecystectomy is a common accidental fi nding that is inconclusive in the absence of clinical symptomatology and with normal laboratory fi ndings. Ursodeoxycholic acid forms the basis of cholestasis therapy, the only treatment whose effi cacy in cholestatic liver disease has been demonstrated in randomized and long-term studies. A further positive is that many years of ursodeoxycholic acid administration are not accompanied by more serious side eff ects. This case report supports the concept of a prompt and at the same time deepening benefi cial eff ect of ursodeoxycholic acid treatment in patients with cholestatic hepatopathy verified by ultrasonography indicated for conservative treatment or refusing invasive treatment. Key words: cholestasis – postcholecystectomy syndrome – ultrasonography – ursodeoxycholic acid

Assistance system for real-time polyp detection based on convolutional neural network

Summary: The use of artifi cial intelligence as an assistive detection method in endoscopy has attracted increasing interest in recent years. Machine learning algorithms promise to improve the effi ciency of polyp detection and even optical localization of fi ndings, all with minimal training of the endoscopist. The practical goal of this study is to analyse the CAD software (computer-aided dia gnosis) Carebot for colorectal polyp detection using a convolutional neural network. The proposed binary classifier for polyp detection achieves accuracy of up to 98%, specifi city of 0.99 and precision of 0.96. At the same time, the need for the availability of large-scale clinical data for the development of artifi cial- -intelligence-based models for the automatic detection of adenomas and benign neoplastic lesions is discussed. Key words: polyp detection – convolutional neural network – artifi cial intelligence – computer-aided dia gnosis – spatial location