OBJECTIVES:VSL#3 is a high-potency probiotic mixture that has been used successfully in the treatment of pouchitis. The primary end point of the study was to assess the effects of supplementation with VSL#3 in patients affected by relapsing ulcerative colitis (UC) who are already under treatment with 5-aminosalicylic acid (ASA) and/or immunosuppressants at stable doses.METHODS:A total of 144 consecutive patients were randomly treated for 8 weeks with VSL#3 at a dose of 3,600 billion CFU/day (71 patients) or with placebo (73 patients).RESULTS:In all, 65 patients in the VSL#3 group and 66 patients in the placebo group completed the study. The decrease in ulcerative colitis disease activity index (UCDAI) scores of 50% or more was higher in the VSL#3 group than in the placebo group (63.1 vs. 40.8; per protocol (PP) P=0.010, confidence interval (CI)95% 0.51–0.74; intention to treat (ITT) P=0.031, CI95% 0.47–0.69). Significant results with VSL#3 were recorded in an improvement of three points or more in the UCDAI score (60.5% vs. 41.4% PP P=0.017, CI95% 0.51–0.74; ITT P=0.046, CI95% 0.47–0.69) and in rectal bleeding (PP P=0.014, CI95% 0.46–0.70; ITT P=0.036, CI95% 0.41–0.65), whereas stool frequency (PP P=0.202, CI95% 0.39–0.63; ITT P=0.229, CI95% 0.35–0.57), physician's rate of disease activity (PP P=0.088, CI95% 0.34–0.58; ITT P=0.168, CI95% 0.31–0.53), and endoscopic scores (PP P=0.086, CI95% 0.74–0.92; ITT P=0.366, CI95% 0.66–0.86) did not show statistical differences. Remission was higher in the VSL#3 group than in the placebo group (47.7% vs. 32.4% PP P=0.069, CI95% 0.36–0.60; ITT P=0.132, CI95% 0.33–0.56). Eight patients on VSL#3 (11.2%) and nine patients on placebo (12.3%) reported mild side effects.CONCLUSIONS:VSL#3 supplementation is safe and able to reduce UCDAI scores in patients affected by relapsing mild-to-moderate UC who are under treatment with 5-ASA and/or immunosuppressants. Moreover, VSL#3 improves rectal bleeding and seems to reinduce remission in relapsing UC patients after 8 weeks of treatment, although these parameters do not reach statistical significance.

SUMMARY BackgroundThe impact of not referring sub-centimetre polyps identified at CT colonography upon the efficacy of colorectal cancer screening remains uncertain.

Background: Type I gastric carcinoids (TIGCs) are neuroendocrine neoplasms arising from enterochromaffin-like cells in atrophic body gastritis. Data regarding their evolution in prospective series are scarce, thus treatment and follow-up are not codified. Our aim was to evaluate clinical outcome and recurrence in TIGCs managed by endoscopic approach. Methods: 33 patients (24 females; median age 65 years, range 23–81) were included and managed through endoscopic follow-up every 6–12 months, with lesion removal and multiple gastric biopsies. Baseline clinical and histological features were analyzed as risk factors by Cox regression. Results: At diagnosis, 7 tumors were intramucosal carcinoids and 26 were polyps (median diameter 5 mm, range 2–20), multiple in 17 patients. Associated severe atrophy was present in 21 cases (63.6%), while mild atrophy was found in 6 cases (18.2%). During a 46-month median follow-up, survival was 100% and no metastases occurred. One patient developed a less-differentiated carcinoid that was radically treated by surgery. 21 patients (63.6%) had recurrence after a median of 8 months, 14 of these (66.6%) had a second recurrence after a median of 8 months following the previous carcinoid removal. Median recurrence-free survival was 24 months. Neither clinical nor biochemical recurrence-predicting factors were found. Conclusions: Although about 60% of TIGCs had recurrence after endoscopic resection, endoscopic management may be considered safe and effective.

Background Random biopsies are recommended to identify individuals at risk of gastric adenocarcinoma. Cumulative evidence suggests that narrow-band imaging (NBI) can be used to grade gastric intestinal metaplasia (GIM). We aimed to externally validate a classification of endoscopic grading of gastric intestinal metaplasia (EGGIM). Methods Consecutive patients in two centers were submitted to high resolution white-light gastroscopy followed by NBI to estimate EGGIM – a score (0 – 10) resulting from the sum of endoscopic assessments of GIM, scored as 0, 1, or 2 for no GIM, ≤ 30 %, or > 30 % of the mucosa, respectively, in five areas (lesser and greater curvature of both antrum and corpus, and incisura). If GIM was endoscopically suspected, targeted biopsies were performed; if GIM was not noticeable, random biopsies were performed according to the Sydney system to estimate the operative link on gastric intestinal metaplasia (OLGIM; the gold standard). Results 250 patients (62 % female; median age 55 years) were included. GIM was staged as OLGIM 0, I, II, III, IV in 136 (54 %), 15 (6 %), 52 (21 %), 34 (14 %), and 13 (5 %) patients, respectively. All patients with GIM except three were identifiable with targeted biopsies. For the diagnosis of OLGIM III/IV, the area under the ROC curve was 0.96 (95 % confidence interval [CI] 0.93 – 0.98) and by using the cutoff > 4, sensitivity, specificity, and positive likelihood ratio were 89 %, 95 %, and 16.5, respectively; results were similar (91 %, 95 %, and 18.1) when excluding patients with foveolar hyperplasia. Conclusions For the first time, an endoscopic approach was externally validated to determine the risk of gastric cancer without the need for biopsies. This can be used to simplify and individualize the management of patients with gastric precancerous conditions.

The quality of colonoscopy was affected by patient-related, endoscopist-related and centre-related characteristics. Policies addressing organisational issues should improve the quality of colonoscopy in our programme and similar programmes.