6 IlANEAAHNIO MJEAPlO IOlOnAOQN @AErMONRBQN NOIQN TOY ENTEPOY (EAAHNIKH o r a w rwm- HZ IQNE)

A r u

9 IlANEMHNIO IYNEAPIO 6 IAIOflAOON @AErMONnbQN N Q M TQY ENKPQY

(EMHNIKH O M A M MEAETHZ IONE)

FODELE BEACH HOTEL

AlOlKHTlKO NMBOYAIO EMHNIKHI O M W ME/\ETHI IONE

Prof. J.F. Colombel Prof. S. Vermeire Prof. C. Gashe Prof. J. Schoelmerich

(EMHNIKH OMAAA MEAETH): IONE)

OMIAIEZ

ANEMIA IN IBD Christoph Gasche . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

THERAPEUTIC PROSPECTS IN IBD Jiirgen Schalmerich . . . . . . . . . . . . . .

LONG-TERM EFFICACY AND IMMUNOGENICITY OF BIOLOGICALS USED IN IBD Severine Vermeire . .

POSITIONING BIOLOGIC THERAPY IN THE FUTURE FOR THE TREATMENT OF IBD JF Colombel.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

THE ROLE OF T LYMPHOCYTES IN THE PATHOGENESIS OF INFLAMMATORY BOWEL DISEASE Konstantinos A. Papadakis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

ANOZOKATAZTAATIKA ZTHN IAlOnAOH QAETMONRAH IlAOHZH TRN ENTEPRN Kwvmavrivoq X. Ka~a6voq . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

0 POAOI THE NTXPONHE AllEIKONIZHZ I T H AlArNRmIKH n P O Z n E M H KAI ANTIMETRlllEH TRN AIOENRN ME NOZO CROHN. llPOITIOEMENH AEIA A n 0 THN XPHZH ENIZXYTIKQN OElRN ITHN YllEPHXOTOMOTPAOIA TOY AEnTOY ENTEPOY 1. A. r~appevi~qq. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

ATIEIKONIITIKH AIEPEYNHZH THZ IONE ME NEOTEPEZ TEXNIKEZ YnOAOrIZTIKHZ TOMOTPAQIAI (YT ENTEPOKAYZH - YT ENTEPOTPAQIA) M. Aao~ahoy1awa~11. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

TEXNIKEI APXEI THE MATNHTIKHI ENTEPOKAYZHI N. nanav1~oA6ou. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

NEQTEPE AnEIKONIITIKE MEOOAOI I T H AIArNQZH THE IONE: A!IOAOrHZH ME NMBATIKH KAI MArNHTlKH ENTEPOKAYZH I. rpappClTlK&Kqq. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

IAlOnAOHI @AErMONQAHZ NOZOZ TOY ENTEPOY ITHN nAlAlKH HAIKIA: KAINIKH EKOPAZH M. @w~ouAa~q. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

IAlOllAOHZ OAErMONQAHZ NOZOI TOY ENTEPOY ITA nAlAlA-AlArNQETl KH n P O I n E M H AiyAq 2. ZEMOU. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - 4 0

OEPAnElA @AErMONQAQN IlAOHZEQN TOY ENTEPOY ITA nAlAlA r 1 6 ~ a Kacppi~ua . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

AAOH ITHN ANTIMETQnlZH TQN nAlAlQN ME IONE - I. flavay16~ou. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

APOPIKEZ EKAHAQZEIZ IYZXETIZOMENEZ ME IAlOnAOH OAETMONQAH NO10 TOY ENTEPOY B. Mapyapi~qq . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46

MH APOPITIKEZ EiQENTEPIKEI EKAHAQZEII IONE r. I. 0 ~ 0 ~ 6 p q q . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

NPlrrOnOlHTlKH NOZOZ CROHN Kwvlvoq Kappipqq . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

XElPOYPrlKA nPOBAHMATA IXETIZOMENA ME TIZ IOEN I.Pwpav6q . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

0 POAOE THE MIKPOBIAKHZ X A Q P l M ZTHN AlTlOnAOOrENElA TON IAlOnAOQN OAETMONQAQN ENTEPOnAOElQN Mapia POUUUO~OUUT~K~K~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

rENETlKH TON IONE Mlxdhqq OIKOV~~OU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

IlEPlBAMONTlKOl TIAPATONTEZ ZTH nAOOrENElA TQN IONE repaa~poq I. Mdvr<apqq K ~ I AyyeA~~fi Xp~mi6ou . . . . . . . . . . . . . . . . . . . . . 73

POSTERS

AnOTEAEZMATI KOTHTA TOY ADALI M UMAB ZTOE IlAD(ONTE1 A n 0 N.CROHN META A n 0 AnOTYXIA 'H ANElllOYMHTEZ ENEPTEIEZ ZE l N FLlXl MAB r. KouKha~qq, N. Aupav~<6nouAoq, E. Eucppalpi6ou, I. M6q(oq, n.Zk<oq, E. nauAi6ou, M. nanayswpyiou, K. MavwACIq . . . . . . . . . . . . . . . . . . 82

MEAETH AElKTQN AnOllTQZHZ KAI NEOArrEIOrENEZHZ ZE MOENEIZ ME IAlOnAOH OAETMONQAH NOZO TOY ENTEPOY. nPOAPOMH ANAKOINQZH KouKha~qq r, TaAoup~<fiq X, Aupa~<6nouAoq N, Eucppalpi6ou E, M6q(oq I, Pwpavi6qq K, MavwAaq K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

OEPAnEMl KH ANTIMETQnlZH IAlOllAOOYZ OAETMONQAOYZ NOZOY TOY ENTEPOY (IONE) ZTA nAlAlA I. navayrcli~ou, I.naxouAa, A.Kwvmavnvibou, A. ABavaub~q, A. ia166pa, A. noAu<oq, E. Opcpavou, E. Pclipa-r~awi~ou . . . . . . . . . . . . . . . . . . . IAlOnAOHZ OAETMONQAHZ NOIOY TOY ENTEPOY (IONE) ZTA nAlAlA ZTHN E W : EMnElPlA 27 ETQN E. Pclipa-r~awi~ou, I. navay~cli~ou, I. naxouha, A. noAu<oq, A. Kovmavr1vf5ou, A. Aoupfaa, E. Opcpavou . . . . . . . . . . . .

IAlOnAOHZ OAETMONQAHI N O I O I TOY ENTEPOY (IONE) ITA IlAlAlA: Ol KOrENElAKH Elll I lTQIH I. naxouAa, A. noAuZoq, I. navayrhrou, A. Kuvmawrvibou, 0. nmponouAou, A. ZdMou, E. Aay~hva, E. Pwpa-rrawi~ou . . . . . . . . . . . . . . . . . . . . . . . . . . 86

AY:HMENH EnlnTQZH TOY NNAPOMOY YTIEPEMIKOTHTAZ TQN APOPQZEQN I E AZOENEIZ ME NO10 CROHN. Bouvo~punibqq n&plKhdq, Kou~Aa~qq ~ B ~ P Y I O ~ , A u ~ ~ T < ~ H o u A o ~ N1~6Aaoq, Eucppa~pibou EACvq, ZCZoq nhpoq, MavuAbq Kuvmawivoq . . . . . . . . . . . . . . . 87

fllAOTl KH NrKPlTlKH MEAETH T H I En lAPEHI T H I NTXOPHTHIHI INOAIiIMAMnHI KAI AZAOElOnPINHI ENANTI THE XOPHTHZHZ YAPOKOPTIZONHI nPlN THN E M H INOAI:IMAMIlHZ ZTHN AflOTPOnH T H I OEPAnEYTIKHZ EKnTQZHI KAI THN EOAAEIA THE INQ>AIZIMAMnHI. A. Xpqmibou, A. POUUUO~, Xp. KaAavrSfiq, I. KOIA~KOU, N. Phmqq, I. KaAacparhq, N Anom6Aou, E. rpipaq, N. Kav&M6nouAoq, I. KaAoysp6nouAoq, nA. nrnsp6nouAoq, N KaAawSfiq, r. I. M6vrZapqq.. . . . . . . . . . . . . . . . . . . . . 88

AElTOYPrlKOl nOAYMOPOIZMOI TOY rONlAlOY NRAMPI I T H NO10 TOY CROHN M. raZodAq, r. I. M6\rrzapqq, A. Xpqmibou, A. Apxrpavbpi~qq, N. n. Avayvou . . . . 89

ElllAPAZH THZ XPONIAZ OEPAnEIAZ ME INOAI3MAMnH ZTHN ANAflTFH AYTOANTIIQMATQN I E EOENEIZ ME IAlOnAOH OAETMONQAH ENTEPOnAOEIA: nPOAPOMA AnOTEAEIMATA. r. I. Mavrzapqq, A. Xpqmibou, I. MnaAaq, A. Pouoooq, N. Kav&M6nouAoq, I. KOIA~KOU, N. P6rnqq, I. KaAacpa~dq, N Anom6Aou, E. rpipaq, A. Torpoyrawq, Xp. nanamrpr6bq, A. N ~ K o ~ , A. Apxlpavbphqq, . . . . . . . . . . . . . . . . . . . . . . 90

MEAETH MAKPOXPONIAZ AZOAAEIAI T H I OEPAnEIAZ ME AZAOElOnPlNH t r H N IAlOnAOH OAETMONQAH nAOHZH TQN ENTEPQN: AllOTEAEIMATA ENOI KENTPOY ANAOOPE. Kwvmawivoq X. K ~ T u ~ v o ~ , Marc Ferrante, Herma Fidder, Liesbet Henckaerts, Aqpfirp~oq K. XprmobouAou, Gert Van Assche, Enape~vhvbaq B. Tordvoq, SOverine Vermeire, Paul Rutgeerts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91

EnlAHMlOAOrlKH nP00flTlKH MEAETH ZYIXETIZHZ IAlOllAOOYI OAETMONQAOE IlAOHZHZ TQN ENTEPQN KAI O@OAAMOAOrIKQN EKAHAQZEQN U H BOPEIOAYTIKH E W T. QehC~qq, M. KITU~VOU, K. Ka~udvoq, A. XprmobouAou, A. ~anaeavau6nouAoq, B. Oe6nrmoq, I. Aurrpoubqq, E. B. Tur6voq. . . . . . . . . . . . . . . . . . . . . . . . . 92

E f l l f lOMMOZ KAI KAINIKH ZHMAZIA THZ YflEPAMYAAWIMIAI ETHN IAlOflAOH OAETMONQAH flAOHIH TQN ENTEPQN K. X. Ka~u6voq, B. Oe6nrmoq, A. nanaeavauonouAoq, 0. Baurou, ll. Zhqq, B. rpappevrdtqq, A. XprmobouAou, E. B. Tu16voq. . . . . . . . . . . . . . . . . . . . . 93

H IlEPlEAPlKH flPOIBOAH THZ NOZOY TOY CROHN ZTHN BOPEIOAYTIKH E M ABav6oroq nanaeavau6nouAoq, Kwvmavrivoq K ~ T u ~ v o ~ , Aqpfi~proq XprarobouAou, Enapewhvbaq B. Tarbvoq. . . . . . . . . . . . . . . . . . . .94

MEMONQMENH EMEIUJH ACTH ZE AZOENH ME NO10 TOY CROHN rehpyloq KaAapn6~qq, BaarAr~fi BaurAeiou, Aewvibaq Xpfimou, AyaeoKhfiq Taa~oouAqq, Enaperv3vbaq B. Tardvoq . . . . . . . . . . . . . . . . . . . .95

AKIOAOrHZH IlEPIEAPIKHZ NOZOY CROHN KATEYOYNOMENH A n 0 TA EYPHMATA THE MATNHTIKHZ TOMOTPAOIAZ nYEAOY A. Mnoupi~aq, H. 3 6 a , B. OIKOV~~OU, n. Mnouppnd~q, I. Kapavravaq, H. KoupoupaAqq, I Kou~poupn6~qq. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96

flPOTYflOll01HMENH flPOOnTlKH MEAETH KATArPA@HI KAI EIOAOrHZHZ nAPArONTQN KINAYNOY YnOTPOnHZ ZE AIOENEIZ ME IAlOnAOH OAETMONQAH ENTEPIKH NOZO (DEN) K. Kappipqq, I.E. Kou~poupn6~qq, n. OumapavwA6~qq, I. MoqavbpCa, H. KoupoupaAqq. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97

01 ANAZTOAEIZ THZ INQAOTONOAEHZ TAFl KAI PAI-I ITIZ IAlOflAOEIZ @AErMONQAEIZ ENTEPIKEZ NOZOYI r. TuroAa~i6ou, I. E. Kou~poupnd~qq, A. Z(puplbd~q, K. Kou~ou~oq, A. OeoboponouAou, H. A. KoupoupaAqq. . . . . . . . . . . . . . . . . . . . . . . . . . . 98

OITIKH IlYKNOTHTA ZE KPHTIKOE KOENEI I ME IAlOnAOElZ DAETMONRAEII ENTEPIKEI N O t O E X. Zapdq, I. Kou~poupn6~qq, I. N&pav~<ouA6~qq, r. nanabd~qq, 0. B o u ~ o u ~ ~ , I. AapqA6~qq, H. KoupoupaAqq . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99

H NMBOAH TRN PAA~OIZOTO~~KQN TEXNIKQN AnElKONltHZ ME THN XPHtH OElQN ElllZHMKMENRN ME Tc-99m I T H AlArNnZH KAI IlAPAKOAOYOHZH TRN AZOENQN ME IAlOflAOEII Q>AErMONQAEIZ ENTEPIKE NOZOE (IDEN) Mapia ZTCI~~K~, I U ~ W ~ S K o w ~ o u ~ H ~ K ~ ~ , Zocpia K O U K O U ~ ~ K ~ , Kwvmavrivoq Kappipqq, HAiaq KoupoupaAqq, N1~6Aaoq Kap~api~uaq.. . . . . . . .I00

ANOZOTENETIKOI AEIKTEZ (AnAOTYnOl HLA) ZE AIOENEII ME NOIO CROHN: X X E T I I H ME DAINOTYnlKEZ EKAHARZEII T H I NOIOY A. Xpqmibou, r. I. MhvTcapqq, AIK. Tapdon, 0. Aeavau~dbqq, Xp. nanamsp~dbq, A. Apxlpavbpi~qq . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,101

MArNHTlKH ENTEPOKAEH ME XOPHrHZH 1x0-OZMQTIKOY YAATIKOY AIAAYMATOZ KAI XPHIH THZ AKOAOYOIK TRUE FlSP N. flanav1noA6ou, K. Ka ppfpqq, I. rpappa~l K ~ K ~ S , L ~ K O U ~ T U O Y ~ ~ W C ) ,

I\. Mnoupi~aq, M. P O U U U O ~ O U ~ ~ K ~ K ~ , H. KoupoupaAqq, N. ~ K O U ~ T U O ~ ~ ~ W ~ ~ . . ,102

STRlCTURlNG ESOPHAGEAL DISEASE COMPLICATING GLYCOGEN STORAGE DISEASE TYPE 1 b (GSB-1 b): CASE REPORT P. Nicolaou, G. Bamias, B. Sazanidis, K. Makrilakis, C. Mavrogiannis, I. Vafiadi . . 103

' (EAAHNIKH O M A M MEAETHE l@NE)

(EMHNIKH OMAAA MEAETtll IONE)

ANEMIA IN IBD

Christoph Gasche,

M. D., Medical University of Vienna, Department of Medicine IV and General Hospital Vienna, Austria. christo~h.gasche@meduniwien.ac.at, fax +43 1 40400 4735

lron deficiency is the most common disorder in the world. The numbers are staggering: as many as 4-5 billion people may be iron deficient; and 2 billion people - over 30% of the world's population - have iron deficiency anemia (WHO report 2002). lron deficiency is not only a disease in developing countries; it also affects the Western world. Food fortification and iron supplementation are in place to battle iron deficiency anemia.

lron is a common constituent in of our environment. It is the essential participant in many redox processes in eukaryotes and most prokaryotes. lron homeostasis in organisms is regulated at the level of iron uptake. This system is conserved through evolution to prevent toxic iron overload. Injuries and diseases, however, may cause excessive loss of iron, mainly by bleeding and may interfere with iron absorption resulting in

iron deficiency anemia. About one third of patients with inflammatory

bowel diseases are anemic. Anemia results from a combination of iron deficiency and chronic disease due to intestinal inflammation. Blood loss is a key symptom of ulcerative colitis. In Crohn's disease, ileal disease location also causes blood loss which is, however, typically invisible. During the past decade relevant progress has been made in the understanding and treatment of IBD-associated anemia. My alert hopes to reach gastroenterologists who care for IBD patients: Start to care about their low hemoglobin levels, since the quality of life in these patients may be as low as in anemic patients with advanced cancer. Successful treatment of anemia can improve quality of life, cognitive function, and the ability to work.

I IAlOflAOnN 1 QAETM0N-N 1 NOX2N I TOY I ENTEPOY~

THERAPEUTIC PROSPECTS IN IBD

Jiirgen Scholmerich

Prof. Dr. Jiirgen Scholmerich, Klinik und Poliklinik fiir lnnere Medizin I, Klinikum der Universitat Regensburg

Thus far all treatments available and most under development aim at inhibiting or modulating the effects of the array of mediators produced by inflammatory cells such as chemokines, cytokines and others. This has led to remarkable success using conventional treatments although neither cure of the disease nor even causal treatment has been achieved. More recently individual cytokines have been inhibited, in particular tumor necrosis factor. The results have somehow been disappointing although a better use of these expensive drugs might improve the outcome. Many other biologicals, for example inhibiting cell adhesion and other pro-inflammatory cytokines, have been developed and are under active investigation. However, thus far none has been shown to be a "magic bullet".

A few alternatives have been discussed, in particular autologous stem cell transplantation, the use of growth factors and hormones as well as completely different approaches using for example antidiabetic drugs and nutritional concepts. It has been in particular found that probably we need a number of different approaches since there is no such thing as Crohn's disease and even ulcerative colitis which both represent a group of phenotypically and genotypically different

disorders probably needing differentiated treatments.

More recently the concept of the defect barrier has achieved prominent attention again. Data from animals and from humans suggest that barrier disturbances including the lack of endogenous antibiotic peptides, erroneous recognition of commensal bacteria and abnormal bacterial epithelial interaction are main causes for these syndromes. Consequently endogenous and exogenous substances influencing luminal contents, in particular bacteria, as well as membrane functions have been tested. In particular probiotics, phosphatidylcholine and even bile acids have been studied, endogenous canabinoids and others will probably be tested as well.

In summary the shift of etiological and pathophysiological thinking from the general principles of inflammation towards more focused barrier concepts leads to novel treatment approaches which need however to be tested in appropriate trials. Pilot results are promising and seem to be more rational than the anticytokines strategies which have been tested in the last 10 years.

LONG-TERM EFFICACY AND IMMUNOGENICITY OF BIOLOGICALS USED IN IBD

Severine Vermeire

MD, PhD, Division of Gastroenterology, University Hospital Gasthuisberg, Leuven, BELGIUM

lnfliximab is a chimeric monoclonal lgGl antibody to tumor necrosis factor alpha (TNFa) and is the first biological therapy that was approved for Crohn's disease (CD). It is composed of a (+75%) human constant and (+25%) murine variable region. lnfliximab is efficacious in patients with luminal or fistulising CD refractory or intolerant to standard treatment with glucocorticosteroids andlor immunomodulators and for patients with ulcerative colitis (UC). The optimal strategy is induction therapy with infliximab 5 mglkg IV at weeks 0-2-6 followed by systematic maintenance treatment every 8 weeks. lnfliximab induces rapid endoscopic and histologic healing. Long-term maintenance therapy with infliximab results in a reduction of the rate of complications, hospitalisations and surgeries associated with the disease. The response to infliximab may be optimized by concomitant immunosuppressive therapy.

Safety problems mainly concern immunogenicity due to the formation of antibodies to infliximab (ATI). ATls interfere with the safety and efficacy of the drug and are associated with acute infusion reactions and loss of response and with delayed hypersensitivity reactions. Acute infusion reactions are manifested by shortness of breath, chest pain, palpitations, flushing, headache and sometimes urticaria and hypotension. They are in most cases easily managed with slowing of the infusion and administration of anti-histamines and (or) hydrocortisone. Patients who have experienced acute infusion reactions should received prophylactic hydrocortisone before each next infusion. The delayed infusion reactions or serum sickness-like reactions occur typically 4-9 days after an infusion and are characterised by arthralgias (which may include unusual locations such as the jaw), back pain, myalgias, fever, skin rash, and leukocytosis. These delayed reactions need management with high doses of steroids for 4-7 days. In these patients, infliximab can be continued but prophylaxis with prednisolone (40 mglday 2 days prior to and 5-7 days after each infusion) is needed. However, with the advent of the more humanized (certolizumab pegol) or human (adalimumab) anti-TNF antibodies, most patients will probably be switched to these therapies, given their lower immunogenicity. Certolizumab Pegol is a pegylated anti-TNF antibody fragment given subcutaneously at a dose of 400 mg at weeks 0 and 2 and then q4 weeks. Adalimumab (Humirap, Abbott) is a fully human anti-TNF alpha

monoclonal IgG1 antibody, given at an induction dose of 160 mg at week 0 and 80 mg at week 2, followed then by 40 mg injections q2 weeks. Both these molecules seem extremely safe and less immunogenic than infliximab.

Actions to reduce immunogenicity include systematic maintenance therapy, concomitant use of immunomodulators and pre-treatment with corticosteroids. Therefore, in all patients who tolerate the drugs, an immunosuppressant should be maintained when the patient is already on the drug or added at the start of infliximab for at least 6 months. The results from the IMlD (Infliximab Maintenance lmmunosuppression Discontinuation) study show that discontinuation of immunomodulators after at least 6 months of combined treatment with systematic infliximab maintenance does not affect long term efficacy, although the patients who discontinued had reduced IFX trough levels in their serum. Latent tuberculosis needs to be screened for before onset of any anti-TNF therapy. The rate of other opportunistic infections is slightly increased mainly in patients treated concomitantly with corticosteroids or immunomodulators. Malignancy rates in patients treated with anti-TNF strategies are not increased.

The long-term efficacy data with infliximab show that 48% of CD patients receiving the drug as maintenance treatment (5 and 10 mglkg combined) maintain response at the end of one year, compared to only 17 % in patients treated in an episodic setting. Virtually all corticosteroid-dependent patients could taper and discontinue their steroids completely after a mean of 22 weeks. At present, there are no controlled study data on infliximab therapy beyond one year. Experienced referral institutions have many patients who are treated with infliximab for more than 10 years with excellent efficacy and safety. Data from our own center including >700 patients treated with IFX and with a median follow up of 48 months show that more than 60% of patients have a sustained clinical benefit of this therapy, with an excellent safety.

The long-term efficacy data for certolizumab pegol and adalimumab show similarly that response and remission in CD patients who initially respond to an induction dose, are maintained. Studies with certolizumab pegol and adalimumab addressing mucosal healing and ulcerative colitis are ongoing.

POSITIONING BIOLOGIC THERAPY IN THE FUTURE FOR THE TREATMENT OF IBD

JF Colombel.

CHU Lille, France.

It is often said that over the past decade, treatment of IBD has been revolutionized by the introduction of biologic therapy. We have indeed learned a great deal regarding the use of biologic agents from the infliximab experience that has been translated for subsequent agents that are currently evaluated for the treatment of IBD. However, the bottom line is that we still don't know how and when to use biologics. We are faced with two fundamental questions: how positioning biologics relative to other therapies and how positioning them relative to each other?

Until recently the main goal for the treatment of Crohn's disease (CD) and ulcerative colitis (UC) has been the induction and maintenance of symptomatic improvement or at best remission. In this context, biologics have been used most often in a conservative approach as a third line therapy as recommended in consensus guidelines. Two notable exceptions include intra-venous steroid resistant UC in which second line therapy with infliximab is considered appropriate and complex fistulizing CD where infliximab is used first-line as the sole effective medical treatment.

The current momentum is in favour of a more aggressive ''top-down" approach to the treatment of IBD, beginning with biologics versus the current "step-up" algorithm. Despite the fact that immunomodulators and anti-TNFs are effective in maintaining clinical end endoscopic remission, there is little hard evidence that these therapies alter the natural history of the disease when used in refractory patients. Data from rheumatoid arthritis studies supports early intervention with biologic therapies, showing that it can prevent the appearance or progression of joint erosions. Similar data are emerging for CD. All anti-TNFs have been shown to be more effective in patients with shorter disease duration. There is evidence from paediatric IBD that more aggressive treatment early in the disease is associated with better response and remission rates and reduced risk of surgery. In a "step-upu versus ''top-down" induction trial, patients with early onset (steroid-nalve) CD who were randomly allocated to induction therapy with infliximab, followed by azathioprine maintenance, had significantly better mucosal healing after 2 years than patients who commenced therapy with corticosteroids and advanced

to azathioprine or infliximab only after failing steroid therapy.

Despite this evidence the time is not ripe for indiscrimant "top-down" approach. Fundamental questions still require consideration. First, what outcomes should be utilized as markers for altering the natural history of IBD ? Debate continues as to whether or not mucosal healing is a surrogate marker for these events. There is an urgent need for developing new relevant endpoints for bowel damage and intestinal disability. The second issue remains patient selection. The risk-benefit of early aggressive therapy needs to be applied to an individual risk-assessment that is not yet identified. Currently identified factors that have been associated with aggressive disease behaviour include young age at onset, fistulizing disease, early requirement for corticosteroids and possibly elevated titres of serological markers.

Available data suggest that after induction with a biologic, regular maintenance therapy is the optimal regimen and in patients who tolerate the drugs an immunosuppressant (IS) should be maintained. It is likely that more flexibility will be introduced in the clinics. Bridge therapy with IS is already an option in na'ive patients. The usefulness of combination therapy in patients receiving scheduled therapy, especially with more humanised biologics, is questionable and it is not clear whether the combination should be maintained throughout. The observation that trough serum infliximab is a key factor determining clinical outcome is an incentive for developing individualized regimens based on pharmacokinetic of the drugs. There are currently no stopping rules for biologics. In the future discontinuation may also be considered on an individual basis.

Finally, we are entering an era in which several biologics will be available for the sahe indication. We already learned that switching from one to another is an effective option in patients who cannot tolerate one drug or have symptoms despite receiving it. Available data including meta-analysis does not enable a direct comparison between molecules. Head to head comparisons trials including efficacy and safety end- points are urgently needed in order to optimize our therapeutic strategies.

THE ROLE OF T LYMPHOCYTES IN THE PATHOGENESIS OF INFLAMMATORY BOWEL DISEASE

Konstantinos A. Papadakis

M.D., Ph. D., Associate Professor of Medicine, Division of Gastroenterology, Faculty of Medicine, University of Crete, Crete, Greece

The nature of T cell response in CD Cs a Thl and possibly Th17

Direct evidence for a role of CD4' T-lymphocytes in CD is lacking, but circumstantial evidence supports the notion that the conclusions from mouse models may be extended to the human situation.' First, active CD is characterized by an increased number of activated mucosal T-lymphocytes secreting interferon g (IFN-y), and by increased mucosal production of cytokines that activate Thl-lymphocytes (11-12 and 11-18). 11-23, which has been recently implicated in the development of mucosal inflammation,? governs the Th17 cell differentiation in the presence of TGF-fi and IL-6. Optimal induction and stabilization of polarized Thl cells would require additional cytokines, such as IL-15, 11-18 and IL- 21. There is a single report that IL-4 transcripts are elevated in the early ileal lesions of recurrent CD, but this may be a special transient situati01-1,~ Secondly, CD may remit after bone marrow transplantation. Thirdly, treatment with depleting anti-CD4 antibodies may induce remissions in CD (as suggested by a small and uncontrolled trial) and anti-TNF antibody treatment may owe its beneficial effects to counteracting activated mucosal T lymphocyte^.^ Fourth, CD, but not UC is classically associated with noncaseating granulomata, the hallmark of cell mediated immunity. There is also circumstantial evidence that the gut flora is also important in CD. Antibiotic therapy is a useful adjunct for distal CD and is of therapeutic benefit in extending remission and there have been studies in patients showing that after surgery, disease does not occur if the fecal stream is diverted. Clear role for bacteria in experimental IBD has been provided by studies where in virtually all animal models analyzed colitis development is abrogated when animals are raised in germ-free environment. Moreover, T cells reactive to CBirl (bacterial flagellin antigen) can drive the generation of colitis when transferred to SClD mice.' In view of this predominant role of T-lymphocytes in the pathogenesis of CD it is of importance to understand how the immune system regulates antigen-dependent T-lymphocyte activation. Briefly summarized, three mechanisms seem to be important: firstly, the engagement of the T- lymphocyte receptor in the absence of a second signal (i.e. costimulation through 87 and CD28) leads to anergy; secondly, most activated T lymphocytes are destined to undergo programmed cell death (apoptosis) through FasIFas ligand interactions; and thirdly,

counterregulatory cytokines (i.e. 11-10) can interfere with the T-lymphocyte activation. Interestingly, the last two mechanisms (in part) explain the effects of anti-TNF antibody treatment in CD.4 Moreover, mucosal T lymphocytes from patients with active CD are relatively resistant to Fas-mediated apoptosis, which may explain the uncontrolled activation that is observed in this condition:

An important aspect of T cells that are involved in normal mucosal homeostasis and IBD pathogenesis is the expression of gut homing receptors. A subset of T cells with a gut-homing phenotype express the chemokine receptor CCR9.'CCR9+ T cells isolated from normal SB exhibit a prominent Thl cytokine profile since they mainly produce IFN-y but little IL-10.7 However, when LP CCR9'CD3+ T cells isolated from inflamed CD SB are stimulated with anti-CD3 Abs or 11-12 and 11-18, they accumulated significantly more IFN-g in culture supernatants compared with normal SBV8 Similar findings were observed in regards to IL-17 production by CCR9' T cells. Approximately 10% of LP CCR9' T cells in both CD and normal SB produced 11-17, and most were distinct from IFN-y-producing cells. When CCR9' T cells isolated from inflamed CD SB were stimulated in vitro with anti-CD3 or anti-CD2 Abs, they accumulated significantly more IL-17 in culture supernatants compared with normal SB.' The addition of TLlA to IL- 12/IL-18 cytokine comb'nation markedly enhanced secretion of IFN-y by CC -A 9' T cells from inflamed CD SB, indicating an important role of TLlAJDR3 interactions in enhancing Thl immune responses in CD from cytokine stimulated CCR9' T cells.' Recently, a proinflammatory role for TLlA has been recently proposed in murine models of SB CD." The presence of activated CCR9' T cells with enhanced Thl- and ThlL-17- producing capacity in human SB CD supports the rationale for the use of selective CCR9 antagonists for the treatment of SB CD.' Recent experimental data suggest a role of CCL251CCR9 axis in the pathogenesis of experimental ileitis."

Other cell surface molecules such as selectins and integrins are critically involved in T cell homing to the intestine. Lymphocyte homing to peripheral tissues is controlled by the combinatorial interactions between cell integrins and their respective ligands expressed on endothelial cells. Selective homing to mucosal lymphoid

tissues is mediated through interactions between a4P7 and MAdCAM-1. Murine studies have implicated an important role for MAdCAM-1, L-selectin, and VCAM-1 in the pathogenesis of experimental ileitis.12 Blocking several integrinslligands in some experimental models has been shown to be required for effective treatment of experimental IBD.12 This could explain the therapeutic efficacy of natalizumab (anti-a4 integrin mAb) in CD by inhibiting the shared a4 integrin moiety of both a4P1 and a4P7 in effector cells.

The nature of the T cell response in UC is that of an atypical Th2 response

UC in its classical form differs so much from CD in its histopathologically and clinically presentation that it is likely to be a different disease. The mucosa is replete with neutrophils, there are crypt abscesses, and severe epithelial damage. In rabbits, a local immunoglobulin (Ig)G immune complex reaction elicited in already damaged mucosa produces a lesion which is virtually indistinguishable from UC in patients. The idea that UC might represent a Th2 type lesion is attractive and recently supported by some experimental data. Fuss and colleagues showed that isolated lamina propria CD4 T cells from UC patients made more 11-5 when activated in vitro with CD3/ CD28 ligation than similar cells from CD patients or normal^.'^ However IL-4 was not increased and overall, the CD4 cells from UC patients produced IFN-y in an order of magnitude greater than that they made IL-5. Where the Th2 paradigm might have some merit is in the sense of helping antibody responses. In UC, the inflamed bowel is filled with IgG plasma cells and IgG1, colocalizing with complement component C3b can be seen on the surface of epithelial cells. This IgG response is presumably T-cell dependent and generated in organized gut associated lymphoid tissue.

In a recent study, a prominent Th2 response as evidenced by the high production of 11-5 and IL-13 when effector CD4+CD25' T cells were activated with allogeneic DC in the absence of CD4+CD25+ TR in UC MLN was reported." The Th2 cytokine profile observed in UC MLN is consistent with a recent study indicating the development of a Th2 response in UC, which is characterized by an increased 11-13 production by nonclassical CDld-restricted NK T cells.15

Regardless of the nature of the T cell immune response in UC, direct evidence for the pathogenic role of T cells in UC pathogenesis comes from the therapeutic trials of modified anti-CD3 antibody, visilizumab, in severe steroid-refractory UC where a rapid clinical response has been observed after two intravenous doses of the antibody often with sustained clinical effcacy.16

Regulatory T cells in IBD Specific T-cell subsets in the intestinal mucosa are

poised with regulatory activity, therefore limiting the development of T-cell responses to intestinal commensal bacteria and the development of pathologic intestinal

inflammation. Of these T-cell subsets, T regulatory 1 (Trl), Th3, CD8+ TrE, and CD4+CD25+ natural TR cells are the ones best characterized thus far.l4, l7 A lack of activation andlor expansion of these regulatory cells could, therefore, play a role in the uncontrolled inflammation seen in IBD.

A recent study has shown that ex vivo TGF-b- induced FOXP3+ TR are able to suppress the development of experimental colitis upon CD4+CD62L+ T cell transfer in vivo.I7 Adoptive transfer of CD4+CD25+ TR cells can cure established experimental col i t i~, '~ suggesting their potential utility of ex viva-generated TR for the treatment of inflammatory bowel disease (IBD). CD4+ CD25+ TR cells may also control intestinal inflammation induced by both innate and adaptive immune responses via 11-10 and TGF-b-dependent mechanisms. Several studies have indicated that FOXP3+ TR cells are expanded in inflamed and uninflamed colon in UC and CD.". lo. 20 Moreover, "functional" CD4+CD25+FOXP3+ TR cells are present in the colonic MLN of UC patients undergoing colectomy for medically refractory disease.14 These cells exhibit potent suppressor activity in vitro in terms of inhibiting the proliferation of effector CD4+CD25' T cells and the production of both Thl and Th2 cytokines.14 Therefore, it appears the subset of FOXP3+ T regs appear to be functionally intact although their frequency may be lower compared to inflammatory controls." In addition, bacteria-reactive Trl cells can be generated in vitro and prevent colitis development when co-administered with pathogenic Thl cells in an animal model.' Other studies have indicated that CD8+ TrE may be defective in IBD.''

Conclusions In both Crohn's disease and ulcerative colitis, the

tissue damage results from an inappropriate or exaggerated immune response to antigens of the gut microflora. Despite having a common basis in overresponsiveness to luminal antigens, Crohn's disease and ulcerative colitis are immunologically distinct entities. Crohn's disease is associated with a Thl T cell-mediated response, characterized by enhanced production of IFN-y and TNF-a. In ulcerative colitis, the local immune response is less polarized, but it is characterized by CD1-reactive natural killer T cell production of 11-13. Beyond these differences, Crohn's disease and ulcerative colitis share important end-stage effector pathways of intestinal injury, which are mediated by an active cross-talk between immune and non- immune mucosal cells. The clarification of the complex network of immune-inflammatory mediators operating in the gut of patients with inflammatory bowel disease has led to the identification of new targets that could, in turn, drive the development of effective biological therapies.

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33. Poppe D, Tiede I, F r i i G, Becker C, Bartsch B, Wirtz S, Strand D, et al. Azathioprine suppresses ezrin-radixin-moesin-dependent T cel-APC

coagulation through inhibition of Vav guanosisne exchange activity on Rac proteins. J lmmunol 2006;176:641-651

EIK~VU. 0 perapohiopdq rqq a<ai3&iorrpi'vqq (K. Karouvoq, 2006).

Hanoofsllre A

. .. .

Ntiwneaylm 1d8ok

I

AbbreLiations: A ZA=azathioprine, 6-M P=6-mercaptcp urine. 6-TG=6-lhicgumine, MT HF R=m& gene Wrahwofd ate reductase, T P MT=thia~urine methyl transfer=e. H[G]PRT=hypoxa-~thine guanine phosphaibos#ransferase. IMPD(H] & ITPA =6-methg thiainosinic mmddilhi-p hasph tase, GM PS=guanosine manaphosphate synthetase, M P C monophosphate kinase, DP K=diph nsphate Yn a s , 6-T U=B#hiuric add, DP=diphosphate, T P=triphasphate, XOIXDH=mnthine omd azhanthine d ehykagenase. A OX1 =aide$ e omdase

' (EAAHNIKH OMAPA MEAETHI I@NE)

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acpeova Kal spcpawj unepa~p1~6 vasa recta. A 6 ~ a an6 T O U ~ EIKOUICV~ alrroljq aueeveiq epcpd-

palpia. ZTO enopevo ypdcpqpa Kat TOV n Iva~a m a ~ ~ u r ~ ~ 8 v ~ E ~ O ~ E V W V aneutovi<ma~ q o 1 3 ~ ~ p t q ~ w v nphv p6y1- u q q KAiqq q q ~apnuAqq etopofiq pmag6 ~ w v unoo- p66wv TOV adevhv pe vooo Crohn Kal q q op66aq

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~ w v ~ y l h v ~ w v a&v6v p& ~ v ~ p y 6 v6ao Kal amhv p& a6pavfi v6oo Kal TWV pap~~jpwv.

01 auO&v&iq p& a6pavrj vdoo av Kal p l~p06 apt& pou &pqCNtoav nap6pol~q T I ~ C ~ p& amCq q q op66aq paplipwv.

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Ev ~ o h o t q ot apxldq &v6&(<&1q moqpaivouv &I q ~ ~ ~ p ~ ~ ~ ~ ~ p ~ y p a ~ l ~ f i p&)lC-nl Tllq ~ 6 0 ~ 0 ~ TOU Crohn pE wfiorl EVLOXL~TIK~V 0uUlhv aK0~fXlKfiq a ~ T @ & q $ ITpOU.rpdp&~ q V 6uvcrr6~q~a EV& ~ V ~ ~ K E L ~ E V ~ K O U Epya- ~ [ O U yla q V a~toA6yrlcq q q EvEpy6TtlTaq q q V~UOU.

H K ~ V L K ~ ~ #1)cnp6~q~a a m q q q TEXVIK~~~ pope i va o u v o ~ t ~ ~ ~ wq E W ~ :

napo~ r j flqpocpopiaq yta q v napapCvouoa q h y - povh6q &v&py6~q~a npouf3ep)ul@vwv E~'KWV UE

aoeev~iq ME 6 q s q KhLVt~hv uupn-rwpOITwv l l p o c y ~ ~ t p q ~ ~ ~ 6 ano~Ae[qo napapivouoaq ~vep- yo6 cphypowjq q napouaiaq p&o~vrept~ol j cpA6ypo- va m (XEVWTU(~~ pA6pq n a p o ~ 6~ayvwcm~fiq pepat6nl~aq UE finla aoacpfi a p x ~ ~ 6 m 6 6 ~ a q q vooou

Goldberg HI et a1 Gastroenterology 1979;77(4Pt2) :925-937

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Ruess L et al, 2000 AJR 175: 79-84

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Spalinger J et at, 2000 Radiology 217:787-791 Mako EK et al Eur J Radiol2000 Turetschek K et al J Comput Assist Tomogr 2002

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N. Gourtsoyiannis et al Eur Radio12004 (14): 1017- 1024

AnEIKONIITIKH AlEPEYNHtH THE IONE ME NEOTEPEI TEXNIKEt YnOAOrIITIKHI TOMOTPAOIM (YT ENTEPOKAEH - YT ENTEPOTPAOIA)

H YT bxE1 lla[c&l qpavrlK6 p0A0 W V E K T ~ C ( T I ~

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Afi TT)q YT. H V E ~ T E ~ T ) ~ Y E V L ~ $ noAu-ropi@ YT (MDCT) CXE~ avayvwplu0ei wq noMa unoqjp~vq pi8060q yla q v E K T ~ M ~ ~OLKUOV na8flu~wv TOU kmo6 ~vrCpou uupepAappavopCvrl$ q q vouou Crohn. Bacn~o -0- vkqpa q q nOhUT0plKfiq YT anmehi o p ~ ~ p 6 q ~ 6 v o q eeCTaqq, q 6uvm6~q~a EK TWV UOTCPWV ensc~pyauiaq TWV ~ E ~ O ~ C V W V Kal T) 6lJvClT0TqTa TplU616UrClTtl~ ail&[- K ~ V I ~ S .

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npoiino0Cmcq yta q v 0p0lj ~ K E L K O V L ~ TOU hEmo6 ~vrCpou. npoq a m q v K ~ T E U ~ U V ~ , TO ~v61acpCpov UIjp~pa ~mi6<mal L ~ L ~ ~ T E P Q q V M EVTEP~KAUUI~ Kal YT Evrepoypacpia nou ouv6ua~ouv q 616Taq TOU

auAo6 IJE q v nohmop~~fi aneu~oviq Kal ava6e~~vOouv TO r E I x ~ p i q ~nlnpOj30AIj E V ~ E ~ ~ K ~ V E ~ ~ K W V . H b h a q TOU auholj ~ n l ~ u y ~ 6 v m a ~ pm6 an6 ~~18~~qpiaUp6 TOU

l2A0u un6 ~ K T ~ V O U K O ~ L K ~ ~ KaeObfiyrlUtl Kal ~0pf iy r lq t~awjq nou6~q~aq rn~aypacp~~o6 piow TOU ~ a 8 m p a (YT EvTE~OKAU~) fi EV~aKTIK6, pma an6 peros xopfi- yrlq TOU u~laypacpl~oli (YT Evrepoypacpia). ITO Tpljpa paq npo~lp6Ta~ q YT Evr~poypacpia nou ~ i va l pCBo6oq mo (pLh~~ l j npoq TOV au9cVJI Kal napCIMqAa npoucpbpe~

~~avono~qTumj 6t6Taq wjandaq Kal ~LhEolj. TO POTE EL- vop~vo o~laypacplK6 eiva~ TO U6ClTlK6 b&Aupa p~ noAu- at8uhEvoyAu~6Aq (PEG) KaL T)AEKTPOA~ES XOPT)YO~~E- vo ~ P O O ~ E U T L K ~ an6 TO m6pa q b l 6 p ~ ~ ~ a 30 min nplv q v ~6CTaq UE uuv6uaop6 p~ cpappa~~urla uno~ovia. To napan6vw o~~aypacp~~6 npo-r~pha~ an6 q v E U ~ C W ~ xpqu~ponoloupevq yampoypacpiq ~cp6uov acpev6q npoucpCpe1 avrl8sq p~ TO EVTEPLK~ ~oixwpa enrrpkno- vraq CTUL q v av66weq TOU T O L X W ~ ~ O ~ Kal acpe-dpou ~ E V ~~PE(~I~o~[<EL q 3D anElK6~1Utl. Boqea OTll hm0- p~pCm~pq ~ m i p q q TOU ~oi~Wpuroq ava6~1~vljovraq ~aAhspa T ~ V T O L X W ~ ~ I K ~ ~ np6uAqqq lj q v av66acq TWV XLTWVWV q v EVEP~O cphEypov06q VOUO. An6 q v 6Mq pept6, q ~ p l j q q q noAuenin~6qq avau6ve~qq nou npoucpCpe~ q noAuropl~fi YT u u p p W ~ q v ava- 6clcq 6Aou TOU pfi~ouq npoNoAfiq Kal uq ~ E A T ~ w ~ q q avipeuqq q q xapqAfiq an6cppacqq EVW q 3D anel- K6vlq PO1786 IIpWTiOTWq OTQV av66~icq TWV ~EUEVTEpl- KWV ~ W E I ~ K ~ V pmaPoAWv.

Iuv6u6<ovraq Ta rrA&ovemjpma q q uuppm~~fiq ~vrep6KAuqq pe E K E ~ V ~ q q YT, q M Evrepoypacpia t j q YT Evr~poKAuq ano~~Aoljv ~8660uq nOU E I ~ ~ T ~ ~ ~ o u v

q 6 l ~ m p q q ~ K ~ v o T ' I o ~ ~ T ~ K ~ ~ ~ &VCEPL@S 6~6Taqq Kal Ttl

A~mop~pCmepq ~lcr ipqq TOU auAo6, TOU ~olxWpcrroq Kal TOU p~mvrepiou. IT^ p~ov~mjpu ra n~pAapp6ve- Tal q amvu~fi ~nlpapuvq Kal q anouaia hErroupy~~6v nhqpocpop1Wv.

TEXNIKEE APXEE T H I MATNHTIKHZ ENTEPOWEHI

EIZArRrH H MayqTtKfi Evrepbtduq (ME) allOT&h&i pta

Taxdwq &5&hlCJ~d~Vll a n & t ~ O ~ t ~ l ~ f i p&8060 TOU kRT06 evrCpou. Ta nto paot~6 rhovetm)pa-ra q q p&8660u, onwq q uqqhfi avri0sq pma50 TOV paAa~6v popi~v, q 6 u v a ~ h q ~ a T ~ L U ~ ~ L ~ O T C ~ T ? ~ ~ ~ ~ E L K ~ v L ~ ~ , 01 ptKp0i n)lCOv xpovot hfiqewq ~ w v ~ o p h v (< 1 sec) aAA6 Kat q CMEuqq lovri<ouowv aucnvopoAt6v, ent~p~nouv 4pepa u q v ME Va ~ L E K ~ L K E ~ oucn66q p6ho OTtlV C~~TELKOV~OTLK~~ 6l&p&o- v q q TOU k m o l j EVTC~OU.

Z~laypacpr~h MCua H o~taypacpqq TOU auholj TOU A~rrrOIj evr~pou

q V wfiq Ka~aMfiAwv o~taypacpt~6~ ~CUUV &ival B&p&)u66qq OTTlV ME. TO 16avt~6 ~~60aUh1~6 UKLaypacpt- ~6 pCoo 8a npdnet va nap&x&t opotoyev~q q p a mov auk6 Kat oacpfi 6 1 6 ~ p 1 q w a 5 d auholj - &vr&plK06 TO\-

xhpa-roq, va pqv anoppocphat and TOV ~hevoyowo UE

uqpavrt~Cq noaoq~eq, va pqv napouota<et oopap~q avent8ljpq~eq evCpyeteq Kat va CXEL ~ E T L K ~ xapqho ~ 6 0 ~ 0 ~ .

H 066q xopfiyrlqq TOU E V ~ O ~ U ~ L K O ~ UKlaypacpl- KOU pnopei va eiva~ nto qpavr t~ f i an6 am6 ~a8'ealrro TO ~ B o q TO o~taypacputolj pioou. M E ~ I qpepa, Cxouv npoTa8ei 600 ~ponot xopfiyqqq: an6 TOU mopmoq KaL pCow ptvoyampt~ou ~a8mjpa p ~ 6 an6 ~ a 8 & ~ p l a ~ p 6 TOU 6~B~Ka6atcrLjhOu.

0 ~a0eqp1aopoq TOU 6w6e~a6atcr~Aou eivat ~aA6q ~ V E K T O ~ an6 TOV ao8&\ril Kal TEXVIK~ &Ux&pfiq 6 ~ a v unapxet q ~ E T I K ~ ~ epetpia. MCow TOU ptvoyampt- KOU Ka8&T?)pa ~0pI'lyO~VTal 2 h i~pa ~~lClypacpl~06 pE q v PofiBe~a avrhiaq pe TOV ao8ewj va pp iu~ r ra~ CE

npq\ril 8CUll P C U ~ OTOV payvrlTtK6 TOpOypacpO. BEATLOTO CI~ laypa~l~6 EXEL ano6et~8~i TO 100-

O U ~ ~ T L K O U ~ ~ T I K ~ 6tahupa nohuat8uA~voyAu~ohr1$ (PEG) p& qktcrpoh~heq. TO U K L ~ Y ~ C ~ ( P L K ~ X O ~ T ) Y E ~ T ~ L CE

6uo cp6oetq: (2~x1~6 pe pu8p6 80-150 mllmin p6xpl va cpT60&1 OTOV T E ~ K O & h 6 Kal O K O ~ O ~ ~ W ~ pE P U ~ ~ O

200mllmin npo~etpCvou va npotdqeei avravatdacxt~fi uno~ovia nou en~~pCna Afiqq EIKOVWV xupiq qeu60~a- TaxOpfi~&l$ KiMlqC,. 0 ~ & p 1 0 p l ~ ~ 6 $ q q K L V ~ ~ T L K ~ ~ C ~ ~

TOU EVI&~OU p l l0~&( T I E ~ C ~ L T & ~ W Va E ~ ~ I T E U X ~ E ~ pE TTl

xopfiyrlq 1 mg ~ A O U K ~ ~ O V O U . H ev6ocp)lCPta xopfiyqq napapayvrl~t~ou m a -

ypacp~~olj (n.~. Gd-DTPA) 8 ~ 0 p ~ h a t anapaiqq yta TOV

~apClKTTlptop0 x ~ ~ o K C I T ~ K T ~ ~ T I K ~ V d d o t h ~ ~ w v Kal q V

etcripqq q q ~v~py6TqTaq q q vooou TOU Crohn. H ava- 6atq TOU cpuotohoyt~ou ~vrept~o l j ~otxhpmoq oe aKo-

A~oAouekq Mayvq~~~qq Eucpd~Auuqq Aemopepfiq p e w TOU AEmolj evr~pou anat~ei

ouv6uaop6 ~ K O A O U ~ L ~ V TI Kal T2 ~ ~ O U ~ V ~ T O ~ L U ~ O ~ , ~axeia Afiqq ~ o p h v yta K ~ O E ~ K o A o u ~ ~ ~ uq 616p~eta o u y ~ p h q q q q q avarrvofiq Kat a n a ~ o v ~ q oe mecpavc aio Kat ey~6poto enine6o. A~ohou8kq pa8pt6wTfiq qxoljq TI npooavmohtopou (2d fi 3d Gradient Echo) neplhappavovrat oe oha Ta n p w ~ 6 ~ o M a ~ { C ~ a q q TOU

k m o u EKE~OU p& MT. tuprrhqpwpa~tK6 q &cpappOyj T E ~ I K ~ V KCITaOTOhfiq TOU O f lpa~o~ TOU hinouq, q E V ~ O - cp)lCpta xopfiyrlq napapayvrl~~~ou o~taypacp~~oO Kat TO

apVllTlK6 E V ~ O ~ U ~ I K O ~~lClypacpl~6 E ~ ~ u ~ ~ & ~ < o u v q V

6p1uq ava6~15q TOU ~vrept~ol j ~olxhpa~oq nou EVL- U@&Tat Kal &pcpavi<&l U$I')hfi 61a~plTl~fi avri@&q UE

qiq ye TO xapqM oljpa TOU 6tmrrapCvou auhou Kat TOU ~ E ~ L T O V C ~ ~ K O ~ hh0uq I lOU neptP6A~t TO T O ~ X U ~ ~ TOU

evrCpou. 'Orav rrhqpoOvrat Ta avw~Cpw TO cpuutoAoym6 ~oixwpa 6taypdcpmat t~avonotqn~a p~ uqqA6 q p a Kat TUXOV PhaP&q - KUP[WS X ~ ~ O K C ~ T ~ K ~ T ~ T I K E ~ dd016o~lq - pnopoOv va x a p a ~ p ~ m o O v an6 TOV ~ l i n o npooAq$qq TOU napapayvrl~t~ou o~~aypacp~~ou. nspat~cipw, q xwpc Kfi 6ta~plTt~fi L K C ~ V O ~ T ~ TIO OPE^ Va P&hTlw8&i aV XpqUl- ponotq8ei pta 3d FIASH aKOhOLI8ia p& naxoq ~opfiq 2 xlhtoma Kat pey6Aq pfi~pa ava~mao~~u f iq q q E L K ~ V ~ S

(n.~. 51 2x5 12). H ~ V ~ Y K Q xopfiyrlqq ~ W E ~ L O T & T L K ~ V

eivat en~~atcrt~fi hoyw q q euato8qdaq nou napoua16<et rl 3d FLASH a~oAou8ia a& ~ ~ ~ 6 0 ~ a ~ a ~ ~ p f i C E l ~ ~iq- q s .

An6 T L ~ a~ohou8ieq T2 npooavmokopoO nou Cxouv npo~a8ei o-rqv a n e ~ ~ o v t q TOU k m o u evrCpou pe MT, rl HASTE cpaivrrat 6Tt U U ~ K E V T ~ ~ V E ~ Ta ~~&~IuuoT&-

pa rh0vetm)pClTa. nap&x&t UqIlhfiq E U K ~ ~ V E I ~ ~ E L K ~ V E ~

oe ALYOTE~O an6 1 ~ E U T E ~ ~ ~ T T T O ava ~opfi , anaMaypC- V E ~ an6 q~u6o~a~a~wpfioetq. To cpuotohoyt~o ~oixwpa TOU evrCpou ane~~ovi<ma~ pe xapqhfi Cvraq fipcrroq, ev6 OL cpkypov66etq q veorrhaopa-r~KCq aM016cr~tq napouota<ovrat pe uqqhfi Cvraq Oflpmoq. H xopfiyq- q avrtneptcxaA~1~6v ~ p i v m a ~ anapaiqq yla q v ano- cpuyj ~ e u 6 0 ~ m a ~ w p f i o ~ w v an6 q v ~ i v r l q - npo68qq TOU E V T E ~ I K O ~ ~ E ~ I E X O ~ ~ V O U . M E L O V E K T ~ ~ ~ TT)q HASTE aKOhOLJ8iaq eiva~ q pq-t~avonotq~~~fi ava6a5q TOU ~EUE- vrepiou Kal TWV ayyeiwv TOU. 'O-rav ~p&t6<&Tat va Aq(p806v ypfiyopa nhqpocpopieq q m t ~ a pe q v KI~TL- K6qTa TOU k I l T 0 ~ EVI~POU, TOV pa8p6 rrhfipwqq fi q V

B t h a q TOU UE ~pf ipma n6vw an6 mevopCveq nepto-

x6q q ecpappoytj un&p-ra~eiCi)v spin echo a~oAou8iwv (n.~. Single Shot TSE) T2 npooavaro)uopoG eivai eac P M L K ~ XPtjol~lrl.

Mia vda a~oAou0ia q onoia ovop&<~~ai trueFlSP CXE~ anobeix8ei id ia i~~pa yptjolpq uqv avaropi~tj mei- K6vlq TOU kmoc E V T ~ ~ O U nap6~0vraq ot: p ~ ~ p 6 ~ 6 ~ 0 E I K ~ V E ~ uqqhjq avri&mtajq i~av6~q~aq, nou 8ev enqpe- azovrai an6 q v avamrorj tj q v ~ E ~ L O T ~ A T L K ~ ~ ~Lqq, a K 6 ~ Kai uqv nepirrrwq h o u 6ev 6xouv xopqyq8~i O T I ~ U ~ O ~ U T ~ K ~ MU^. AV Kal ~ i va i uppdi~dq E L K ~ V E ~

(peiypa TI Ka[ T2 npooav~okcrpoir) 8a nphei va eppq- ve6ovrai pe q v qp&ioAoy[a ~ w v ei~6vwv T2 npooava- T O ~ L U ~ O ~ ~ . Bao1~6 Id&0~6lm)pa TUV E L K ~ V W V q q

trueFlSP a~oAou8iaq ~ iva i q e5aipmtaj avmopitaj av6- 6eiSq TOU p&mvr~piou aK6pa Kai UE enirre60 pi~phv 6opQv onwq eu06a ayyeia, pi~poi k~lcpa6Cv~q mA. Qq w K 6 paovCqpa TUV trueFlSP E ~ K ~ V U V 0a npdnsi va avaqxp8ei q napouda ~ J E U ~ O K U ~ C I X C ~ ) ~ I ~ ~ ~ I $ pe q v popcprj k m q ouvexoirq pa6pqq ypapmq mq enicp6- VELE~ nou 6~axwpi<ouv TO neprrovai~6 hhoq an6 6peoa ~ E ~ ~ o v ~ K o G ~ LO TO^^ 6nwq TO T O ~ X W ~ ~ TOU E V T ~ ~ O U . H qeu6o~araxdpqq a m acp' ~v6q eivat 6p~oa avayvw- p i w q Kai 6ev ernlpe&<ei q v av66ei5q na0oAoyi~tjq qpaoAoyiaq Kai acp' malpou wopei va neptopiu6ei &cpapp6<ovraq TEXVIK~~ K U K ~ O T O A ~ ~ ~ TOU M~(TCOS TOU

Ainouq.

NEnTEPEt AflElKONIZTIKEI MEOOAOI XrH AlArNQIH T H I IONE:

EIOAOrHEH ME ZYMBATIKH KAI MArNHTlKH ENTEPOWYZH

I. r p a p p a ~ l ~ h ~ q q

Errip~hqrrjq A Epyamqpiou larpi~rjq Arrei~6viaqq /7av&rcimqpia~ol Noao~op&iou HpaKAEiou

H voooq TOU Crohn eiva~ pla ~pov~a,ayvharou amohoyiaq cpkypovh6qq naBqq,nou pnopei va npo- 0~&&1 O ~ O I O ~ ~ ~ O T E Tpfipa TOU rEZ.

Xapaqpi<e~al an6 ~ I ~ T O I X ~ ~ C I T I K ~ cpheypovtj TOU E V T ~ ~ O U pe a p ~ p a ~ q Kal anpopkrrq nopeia Kal aaraerj avranonp~q q 8epaneia.

Iuq86arepa evroni<ma~ aro k m o 6vrepo nou cca~~iaq q q ava-rop~~rjq 96qq Kal TOU pey&Aou ptj~ouq TOU, alT0TEhEi TO Tpfi~a EKE~VO TOU Y ~ U T ~ E V T E ~ I K O ~

owhfiva pE q V ~ U O K O ~ ~ T E P T ) 6laYVWOTl~fi 17p006fliq Kal TO povo p6p0q nou q ev6ou~onqq,pc e5aipeq TO

12/A0 Kal TO T E ~ L K ~ ~pf ipa TOU EI)IEo~, ~ E V aTI0T~ki T V

Kupiap~rl 6 l a ~ w ~ r l K r j p68060. Kma UUV&IT&ICI 0 ~~&IKOVIUTIK~$ &~xoC, ano6el-

w l jma~ 161ai~epa ~pfiutpoq, T ~ U O yla q v a p x ~ ~ r j 616- yvwq, ooo Kal yla q v avayvhplq E ~ I ~ A O K ~ V rj q v napartoAolj8qq adevhv pe yvwo-nj vooo Kal KAIVIKI) oupmwpmoAoyia uno~ponfiq.

An6 Tlq 6 ia86~lp~q qp&pa ~ ~ & I K O V I O T I K ~ ~ p&80- ~ O U S , 0 ~KTIVO~OYIKO$ E ~ ~ X O S p& paplo p& TT)V TEXVLK~~

q q evrepoKhuqq, CXEI ano6~1~8si o ~axhepoq Kal a~plp6m&poq T ~ o ~ T o ~ TOU k m 0 ~ EV~~POU pE apnma uqqAfi 61ay~wOTlKfi eua1o8qoia (93.1%) Kal ~161- K6qTa (96,9%), a ~ a ~ ~ p ~ < O V T a ~ pE E ~ ~ L P & T L K ~ ~ 0acpfi- vela aMo~hoe~q nou acpopoliv TOV pkwoydvo, q v 61a- popcpwq enlcpaveiaq Kat q v 61apmpo TOU auAou TOU

evrep~~oli owAr)va. 0 1 V E ~ T E P E ~ ~ ~ E I K O V I U T L K ~ ~ @80601 ~ ~ O ~ E L K V L ~ O -

vral 161ai~epa xprjo~peq q v ava6~15q TWV E V ~ O ~ U A L K ~ V Kat e~wpkwoyov~~hv aMo~hoewv, 6xovraq oav ~ l j p ~ a onha T O U ~ q v awuq a n a ~ o v l q TOU ~o~xhpmoq Kal TOV E ~ W E V T E ~ I K ~ V 60phv, 6nwq p~oevr6p10, ayyeia, kpcpa66veq Kal napeyXupcrr1~6 opyava.

H MayvrlTlKfi Evr~poKhuq, p& TIC, TEXVO~OYIK~~

~ E A T I ~ U E L ~ nou acpopolioav q v ecpappoyrj nqviov en[- cpaveiaq Kal q Arjqq yprjyopwv ~ K O ~ O U ~ I ~ V TI Kal T2 npooavmoA1opo6 crco ~pckqpa plaq avamlofiq, nepto- ploe qpav r1~6 Ta artifacts ~ i q q q . Eniqq pe q v LKa- vonouq-rucfi nhfipwq Kal616Taq TOU E V T E ~ I K O ~ ~ owAfiva HE ev6oauA1~6 ~~ laypacp l~6 pm6 an6 plvoqar161~6 ~a8qp1aopo Kal q v ecpappoyrj q q ~m&AAqAqq aKo- Aou8iaq Kat TEXVIK~~~, E~~U(P&AIUE qpavrtmj nAqpocp6 pqUll600~ acpop6 V V ~ E L T O U P Y I K ~ ~ T ~ TT)C, ~ ~ U X O I J U ~ S ne~lo)(r j~, q v d q p ~ ~ & p q xapTo~~Cl(prlq v q 6 u a q q Kal T V ~VTIKEI~EVIK&EP~ E K T ~ ~ T ) ~ TTlq paphlTaq q q v6oou, av&oya pe q v evepy6 cpA&ypovh6q, 61mpq~1- Kfi, OTEVWTLK~~ fi O V E V E ~ Y ~ popcpfi & ~ ( p p a q q q .

Z T ~ p a o ~ ~ a rrhEovemjpma q q pe806ou ouy~a- ~aA6yovra1 q anouoia ~ovi<ouaaq alcr~vopoAiaq, r j nohuenineliq a n e ~ ~ o v i q Kal q uqqhr) avr18m~~rj lKa~6- W a , dlai~epa s f i o~pq 6Tav U U V ~ U ~ < E T ~ I Kal pe q v e.9 xoprjyqq napapayvrl~~~oli o~~aypacp~~olj , q v E K T ~ ~ T ) ~ E V V E ~ Y O ~ V ~ U O U p& q V av66~15q TOU 016fipClToq rj o-qv 616rKplar) OTEVWTIK~~~ v6oou TTOU ocpeihETa1 OE

ivwq. A a pe~ove~pcr ra neplhaClp6vovra1 q 61a8eo1- p6qTa, TO K ~ O T O ~ , q a n a p a i v E ~ O I K E ~ W ~ pe q v T E ~ I ~ Kal 01 TUXOV Q E U ~ O K ~ ~ X W ~ ~ ~ U E I ~ .

ZTI~ p . 6 ~ ~ dlpepa unapxoumq pe&eq q M a w - ~ t K i l EvrepoKhuq cpaivma~ va CXEI ouy~pio~pa ano-re- hCupma pe q v Zuppm~~fi Evrep6Khuq o-qv ava6~15q TWV popcpohoyi~hv ~ M O I ~ U E W V ~ ~ vooou. Zqv evepyo cpkypovh6q popcprj q q , pnopei va a v ~ p e l i m ~ naxuvq TWV KUK~OTEP~V ~ U X ~ V , 61a~plT6~ E ~ E ~ K ~ U E L ~ fi Kal paehepeq ypappoetdeiq pe 61apopcpwq d a ~ o m p w - TOU, naxuvq TOU ~o~xhpmoq pe baarpwphwq Aoyw 016fipmoq Kal ~ E ~ I E V T E ~ I K ~ ~ unepa~pia pe 6iCrraq ~ w v eu86wv ayyeiwv (comb sign).H 6l~i~pqTutfi popcprj Xapa- q p i < m a ~ an6 Ta pa816 61mpq~l~d Ckq, ~ o u q uup~y- yh6aq n6pouq nou ~maArjyouv T U ~ M rj a& K O I A ~ T ~ T ~ , Ta oupiyy~a pe TI$ yljpw avmop~~Cq 6opCq Kai TO m- pm1op6 (pkypovh6ouq pa<aq fi anoo-njpmoq. tq are- VWTIK~~ C~cppaq q q voaou fi ~up ia K~IVIK~~ ~ ~ 6 r j h ~ q eiva~ o anocppatcr~~oq ekoq, nou o ~ a v eiva~ q p a v r ~ ~ o q ouwa avayvwpi<mai q v anhrj amvoypacpia ~olhiaq. Xapatqpi<ma~ ano ~ A h w q q q baphpou TOU e m - p1~06 auAo6, ~ ~ o O T E V ~ T I K ~ ~ 616Taq Kal n k u v q TOU

~olxhpmoq A6yw evan6B~oqq K O M ~ ~ ~ V O U Kal ivwqq, nOU q V MawTlKfi Evrep6Khuq KClTayp6cp&Tal pE opoloyevtj Kal pkrpia ~ o l x w p m l ~ ~ j np6oAqqq p & ~ 6 q v E.9 xopfiyqq r1apapayvllrlK06 ~~laypacpl~06.

M6w1 oljpepa 6ev EXEI aK6pa aveupeeei q ano- h q ~~EIKOVIUTIK~ p68060q nOU 8a Ka~ayp6cpe16hO TO

cpaopa ~ w v popcpohoyi~hv aMothmwv q q vcioou,ano TI? rAiov npdiiveq p . 6 ~ 1 T L ~ nep~ooo~epo npoxwpqpb- VEq. Kcra U U V ~ ~ E I ~ 0 p6A0q TWV ~ ~ E ~ K O V I O T ~ K ~ V p~80- 6wv 8a np6nei va eival oupnAqpwpa~1~6q Kal q e n l h o ~ q q apxlmjq pe866ou 8a np6ne1 va e5ap~Crra1 an6 TO

K~IVIKO ephqpa Kal q V ~ U V ~ T O T ~ T ~ ~ K P I ~ ~ E O T E P T ) ~ eui- pqqq q q uupnep~cpopaq Kal paphq-raq q q vooou.

H CT~pflClTlKfi EVTepoKhUCTl h 0 y ~ TTlq u I / J ~ ~ ~ T E P T ) ~

6laOTllpClTl~fiq 6 l a ~ p l T l ~ f i ~ I K ~ V O ~ T ~ ~ , a i l 0T~k i q V

a ~ ~ l ~ 0 ~ l O T l ~ f i pi8060 &KhOfiq W V ~ v ~ X V E U ~ npdiipwv aMothaewv oe aoeeveiq pe un6v01a V~UOU.

H MayvllrlKfi Evrep6Khuq cpaivma~ va ~ X E I ~aAfi

pa~poo~orr~~wv EKE~VWV K ~ L T ~ P ~ W V ROU 8a xapaqpi- Couv q vouo ~ v ~ p y 6 , ~ a 8 h q KaL EKE~VWV nou Oa TT)V ~a8~crroOv pq avacrrpCq~pl Adyo ivwqq.

(EAAHNIKH O M A M MEAETHI I(DNE)

IAlOnAOHt Q>AErMONQAHZ NOtOt TOY ENTEPOY n H N nAlAlKH HAIKIA: KAINIKH EKQPAZH

H &A~66qq K0hiTl6a Kat rl V O U O ~ TOu Crohn, 01

600 popcpCq q q dtona8ouq (pkypovh60uq V ~ U O U TOU

EVTC~OU, E K ~ ~ A ~ V O W ~ I ouvljewq a& qA1Kia p&yahlh&pq TwV 10 X~OVUV aM6 eival ~IJVCITOV va & K ~ ~ A u ~ o ~ v Kal U& nadta qht~iaq ~ L K P ~ T E P ~ ~ TWV 10 X ~ ~ V W V . 01 &VL- K ~ S E K ~ ~ A C ; ) U & L ~ TUV 600 KCTT~(X~U&WV napoua~6<0uv opotoq~eq KaI61acpopbq 01 onobq 6uvmov va acpopo0v TOV E V T E ~ I K ~ uwhfiva fi va eival E ~ W E V T E ~ L K C ~ . Eniqq eivat nap6poleq pe e~eiveq TWV E ~ A ~ K W V aM6 napou- at6<ouv Kal BacpopCq. H qpavrl~irrepq 6tacpop6 anop- p k t an6 TO yeyovoq h t q 11al6tKfi Kat ~cpqpt~fi IlAtKia xapaqpi<e~at an6 q v aucqq Kat wpipavuq TOU

opyavlopou ot onokq aup6 enqpea<ovrat.

N6ooq Crohn 01 ~ L V K C C , E K ~ ~ ) A ~ u & L ~ q q vouou TOU Crohn

~aeopqovrat an6 q v evr6n~q Kal q v Cmaq q q pA6- pqq mov n&n~lK6 owAfiva Kat q v napouoia ecwevrepl- K ~ V E K ~ ~ ~ ~ U E W V . H K h ~ U l K f i KhlVLKfi ~0~cp f i E K ~ ~ A ~ v E - TaL US E K T E T ~ ~ ~ V ? ~ ~ ~ 0 ~ p 0 h f i TOU h lT00 EVT&POU Kal neplhapp6vet q xapam-qp~m~~fi ~p166a TOU ~olhta~o0 n6vou, ~ q q Xpovtaq 6tappo1aq Kat q q an8As1aq P6p0uq. Av&u~~uK&T~L apK&T6 Kal CKflV nat61Kfi q k ~ i a . Eival 6uvmov va auvo8eumat Kat an6 &€,WEVIE- ~ L K E ~ c~6qAC;)m1q. H d a u u ~ ~ r j popcpfi pe fi xwpiq &ewe- vrep~~dq ~~6qAC;)aelq btantmhvma~ nepinou mo 80% TWV natdthv Kal &cpfipwv p& V ~ U O TOU Crohn. 0 K O ~ ~ L ~ K O $ n6voq eival 6uvm6v va ano~&A&i TO povo oupmwpa ma q v epcpdv~q q q V~UOU, eivat ouwjewq neptoy cpaht~oq aM6 pnopei va evroni<ma~ Kat mo 6~516 ~Crrw T&Tap~p6pl0 TTlq K0lhl6~ UE ~ [ & ~ t ~ h U & l q T&hKfiq & h i - ~t6aq. I e npoopohfi TOU naxCoq evrCpou evroni<e~at m o unoyamp~o Kat 6uvm6v va U U V O ~ & I ~ & T ~ I an6 alpop- p a y t ~ ~ q ~evhuelq. 01 61appoi~Cq K E V ~ U ~ I ~ , av Kal uuxvt) e~iSfiAwq, &iva16uvmov va pqv unapxouv, 16l~iT&pa av q voaoq evroni<mai povo mo k m o Cvrepo. Ma~po- o~ontmj anC;)A&ta aipmoq an6 TO 0p86 eival m6vta o ~ a v q v6aoq evroni<ua~ povo crro Aerrr6 Cvrepo. H napouoia pAewoatpa~qpdv ~evC;)oewv uno6qAC;)vet npoopohfi TOU naxCoq ~vrCpou. ITL~ nepm-rhoe~q am&, (10-15% ~ w v nep~mhmwv) q b 6 ~ p l q pma@ q q V O ~ O U TOU Crohn Kal q q ~ h K 6 6 0 ~ q ~0hi~16aq &ival ~CUKOAT) KCIT6 Ta apxlK6 TOU)~CIXLOTOV m661a Kat Xapa- qp i<ov ra~ wq ~oAi~l6a a~aeoptmou ~Onou. I e npo- apohfi TOU ~ E ~ L V E O U , q onoia ~ i v a ~ auxvt), 61antmhvo- vral 6&ppa~lK&q rrruxCq, aupiyyta Kat anoanjpma u q v nep~oH.

H voaoq TOU Crohn u q v natdt~fi qht~ia eiva~ ~ U V C I T ~ V va &~6rlhWe&i, ~Opiq aupmhpma an6 Tov E K E ~ L K ~ ~WAfiva, p& maorp6~q~a Tqq U W ~ ~ T I K ~ ~ S av6- rnuqqq Kal ~aeucrrkpquq q q ecpqpeiaq. H maatp6qTa

awpmt~fiq avamucqq xapaqpi<e~at an6 ~a8umCpq- q q q ypapplMq a0cqqq a& auv6uaopo pe ~aBumC- Prlarl -olS 0mtMcil~ r l h ~ ~ i a ~ Kal -o?S Cvaptqrl~ VS fipw. To papoq at: q@q pe TO 6q0q eivat ou~v6 cpuo1oAoyt~6, aM6 TO u$oq UE ~15q pe q v qhttia, unokinmat. Ze noaomo 88%, o puepoq q q a05qqq napoucna<e~ e h h w q nohir nptv yive~ q 6tayvwq Kal a& nouomo 42%, npoijn6pxet ~ o v evtep~~C;)v crupmwphwv ma 1- 2 ~p6v~a . H maolpoq~a o w p a ~ ~ ~ f i q avarrru~qq ano6i- 6mat oe ouv6uaop6 napay6vrwv onwq civat q avenap- Mq np6oAqqq 60plKC;)~ aummt~C;)v p& q v ~pocpfi &<at- ~ i a q q q avope~iaq, q n)\qppeAfiq anoppoqqq a& npo- opoAfi q q wjmtdaq, 01 au€,qpCveq anhkteq an6 TO

Cvrspo, Kal rl 6 p 6 q ~ w v npocpkypovo6Qv K ~ O K L V C ; ) ~ an6 TO (pkypaivov Cvrepo.

H avalpia a& natdta pe vouo Crohn eiva~ ouxvt). Elvat Kupiwq otbqponevlmj (70%), fi p&yahophaOTlKfi an6 aven6p~eta cpuMt~o0 o@oq fi PI-rapiqq 812 (15%) fi eiva~ ouvCnela q q xpov~aq vouou (1 5%). f2q npo&xov u0pmwpa ~ m 6 q v apxlmj epcpavtq q q vouou avacpC- pmat ae nouom6 nepinou 3%.

An6 Tlq 6M&q & ~ W & V T E ~ L K ~ $ E K ~ ~ A ~ C T E L ~ , 01

apepahykq Kal AtyilTEpo w p 6 q ~pepiTl6a ban~md- vovral a& noaomo 15% ~ w v ecpfipwv pe vdao Crohn Kal eiva~ 6uvm6v va npoqyolivra~ ~ w v & K ~ Q A ~ U & W V an6 TO

n&nTlK6. Omeonevia eniqq avacpCpmat pixpi Kat oe noaomo 25% ~ w v veo61ayvwa8Cvrwv ecpfipwv nplv an6 T V Cvapeq aywyfiq p& K O ~ T L K O E ~ ~ ~ ~ .

mK46qq K0Ahlda H v6ooq E K ~ ~ ~ ~ V E T ~ L p& ~ I C I ~ ~ O L K ~ C , KEvC;)U&I~, 01

onoieq nepdxouv aipa Kat phCwq wq a n o ~ ~ k o p a q q npoapoAfiq TOU naxCoq evrCpou. Auvmov va npoqyo6- ma1 K0lhlaK6 &yrl KaL T E I V E U ~ ~ ~ . K a ~ 6 q V 6vapcq Tllq vooou, p6vo Ta 213 ~ w v nadl6v &xouv bapp01~6q KEvC;)- uetq Kai p6v0 TO 113 aopapfi a~poppayia an6 TO oped. 'AMEq &~6qhh~&lq eiva~ avopecia, nupmoq, at6qponevt- ~ f i avalpia Kat an6kta p6pouq. H bvapcq q q voaou pnopei va finla pe 0~a6taKfi e n i ~ a q TUV aupmwphwv fi va eiva~ ~epauvopoAoq. H papljnl~a q q voaou not~i- AGI Kal ecap-rhat an6 q v h a q Kat q v Cvraq q q (P)LEY~oW)~. ME 00papfi K0hiT16a E K ~ ~ A ~ v E T ~ ~ T ~ E P ~ ~ O U

TO 10% TWV neptmC;)aewv u q v natdt~fi rlhltia. I e nooo- mo 30% 6tan~mhvmat W p ~ a q p a p m a q voaoq pe ~ k ~ ~ a l p a T q p & q bapp0tKkq K E V ~ U E L ~ , K O I A L ~ K ~ ~ 6 ~ 0 , avopscia Kal nupe~6. noA0 finleq neptrrrhaetq auwj8wq ocpeihovra~ ae evrontapCq ~ p w ~ ~ i T t 6 a .

0t UUp6T&p&q e€,wevrspi~Cq & K ~ ~ A C ; ) U & L ~ eival TO

o<Q6eq epueqpa TO yayypalvh6cq nu66eppa, q apepi- Tl6a Kat q mov6uAi~tda ot onoieq 6uvm6v va npoqyoir- vat TWV E V T E ~ L K ~ V ~~6qAC;)a~wv. OcpBaApt~fi npoapohfi

6 ~ a n ~ m h v ~ ~ a l m nooocrr6 1-3% nadthv C(E cpkypovh- 6q vouo TOU ~vrCpou. H npclrronaefiq o~Aqpuvru~fi ~ 0 A ~ E i i T l 6 a ban~mhvma~ a& nouocx6 33% TWV nal- 6tQv ouv@oq yrr6 q 6t6yvwq q q ~hKw60uq KOA~TI- 6aq, av Kal &ivai 6uvm6v va npoqyeha~ TWV &Mov KAL- V L K ~ V EK~TJA~UEWV. Al jcqq TWV ~pavuap~vaohv 6~anl- mhvmac m o 12 % Kal ox&ri<crat pc: q p a p m a q q V ~ U O U Kal TtlV cpappCl~~UTl~fi ayWyI).

Zuvoqi<ovraq, napbAo nou 01 KALVIKE~ E K ~ T ) A ~ - GELS q q c6lonaeoOq cpkypovh6ouq vooou TOU ~vrdpou m a naldta 6ev bacpbpouv K ~ T & P a q an6 E K E ~ V E ~ TWV

E ~ M K W V , EV T O ~ O I ~ u q v r1a16lKfi t lhl~ia napouati<ouv q p a v 1 1 ~ 6 ~ l b l a l T E p 6 ~ ~ ~ ~ 01 onokq O(ETi<oVTCIl pE Ill!! avan-rucq Kal wpipavq TOU na161~0O opyav~opolj. H avayvhp~q alrrhv q v 161alTEp0~W~ ~ i v a ~ ~p iu~pqq qpadaq yla l? lV G c p E q q q ~ P ~ O T L K ~ ~ T ~ ~ TT)q V~UOU,

q 6topewq TWV bcrrapaxhv q q 8piqqq Kal q v ano- K ~ T ~ C J T ~ O ? ~ q q cpuaoAoy~@q av6mucqq Kal bvapcqq T S EcprlPEias.

1. Alan M. Leichtner MA, Higuchi L. Ulcerative Colitis In Allan Walker: Pediatric Gastrointestinal Diseases Pathophysiology Diagnosis Management p:798- 803, 4' edition 2004

2.Anne M. Gr i ihs MA, Hugot JP. Crohn Disease In Allan Walker: Pediatric Gastrointestinal Diseases Pathophysiology Diagnosis Management p: 829- 833 4' edition 2004

3. Kanof ME, Lake AM, Bayless TM. Decreased height velocity in children and adolescents before the diagnosis of Crohn's disease. Gastroenterology 1988;95: 1423-7.

4. Walker - Smith JA. Clinical and diagnostic features of Crohn's disease and ulcerative colitis in childhood. Bailliere's Clinical Gastroenterology 1994; 8(1): 65-81

5. Brain CE and Savage MO. Growth and puberty in chronic inflammatory bowel disease. Bailliere's Clinical Gastroenterology 1994; 8(1): 83-100

IAlOnAOHI DAETMONQAHI N O I O I TOY ENTEPOY ITA IlAlAlA-AlArNQETI KH IlPOZflEAAZH

naidiarpoq ramp&~&poAdyoq- HnaroAoyoq zuv&py&qq A' n a i d i a ~ p ~ ~ r j q KALVLKJI~ nave~iu-tqpiou A B ~ V ~ V

Ynelieuvq naidoyamp&n&poAoyi~oci Tpqparoq I7aidiarpi~JIq KAivi~rjq (~MqrCpa~ Visiting Assisstant Professor f lai6ia~pi~rjq, Johns Hopkins University School

of Medicine, BaAripdpq, H.n.A.

Ta T~kUTaia 30 ~p6vta q bayvwmt~fi npomkAa- q TOU natbt06 p& t6~0naBfi cphEypovhbq vouo TOU &KC- pou (I@NE) CXEL aM65et q p a v r ~ ~ a , nspvhvraq an6 q v amtvoAoytmj Kat x&~poupyt@ btb/vwq, q v ~upiwq tmoAoyta btdyvwq. Am6 ocpekat q v av6rrru~q Tflq E ~ E L ~ E ~ K E U O T ) ~ Tllq ~ a l b ~ a p t ~ f i q ~ ~ ( T C ~ E V C E ~ O ~ O -

yiaq Kat Avatu9qotoAoyiaq nou ent~pknet nio eneppa~t- ~ f i napCppaq, ~aBtmhvraq q v K O A O V O U K ~ ~ ~ Kat yaOTp00~6nqq, p& w q q P L O ~ L ~ V wq a p ~ t ~ f i E K T ~ C L T ) ~

TOU na~bta-rpt~oLj a&&v06q p& ntBav0 IQNE.

ApxlKT'l KAtvtmi emiunm. H t&v~~oepyao-qp~aKlj EKT~C(T)OT) TOU natbto6 Kat

ecpfipou p& IONE neptypacpmat m a Alayvwm1~6 KptM- pta TOU l l 6 p ~ 0 (The Porto Criteria) Kat nsplhappavet UUOT~CJE~S yta T V MQq tU'Copt~06, q V aVT~~&tp&Vl~fi &c&aq, V V &pyaOTIlplCIKfi KaL E V ~ O U K O ~ ~ K ~ ~ b 1 & ~ & 6 ~ ~ ) - q TOU aoBev06q.

H KJUvt~fi unoqia yta 6napE,q l@NE q v natbtmj qhu~ia aucavma~ o ~ a v unClpXouv enipova (1 4 epbopa- beq) fi enavaAappav6peva (2 2 ene106bta oe 6 Nveq) oupmhpa-ra 6nwq ~ o l h t a ~ 6 Myoq, bdppo~a, atpoppa- yia an6 TO ope6 Kat anhkta p6pouq.

Zqv quo~mj eckaq , apx1~6 pmphat TO p6poq Kat 6+0$ yta Tl lV qhl~ia Kat TO p6poq U& mq p& TO

6q0q Kat q ~axhq-ra avdmucqq. To Oqoq ~ w v yovCwv ~crraypacpma~ Kat x p q o ~ o n o ~ e i ~ a ~ yta TOV unoAoytop6 TOU ~ V ~ ~ E V ~ ~ E V O U T E ~ K O ~ 6qouq TOU natbt06. TO ma- 610 ewjpwqq ~mCl Tanner ~mayp6cpmat Kat naparco- AouBei~at av6 T ~ K T L K ~ X~OVLK& kaomjpa~a. rivmat k-oq TOU b ~ p p a ~ o q yla w ~ p 6 ~ q ~ a , avatpia Kat dq- mpoba~~uhia, ~(avBljpma, o<hb&q ep68qpa. H ~otAta- ~ f i xhpa E & T ~ < E T ~ L yta qpeia euat&qaiaq, av iyeuq p&<aq (qpeia eA~ii~16aq fi KOAI~KOU anocmjpmoq), KaL ~pya~~p&y&iClq. H movbuk~ l j 0If)Aq EE,ET&<&T~~ yta qpeia cphEypovflq I E ~ o A ~ Y O V ~ T ~ ~ ~ . H neptofi TOU

npwmolj E ~ E T ~ < E T ~ L yta payabeq, oupiyyta lj anocmj- pa-ra. Ta 6Kpa eQ!-ra<ovrat ~ ~ O U E K T ~ K ~ oe nep~rrrhoetq apepahyiaq yta va ano&tu9si apBphtba.

Epvamr>ta~n E€&aq OQia Aoiphbq aha evrephtbaq 4 ~oAi~tbaq npC-

net va ano~taBoOv pe K ~ M I C ~ Y E L E ~ ~onpavwv (yta Salmonella, Shigella, Yersinia, Campylobacter, Kal Clostridium difficile), Kat p k p q q ~ocivqq A Kat B yta

Clostridium difficile, Giardia lamblia Kat Entamoeba histolytica. 0 evrontopoq naBoy6vou bev ano&iet q v napoucda IONE, acpo6 pnopd va a n o ~ e k i EKAUTIK~ napayovra q q v6oou. To EV~EXO~EVO cpupa-riwqq Ba npCnet va e&r&<ma~ UE neptoxiq 6nou evbqpei q v6ooq.

'EAe~yoq aipa-roq npknst va neplhapp6vet yevt~fi eckraq aipa-roq, TKE, CRP, oupia Kat ~pea-rtviq, ahpoupivq, ~pavoaptv&oeq, Kat m optopCveq neptrrrh- oetq npdna va yivcrat Kat C k y ~ o q K O L A I O K ~ K ~ ~ . H Aao- otmj epyauqpta~fi E I K ~ V ~ I@NE n&plhapp6~&1 pewpkvq atpoocpatpiq Kat aAf!oupivq opo6, Kat aucq@vq TKE, CRP Kat atponmMta. IlapdAa am6, oe oetpa natdta- T ~ L K ~ V a&evhv pe ehKhbq K O ~ [ T L ~ ~ oe Cgapq, napa- qpodvrat cpuaohoy~~kq ~ylCq TKE, a~poocpatpivqq Kat atyonmaAiwv. Mia np6ocpcml p e w C ~ E I ~ E 6;n ot: nat- bta ME unoqia IQNE o ouvbua~6q avatpiaq at Bpop- p 0 ~ ~ 6 p ~ q q npoobtopi<et pe peyMq a~pipeta q v hap@ q q vooou (positive predictive value of 90%, negative predictive value 81%).

AucqpCveq ~pavoapwaoeq Cxouv napa-qpqesi a& 14% TUV natbthv KClTa wv btapK&la q q vouou TOUS. Eav ot ~pavoaplv6o~q napapkvouv au<qpkveq yta neptooo- T E ~ O an6 6 Clljveq, tbtahpa e6v q GGT eival aucqpCq, TOTE ntBavoAoyeha~ E~TE u~Aqpuwtmj X O A ~ W E ~ ~ T ~ ~ , E~TE Xpovta qna-rhtba. I& amCq ~ t q nsptrrrhoe~q ~petd- <mat unepqxoyp6cpqpa fina-roq Kat MRCP Kat ptoqia fincrroq.

H p ~ ~ p q q E I ~ L K ~ V ~VIIUW~CITWV ASCA (anti- Saccharomyces cerevisciae antibody) Kat ANCA (anti- neutrophil cytoplasmic antibody) aucave~ q v KAIVLK~~ unoqia yta q v V. Crohn Kat q v E A K C ~ ) ~ ~ ~oAI~tba avri- motxa, aM6 q euatu9qaia ~ o u q eiva~ pmat$ 60-80%. H wfiq 6pwq TUV avr~owphwv ANCA Kat ASCA bev cpaivmat va poqB6 tbtai~epa o-qv ~ I E U K ~ ~ V T ~ ~ q q v6oou, ago6 q nhtoqqcpia TUV na15tCi)v pe anpoo616pt UTIl K0NTda 6 x 0 ~ ~ apq~lK6 ClVTI~hpcrra. H p&pqq omu@q n u ~ v 6 q ~ a q pnopei va poqBfioet q 61ayvwq aMa K ~ I q xopfiyrlq Bepanehq.

Evdoo~6nnq Kal ~OTOAOYIK~ E E . ~ T ~ U I ~ - A K T ~ V O Y ~ ~ ~ ~ I K ~ $ Ckmoq

H K O A O V O U K ~ ~ ~ ~ U I ~ Kat q ha^ TOU T E ~ K O ~ &A&- 06 pe noManhCq ptoqieq TOU evrCpou UE btacpopa ava- T O ~ L K ~ q p & h (TE~KO$ &LhE6$, TU~M, ~VIOV, EYK~PULO,

K C ~ V , olyp0&16dq Kal op86) alT0T~ki q v P 6 q yla q v 616yvoq Kal 6~acpoponolei q v vooo Crohn an6 -qv &hKh&l K0hlTl6a. H n a p o ~ d a p&povW@~q ~LhEiT16aq eni cpua~ohoy~~~jq ~ohovoo~onqqq ouppaive~ oe 9% TWV natbthv p& IONE.

H p~A6-q Kal q ma6tonoiqq q q vooou eival qpavrumj ene16fi q a n 6 v q q uq tcAaoolmj Bepancia eCap~6Tal an6 amj . To U ~ ~ A O ~ R O k m 6 dvrepo npinel va E(ET~<ET~L p~ 6t6paq krrrolj E V T ~ ~ O U fi emp6Khu- q. Tekvraia, nl0 E u C ~ ~ U ~ ~ ) T & ~ TE)(VLK~S 6nwq q p a w - TIKO ~opoypacpia pe fi xwpiq evr~p6tcAuq Kal ev60cpM- pta xopfiyqq gadolinium, q evrepoo~onqq Kal q ev60- o ~ 6 n q q p~ ~6QouAa ixouv apxioet va &cpapp6<ovra~ Kal m a naldt6 p& aocp&la Kal ~aA6 anmeMqmra. M I ~ peA6-q o ~ i y ~ p t q q q q ~mohoyt~fiq ~6CTaqq Kal payvrln~fiq ~opoypacpiaq evrCpou C(E gadolinium (G- MRI) m 58 nat6t6 pe IONE, 66etge 6 ~ 1 17 G-MRI xpqoi- peuoe o-qv evr6mq v6oou Crohn, a& na1bt6 p& anpoo- 6 d p l q vooo, Kat entpepaiwm q v ~mohoyt~fi b6yvw- q -qq ~A~h6ouq ~ohiT16aq. H atovumj ~opoypacpia KOI-

Aiaq C6a4e u$qAIj ou*lq pe Ta eupljpcrra q q G-MRI q v 61ayvwq m q v6oou Crohn.

tqpeia 6~ac~onoinmc mc IONE oe nat616 Kat evqhi~ouc. ZE q C q pe T O U ~ E~ I@KE~, Ta n a ~ 6 ~ 6 UE peyaAlj-

T E ~ O nooom6 epcpavi<ouv v6oo TOU O I U O ~ ~ ~ ~ O U , mop6- xou Kal 6 ~ 6 e ~ a 6 a ~ ~ l j A o u (nooom6 30-40%) Kal E&O- ~0hiTtba (nooom6 48%). H ou)(V6Trrra q q epcp6vlqq q q V ~ U O U o-q vTjm~6a Kal TOV EAEO (vqm~60~1A~inZja) eiva~ peyaAhepq m a nat616 oe W q pe ~ o u q EVT~ALKE~ (20% 6vam 4%). I& nat6t6 p~ ehK66q ~ohh16a, q voooq &pcpavi<ma~ apx1~6 E~TE mo aptmep6 ~6Aov (nooom6 57%), E~TE UE 6Ao TO naxc 6vrepo (nav~ohhda, nooo- m6 32%), E~TE m o p6v0 OTO 0p86 ( nooom6 1 1 %). -

=ExW~IOT~ K ~ V L K ~ cpalv6T~~un0 anmholjv Ta nat- 616 pe apxl~fi ~~6fiAWu1l q q IONE w q k ~ i a ~6Tw TWV 5 E T ~ V . Ta nat6~6 p~~pClTEpa TWV 5 E T ~ V nou napouot6- <OUV ~ h K 6 6 ~ ) ~0hlTl6a fi vouo Crohn, &pcpavi<ouv HEpO- V U @ ~ KohiTtba, Kal 8 ~ ~ 1 ~ 6 OLKOYEVE~QK~ LOTO~IKO UE ouyyevTj nph~ou paepoli. 01 Brant et al. &6&16av hl q vouos Crohn (TE ~10161~fi qhl~ia Kal r) PapljnlTa q $ v6oou ouqcri7,rra~ pe TO IBD I susceptibility locus NODZICARDIB (nucleotide oligomerization domain 21 caspase activation and recruitment domain 15) nou ppi- UKETaL CKO xpWp00Wpa 16. 0 yovl6la~6q & k y ~ 0 ~ ~ E V yivETal6pwq U& 6layvwOTL~6 6bm0 pomivaq.

IT^ na~6~6, un6pxel eniqq pcyaAhepq o u ~ v 6 q - Ta anpoo6t6p1qq ~ o h i ~ d a q (indeterminate colitis, IC) oe &q pe ~ o u q evrlhi~ouq nou pe q v n6po60 TOU

xpbou &<&AiooETal E~TE 08 vouo Crohn, eke UE ehKh6q KohiTtba. Ta qpeia nou nt8avoAoyoOv anpoo6t6p1m-q ~0)liTldCl E[VOI Ta llCipClK6T~: 1) K0hk16a E V ~ O U K O ~ ~ K ~

Kal ~mohoyu6 cpuotoAoy~~6 pAswoy6vo op8olj (absolute rectal sparing), 2) fima eAei~16a x ~ p i q backwash ileitis, 3) p l ~ p o o ~ o n ~ ~ f i eL)LEi~16a oe au8eveiq pe aplmepfi ~oAi~tda, 4) papet6 e m ~ a ~ r j yampi~da, 5) na~K0hkl6a (I& nEplllpW~~lK6q pay66eq Kal tags, 6) KohiTlda p& m a a p 6 ~ q ~ a av6rrruCqq.

np6ocpanl peA6-q an6 250 nalbta (Calvalho RS et al.) p& @ q q k ~ i a 9.8 f l hv (SEM 2 2.5 h) C~ELE,E 6 ~ 1 29.6 % (n=74) ~ ixav A6pa apx1~6 q 616yvwq -qq IC.

MET^ an6 napa~oAolj8qq 7 pqvhv - 4.5 ET&, 10% (n=25) TWV natd~hv IC ~ i xav 6~ayvwmei E~TE p& v6oo Crohn (65%, n = 16), E~TE pe ehKwbq ~ 0 h i ~ l 6 a (36%, n = 9). Ta nalbt6 pe IC Kal Ekh6q ~0hkl6a ~ i xav ~ L K P ~ T E ~ ~ IlAlKiCI ~ m 6 q v apxl~fi 6tClyvwq m cq$uq pe am6 nou eixav v6oo Crohn. H rrA&toQqcpia TWV natdtlv pe IC eixav 6layvwcrrei apxlK6 pe aptmepfi ~ohi~tda, nou 6pwq pCoa oe 6 xp6v~a E ~ E A ~ X ~ ~ K E UE nav~ohi~t6a, pe 161aiTEpa &~18&T1~6 ~ClpaKnSpa m a JIIK~~TEP~ na1616.. YnapxEl Ao~n6v unoQia 6rl Ta na16t6 pe IC Cxouv 6~x0- p ~ m 6 KAIVLKO cpalvhuno pe paphepq v6oo.

Ta ~~AEmaia xp6vta 6ivmal peydq qpacda q v o u y ~ k v r p ~ q Twv nad1aTplKhv ~&plOT~lTlKhv IONE UE ~ o ~ u K E V T ~ L K ~ ~ ~&?&TE< pE L E ~ O T E ~ C ~ I ~ T ~ ~ ~ C ~ T V KddT~pIl Kal Cynalpq 6 ~ ~ p e h q q nou pnopei va ~a8opimt q v pc-rins~~a av6mutq KaI KAIVIK~~ nopeia TOU wq ecprjpou Kal &MkKa.

1. Differentiating ulcerative colitis from Crohn disease in children and young adults: Report of a Working Group of the NASPHAN and CCFA .2007; JPGN 44: 653-674

2. Brant SR, Panhuysen CI, Bailey-Wilson JE et al. Linkage heterogeneity for the IBDI locus in Crohn's disease pedigrees by disease onset and severity. Gastroenterology.2000; 1 19: 1483-1 490

3. Calvalho RS, Abadom V, Dilworth HP. Indeterminate colitis: A significant subgroup of pediatric IBD. lnflamm Bowel Dis. 2006; 12:258-262

4. Cuffari C, Dubinski M, Darbari A et al. Crohn's jejunoileitis: The pediatrician's perspective on diagnosis and management. lnflamm Bowel Dis. 2005; 1 1 :696-704

5. Darbari A, Sena L, Argani P et al. Gadolinium- enhanced magnetic resonance imaging: a useful tool in diagnosing pediatric IBD. lnflamm Bowel Dis. 2004; 10:67-72.

6. Hyams J, Markowitz J, Treem W et al. Characterization of hepatic abnormalities in children with inflammatory bowel disease, lnflamm Bowel Dis. 1995; 1 :27-33.

7. IBD Working Group of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition, Inflammatory bowel disease in children and adolescents: Recommendations for diagnosis-The Porto Criteria. J Pediatr Gastroenterol Nutr 2005;41: 1-7

8. Paul T, Birnbaum A, Pal DK et al. Distinct phenotype of early childhood inflammatory bowel disease. J Clin Gastroenterol. 2006;40(7):583-6.

9. Polito JM, 11, Childs B, Mellits ED et al. Crohn's disease: influence of age at diagnosis on site and Clinical type of disease. Gastroenterology. 1996; 1 1 1 : 580-586

10.Tolia V: Perianal Crohn's disease in children and adolescents. Am J Gastroenterol 1996;91:922-926

OEPAflElA OAETMONOAON IlAOHZEON TOY ENTEPOY ZTA nAlAlA

Ta na16t6 pe IONE eiva~ ~a-rpu~a n0Aljnh0~01 a&&- velq Kal anarroljv avr~pc-rhn~q an6 Cpnapq opdda kl- ~oupyhv uyciaq pe m6xo q v napox4 q q nt6avlKfip ~ m 6 nepirrruq Bepaneiaq. H enAoyrj TWV qapp6KW~, q 6la~Trrrutctj napdppaq, q +uxoAoy~~fi unoonjplcq Kat q xelpoupy~~fi avnpe~hn~q (o~av eiva~ anapaim) €la npCns1 va ouv6u6<ovra~ wme va ~n~~uyx6vtrra~ q ljcpeq Kal q 6 1 q p q q qq, q ~Aa~lmonoiqq TWV E~I~IAOKQV q q v6oou Kal TUV napevepyelhv TWV cpappa~wv pc m6xo q v ecaocpClhlq uy~odq av6rrrucqq.

Ta apxi~6 qdppa~a uqv eni~eu~q 6qeqq uqv ~hKh6q ~oAin6a E ~ V ~ L Ta ~ ~ ~ v o u ~ ) ~ u K A L K ~ (yla fima vooo), ~op~t~omcpoe~bfi (y~a peoaiaq paphq~a vbo) Kal ~uKAomopiq (yta papeta v6oo). Av o adewjq avrano~pt8ei Kal pnei oe ljqeq, a~oAouBei Bepaneia ouvnipqqq pe ~~LVOU~AUKIALK~, pep~arrronoupiq Kal a<aBe~onpiq. H ~ o k ~ ~ o p r j Kal q 6qp~oupyla eL)IEoop81- tctjq avamdpwqq (J pouch) ano~eAei Bepanela q q ~ V ~ E K T I M ~ ~hKh60~q K0hiTl6aq Kal UTIq ~ ~ E ~ I u u ~ T E ~ E ~

l l & p l ~ h ~ & l q ~ E A T L ~ V E I CJ~~CIVTLK~ TO &nhl&60 <Wfiq TWV

au9evhv. Bipa~a oe ~ 6 8 ~ n e p i m ~ q npkne~ va <uyi<o- vral 01 ~iv6uvol nolj qrrqovra~ T L ~ aucavdpeq wfiq ~ v o u o K C ~ T ~ U T ~ ~ T ~ K ~ V p& Tl lV &nleupia TOU a d & - voljq va 6 l q p f i o ~ l TO naxlj CVTE~O Kal va anoqljY&~ pla npoowp~\nj fi ~ U ~ T L K ~ pdvlpq ~Aeomopia.

H qappa~em~~fi Bepanela q q v6oou Crohn eiva~ nlo nohljnho~ll Kal &?ap-rhal an6 q v evronlq ~ t l q vooou (yampo6~6e~a6a~~uh~tctj, k m 6 Cvrepo, nqlj ivrepo), ~aBhq Ka1 q popqfi q q vdoou (qhEypoM $kwoy6vou , mivwq, 6thpqq). H Bepancia ecpo60u yla q v6oo Crohn ouMBwq nepAap$6v&l aplvooa)lu~~- A L K ~ Kal ~VTI~IOTLK~ (yla finla pkwoyov~~f i v6oo) ,6~al- W L K ~ ~ Bepaneia (noAupep~~fi fi molxe~amj 6ialTa), ~ o p - ~u~omepoet6fi (yla pkqq papIjq~aq vdoo), Kal inflixirnab (yta avBstm~~fi q v K O ~ T I < ~ ~ fi vooo pe oupiyyla). Ta ~ ~ L v w ~ u K L ~ K ~ , q p~p~amonoupiq, q a<aBe~onpivq, q peBo~peQZ~~q Kal o inflixirnab pnopei va ~pqmpono~qBoIjv oav Bepaneieq ouvnjpquqq.. H XEL- poupy~~fi avr~ptrrhn~q q q v6oou Crohn 6ev eiva~ Bepanem~~fi Kal y~am6 neplopi<trra~ povo yla aoBev~iq pe enipovq vooo Kal nep~opl<opeq oe pl~p6 ~ m p a TOU

evripou (TEALKO~ eL)IEdq, ~uqho) fi yla q v avr~ptrrhnlq enmr~Ao~hv q q V ~ Q O U onoq m i v w q fi an6qpa. 'Orav TO X E L ~ O U ~ Y E ~ O eiva~ anapaiq~o q ouvdx~q q q Bepa- neiaq ptrreyxe~pq~~~a Ba poqBfioe1 q v C k u q uno-rpo- fiilq

na16t6 p& ~ A ~ h b q ~0hiT16a Kal VOBO TOU Crohn eiva~ UE aucqpho K ~ V ~ U V O yla aven6p~wa p ~ ~ p o B p ~ m ~ - K ~ V U U ~ ~ T L K ~ V ((PUAAIKOIS ogioq, m6fipou, ptrapivqq D) Kal anal~odv ou~vrj napa~oAoljBquq.

AAOH ITHN ANTlMETOnltH TON flAlAlON ME IQNE

Ta nat6ta pe 'phEypovh6q voao TOU evripou, am- npoowneljouv pia tdlai~epq op66a, pe noA6nhono np6- pAqpa, nou u q v avr1pmwn~N q q aupp6Mel pia opa6a E L ~ I K ~ V .

H 616yvwq Kal napa~oAou8qq TUV adevhv amhv npdnel va eival pe806l~fi. r ia q v 6t6yvwq anal- T E ~ L K~IVLKO$, &~yaCITTl~laK6$, ~K~IVO~OYLKO$, ~ ~ 6 0 - ~ K O ~ I K ~ $ Kal 1~~0A0yl~dq 6hm0q. ~ ~ O T ~ U E L ~ yla q V

bepe l j qq ~ w v naldthv, Ka8hq Kal q v napa~oAo68q- ail TOUS CXOUV 8&(~nlOT&i an0 T l l V Eupwnai~fi ETalp&ia natd~a-rpl~fiq rampevrepoAoyiaq, qna-rohoyiaq Kal Ata- ~po'pfiq (ESPAGHAN-Porto Criteria, 2005).

R6xo q q Bepansiaq anmehi q 69eq KaL 6x1 q a m KAIVIK~~ anavqq.

Wrfipla 6q&qq ~ ~ ~ O T E A O U V q $ & A T ~ U ~ fi ~ea'p6- v ~ q KALVLK~V uupmwpCTTwv, C I T [ O K ~ T ~ ( T I ~ ~ TWV &pya- q p ~ a ~ h v napaphpuv, ~aAfi u w p a ~ ~ ~ f i avarrrucq, (PUULOAOY~K~~ 00~1Kf i ~ u K v ~ ~ T ~ , Kal ' ~ U ( J I K ~ L~oAoYIIC~) a n o ~ a ~ 6 m a q . I lo t~ iAo~ Bepaneu~~~oi napdyovrsq ixouv npo~aeei u q v avrtprrhnlq ~ w v nat613v pe IONE, KO~TIKOEI~~~, a<aeaonpivq, opep~amonoupivq, pe8o~pechq. 0 npoab~op~apdq &n6p~&laq ToU E V ( ~ ~ O U

8elonoupivqq, p€8~hTpav09&paq (TPMT) 8&wp&iTal en~pEpAqpCvoq nplv q v ivapcq Bcpaneiaq pe AZA fi 6- MP. I& apphmouq av8sKf1~oljq u q v avw~Cpw aywd npo~eivovral vCo1 napayovreq (PLOAOYLKO~), onwq, inliximan, adalimuban, ~uKhomopiq, tacrolimum (FK- 506) Kal q 8aAt6opi6q.

A~6pq Kal nat616 m ~aAfi yevl~fi ~ m d c n a q , npC- na va napa~oAou8oljvra~ o u u ~ q p a ~ ~ ~ a (av6 ~pipqvo nephou), onou E A ~ ~ X O V T ~ L q ouppop'pwq Kal avoM npoq q v aywyrj, q owpcrrt~fi avamucq, 01 napevipyec eq TWV 'pappd~uv, q bv6aa p~~pomo~xeiwv, q opipavq TUV 6~lrrepoyevhv ~ a p a q p ~ c m ~ w v TOU 'pljhou Kal q o m ~ ~ f i n u w o q ~ a .

BaolKfi napaprrpoq u q v napaKoA068qq TWV

nadthv pe IONE eiva~ o i61oq o 6ppomoq Kaloxl p6vo TO "CVTEPO TOU". 'ETUI 8' ~ ~ O ( P E U X ~ O ~ ~ V ~ T ) C I C I V T L K ~ npo- PAfipa-ra onwq:

- Aaveaapivq 6thyvwq - A Q o A ~ ~ I ~ ~ P ~ V O q q K ~ L v I ~ ~ E L K O V ~ ~

- Yn&pPoM Kal K C K ~ X ~ ~ U I ~ m a av000~aTaUTah~l- ~a UE apphmouq nou eival uno+fi'p~ol yla K O ~ K T O ~ ~

- Kappia eua~a0q~onoiqq mqv ntBav6~11~a ~ E T E ~ E L ~ ~ T L K ~ ~ ~ uno~ponfiq q q v6aou

- Kal aFoA6yrlq TUV owpcrroprrpl~hv mol~eiwv Kal TOU enlnC60u TOV I ) (VO~OLXE~WV

- Mq +UXOAOYI~ unourfpl~q a& nat6ta nou fi6q mqv apfi q q v6oou napoucna(0uv amoq Kal ~crr68Al- +rl

- An6Au-q Pepatoq~a yia q v auppbp'pwq fi q v npooappod ~ w v apphmwv

Mey6Aq npouofi Ba npinel va 608ei u q v p.5~6- P a q TWV na~6~hv p& IONE m o xhpo TUV eqhi~wv. 01 EMALKE~ yampevrepoA6yo~ 0a npCnel va eival &rocpol v' anavnjoouv oe qpavruta epwnjpa-ra, onwq pCMov, uno-rpornj, ~ O q q , yovlp6~qTa K.&. Oa npine~ eniqq va K ~ T ~ V O ~ ~ U O U V 6 ~ 1 TO nadi ~ E V &ival pl~p6$ &vljkKaq.

1. Markowitz J. et al. A multicenter trial of 6-MR and prednisone in children with newly diagnosed CROHN's disease. Gastroenterology 2000; 1 19(4): 895-902.

2. Cokhale R. et al. Bone mineral density assessment in children with IBD. Gastroenterology 1998, 114(5): 907-1 1.

3. Bollinger AB, Savage MO, Sanderson IR. Delayed puberty associated with IBD. Ped Res 2003; 53: 205- 210.

4. Joonses, Reinich W. The role of serologic marker in inderteminal colitis. Gastroenterology 2002, 122: 124-27.

0 I I A t l P M m K ) m 6 WIIIM#)I (HBm)NOAONl m w m

(EMHNIKH O M A M MEAETHI. l@NE)

APOPIKEI EKAHAOIEII XXETIZOMENEZ ME IAlOnAOH OAETMONOOH NOZO TOY ENTEPOY

OL d~onaesiq (phypov46aq na8fioe~q TOU em&- pOU (IONE) p& Kupiapxeq q v &hKL;)6T) K0AiTda (EK) Kal q v6oo TOU Crohn (NC) uuopd<ovral pe noMCq egwe- v r&p l~ i$ KALVLKC~ E K ~ ~ ~ W U E L ~ (EE) npoop6Movraq ~upiwq T L ~ ap8pho&~q, T O U ~ 0cp8aApo~q TO 6Cppa KaL Ta ~oAqcp6pa, av KaL 0 ~ ~ 6 6 ~ ~ 6 8 ~ oljo-qpa TOU OpyaVI- upolj pnopsl va npoupAq8ei. To 20-40% ~ w v a d w h v pe IONE 8a epcpavioe~ ~ouA6~~urov pia EE. H apepi~~6eq E ~ V ~ L pLa ~ 1 ~ 6 KOI@ EETTLRAOKJ) TWV IONE KL ~6qAhv0- vraL a& Cva 10-20% ~ w v adevhv. Taclvopoljvral ouvlj- 8wq ue mov6uAoap8pon68~~~q ~evrp l~o l j T ~ O U (axial athropathy) Kal nep~cpspu~~q ap8p[~16&~ T~~I~ou I KaL II ~ a e h q avaoya q u x 6 q nou Cxouv pe q v evepy6q~a Tqq V~UOU.

IlAOOrENElA 01 uns68uvo~ pqxavtopoi ~ w v EE 6ev ELvaL nAfipwq

anooacpqnopCvo~ aM6 cpaive~al nwq e p h i ~ o v r a ~ nap6yoVTeq ~ L K ~ O ~ L ~ K O ~ , YEVETLKO~ KaL TOU aVOUO~01~TL- ~ o l j . NOD2lCARD15 yovlb~a~oi noAupopcp~opoi ouox&ri- {ovral pe q v napouuia ~epoAayovi~~6aq (IA) oe ade- veiq NC. 01 adeveiq pe apBpi~~6a ~ l jnou I fi II nCpav TOU ~LCI(POPETIKO~~ ( ~ ~ L V O T ~ ~ I O U 6 x 0 ~ ~ KaL 6~acpopml~o yov6mno. H auroavooia ~a-raAapphve~ ~ e v r p ~ ~ r j O C q m a 6phpeva. AUTO qaivcral ~ 6 0 0 an6 q v ljnapcq auroavr1owpCrrwv 6nwq Ta pANCA o-qv EK, 600 KI ano TQV ~ ~ o T E ~ E u ~ ~ T ~ K ~ T I ~ T ~ Tqq ~ V O U O T ~ O ~ O ~ O ~ ~ T ~ K ~

aywyr5q. Eniqq aveupC8q kauraupoljpevq avd6paq jkTaE,O &llleqkaKfiq TlpwT~iVIlq TOU IlClx~wq evrCpou (p40) pe enkonouq oe aMouq 1m06q - onwq Ta xoAq- @pa, OL opeahpoi KaL Ta xov6po~hrapa. IE netpapa- T L K ~ povrCMa enipueq eAElj8epo~ E V T E ~ I K I ~ ~ xAwpi60q EK~MWU~V K0hiTda KaL ap8piTlba 6mepa an6 anoKa- ~ 6 m a q q q e v r ~ p ~ ~ r j q ~AwpBoq. Oaivma~ Aomov 616- 6 p a q pma56 TUV pl~poopyav~qhv Kal uno6oxCwv m o ent8fiA~o TOU evrCpou, m a povo~hrapa, pa~pocp6- ya KaL & V ~ ~ I T L K ~ ~h-rapa pe C K K ~ I ~ pmaplpaurhv KaL evepyonoiqq TWV kpcpo~mapov. Ta-Khrapa o-qv lamina propria o-qv NC KaL UE ao8sveiq pe EnA nap&- youv ~vrepcpepoq-y pe anarChopa q v napaywyrj npo- cpA~ypovw6L;)v K ~ Q ~ O K L V ~ V (TNF-a, 11-6, IL-1 ) . H avelj- p e q opoiwv o~ lphv ~ a v a u r e u r ~ ~ h v T-~~rrr6pwv mov pAEwoyovo TOU IlE KaL mo alps KaL u q v opoy6vo pep- pp6q, e v ~ ~ u o u v a m q v Bewpia.

EONIKOI IKEAETOI H npoopo)ll5 TOU ~ ~ O V I K O ~ ~ mekrol j nepLhapp6ve1

q V 1epoAayovh~6a (IA) KaL q V ~ ~ K U ~ O ~ O T ~ T L K ~ OTIOV~U- h 6 a (AZ), napqpeha l uro 3-10% ~ w v ao8evhv pe IONE KaL ~up ioq oe 6v6peq (2:l). nap'6Ao nou axial dis npoop6MEt TO 3% ~ w v adevhv pe IONE cpaive~a~ nwq Cwq 25% ~ w v adevhv pe NC pma ~ K T L V O A O ~ L K O 6- pe AT Cxouv aouprrrwpm~~fi IA

H oupmwpa-roAoyia eiva~ oocpuahyia pe avrav6- K k l q OTOUq YAoUTO~~S, pE ~ ~ ~ O O ~ E U T L K ~ E ~ ~ ~ E L V O ~ ~ ~ E V O

xapanflpa 616pK~laq pqvhv, pe npwlwj 6umapqia, pe enldsivwq u q v avhauq , UE ao8eveiq uuvlj8wq c40 mhv.

H 6~ciyvwq q q IA yivmac amvoAoy~~6 oe anAfi am~voypacpla rj a~6pq ~aAhepa Aoyw aucqpCvqq eual- oeqoiaq w MRI pe fi xwpiq ya6oAivlo. Av T E K ~ ~ ~ L W ~ E ~

QKTIVO)IOYIK~ T) I/\ T ~ T E anamha1 pk!TpqUTl q q KIVWK~-

q r a q q q onov6u)u~fiq onjhqq Kal q q Cmueqq Ohpa- Ka y16 q v aveljpeq nt8avrjq AZ. Xprjcnpoq 6ei~7-q~ yla ev6c~opevq p&Movrt~fi AI eivat Kal TO HLA-B27 av Kal TO 2040% TwV ad&vhv p& f i E ~ V ~ I HLA-B27 ~ ~ ~ T L K o ~ .

H 6t6yvwq q q AZ yivma~ pe K)\LVLK~ (uuppma oup~rh- pma ~ouA6x~mov an6 ~p~pfivou, 8 m ~ o Schober test pe na8oAoyu~fi Cmucq 8hpa~a) KaL a ~ ~ ~ v o A o y 1 ~ 6 ~ p ~ a p i a (a& ad r j amvoypacpia, CT rj MRI).

IlEPI@EPIKEI APQPITIAEI OL neplcpepl~bq apepahyieq eiva~ o u ~ d q mouq

ao8eveIq p& IONE 6nwq KaL mov ~ 0 1 ~ 6 T K A ~ ~ u u ~ ~ . 01 adeveiq pe IONE popoljv va naqouv an6 cphy- povh6e~q opoapvqr~~Cq yla RF ap8pi~tbcq 01 onoieq ouvljewq npoopcVAouv o u y h p a adeveiq pe mi- &y@vq vooo ~ a 8 h q KaL adevsiq pe vouo ~upiwq mo K~AOV. Kma d p p a q ~a(lvopoljvra1 O T L ~ eefiq 6uo KQTT)YOP[ES.

APOPOnAQElA TYnOY I Eivat ohyoapepu~fi apephda (c6 apephm~q),

K U ~ ~ U S U& p&y&&q ap8ph~&lq pE ~ u p 6 T ~ p q T l l V Ka~6 y6vu apepwq, uuoyxi<cra~ pe ecdpwlq q q IONE av KaL pnopei va npoqyqeei q q 61ayvhoehq 1-11~. h v eiva~ nappopcpw~~KJ) rj alappw~tKJ), TO 30% TUV adevhv pno- pci va CXEI nhCov q q piaq unmponfiq KaL uuvun6p~e~ aucqpivq enirrrwq o<L;)60uq epu8fipcrroq Kal L~WOKU- KAiTl6aq.

APOPOnAQElA TYnOY II np6~~LTCll yla o ~ p ~ p l ~ f i ~EPLK&$ cp0pCq PETaVa-

ureurl~f i IToAuapepiTda nou npoopC1ME~ ap~mCq

I IAlOnAOnN I @AErMONWX2N ( NOX2N I TOY I ENTEPOY]

ap8phue~q. H nopeia q q eiva~ ave56pq~q an6 amjv q q IONE, pnopei va blap~ei Clrjveq evh napouat&<&~ ouyEq unmpondq. Iuopxi<ma~ pe ~ p ~ b o ~ u t d i ~ ~ b a aM6 6x1 p& 07;hbeq ep68qpa.

Av6peoa urouq 600 auro0q ~6nouq un6pxe~ aMqAoen~~Mu$q. 0 kaxwp~up6q ~ o u q em6q an6 KAL- V L K ~ ~ p ~ a p ~ a gaivma~ va vnapxei KL avoooyevrn~6. 0 ~0noq I auq&~i<mai pe HLA-B27, 835 DR103, evoi o T6Il0~ II pE HLA-B44.

H b ~ d y v m T O U ~ yivma~ ~upiwq p.s Khv~~oepya- ~ p L a K 6 ~ p l a p i a evoi q v 61acpop~KIj 6~6yvwq 8a npCnei va a n o ~ A ~ ~ d o 6 v q oureovC~pwq, TO 07;htieq eplieqpa av q PAaPq eiva~ n~pLap8plK6, u q v apepon6- 8e1a ~6nou I: q q r r r ~ ~ r j ap8phiba, q oupu~tj apepi~lba KL

01 ap8pkl&q pm6 an6 AoipwSq TOU O U ~ O ~ E V ~ I K O ~

Uumpa~oq. T I ~ ~ O U 11 @UU TOU E ~ ! ~ X O U TOU RF KL

auroavr~owpa~wv va anoKhe~u8ei q p&~paT0&16~$ ap8phda

H Bepanda ~ w v ap8p1~hv e~bqAhoewv 8a npCna va npooapp6<rra~ avMoya q v &VIM E L K ~ V ~ TOU E K ~ - ~ O T E au8evoLjq ~ a 8 h q Kal TOV Mep6 evepyhqTaq q q e m p ~ ~ f i q V~UOU. H ~ ~ O T E ~ C J ~ C T T L K ~ ~ Cly~Yf) q q I@NE Kal q b ~ f i p q q q q m Oqeq &ha[ ouy6 a p ~ m KaL yLa TOV CAEyxo TWV uuqm~<opCvwv ap8pona8e~hv. H kaxeiplq ~ w v adevhv pe apepm6a Kal IONE e5ap~d- TaL an6 q cpcq KaL 6 t a p ~ ~ l a q q ap8phhq. Kupiapm 8Cq KaTahap$6v&l q avahyqoia, q P E A T L w ~ TWV aupmwpirrwv bumap~piaq tj K 6 1 ~ q q Kal yLa q v AZ q b~crnjpqq TIl$ ~LTOUPYIK~TI)TQS TT)q mov6uA~KIjq Cmj- Aqq m o p m o v

M U * yLa a p m 6 Xpov~a q xopjyr lq MZAO cx ouv- 6uaup6 C(E amfiue~q KaL (~uu~08epan~ia *av q tdaucn- a Bepaneia. H K h v ~ a m 6 q q eivai ~axeia TOGO yLa n e p ~ p p ~ ~ C q ap8pon68eleq 600 KaL yLa q v npooPoArj TOU ~E,OVLKO~ [ T K E ~ O ~ , aM6 un6pxouv uuxvCq uno- ~pongq pe TO nCpaq q q aywyrjq. ITL~ InA TWV IONE 6pwq 01 nep~uu6~epo~ 61ur6<ouv va xopqyr@fouv MZAO A ~ Y W avagopoiv ena~6Aou8wv &Sapmwv Ttlq KohiTdaq av KaL K ~ ~ O L O L ao8eve[q pe IONE cpatvma~ va avdxovra~ ~ a h 6 Ta MZAO. H Xp jq TOUS UE EVEPY~ IONE &V E V ~ L -

KvuraL evh a& avevepy6 vouo pe Ta n p h ~ a qpeia uno- ~pornjq 8a npenel va 61a~6rrrovral.

AvamoAsiq ~udooF,uy&v6qq-2 (COX-2): nap6 q v PeA~iwq TWV ap8paAythv napapCve1 o npoplqpcrrl- up6q yLa q v aucp&A~t6 ~ o u q m pa~po~p6v1a xopfiyrlq Ka8hq KL OL EITLITAOKE~ an6 TO ~ E T K L K ~ , ~ 6 0 0 UE nelpa- pmu<Cq Kohinbeq (m8avhq Aoyw q q uuppcroMq q q COX-2 urov noManAao~aup6 KL eno6Awq TOU evrepi- K O ~ ent6qAiou), 600 Kal ue avacpophq enlbeivwqq q q IONE m o 7,4% ~ w v adevhv pm6 an6 xoprjyqq ava- crroACa COX-2.

K O ~ T I K O ~ E ~ O E I ~ ~ ~ : r) IV ~ 0 p f i y q q TWV UE bolus (500mg - I g methyl-prednisolone) b6va~a~ va ~pqcnpo-

notqeei ~ m 6 T L ~ E ~ ~ P O E L ~ TWV ap0ponaOe~C;,v. H (NVE- fiq xopfiyrpj ~ o u q xpfi<e~ npooofiq A6yw q q ~nmp6- &&qq pe q v ~ l j p la n66qq (IRA Kal IONE) omeono- ~ W T L ~ T O U ~ 6p6q. H T O ~ I K ~ xopfiyrlq ~ o p ~ ~ ~ o u r e p o - E L ~ ~ V E ~ V ~ L ~ K O T E A E U ~ ~ ~ K ~ ~ T ~ U O UTL$ ll&plcp&p\K~q apep0~168~lq~ wo Kal W V IA KL &~8&o(Tda. I~v EP@- vouua povoap8pi~tBa napkxouv avaK06(plq, aMa bev 8a npbne~ va uneppaivouv TI^ 3-4 eyx0ue~q av& &oq.

IouAqauaAa~vq: &n~gCpet pucpj P E A T L w ~ u q v nepl- qepi~fi O ~ O Y O V I T L ~ ~ OM6 ~a06Aou u q v npouPoAfi TOU

~ ~ O V ~ K O ~ ( T K E ~ T O ~ . H 8 p 6 q q q eival ~ a h h p q U&

uuvun(lpxouua evcpyb evr&pu<rj v6uo KaL q v EK an6 q v NC.

A ~ I v o u ~ ~ ~ K u ~ K ~ : p i ~ ~ j b p a q Touq q v K, E A ~ L - m a bbopkva yta finla PeA~iwq ~ w v neptcpepu~hv apepl~lbwv.

' m a cp6ppa~a nou &ouv bo~opaaeel m p~~pCq peM- TEC UE avaa)e~6ueva ~ E T I K ~ a n o ~ ~ u u c r r a m ~ c ne~ia)e-

Anti-TNF-a: avcylgi$oAa q ~EhEuraia ~ n a v 6 u r a q u q v e&paII&iCI TOUO ~ w v IONE 600 KaL ~ w v peupcrru~hv na8j- mwv 6ev 8a pnopoljue va pqv EXEL eqappow urlq IRA TWV IONE. OETLK~ ano~eA6cyaTa m q Id TWO TO

infliximab m b 6 q 5mglkg 600 KaL TO ethanercept, o anti-TNF-a uno5o~Caq (nap'6lq Ta mwx6 TOU anOTeA6- q m a uro E ~ ~ E ~ L K O ent8r5)uo q v NC). Yndpxouv Pepaiwq a~6pq noM6 avan6mq~a epwmjpcrra, 6nwq q tbav~uj bouoAoyia, q 616p~ela TUV peuoti~auqphwv prra50 ~ o p q y l j m v , q enAod ~ w v ~mdMqAov a d & - voiv KaL TO WULK~TE~O o-qv AE av avaxarcl<ma~ q npo- 060q q q v6uou.

I u p e p a q m ~ ~ a q v enAoYf) 8cpanelaq ~ w v ap€ipu<hv EK~~AWUEWV TWV IONE, eiva~ qpavr1~6 va &IlGy&Tal ll WhTlCJTtl aywd lTOU ~alp16<&1 OTOV E K ~ - ~ O T E a d ~ w j , KL wq ur6~0q q q aywdq va eiva~ q MA- ~ l w q q q not61qroq Frjq. & en~kypCveq nep~moimlq q w t j q gappa~ou Behepqq ypappjq elvat anapaiq- q KL 866 01 anti-TNF-a napayovreq ~Lvai OL d o v ano- rehupa-rt~oi evh UE a p ~ d q nep~rrr8m~q pnopei va a n m ~ o o u v q v npwq paq &nAod

Smale S, Natt RS, Orchard TR, Russell AS, Bjarnason I Inflammatory bowel disease and spondyloarthropathy. Arthritis Rheum 2001; 44:272&2736.

Evans JM, McMahon AD, Murray FE, McDevitt DG, MacDonald TM. Non-steroidal anti-inflammatory drugs are associated with emergency admission to hospital for colitis due to inflammatory bowel disease. Gut 1997; 40: 619-22.

Felder JB, Korelitz BI, Rajapakse R, Schwarz S,

Horatagis AP, Gleim G. Effects of nonsteroidal antiinflammatory drugs on inflammatory bowel disease: a case-control study. Am J Gastroenterol 2000; 95: 1949-54.

Mahadevan U, Loftus EV Jr, Tremaine WJ, Sandborn WJ. Safety of selective cyclooxygenase-2 inhibitors in inflammatory bowel disease. Am J Gastroenterol 2002; 97: 910-4.

Clegg DO, Reda DJ, Weisman MH, et al. Comparison of sulfasalazine and placebo in the treatment of ankylosing spondylitis. Arthriiis Rheum 1996; 39: 2004-12.

van den Bosch F, Kruithof E, De Vos M, De Keyser F, Mielants H. Crohn's disease associated with spondyloarthropathy: effect of TNF-a blockade with infliximab on articular symptoms. Lancet 2000; 356~1821-1822

Ellman MH, Hanauer S, Sitrin M, Cohen R Crohn's disease arthritis treated with infliximab: an open trial in four patients. J Clin Rheumatol20017:67-71

Marzo-Ortega H, McGonagle D, O'Connor P, Emery P. Efficacy of etanercept for treatment of Crohn's related spondyloarthritis but not colitis. Ann Rheum Dis 2003; 62: 74-76

Kaufman I, Caspi D, Yeshurun D, Dotan I, Yaron M, Elkayam 0. The effect of infliximab on extraintestinal manifestations of Crohn's disease. Rheumatol Int 2004; 12:63-66

Generini S, Giacomelli R, Fedi R, Fulminis A, Pignone A, Frieri G, Del Rosso A, Viscido A, Galletti B, Fazzi M, Tonelli F, Matucci-Cerinic M. lnfliximab in spondyloarthropathy associated with Crohn's disease: an open study on the efficacy in inducing and

maintaining remission of musculoskeletal and gut manifestations. Ann Rheum Dis 2004; 63:1664-1669

May E, Marker-Hermann E, Wittig BM, Zeitz M, Meyer zum Buschenfelde KH, Duchmann R. Identical T-cell expansions in he colon mucosa and the synovium of a patient with enterogenic spondyloarthropathy. Gastroenterology 2000; 119 1745-55.

De Vos M, Mielants H, Cuvelier C, et al. Long-term evolution of gut inflammation in patients with spondyloarthropathy. Gastroenterology 1996; 1 10: 1696-703.

Gorman J, Sack K, Davis J. Treatment of ankylosing spondylitis by inhibition of tumor necrosis factor. N Engl J Med 2002; 346: 1349-56.

De Vos M; Joint involvement in inflammatory bowel disease. Aliment Pharmacol Ther 2004 ; 20 (Suppl.4): 36- 42.

Padovan M, Castellino G, Govoni M, Trotta F. The treatment of the rheumatological manifestations of the inflammatory bowel diseases Rheumatol Int 2006; 26:953-958.

Orchard TR, Wordsworth BP, Jewell DP. Peripheral arthropathies in inflammatory bowel disease: their articular distribution and natural history. Gut 1998;42:387-39.

Holden W, Orchard T, Wordsworth P. Enteropathic arthritis. Rheum Dis Clin North Am 2003; 29:513-530.

De Keyser F, Van Damme N, De Vos M, Mielants H, Veys EM. Opportunities for immune modulation in the spondyloarthropathies with special reference to gut inflammation. lnflamm Res 2000;49:47-54

MH APOPITIKEI EXlENTEPIKEt E M H A n I E l t I@NE

H N.Crohn (N.C.) Kal q eA~h6qq K O A ~ T L ~ (E.K.) ano~eAo6v TLq ~lipleq ~ O P P C ~ TwV ( P A E Y ~ O V W ~ ~ V VOW- phwv TOU evrCpou. 01 v6uo~ auroi e d q an6 TI^ evre- p1~6q E K ~ T ] A ~ u E L ~ xapaK-qpi<ovra~ Kal an6 Mheq auuqpm~~Cq bmapaxiq nou pnopei va eqpeauouv &a 6pyava nAqv TOU TEI, T L ~ A~ydpeveq Kat eE,uevre- p l~dq E K ~ ~ ~ ~ U E L S (EEE). OL E K ~ ~ A ~ B L ~ amCq pop&[ va acpopoliv q ~ 6 0 v K ~ O E 6pyavo TOU avepcrin~vou uhpmoq, pe TLS uuq0Cmepsq va acpopoliv TO abppa, T O U ~ ocp8aApoljq,~~q apBphue~q, Ta xoAqcp6pa Kal ~ o u q nveOpoveq. Xapatcqptm~~o eiva~ 6 ~ 1 p e p ~ ~ i q e5 aurhv CXOUV ll&plUU6~&p0 U U O X ~ L ~ pE IT) N.Crohn (OTO~WL- K&, ~0h0)U8iaq,nay~p&aTiTlq, v&cppoAt0iaq, apuAoei- 6wW),&vh a<, n.X. 01 6&pp~mKCq Kal 01 ocp8uAp~~Cq avacpkpovra~ pe nap6pola nouom6 q N. Crohn Kal OTl lV ~ h h 6 q K O ~ ~ T L ~ ~ .

Iuq8wq a~oAou0oOv q v KhlVl~rj nopeia Kal evep- y 6 T a TIlq &~~&plKfiq V ~ U O U Kal &~T~PE~<ouv TI lV 1-1016- TTlTa ?&fiq, Ttl v o q p 6 v a Kal Tt l 6WlT6TtlTa aUThv TUV

adevhv. Am6 6ev L ~ ~ E L yla 6AEq T L ~ E ~ W E ~ ~ E P L K C ~ ~ ~ 6 q A h u e ~ q , ~ a 8 h q pep~~Cq 6ev ouqmi<ovra~ pe q v evepy6~q~a ~ q q vouou (npw~onaefiq oKhqpuvr~~rj ~ 0 A a ~ ~ l i ~ l 6 a , a y ~ ~ h ~ n ~ l q ~ l ~ f i mov6uAhi6a). np6pAqpa yla TOV KALVLK~ y ~ a ~ p 6 a n o ~ e k i TO yeyov6q OTL pp1~Cq cpopkq eival 66o~oAoq o KAIVLK~$ baxwpl- q ~ 6 q T O U ~ an6 &urepona8eiq entnAo~Cq ~ w v voqpa- TWV aurhv, A6yo n.X. 61mapaxhv BpCqqq, an6 q v i6ta q ~ 6 v 1 a cpkypoq Kal an6 enlnAo~Cq TUV 0epane~hv q q v6uou.

H napouoia aurhv ~ w v Khvl~hv e~6qAhmwv mouq adeveiq pe d[onaefi cpkypovh6q voqpma CXEL o u q m ~ d e i pe o p ~ u ~ v o u q YEVETLKOU~ napdyo- vreq, 6nwq HLA-A2, DR1 Kal DQw5 uq N. Crohn Kal LA- DRBI *0103, B*27, B*58, HLA B8lDR3 (PSC) TV ~ h h - 6q KoAiTda (1 -3)

H u u p r n a ~ o u q n o t ~ W 1 avdoya pe TI^ ~EAC- T E ~ ava TOV ~6up0 an6 6%-47% mouq adeveiq pe IONE.(4-7). An6 amCq T L ~ e~6qAhue~q 01 nlo uu@q &ival 01 ~ E P ~ C T C L K ~ S EK~~A~u&I$ (dqv ~&plllpCOKTlKh~ 5eppml~hv ~ ~ 6 q A h u e ~ v ) , o n ~ q TO 0<h6&~ ~p68qpa (6- 15% a& N.C.) Kal TO yayypalvh6eq nu66eppa (0.1- 1.2%). k 6 p q noA6 u u ~ d q eiva~ q npw~onaerjq odqpu- v r ~ a ~oAayyeth16a (IlM) (2.5-7.5%) Kal q npodla pay0~16iTlq (fi L ~ L ~ O K U K A ~ L ~ ) 4-6% U& N.C.

EEf2ENTEPIKEI EKAHI\NEIT An0 TA XOAH@OPA KAI TO HnAP

A. npw~onaefiq mA7puvnwfi xoAayyeli~~q (nM) H npw~onaerjq aKAqpuvn~fi xoAayyein6a eival

~ p 6 v ~ a xohocxm~a v6uoq nou xaparqpi<e~a~ an6

np006eur~~fi cpkypov06q ivwq, ~mampocprj, ~ C V W - q Kal anocppa5q TOU xoAqcp6pou 6ev6pou p~ ~ o L K ~ A ~ npoupoArj ~ w v 6~acp6pwv ~ p q p h v TOU, ev6oqnarr~~hv Kal ESwqnClTlKhv L'OU ~ 0 p & i Va O~~MUEL UE Kippaw rjnmoq, nuAaia unCp~aq Kal qnmumj aventtp~aa rj va enlnha~ei an6 ~ ~ M a y y e ~ o ~ a p ~ i v w p a nou anmehi Kal TO uo$apo~epo np6pAqpa ue auroliq ~ o u q adeveiq pe KaKq np6yvwq (8).

2 nooom6 62-77% qmi(ma1 pe cpAEypovhI5q v6uo TOV EVTC~WV (10-15% /.I& V ~ U O Crohn KaL 80-85% p& ~hKh6q ~oAiTl6a). H U u p m d q q moAoyi<mal UE

57.5% UE ad&v&iq &hKh6~) K0hiTl6a Kal UE AIYOTE~O TOU 1% B au8eveiq pe v6uo TOU Crohn. Adeveiq pe v6uo Crohn naxCoq evrCpou napoucna<ouv enirrroq i61a pe a m TWV adevhv pe eA~h6q ~0Ahl6a (9). H o u p 6 q ~ a q q v6oou pnopei va unoempha~ K ~ ~ O T L

unoKhvu~Cq popcpCq pnopsi va 6~acpeliyouv TOU ouvJI- 80uq ~A6yxou. Xaparqp~crr~~o yvhplupa, 6nwq Kal m 6MEq e~wevrep~~Cq &~6qhhU&lq TUv I@NE anmeki aveE,dpq-cq KALVLK~~ nopeia q q nM Kal q q IONE (lo), EVO napoucn&<e~ a p q n ~ f i o u q k ~ q pe TO ~&m/~upa (1 1). npoupC1MEc ~upiwq dv6peq (ue 6~nAdula uup6q- Ta) pE O U ~ ~ T E ~ E ~ ~ A L K ~ E ~ &pcp&vlqq pmat6 25 Kal 40 ml

H 616yvwq q q v6uou q p 4 m a ~ a& Xaparqpt- mut6 ~ ~ L V O A O Y L K ~ eupfipma, ue ~LOXT)~LK&$ &E,m6u&lq Kal ue tmoAoyu~a euprjpa. To 60-85% ~ w v adevhv EXOUV 8ETLK6 ~ ~ L O U ~ E T E ~ O ~ E V ~ K ~ K~~ap0nAaUp~rlK6 avr~uOpma (pANCA), xwpiq 6poq aura va eiva~ ~ 1 6 ~ ~ 6 TT)q ~168qqq Ka86Tl napcmlpolivral Kal q V &h6q ~0AiT16a.(12) H xapa~~rlplcm~fi onion skin PAdpq q v ~moAoy1~fl e6CTao-q TOU rjnmoq ~aparqp1~6pevll an6 uuy~evrpt~oljq I V ~ & L ~ Bamuhiouq ylipu an6 Cva ano- cppayMvo xoMayycio an&vla n a p q p e i ~ a l q v 61a- 6epp~M P~oqia rjna-roq (15%) evh oupa napa-qpo6- vral A L Y ~ T Z ~ O ~161~6 eupfipma.

Eacpfiq aLTl0A0yl~fi Bepaneia ~ E V un6pxel 6nwq eniuqq 6ev unapxe~ T E K ~ ~ P L W ~ E V ~ Bepancia nou va epno6i<&l q V E ~ C A L ~ ~ T)q V~UOU.TO O U ~ U O ~ E O ~ U X O ~ ~ K ~ 056 ue 66u&lq 13-15mgrlKg q v qpCpa 6ev cpaivmal va E ~ o ~ ~ < & L q V e~CA15q q q V ~ U O U (13) E V ~ U ~ ~ A ~ T E P E S 66aetq pope i va eiva~ nlo ano~eAEq~a~t~iq(14).

Oepansur~~fi napCpPaq pe ERCP pnopei va anatq8ei ue &nd&l~06p&Vq v6o0, ue imepo, xoMayyec iT16a, unoqia xoAayy~~o~ap~~vhpmoq rj xoAq6oxoAl0ia- q q Kal ue 61epe6qq pov~pqq Kal aopaprjq mCvwqq. T ~ v T&kUTaia b&Ka&Tia q payvrl~l~fi XOMC~~/E~OIKC~~K~&- moypacpia 8a npine~ va npo~tpCna1 q q ev6ou~onu~q ~~Mayye~oypacpiaq o ~ a v ~pet6(mal povo 6 t d y w q Ka06Tl ~ E V E~VOL e n ~ p p a ~ l ~ r j pC8060q Kal U& 616(#0p&q pehkeq cpaivmat va napouot&<e~ euacu8qoia Kal ~ 1 6 ~ ~ 6 -

W a napbpota pe a m q q E v B o ~ K o ~ I K ~ ~ ~ XOM~WE~O- ypacpiaq(1 5).

!2q Oepan~ia, q p m a p m e u q fincrroq anomhi q v ~ e h t ~ f i enLhorl) (q 4q mo o u M arria pmapoo-xEljm- wv). Ent~ufiq p&-raphx&uq p&Anhv&l q v enlpiwq (3cnjq emp(wq 6vw TOU 85%) ~ a e h q Kat q v notdrq~a p f i q TWV adevhv E V ~ uno~pofi nM prropef va napa- qpqeei peg1 Kat m o 20 % ~ w v nspimha~wv.(l6)

r. XoAayy~lPnBa pliqxhv QYYE~SV. Eivat pia EEE q onofa epcpad<mat mtq l a ~ q qk-

KtaKkq 0p66~q p n n Kai K U ~ ~ W S or 6~6psq. H E@- kefi t-qq ~ 6 o o or IlM, 600 oe ~ i p p w q KaL ~oA6yyao- ~ap~ivwpa BEwpri~at m6vta (1 7).

A. XoAokBiacq Av at q enirrrwq t-qq xoAokQiaqq 5ev 61acpCpa

mouq adeveiq p ~hXh6q fi Crohn ~ o M ~ i 6 a oe q C q pe TOV YEVLK~ nhqeuop6 m adeveiq pe TEALK~ E I ~ ~ ~ T L ~ Q

E K T O ~ ~ ~ fi bypass TOU TEAIKOC EIAEO~~ ~updvmat an6 13- 34%.(18) H napouaia xoAohlBwv or au8eveiq p& I@NE &(vat UUM , q q f 6 5 & ~ TOU 25% Kal kx&t an0608ei 6uoanopp6cpqq TWV XOAIK~V ahtrrwv an6 TOV cpkypo- v&q T E ~ K ~ EIAE~ (1 9).

E. A~atapaxq qnm1~4q ploxqp~iaq Mnopei va ocpehxat or ~ a ~ f i 8pCI4q ,4 I4q fi UE

A~nh6eq finap (an6 ~ a a Btcrrpoqfi, G~pancia pe mepo- ~16fi). Xapatqptm~f i eivat q unoxhpqq t-qq w & an6 pe ljcpeq t-qq v6Uou . H q n w apuAoei6wq ~ivat pLa mhvla emnAo~rj , q onoia ou@aivet or nouomd <I% UE N, Crohn. PIO- +(a fincrroq or adevelq p~ N. Crohn epqaeovrat evio- TE K O K K ~ ~ ~ ~ T ~ .

IlNKPEATIKEZ f32ENTEPIKEI: EKAHMZEII OL au9eveLq pe tdlonaefi cpkypovd6q vdao TOU evrkpou napouor6<0w aueq@q enimwq ~ 6 u o *e(aq 600 KaL g6vtaq nay~pmht6aq ev6 or 7-20% ~ w v a ~ e v h v napanlps~at aouprrrwpcrrt~fi aljE,qq T ~ V nayKpecm- KWV ~v<ljpwv (20). H enirrrwq q q ocelaq nayKpscrrh~- 6aq eivat ~mpaduu ta UE au9sveLq pe voao TOU Crohn Kai 61rrh6aa or a&veiq p~ K O A ~ T L ~ oe q C q

, pe TOV Y E V K ~ nAq8uup6 (21). H nayKp~crrtr15a prropei va ocpekat m a ouvf)Oq aina 6nwq urov ~ E V L K ~ nhqeu- a@ (aA~o6A, ~oAoA~8iaq, unepAin~6aipia Idvr), va eival anmkA~crpa e~wevrep~~hv entrrho~hv (evr6ntq vboou mo 6w6&~a66~-ruAo, xokokeiaq, IlIX) fi va ocpek~at ae napevkpyaa t-qq cpappa~emtMq aywyilq (a<aeeto- npfq,6- ~ E ~ K ~ ~ ~ T o T I o u ~ ~ , apl~~~ah~Kl)clKb, pCTpOVL- 6a<&q, K O ~ T L < ~ V ~ ) . ZE Cva p l ~ p 6 nouour6 6ev avayvo- pE<mat at~ia Kat BewpeI~a~ aAqefiq E ~ U E V T E ~ I ~ e~6qAw-

q q q cpkypovh60uq V ~ U O U TWV evrkpwv. napqpe i - Tat nto oup6 or aoe~veiq pe v6oo Crohn Kat uuvljeoq 6ta6pape~ finla nopeia KaL ano6papet pe q v p ~ h ~ i w q q q E V E P Y O T I ~ T ~ ~ TTlq E V T E P L K ~ ~ ~ ~ 6 0 0 ~ (22).

AEPMATIKEI EERENTEPIKEI E K A H M E I I

A.O<w6&q ~puBqpa Eivat t l nto ~ ~ > ( \ r i l ~ E P ~ ( I T I K ~ ~ &~6 f ih~U l l Kat np0-

a p W t ouvlj8wq ao8eveiq pe N. Crohn (15 %). nto oup6 n p o o p W t yuvai~eq. Enqpea<a TO unopkwo- y6v~o Ainoq , E V ~ q Khaa1~4 popcpohoyia q q eiva~ enh- 6uva un6oKhqpa epuBqparh6q o<i6ta nou ppio~ovra~ CJlJ~eOq W V &KTClTlKfi E ~ I ( P ~ V E I ~ TOV K ~ W a~ f l~v Kat ~upiwq q q ~vljpqq. H enolihwq ~ w v o<t6iov yive~at xwpiq q Bqptoupyia kh~ouq, evh q npoyvwq eiva~ ~ahfi. Av Kat pnopei va uno~pontauet uuy-xpovwq pe T L ~

~piaetq q q evrep~~fiq VOUOU, mavta uno~pon~a<~t p e ~ a an6 ~ ~ W K T O K O ~ K T O ~ ~ ~ .

H at~toAoyia q q eivat h y v w q , E V ~ ~ X E I yivet auqhtuq pe n~ptof i HLA OTO ~ p . 6 (HLA-B ). (23) tuVf@6.l$ e&pan&ia ~ E V E ~ V ~ I &dL~~(Cl~ahyrlTl~a p.OS , K O ~ T L K O E I ~ ~ ~ ue oopapkq neptrrrhoetq) Kat q eepaneia q q E V T E ~ I K ~ ~ ~ V ~ U O U chat a p ~ ~ yta t-qv avrtpe~hniq TOU.

B. rayyparvh6~q nu66~ppa (rn) Eivat Il oupo~epq 6~ppaTlKfi ~ ~ 6 f i h ~ q nOU

U U ~ ( < E T Q L p& q V eA~h6q KOhiTt6a (0.5%-2% ). TO 36%-50% adevhv pe rn naqouv an6 I(DNE. Mnopei va a~oAoueei avecapqq nopeia an6 q v ~vrept~ f i ~600. tuvlj8wq epcpavi<e~at uuyp6vwq pe &M&q EEE (apepi- TI< ,o<h6eq epCBqpa). H 6tayvwurj TOU eivat ~upiwq Kht- v t~ f i KaL tmohoyt~fi. H Afim pto+thv eiva~ anapaiqq yta va yivet ano~A~~op6q ayyeti~16aq fi Aoipwcqq.

H Khtm~fi t-qq EIKOV~ eivat pta enh6uvll epueqpa- Th6qq Il&plofi nOU E ~ E ~ ~ ~ U E T ~ I U& cphirtcratva pE KEVTPI- ICi] v k ~ p w q Kat khoq, w kva fi neptoa6~epa qpeia TOU a6pcrroq.To kA~oq ou~va ~XEI avhpaha opta. 0 ~paupa~topoq t-qq neptofiq, q wfiq Pehovwv prtop~i va npo~ahkmt vCeq phdlpeq rn (qa~opevo naeepyiaq- pathergy). Epcpavi<mat ouvlj8oq m a ~Crrw a ~ p a , aMa pnopei va ppe8ei Kat O ~ O U ~ ~ ~ ~ O T E mo akppa, a~6pq Kat ~ E ~ I ~ o ~ C I T I K ~ .

!2q nphqq ypappfiq e&pan&ia ~ E W ~ ~ E ~ ( X L q E V ~ O -

cphkpta xopfiyqq u+qhfiq 6ooqq ( T T E ~ O E L ~ ~ V

(prednisolone), 0 X E I ~ O U ~ ~ L K ~ ~ ~aeaptopoq pnopei va npo~aA6oet epcpavtq vkwv neptoxhv (naeepyia) q q v6oou. H ~ o n t ~ f i neptnoiqq ano~&i ou~dqpwpa~tKtj aywyil. I& ~ T E ~ o E ~ o - E ( ~ P T W ~ E V ~ fi (TIEPOEI~O -CIV~E-

RIM vouo (6x1 P E ~ T ~ w ~ w 6 5 qpdpeq), ~Oplly~iTal avouo~crraurohj pe npouofi, Aoyw K L V ~ ~ ~ V O U naeep- yiaq.

KaTa ~atpoljq kxouv avacpepeei &q Bepaneieq (TontKa tacrolimus,thalidomide,~ontK6 cromoglycate, Clofazidime-6x1 ano~eheopa~t~fi , plasmapheresis, granulocyte apheresis, uneppap1~6 oQ~y6vo) , evh a& aveent~kq neptrrrhoetq xopqyei~at infliximab (5 mglkg). H dapsone p 6 ~ fi o& ouv6uaopo p& ~ T E P O E I ~ ~ ~ )$T)(St-

ponolei~a~ CJE nepimwq uno~ponta<ouaaq rn. (To 35% ~ w v aoeevhv epcpavi<ouv urto~ponfi q q rn).

r. 'w EQIMVTE~IKC~ & P ~ ~ T I K C < E K ~ ~ ~ A ~ O E I C I l ~ A ~ a p t O p ~ q &&V, 6~ppaT~KCq ~ ~ 6 t l h h ~ ~ ~ q

Cxouv avaqepBei UE au9evdq pe IONE, pe mo Xapaq- ptmtcfi a m TUV acpBw6hv crroymt~hv ehhv, Ta onoia aveupimovrat nto oupa m N.C.( 20%30%), nap6 a& E.K.( 10%). H ircpecnj T O U ~ enrruy~6vmat pe q v rjrpeq q q v6oou.A~~ nphel va ~ E X V ~ ~ E q v mopmht6a aK6pq uq &nm)loM q q Bepaneiaq p& rnethotrexate. W q ~ ~ 6 q A h m t q &(vat TO I. Sweet (ou~ETE~~L~~KI~ 6 & p p h q ) , q ~ U K O K U T O K ~ ~ ( T C I K ~ ~ C ~ W E I ~ T ~ ~ C ~ , q qwpia- q, q cpuoaAdh6qq ent6epp6Auq -(epiderrnolysis bullosa acquisita), q 6eppmt~rj 0<h6qq noAuuqpthtq Kat q p m a m m ~ ~ f i N. Crohn. H ywvia~fi xeAhtq (8%) alloT&ki C V ~ E I ~ ~ cnljrlponevbq (24).

OWAAMIKE EEQENTEPIKEI EKAHMXEIZ To 2-5% ~ w v ~ B E V ~ V pe IONE Cxouv ~anota

ocpBaAptM E<WEVTEPLK~~ e~bf iAwq , q onoia pnopei va epcpav[SETat npo q q e~6f ihwqq q q EK fi TOU IONE. (25) ~ O L K ~ O U V an6 rr)V & l l t ~ & c p ~ ~ i T d C l kwq TLS Ill0 uqpavntdq e~6qAOm1q an6 ~ o u q ocpBaJqorjq 6nwq n.X. q v tpiTt6a, ~ntudqphda, aKhqpi~t6a Kat np6oBta payoetdin6a. To np6pAqpa elvat 6n u q y 6 6ev entq- yaivovrat an6 TOV KhLvtK6 Imp6, aMa npo~ahoirv ~ 6 - Aq voqphqra Kat ~iv6uvo yla ~BcpAwq. EnoMvq o h y ~ o q ~ w v ocpBaAphv npCne~ va a n o ~ e k i e t h a q pourivaq oe aaeeveiq pe IONE.

A.Emcrdypinq Eivat nto ou~vq oe N.C. Iu\rilBwq ouv6u&<~~at ye

&v&pyo evreplK7j cpA&ypov?j,&vh ~ E V enqpe6<&~ q v orrrt- @ oQhqTa TOU au9evoirq.H Bepanela eivat q avrtpmh- T I l q q q u ~ o K E ~ ~ E W ~ ~ E V I E ~ I K ~ ~ ~ vouou KaL T) XO~~~YI)OT)

T O ~ K ~ V K O ~ T ~ K O ~ E ~ O E I ~ ~ V .

H mAqpi~tq evroni<mat oe PaBrirepa mphpma TOU

ocpBaApoir Kat av 6ev xopqyqB~i ~m6MqAq Bepaneia 8a napapeivct unoAhpmt@ pA&pq.

B.Payoslbh~q Aveupimat m o 0.5%-3% ~ w v au9evhv. &v em-

pe&<et q v orrrtM othq-ra (em6q av npoupqBei TO oni- &to ~pfipa). Eivat nto uu~vf i q npoopoAfi ~ w v 6uo ocpBaApdv, evh nto oup6 ~pcpavima~ m yuvai~eq ye IONE. b v eivat a n a p a h ~ o q epcpawmj q q va owo- 6ebmat an6 evrepN ~vepyhq-ra. 'Eva oeir &n&t~66l0 payoet6h6aq pope l va npo~aldoet p6vtpq pAapq pe mpocpia ipt6aq Kal evanoBCmtq crrouq cpa~orjq. Anarrei- Tat nto ent8m~fi Bepaneia, tdioq UE npoopoAfi TOU oni- 0810~ 8aA6y0~ ocpeahpoc. (crrepoel~fi ~onut6, m q - pm1~6 fi Kat ev600cpBaAp~~Cq eyXljmtq). TCAoq CXEL ava- cpepBei ano~ekapcrrt~fi Bepaneia pe infliximab (26).

r. O@~&IK& EHIHAOK& I@NE EKT6q an6 TLq # U & V T & ~ I K ~ ~ EK~@~u&&, & E q

entnho~Cq pnopei va epcpavturoirv us K ~ T ~ O T ~ U E ~ ~ ouMq cr& IONE.

H 6uoanoppckpqq q q pt~apivqq A npo~ahEi K & p ~ ~ n b ~ & t a Kat ~~)(r&ptv?j Tdcph~q.

Ta uuqpmu<hq xopqyoirpeva mepoet5fi npo- K ~ O ~ V T l lV E ~ ( P ~ V L U ~ K ~ o P ~ K T ~ ~ , E V ~ Ta TO TI KC;)^ XOpq- yoirywa mepoedrj npo~aAoirv a66qq ~ q q ev6ocpBclA-

plaq n k q q Kat yA6u~wpa. Inavta 01 ocpBaApt~Cq e~bqA6oetq an6 ~ o u q ocpBaApoirq eivat ayyetaaq at~toAoyiaq TOU apcptpAqmpoet6oirq (andcppaeq ~evrpt~rjq cpkipaq fi ayyeti~tq), neptcpcpu~hv &hh K E ~ ~ O E L ~ O ~ ~ fi E V ~ ~ O ~ E U E U V K E ~ C T C O E L ~ O ~ $ .

0 1 avr~xoAivepyaoi napayovreq nou uu~vCl ~pqot- ponotouvrat yta q v avrtpmhntq T ~ V ~ o A t a ~ h v aAyhv ue aoBeveiq pe IONE pnopei va npo~aAioouv pu6piaq, E V ~ m&ta pnopoirv va npo6taBCoouv oe yhair~wpa oteiaq ywviaq oe optoyCvouq au6eveiq.

H avooo~crracrraA~t~ aywyrj Kal ~upiwq q KUKAO- mopivq pnopei va ,npo~ahCoet orrrtK7j veupon6Beta, ocpBaAponAqyia Kat vumayp6. EnopCvwq oe avoooKa- ~ a u r a A ~ t ~ f i aywyrj 01 au9eveiq npinst va Cxouv are@ veupo-ocpBaApoAoyt Kai veupoAoyt~fi napa~oAouBq- ="-I.

OPOMBOEMBOAIKEZ ElllflAOKEZ 0 1 au9eveiq pe IONE Cxouv autqpCvo ~ivbuvo

avdrrrutqq BpoppoeppoAt~hv entrrho~hv, 6nwq EV TU

p68a (qA@tM Bp6ppucq Kat nveupovl~fi eypohfi. Ot nto oupCq Bpoppdoetq eivat ot cphpt~Cq. H &v&py6~q~a q q v6oou Kat q Cmaq q q V ~ U O U m o KOAOV uuop-ri<ovra~ pe TOV K ~ V ~ U V O avdrrru~qq Bpoppo~ppoAt~oir ene~o06i- ou. (27). H Bpoppo~mapwq, pe a i r tqq TOU ap18poir TWV atponmaAiwv pixpi Ta 800.000/~rn3~at q autqpivq ouy~Cvrpwq napay6vrov nfitewq (tvw60y6v0, napa- yovraq V, VIII, IX, ~ i w q avrt8poppivqq Ill Kat npw~e'i- vqq S, ~aewq Kat pmmacq nap6yovra V-Leyden) o6q- yoirv UE pta ~a-racrraq unepnqrcrt~6q~aq. H rrhE1ov6- q-ra aurhv TWV aoB~vhv EXOUV evepyj ~ 6 0 0 an6 TO

Cvrepo. I& npoocpcml p&A&q q i6ta q IONE Bewpei~at napayovraq ~1v6irvou yta avarrrueq Bpopposppok~hv ~neioo6iwv. (28) I& noooma avw TOU 50% ~ w v au9evhv ~ E V C~VEUP~UKET~L K ~ ~ I O I O ~ np06taB~ot~6q llapay0- vraq. (29)

EnmMov Mhot napdyovreq onwq q a~tvqola,q OXETLKT~ acpu6hwq, q voqk ia , q orjqq,q ntBawj ouvlinapcq ayys1i~t6aq Kat ot eneppcrrt~bq np6Cetq aueavouv TOV ~iv5uvo Bpopphmwv.

A~6pq q Bepaneia pe ~op~t~ocrrepoetbfi pnopei va 6qptoupyljoet ~ m a m a q unepnqm~hqraq. @a pno- poiroe va ouanjvmat mouq voqku6pevouq au9eveiq pe IONE va Aappavouv xapqhjq 6 6 q qnapivq yta npo- cpOAa6q an6 Bpopp6oe1q, )lqv ~ w v neptrrrhueov oopa- phv atpoppaythv an6 TO Cvrepo.

EKAHMEIZ All0 TO AlMOllOlHTlKO ZYZTHMA H avatpia eivat 6va oup6 np6pAqpa mq IONE.

YnoAoy@at 6 ~ 1 TO 30 % (6,2%-73,7%) TUV au9evhv pe IONE napouot6<ouv avatpia. (30) Kupiwq ocpeihrrat oe CUEtqq utbfipou ,m avatpia ~p6waq vooou Kat oe uuv- 6uaop6 TOUS. 'AMa a i~ ta elvat q peyaAopAamt~fi avat- via, q CUEtqq prrapivqq 812 fi cpuM1~06 oe N.Crohn TEALKOU eA&olj , q auroavoq atpoAurtM ava~pia Kat q atpoAuq an6 cpappa~a (uouAcpaoaAa<Lvq).

OYPOAOTIKE EEQENTEPIKEZ EKAHMZEIZ

A. N~cppoAleiaaq Mta an6 T L ~ U U ~ T E ~ E ~ en~)lo~Cq q q N. Crohn

eiva~ q vecppoht0iaq. 01 hi001 oe au-roirq ~ o u q au0eveiq qpcrri<ovral ~upiwq an6 oupl~6 066 E~TE an6 o(aA0~1- KO aapCur~o(o& N. Crohn TEA. Ehoir). 0 ~iv6uvoq ava- rrrucqq hi9ov and oupu~o 066 au66v.s~ pe q v a n l h t a uyplv ( n . ~ 6tappola, ekomopia) Kal ~aTa Ta uneppe- ~ a p o h ~ ~ a ma6la UE noAir ~mlpeaq.kvouq KAlvt~a a&&- veiq . H np6Aqqrj ~ o u q nspiAappave1 evu6hwq Kal ahKaAonoiqq ~ w v oirpwv, E V ~ q np6Aqqq 6qp~oupyiaq M0wv an6 oeaAo61~6 au$Cm~o nspiAapp6vel 6ial~a xapqAfi o& ocaAo(~~6 Kal avarrArjpwq aopemiou an6 TO mopa. (1-2 gld).

B. NE(PPIK~~ ap~A0Ei60~q Eivat ouvrj0oq ano~&opa q q ~ p 6 v ~ a q cphypo-

vrjq Kal ouvavrhal nlo ou~v6 ue N. C. pe q popcpfi q q ouqpmi@q AA apuAoei6wqq an6 E ~ W K W ~ P L E ~ Eva- no0Cmlq ~pqpCrrwv ~~~Aocpopodvrwv npOT&'ivdv oceiaq cpamwq (SAA). H Cvapcq q q oupmwpa-rohoyiaq oup- paivel 15 kq pm6 an6 nq evano06oelq apuAoet6odq, E V ~ q E ~ C A L ~ ~ q q apuAoe5wqq pnopd va E ~ L T E U ~ ~ E ~

pe TOV dkyxo q q ~pbviaq cphypovrjq

KAPAIOAOrlKEI EKAHMZEII 'Exouv avacpepeei oe pepovwpdva nep~ma-r~~a

(case'reports), n~p~~ap6t r l t ja Kal nep~puo~ap6i~tda, evh ~ ~ ~ u K o A o ~ &ivalO arro~A~lq16q Tllq cpappClK&UTlKfiq TO~L- KhlTaq all6 U ~ U K U ~ K ~ .

NEYPOAOrIKEZ EKAHWEI I IE aoeeveiq p~ IONE dxouv avacpep0ei au-rodvo-

UEq v~upoAoyt~Cq 61mapaxdq (uKA~~Puv~ Kurd nh6- Kaq),OTIopa&Kdq V E U P O ~ ~ ~ ~ E L E ~ (0lTlIKfi V E U P ~ L ~ ~ , IlEPL- cpep~~dq veupon&€~~~eq), ~ v d pm6 an6 Bepaneia pe natalizumab (avriowpa Ka~6 a4-integrin,) anti-TNFa- infliximab, etanercept Kal adalimumab CXEL avacpepeei npw~oiraa A~u~o~y~~cpaAon60e~a (progressive leucencephalopathia).(31,32)

H xoptjyqq metronidazole pnopsi va npo~&ml noAuv~upon60ela evh KAlvl~fi uupmwpa-roAoya pnopei va ~~6qhw0e i p&T6 an6 TV ~ M & L ~ T ) O ~ L U ~ ~ V W V

ouotlv,6noq q pl~apivq B12.

BPOn<OIINEYMONIKE EKAHMZEII Atdcpopeq e~6qAhos~q an6 TO avanveuaru~6

o l i q p a avacpdpovra~ m a IONE Kal nepiAappavouv 6uoh~~oupyieq ~ w v pey&wv Kat p t ~ p l v aepaywycjv ~ a 0 h q Kal anocppam~dq Kal6tapemq mreupon~dq ba- ~apaxdq. Zumj0wq Ta avarmeumu~6 ouprrrlpura aKo- Aou0oOv q v ~vepy6qTa TWV IONE. Oaivmal 6 ~ 1 q KO&

moprj a n o ~ e b i napayovra K ~ V ~ I ~ O U yia avarrrucq rmeupovt~lv ouprrrwphwv.(33)

npoocpma, oe pLa Kavak~fi pek2-q Ta avameu- m ~ ~ 6 voarjpma Bewpocivral wq q nlo o u p j ouvmap- Xouoa voooq o-q N.C. Kal q 6eljTEpq n ~ o (SUM o-qv EK. H uqqhfi u q v 6 ~ q ~ a avarm~uur~~fiq ouppmofiq urtq

IONE nt0avlq ocpeka~ q v K O L V ~ ~ npodhuq TOU

ppoy~l~oir Kal ~ v r e p ~ ~ o l j hpcp1~06 lmolj. A~6pq KaL q unoKA~vu@ nveupov~~fi uuppmo~~j eiva~ nohir uqrlhfi (30%-60% UE N.C) .(33)

H ~IAELOV~TTTC~ ~ w v au0evlv pe IONE KaL ava- r~veuml~dq ~~6qAhuelq n a w l an6 ~ p 6 v ~ a ~poyXiT1da fi ppoyX~&mad&q.H nlo o u M 616peq rmsupovl~rj v6ooq nou uuupzri?@ra~ pe q v IONE eiva~ rl opyavonot6q T W E U ~ O V ~ ~ p& allocppa~~l~fi pp0yX10h~~lda (BOOP) (34) H TunlKfi ~o~~lwpa-rcj6qq 6 ~ 6 p ~ q ~VEU~OVI@ V ~ U O ~ q N. Crohn ondv~a, npooopo~&<e~ pe q v oap~oei6w- q Kal x a p a i q p i < ~ ~ a ~ and q v 6napcq pq ~upeoet60- llolq@vwv K O K K L ~ ~ & ~ V . ( ~ ~ ) H 0p0y0~hlq ouppaiv~l U S ~ 6 0 1 6 ~ p a ~ l ~ f i d ~ ~ p t ~ l ~ f i U U M O ~ , ~ E P L K ~ ~ ~ ~ L ~ , m u - ~ o ~ E ~ L K ~ ~ ~ ~ T L ~ Kal pLJ0~Clp6iTlq. (36)

AKON q rmeupowrj uuppmo>crS pnopei va ocpei- A E T ~ L oe cpappa~a (n.~. mesalazine, sulfasalazine, methotrexate). A&v npdmt va napapunma~ Kal q nt0a- ~6Tl'lTa Cl~dIlT~cqq E U K ~ I ~ ~ ~ K ~ V Aotphcewv UE a@&v&iq ROU Aapphvouv ouvauaup6 ~ V O U O K C K C ~ ~ ~ T L K ~ V (pap- pa~wv.

A&v eival an6Ama ~ L E U K ~ L V L ~ ~ ~ V O av o au0evrjq pe auupn-rwpur~~fi v6oo npCnet va Aappdvel Bepaneia . Ildvrwq 01 ao0eveiq pe IONE Cxouv aucqpdvo ~ i v 6 w o 0vrp6q~aq A6yw rmeupov~~rjq v6oou.(37) Av6Aoya p& TOV ~ l j n o q q rmeupov~@q en~rrAo@q, q 9epan~ia pe aorrve6~va r j 0ui~~qpa~lK6 mpoe16fi pnopei va ~ i v a ~ an0T&k~~CKl@.01 a&&v&iq pE ~ P O ~ ~ L E K T ~ U ~ E S ~ i v a l rno anieavo va a~ran0Kpl806~ q v aywfl pe EI(TITVE~- pwa m~poedrj Kal pnopei va anal~oirvra~ mspoet6fi an6 TOU mopa-roq. ZE oopapfi cphypovrj ~ w v aepayw- ydv ~pqu~pono~o6vra~ Ta ev6ocphCp~a mepoa6fi. H 616- p e q rm~upov~~f i vbooq anal~ei q v xoprjyrlq o u q - p u r ~ ~ d v O T E ~ O E L ~ ~ ~ V n .~, prednisolone 0.5-1.0 mglkg q v qp6pa yla peychq ~ p o v l ~ d q nep~660uq, ouvrj0wq five^.

ZYMIIEPMMATIKA H IONE ~ i v a ~ uuqpcrnlcfi vdooq Kal 6ev neplopi-

?&a1 q 6 p 6 q q q p6vo mov nerrn~o uwhflva. Zxe66v ~ 6 0 ~ 6pyavo TOU o l p u r q pnopei va erqpeamei an6 q v cphypovl6q 6ta6wada. 0 6laxwp~op6q pmacir v6uou Kal en~rrAo~lv an6 q Bepaneia eival E ~ ~ I P E T L K ~ 6uwpf iq Kal p e p ~ ~ ~ q cpopdq a6irvmoq. M E ~ L K C ~ cpopdq eiva~ 61jo~oAq q bayvwq ~anotaq ~ ~ 6 r j A w q q (n .~ . v~upohoy~wjq , ocpt)O)YLoAoy~~rjq) Kal yla am6 anal~ei- Tat q KALVLK~ unoqia an6 TOV B~panovra mp6.

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35. Bewig B, Manske I, Bottcher H, Bastian A, Nitsche R, Folsch UR. Crohn's disease mimicking sarcoidosis in bronchoalveolar lavage. Respiration 1999; 66: 467-469

36. Mahadeva R, Walsh G, Flower CD, Shneerson JM. Clinical and radiological characteristics of lung disease in inflammatory bowel disease. Eur Respir J 2000; 15: 41-48

37. Winther KV, Jess T, Langholz E, Munkholm P, Binder V. Survival and cause-specific mortality in ulcerative colitis: follow-up of a population-based cohort in Copenhagen County. Gastroenterology 2003; 125: 1576-1582

/ IAlOnAOQN I OAErMONC2mN I NOEQN I TOY I ENTEPOY~

ZYPIrrOnOIHTlKH NOZOZ CROHN

H nteavhq~a av6rrru6qq uuplyyiwv o-q vboo TOU

Crohn (NC) ~ i v a ~ " 33% m a 10 &q Kal "50% m a 20 h l (54% ~ E P L E ~ ~ L K ~ , 24% &VT&p0-&vr&pl~6, 9% 0pe0- K O A ~ L K ~ Kal 13% &a U ~ U ) [I]. H & p ~ & l q ~EPLE~PI- K 0 l j UUPLW~OU aIl~T&hEi T V n p h q & ~ 6 f i A ~ q UE " 10% ~ o v aoecvhv p NC Kal pnop~i va npoqyqe~i a p ~ m 6 p o v ~ a q q epcpav~qq &Mwv oupmwp6Twv [2].

H NC ano~&hEi q U U ~ O T E P ~ a l ~ i a ~pcpav~qq nsp1s6pu~hv ouplyyiov. k v ~ i v a l an6Ama oacpdq no101 nAq8ucrpoi p~~popiwv K U P L ~ P X O ~ V ~ O V an0~~1op6 TOV

E ~ W T E P L K ~ V oup~yyiwv [3,4]. ~ U ~ K E K P L ~ & V E ~ napaMa- yCq TOU OCTN (carnitinelorganic anion transporter) o-q 8 & q 5q31 (IBD5) I ~ ~ ~ C I V O V OX&TK0VTal cpal~0TUnl~6 C(E

q uup~yyono~rrr~Ki) NC [5]. H XEIPOUPYLM T ~ ~ I V ~ C ( T I ~ xwpi<&t Ta oupiyy~a UE

xapqM Kal uqqA6 avdoya p& q c & q ~ o u q p& q v 060vru-nj ypappfi &vh q Ta61~6pqq ~ m 6 Park nEp1- ypdcps~ 5 ~ q y o p k q ouplyyiwv av6Aoya pe q 0xko-q T O U ~ p& TOV 950 ocplyMpa TOU n p w ~ o 6 (enlcpave~a~6, p~ooocptyqp~a~6, 6~aocplytcqp~a~6, unepocplyqpla- ~6 & Cgw ~cply~rrlplaK6). llp6ocpcrra &EL npo~aeei Kal pia KALVLM Ta~lv6pq~fl nou 6laxwpi<&~ Ta oupiyyla IJE aartAau Kal <aljv8rra>> [6].

1 ~ 1 ~ Khl~lK6~ p&hCT&q q E V E P Y O ~ ~ q q ~EPIE~PL- ~ f i q NC unoAoyi<&ra~ ps q p h p q q TOU puepoli napo- X C T E U ~ ~ -(Fistula Drainage Assessment Measure). ~ e p ~ o o 6 ~ ~ p o a ~ t 6 n ~ m ~ q p&006016pwq E ~ V ~ L q MRI nu&- AOU Kal TO 0 ~ 6 0 - ~ P W K T L K ~ EV~OUKO~IKO U l l ~ p q ~ 0 ~ ~ 6 ~ f l - pa (EUS), 01 onoieq pCow p~)cnhv Cxouv 6&i5&16Tl &va oupiyylo pnopei va napapCve1 ~vepy6 nap6 q o6yKA~- q TOU E~WTEPLKO~ TOU ~ T O ~ ~ O U [7]. KhvlKfi ITp66~) Xpqolponol~hal oup6 Kak o PDAl (Perianal Disease Activity Index).

H 6aRuAlKfi E~~TCIOT) Wq &llAoyfi 6& ~ E W P E ~ - Tal ~nap~ f iq . ~ U Y K P L T L K ~ ~ p ~ h c q pmatir ~6CTaqq uno y&viKi) ava1uOqoia (EUA), MRI nuChou Kal EUS av&6&15& nap6po~a 6layvwm~M a ~ p i p ~ ~ a ("90%) Kal yia TI^ Tp&lq p~8660uq [8]. E T ~ Ta pq n&p~6p1~6 EUUTE~LK~

uupiyyta &EL ouy~ptesi TO UIS ~oAiaq p& TOV a~lvoAo- ~ L K O Ckyxo (85.2% Cvavrl 84.8%) [9] aMa Kal p& q v MRI ~oAiaq (31 % Cvavr187%) [ I 01.

Ta avnplon~a arIOT&hol\~ q uuvqeCarepq &pa- nsia nphqq ~KAoyilq o-qv n&pi&6pu~fi NC (prrpovt6a- 56Aq: 750-1000 xyp., mpocpAo~advq: 1000-1500 xyp. qpvrldwq) [11,121. H pa~po~povla mfiorl vs wpom- 6a<dAqq (6vw ~ w v 3-4 pqvhv) avr&v6&i~vu~a~ A6yw oopaphv napsv~pye~hv. H 6laKofi q q avr@~o~ucr)q ayuyrjq o6qyei o6vropa a& uno~pornj. AEV un6pxouv p&hCT&q U& m a T I A ~ V n&pl&6plKhv E U C ~ T E ~ I K ~ (5Upi~lCt.

H a<aeslonpiq (2-2.5 ~yp.l~A61qp6pa) Kal q 6- psp~arrronupiq (1-1.5 xyp.l~Aolqp&pa) xpqolpono~oir- vral oup6 q v neple6pu~fi NC (54% Cvavr~ 21% placebo a& pma-avMuq). 0 pCooq ~pbvoq avranb~pl- q q civa~ 3-8 mv&q [13]. KaAoi npoyvwmutoi napdyo- V T & ~ a~Cn l6~p lqq : anouda ouply/iwv, 616p~aa NC <22 Kal tlhlKiCi &p@vlUtlq NC >40 E T ~ V [14]. 1~01xeia yla M a m v n ~ p 1 ~ 6 p ~ ~ h v oupiyy~a un6pxouv an6 p1~pCq o&lp&q n e p ~ m m ~ h v .

H ~~Khomopivq-A (CyA) 6&v CXEL ~rnpqeei UE

&hEyXdp&V?l p&GTQ. MLKPC~ U&IP&~ (4 X~P./K~O/T)P&PC~ &v60(pk$iwq yla 6-10 q~&p&q, K ~ T O ~ ~ V 8 xyp.l~AolqpCpa an6 TO aropa) 6 ~ i p o w apxt~o nooo- m o avran6~plqq Cwq 83% UE 4-7 qp&peq [15]. To tacrolimus (FK-506) &pcpavi<&l ~aAh&pq anoppocpqq an6 q v CyA Kal &EL 5 0 ~ ~ p a r n ~ i o& &hEyxop&q p ~ k h q (0.2 ~ P . / K A o / ~ @ P ~ an6 TO m0pa yla 10 &P60p66&~ - 43% &vavrl 8%) [16], np6ocpma ane6eixBq ~ ~ o T E ~ E - W ~ L K ~ Kal UE a&&v&iq pE I ~ E P L E ~ ~ L K ~ ~ NC ~ V ~ E K T L K ~ ~

aro IFX [17]. To infliximab (IFX) CXEL Xpqolponolqe~i o& &A&y~6-

p&v&q p&hCT&q TOUO yla q v &naywM (62% Cvavrl26% ouyKhq 1 50% TWV &v&pyhv ouplyyiwv, 55% oliyKh1- q ohwv TWV oup~yyiwv) 600 Kal q 6 ~ a n j p q q q q 69s- q q (36% Cvavrt 19%). Xpqolponoleka~ o& 6 6 q 5 fi 10 mp.IKh6 (~~60cphcPla & y ~ U q - &p60pClda 0,2,6, ~ a ~ d n l v ~ 6 8 ~ 6-8 cP50pa6~q) [ I 8,191. ZE post hoc av6Auq TO

64% ~ w v yuvau~hv ps opeo-KOA~IK~ oupiyyla avrano- K P ~ ~ T ) K & apxlK6 OTO IFX Kal 6laTt'lpfieqK~ IJE U ~ E O T ~

~ & ~ I U U ~ T E ~ O (46 6va~I-L 33 E P ~ o ~ ~ ~ w v ) [20]. H ~0pfim- q IFX ~ACrrrwo~ TI^ v o q h i ~ q Kal n q x~~poupy1~6q KaL 6 M ~ q nap&ppao&~q [21]. Qcrrooo TO 73% ~ w v auO&vhv p& 6t6cpopa &i6q U U ~ ~ ~ ~ U V X ~ E L ~ ~ K & TEALK~ K ~ O L O

~ i h q ~&tpoupy~Ki)q napCppaqq yta q v avr~pmhnlq q q vooou [22]. H pfiq TOU 68 cpaive~a~ va ux&ri<rra~ p& auSqp&vo K ~ V ~ U V O oxqpc~~~upo~j anouqp6Twv an6 npowpq ol iy&q TOU E~WTEPIKO~ aropiou [23]. T E V ~ L - KO( (noAupopcptupoi ~ R O T T T W T L K ~ V YOVL~~WV) Kal K)\LVLKO~

(CRP, TNFa opo6, ouyxopfiyqq AZAIG-MP, &6oq ouplyyiou, ~6rm1opa) npoyvwaru~oi napayovr~q nt8av6

E ~ ~ & ~ < o u v q V ~ ~ o T & ~ & ~ ~ K ~ ~ ~ TOU IR( [%,%I. ZE avr(eeq pe nl NC TOU EVTE~LKOO auAoO uq uup~y- y0no l~Kf ) NC llq~lTIlp~iTa1 TIpWip6T~pq L I ~ ~ O T ~ O ~

~ET&TI) 61aK0m TOU IFX [26]. H kaK0m q q ~0pfiyrlMq TOU Ao1n6v ~aAIj,epo ~ [ v a l va paoi<ma~ o-qv anelltovl- uru~fi 6laniorwq q q nhfipouq et&A&~$qq TWV uupty- yiWv. TfioC, &EL ~ O K L ~ ~ O T E ~ Kal r) T~ll l lCf) (~KE~IE~PLK~) t i y ~ u q IFX ~aAa ano~eA6apcrra [27].

ehEy~6peq p&W q xopfiyrlq adalimumab (ADA, anti-TNFa avBphne~o ~ O V O K A W V L K ~ IgG1 avrbw- pa), 06rjyrlm ae dyaq 6 A ~ v TUV oup~yylwv @em&- peliov m6xoq - 33% Cvavrl13% q v 52" ep5op66a) [28]. ZE h p ~ ) E ~ ~ ~ E V T ) PEW yla q Nc TOU evrep~~oO auAo6 TO sargramostim (GM-CSF) avC6aQ ev8appuvrc ~6 anmEhCapura ue hlyouq adeveiq pe evepy6 oupiy- yla [29]. I& ava6pop~Cq peM~eq CXEL e~e-ramei Kal q anmehEqtm~~6nlTa q q peBmpQhqq xwpiq wm6ao E~[UOU ~~avono lqn~6 ano~eA6apura onwq uq NC TOU

auAo6 [30]. Eniqq tixouv xpqcnponolqBei m pepovwptiva

nep lma~ l~6 fi p~~pCq TO uneppap1~6 O ~ U ~ ~ V O , q BaMSopithl, q OKI~EOT~~T), TO mycophenolate mofetil, T)

m o l x e l a ~ 6ial~a Kai q OALKJI hapevrepi~~~ 61mpoqfi aM6 xpet6<ovra1 pyahhepeq phCTeq np~v Y~VEL O ~ O L - a6f inm o l i m a q yla xpf iq TOUS.

0 p6Aoq TOU xetpoupyo6 uq oup1yyono1q-r~ NC ~ E V nepAapp6ve~ p6vo T I ~ V EUA. Eni xapqA6v cruply- yiov &EL 6o~ipams[ q auplyyaropj (39% unmpom mouq 72 prjveq, 50% ~pcp6v1q a~phelaq, endeivoq opBh16aq). R a auvt3ma uupiyyla CXEL neptypaqei q sfiq setons (unmponfi 30-40% pETCL acpaipeq, 23- 44% neple6p~~fi mjqq p& Ta seton in situ) Kal ev60-0~81- ~ f i q npo~eo~lpevqq r n a q [31,32]. 0 ouv6uaqt6q SetOns, IFX Kal ~ V O U O K C ~ T ~ U ~ T I K ~ V ( T O T I O ~ ~ T I ~ ~ setons npo q q Cvapcqq xopfiyrlqq IFX Kal acpaipeqq amhv pm6 TT) 2"nuq) 06fiyrlm ue u h d q ~ A W V TWV crup~yyi~v UE nou rn6 C q 67% Kal p&purj m- q uro 19% aM6 m @uo 616uqpa napa~oAoOf3qqq 21 mvhv p6vo mo 18% TWV aaBEvhv naptipeve q dydq [33,34]. Qq evaMatm~~tiq TEXVIK~~ WUV ava- cpepeei o ~ a q p ~ a o p 6 q pe C02 Kat q ucpp6y~q TOU

auAo6 TOU ( N ~ L ~ ~ O U K O M ~ 1vlKf)q.

IuunspClupara H uuplyyono~m~fi NC n p o ~ a k i ao(3aptiq cpuol-

KC$ Kal I ) U X W W ~ ~ L K ~ ~ napevtipy~~eq. k 6 p a Kal C(E q v ~aAlirepq popcprj Bepansmfiq napCppaqq TO noao- m 6 d y d q q 6Awv ~ w v auplyyiwv &v ~ i v a ~ nsp~uu6- T E ~ O an6 50% UE PaBoq xp6vou. H ouv~pyaoia yacrrpe- V T E ~ O A ~ ~ O U - X E ~ O U ~ ~ O ~ moT&hEi K O ) ~ @ K ~ q p l o yla q v e n l ~ m C ~ p a q 1-11~ Bepaneiaq.

1. Schwartz DA, Loftus EV Jr, Tremaine WJ, etal. The natural history of fistulizing Crohn's disease in Olmsted County, Minnesota. Gastroenterology 2002; 122: 875-80.

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press). 3. Toyonaga T, Matsushima M, Tanaka Y, et al.

Microbiological analysis and endoanal ultrasonography for diagnosis of anal fistula in acute anorectal sepsis. Int J Colorectal Dis 2007; 22: 209- 13.

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5. Vermeire S, Pierik M, Hlavaty T, et al. Association of organic cation transporter risk haplotype with perianal penetrating Crohn's disease but not with susceptibility to IBD. Gastroenterology 2005; 129: 1 845-53.

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13. Pearson DC, May GR, Fick GH, Sutherland LR. Azathioprine and 6-mercaptopurine in Crohn's disease: a meta-analysis. Ann Intern Med 1995; 123: 132-42.

14. Lecomte T, Contou JF, Beaugerie L, et al. Predictive factors of response of perianal Crohn's disease to azathioprine or 6-mercaptopurine. Dis Colon Rectum 2003; 46: 1469-75.

15. Hanauer SB, Smith MB. Rapid closure of Crohn's disease fistulas with continuous intravenous cyclosporine A. Am J Gastroenterol 1993; 88: 646-9.

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placebo-controlled trial. Gastroenterology 2003; 125: 380-8.

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18. Present DH, Rutgeerts P, Targan S et a/. lnfliximab for the treatment of fistulae in patients with Crohn's disease. N Eng J Med 1999; 340: 1398-405.

19. Sands BE, Anderson FH, Bernstein CN, et a/. lnfliximab maintenance therapy for fistulizing Crohn's disease.N Engl J Med 2004; 350: 876-85.

20. Sands BE, Blank MA, Patel K, van Deventer SJH. Long-term treatment of rectovaginal fistulas in Crohn's disease: response to infliximab in the ACCENT II study. Clin Gastroenterol Hepatol 2004; 2: 912-20.

21. Lichtenstein GR, Yan S, Bala M, et a/, lnfliximab maintenance treatment reduces hospitalizations, surgeries and procedures in fistulizing Crohn's disease. Gastroenterology 2005; 128: 862-9.

22. Poritz LS, Rowe WA, Koltun WA. Remicade does not abolish the need for surgery in fistulizing Crohn's disease. Dis Colon Rectum 2002; 45: 771-5.

23. Sands BE, Blank MA, Diamond RH, et a/. Maintenance inflixirnab does not result in increased abscess development in fistulizing Crohn's disease: results from the ACCENT II study. Aliment Pharmacol Ther 2006; 23: 1127-36.

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after inducing remission with infliximab: how long should patients be treated? Aliment Pharmacol Ther 2005; 22: 1107-13.

27. Poggioli G, Laureti S, Pierangeli F, et a/. Local injection of lnfliximab for the treatment of perianal Crohn's disease. Dis Colon Rectum 2005; 48: 768- 74.

28. Colombel JF, Sandborn WJ, Rutgeerts P, et a/. Adalimumab for maintenance of clinical response and remission in patients with Crohn's disease: the CHARM trial. Gastroenterology 2007; 132: 52-65.

29. Korzenik JR, Dieckgraefe BK,Valentine JF, et a/. Sargramostim for active Crohn's disease. N Engl J Med 2005; 352: 2193-201.

30. Mahadevan U, Marion JF, Present DH. Fistula response to methotrexate in Crohn's disease: a case series. Aliment Pharmacol Ther 2003; 18: 1003-8.

31. van der Hagen SJ, Baeten CG, Soeters PB, van Gemert WG. Long-term outcome following mucosal advancement flap for high perianal fistulas and fistulotomy for low perianal fistulas Recurrent perianal fistulas: failure of treatment or recurrent patient disease? Int J Colorectal Dis 2006; 21: 784- 90.

32. Thornton M, Solomon MJ. Long-term indwelling seton for complex anal fistulas in Crohn's disease. Dis Colon Rectum 2005; 48:459-63.

33. Topstad DR, Panaccione R, Heine JA, et a/. Combined seton placement, infliximab infusion, and maintenance immunosuppressives improve healing rate in fistulizing anorectal Crohn's disease: a single center experience. Dis Colon Rectum 2003; 46: 577- 83.

34. Hyder SA, Travis SPL, Jewell DP, et a/. Fistulating anal Crohn's disease: results of combined surgical and infliximab treatment. Dis Colon Rectum 2006; 49: 1837-41.

XElPOYPrlKA IPOBAHMATA IXETIZOMENA ME T I I IQEN

A I Q ~ E P ~ I K ~ ~ H~POX~EUUI ) E V ~ O K O I ~ I ~ K ~ V anomqp6- TOV

A~OTEAE~ nhCov q v ensppaq EKAOM~ yla q v napoxmeuq ev6o~ol)ua~hv a n o q p h v nou ocpeho- vral m evron~opCq 6 ~ h p q q TOU ~o~xhpmoq TOU em&- pou Aoyw vooou Crohn. l l paypmono~ i~a~ p& q pofi- Baa unepqxo~opoypacp fipmoq fi unoAoy~mu~fiq TO~O- ypacpiaq. H 6 t t i ~ p l q pmatu anofipmoq Kal cpkypo- ~ 6 6 0 ~ ~ p6<aq yiVETa1 p& ~ ~ E L K O V L U T L K C ~ ~ E B o ~ o u ~ . EvioTE a n o ~ e k i oupdqpwpm~~fi np65q - npoocpCpo- vraq npoowplq unoxhpqq q q KALVIKI~~ e~~ova-ue ena~6AouBq ~ ~ l p o u p y l ~ f i avrlp-rhnlq. A d & anofi- pma avr~pmwni<oovra~ K ~ B O A L K ~ an6 q @806o ev6 TO

nooom6 avran6~plqq d o v ouv9hwv Kal &nmnA.&ypC- vov avipxma~ UE 65-90% UE 6lacpopsq oe~pCq. Yn6px~~ peyMq nou~aa ~aeerilpwv Kal TE~IKC;IV e~oaywYi)q. H piB060q a n o ~ e k i q v d o v avnrnpoownelrru~fi np66q q q eneppmt~fiq aR1voAoyiaq auv6ua<ovraq anemon- m ~ C q peB65ouq yla q v ano~&Au+q, n a p a ~ C q q 61a peMqq yla q v 61dyvwq Kal ~Choq ~a9crqp~aopo yia TTJ Bepaneia.

vansonnenberg E, Wittich GR, Goodacre BW, Casola G, D'Agostino HB. Per-cutaneous abscess drainage: update,World J Surg. 2001 Mar;25(3):362-9 Men S, Akhan 0 , Koroglu M. Percutaneous drainage of abdominal abcess. Eur J Radiol. 2002 Sep;43(3):204'18 Krolak C, Rock C, Reiser M. Radiological interventions in inflammatory bowel disease. Radiologe. 2003 Jan;43(1):59-65, 96.

nAaUTIKfi TWV U~&VWOEWV A ~ o T E ~ E ~ EV~M~KTLM xe~poupy~~fi npooCyy~q UE

616xur~q evronioe~q q q vdoou TOU Crohn. Iuv ima~ai UE nh~UTlKfi fi Kal napdnapqq ~ w v mevhoewv m pia n p 0 ~ ~ 6 8 ~ L a anocpuyilq fi Kal nep~optopoli TUV evrepe- mophv, p~ ano~CA~upa acpevoq q b m p q q TOU

pfi~ouq TOU k m o l j E V T C ~ O U acpmkpou 6s q v avrlpmh- n lq TWV oupmwphwv q q mCvwqq. H ~(PappoM q q p~866ou eiva~ 6uva-nj KaL oe aoBeveiq p& EVE~M vooo.

ITlq EV~EREL~ nEpAapp6~0Vral ~~&XUTE< Kalnoh- h a d q evronioe~q q q vooou, npoqyqBeiosq E K T O ~ C ~ (>I00 EK AEmolj evrkpou), ~axeia uno~ponfi vooou E K ~ ~ A O ~ ~ ~ E ~ wq anocppaSq, mCvoq m aoB~vrj C(E cnjv6popo ppaxCoq evripou ~aBhq Kal ljnaptq LVWTIK~)~

pq cpkypovh6ouq mdvwqq. 0 1 avrev6ei<&~q n&pAay pdvouv ekljeepq fi n~plxapa~wpCq 8 t h p q q AEmou, cpkypovh6q mCvwq, napouoia E U ~ T E ~ L K O ~ ~ fi E~WTE- ~ L K O U ouplyyiou mo qpeio q q mCvwqq, napouoia

m i v w q q dqaiov ~pfipmoq nou n p 6 ~ e t ~ a ~ va eimap~i, k u ~ w p a ~ i q opolj c 2,O g/dL.

'Exouv neplypacpei 6t6cpopeq ~epu<Cq avaA6ywq TO p f i ~ q T'llq ~ T E V ~ U E W ~ . 0 E V ~ E ~ E ~ ~ S C M O S 0A0- KAfipou TOU pfi~ouq TOU k m o l j evrCpou npoq anonMu- qq mevhoewv 01 onoieq ~ E V eivat Clpeoa opmCq Enl- ~ v y ~ & v m a ~ p& q v ~ L E K $ O ~ ) ~ a e m p o q Foley an6 Em&- po~opfi p& EAacppa b h a q TOU mpoBaAapou &p lq 6lapd-rpou 2 EK. H anholimepq ~ e p w j T ~ O U Heineke- Mikulitz &cpappo<&~a~ oe ( T T E V ~ U E L ~ ~ L K ~ O L ? pfi~ouq pd~plq 10 EK. H 6 ~ 6 ~ 0 ~ 5 ~ ) TOU auholj q $ ~ C V U ~ S yive- Tal EITLMKW~ KaT6 TO ~ ~ L ~ E U E ~ E ~ ~ K O WKOS Kal r) UUP- pacpfi yiV&Tal EyKapdwq pE UUVEXE~~ fi ~ I ~ K E K O ~ ~ E V E ~ pacpCq. H T E ~ L K ~ ~ ~ a ~ a Finney ~cpapp6<ma~ m peyaAu- ~ ~ p e q mevhoe~q Cwq 25 EK Kal n~pLhapPave~ dayto- nA&y~a avam6pwq pe auve~eiq pacpCq. Eival 6uvmov va ecpappomoljv napaMayCq fi Kal ouv6uaupoi ~ w v napanavw pe866wv.

H damumj TWV ~ E V ~ U E W V a n o ~ ~ k i aocpahfi Kat a ~ ~ ~ & k ~ p ~ l ~ f i pi0060 X E L ~ O U P Y L K ~ ~ ~ aVT~pEThIllO?lq ~tcrmapdvwv K ~ L 6~axhwv m~vhmwv q q vooou. I& pia p&-ravMuq 15 p e h h v eni 506 au0&vhv, m o 56% &cpapp6q~& ~ O V O V d a m ~ ~ f i E V ~ mouq unoAo~nouq W V ~ U ~ ~ K E Kal pE E K T O ~ ~ ~ E M ~ ~ O U . 01 U U ~ B ~ E ~ E ~ &nldoK&C, *aV q E V ~ O K O ~ L ~ K ~ ~ Mqq, Il aVdlIT~6q ouplyyiwv, q a~poppayia q b d m a q TOU ~paljpmoq Kal q ml~upovuM eppo)Ui. 0 K ~ V ~ U V O ~ ~pqavioewq en~nAo- K ~ V 6pwq f i~av xapqAoq Kal oq EK TOIJTOU (paivma~ va anoT&khEi Ttl pC8060 EKAOM~ q v avr~pmhntq q q (TIEVWTLK~~~ V ~ U O U TOU Crohn.

Fazio WV, Aufses AH Jr. Evolution of surgery for Crohn's disease: a century of progress. Dis Colon Rectum. 1999 Aug;42(8) :979-88. Hancock L, Windsor AC, Mortensen NJ, Inflammatory bowel disease: the view of the surgeon. Colorectal Dis. 2006 May;8 Suppl 1 : 10-4 Roy P, Kumar D. Strictureplasty. Br J Surg. 2004 Nov;91(11):142&37 Tichansky D, Cagir B, Yoo E, Marcus SM, Fry RD. Strictureplasty for Crohn's disease: meta-analysis. Dis Colon Rectum. 2000 Ju1;43(7):911-9

0 6 E h AqKl Ie i l f ia H enavopBw~~~fi ~ ~ W K T O K O A E K T O ~ ~ ~ (restorative

proctocolectomy) pe q 6qp~oupyia ~ e p q ~ r j q Aq~ljBou (pouch) an6 TOV TEAIKO E&O, a n o ~ e k i q v enCpPaq E K ~ o M ~ mOUq aoB&V&iq pE ekh6q K o A ~ T L ~ ~ . Ynd TOV

6po ATlKLl8iTda (pouchitis) ~wosha l q lB0TCCtefi~ O C E ~ I fi

~pbvia cpkypov66qq avri6paq q q Aq~ljOou. Ava- rrr l jama~ Cuq TO 60% ~ w v aoeevdv pe E A K O ~ ~ K O A ~ T L ~ ~ Kal ~XEI U U ~ K E K ~ L ~ ~ V ~ ALVIK~, EV~OUKOT[ IK~ Kal lOT0A0-

Y L K ~ xapaicqp~mc~a. OplopCvo~ ouyypacpeiq unoo-qpi- <OUV 6 ~ 1 r) hqKu8h16Cl &hl U U ~ ~ T E P ~ KC~T& V V 616pK~la TOV npd~wv E T ~ V pET6 q v enCppaq, WOL war600 n~meljouv 6 ~ 1 q aup6-q~a q q auc6vel maeepa p q v nap060 TOU ~p6vou.

H Aq~uei~tda xapaicqpl<mat an6 a l j tqq q q oup6~q~aq Kal q q peum6~q~aq ~ w v E~~EPLKOV KEVO- UEWV, K W ~ ~ K O E L ~ ~ ) KOAI~K~ &tm, T E L V E U ~ ~ , aKp6T&la K O ~ I ~ ~ V U V Kal nep~mautana an6 napouaia aipa-roq mlq K E V ~ U E L ~ fi nupe~6. ZE pla paoqqcpia aaeevdv 01 Am- KC^ E K ~ ~ A ~ O E L ~ eiva~ ap~r r6 aopapCq h m va anal- T O ~ V E V ~ O V O U O K O ~ I ~ K ~ ~ u ~ ~ o ~ P L S ~ , E V ~ E~VOL ~ U V ~ T ~ V

va U R ~ ~ X O U V UUv06dq EQA)EVTEP~K~~ ~K6qAd~~lq. AV Kal mo 40% ~ w v nep~rrrdmwv TO ene1a66~0 q q A ~ K u ~ ~ T L - 6aq eiva~ pepovw@vo, mo 60% ~ w v ao8evdv q v6ooq 8a unmpontaue~ EK VCOU oe 6ehp0 WOVO, mo 5-10% TOV ao8evL;IV q v6ooq Ba CXEL ~p6vta evspyd nopeia Kal ea analTfim1 pa~po~p6v~a Bepaneia, evd w Cva pl~p6- TEPO nooom6 8a avarrrux8ei Aq~u8htba av8etalM o-q cpappaK&UTlKfi Clywyfi.

H a~p~pfiq al~~ona8oyCve~a Kal 01 na8ocpua~oAoyc K O ~ pqxav~upoi nou o6qyoljv uq cphypovd6q avrmpa- q q q Aq~ljeou ~ E V eiva~ yvoaroi. lmona8oAoy~~dq q Aq~uOi-rda xapaqpi<rra~ an6 mo~xeia oceiaq Kalxp6- vlaq qkypowjq TOU pkwoy6vou q q ~&O)ulK680U. Ta eupfipma )(pbviaq rpAEyjiowjq, 6nwq q a-rpocpia ~ w v Aapdv, q napapopcpoq r j unepdaaia ~ w v ~purrrdv eiva~ pq ~ 1 6 ~ 6 Kal aveupio~ovra~ 0 ~ ~ 6 6 ~ rn 6kq nq )ulK680Uq (nueA~~Cq fi T ~ O U Koc~) E V ~ ~ E V anm~A06v KPL~PIO cphypowjq oh& qe-rqovral pe q AELTOUPYL- K6TqTa TOU pouch. I q v npaypa-r~~oTqTa avnnpouw- neljouv q cpua~oAoy~~fi avrmpaq npooappoyfiq TOU

&A&~Kou ~UA&KOU (XO VEO lI&plp&O~ ( m 6 q KOIlp6- vwv), nou CXEL wq ano~ikopa q v popcpohoyl~fi px6- TlTwq Tflq AC~XVWTO~~ E I ~ L ~ I ~ ~ ~ o u TOU hEIlT0lj EVT~POU mov a 6 ~ ~ 1 ~ 6 T I ~ O ~ntBqAiou TOu naxhoq. H ~ E T ~ T T T W ~

a d ovopa<ma~ KOAUO ji&ra~Aaoq (colonic metaplasia) . Ta 1~0AOyl~a eupfipa-ra, o{eia~ cpAEypowjq pe

noAupopcponupqw~tj 61fi8qq, ~ p u r r r ~ ~ a anoqpdrr~a Kal pA&woy6v1&q E ~ E A K I U E L ~ anmeholjv avay~aia K ~ L -

qp la yla TT) 616yvwq q q A ~ K u ~ ~ T L ~ o $ Kal q PapljnlTa TOUS UX&T~&Tal &~&UCI p& TTl ~ I T O U ~ ~ L K O ~ T ~ TOU

pouch. Kmd ~alpoljq Cxouv npo~aeei nomq uno8Coelq yla q 61aA&UKa~q q q na8oyCvwaq 01 en~~pa-rCmepeq 6pwq eival q m a q ~onpClvwv Kal p~~popla~f i mepav6mu~q Ka86$ Kai avouoyev&r~~oi pqxavlopoi napopolol pe ~ o u q acmonaeoyevrr~~oOq pqxav1opo6q q q ~A~d60uq KOA~TLBO~.

Zr&oq - Mi~po@~~r j ui-c&pavdmuQ: ME q v Kma- UKEU~~ TOU ~LhE'iKolj ~ U ~ ~ K O U , q (PUULOAOYL~ ~ L T O U P Y ~ ~

TOU TEAIKOO ~LhEolj aM&<&l Kal an6 6pyavo anopp6cpq- q q yivrra~ opyavo anoefi~euqq. 0 p6Aoq ~ w v pamq- ptdla~dv avrly6vwv cpaivma~ eniqq va eival qpavrl- ~ 6 $ , a906 q hqKUeiTl6a acpev6q p&V &pcpavi<&Tal PET& T l l

oliyKAE~q q q npommm~mjq eAeomopiaq Kai q v 6 ~ C k u q K O ~ I ~ ~ V U V piaw --qq Aq~ljeou, acpmCpou ana-

vr6 euvoi~a o-qv eepaneia pe avr~plmu~d. Aev eivat om6oo yvwm6 eav q cpcpkypovd6qq 51epyaaia ocpeh- Tal oe unepavarrru{q q q cpuutoAoy~~tjq E V T E P L K ~ ~ ~ xAw- pi6aq fi rn enlhoipoeq. revu~dq o-q xAwpi6a ~ w v Aq~lj- 8wv unepCxouv Ta avaepopta Kal aveupimovra~ nepla- o6~epa meACxq Bacteroides Kal bifidobacteria a& o l j y ~ p ~ q pe TOV apt8po pl~oplwv TOU svrep~~olj ~EPLE- xopCvou nou anopC1METa1 an6 pia ~LhEomopia. 'Opwq U& a08&v&iq p& hqKU@iTl6a 0 UUVOAIK~~ apt8p6q aEp0- piwv Kal oplupCvwv naeoy6vwv p~~popiov 6nwq CI. Perfrigens Kal ~ I ~ O A U T I K ~ meMxq E. Coli ~(~[opei va eival aueqpdvoq, evd o apt8p6q ~ w v avaepopiwv va CXEL pe~weei. nap6Ao nou q xopfiyqq avr~p~o~utdv pe~dve~ TO UUVOALK~ aptBp6 pwpopiwv Kal ecakicpet Ta naeoy6 va meMxq, q napa-rr)pqq auTfi ~ E V CXEL en~pepa~weei.

Zuc~~CTiuq p& &A~66q ~oAh6a: TO yeyov6q 6n r) Aq~uOhtda epcpavi<mal 0x056~ anoKA&lm~~a o& acre&- veiq 01 onoiol ~e~poupyoljvra~ ma daiala ehKd60uq KOhiT16aq Kal6~1 (YC avroljq nOU U l l ~pmov~a l OTllV i61a enCppaq A6yw o~~oyevoljq a6evwpmd60uq nohuno- aiaqq, vno6qAdv~~ q v unapcq ~dnolaq yevml~fiq npo- 6t68~qq.

Enmdov mo~xela nou ev~qljouv a m q v anoqq &ival q ouxhlq TllC, A ~ K u ~ ~ L ~ o $ PE E ~ U E V T E ~ L K C ~ E K ~ U - Adoe~q q q EK (tdlai~epa npw~onaefi aAqpuvrua ~Oha~~l iTlda), pE EKTET~MVT) tl pap&ia ~AK66q KOMTL- 6a, pe q v veaptj rlA1Kia ~ m & q v bClyvwq q q EAKO- 60uq KoAhl6aq, pe TT)V napouaia naAlv6p6pou EIAELTL- 50q, aMCl Kal pe q v ou~wj ~ p q q Mm@, pe q v napou- aia mov 0p6 TWV pANCA, Kal pe U U ~ K E K ~ I ~ C V O U ~ nohu- popcp~opoljq Tau yovi6iou nou K ~ & K O ~ O ~ E ~ Tov TNF Kal TOV avraywv~anj TOU uno6oxCa q q IL-1. AvacpopCq un6pxouv y la TOV npoma~elrr1~6 poAo TOU ~armiopmoq OTIlV &p(p&vlO?l A ~ K L J ~ ~ I ~ O S , E V ~ 0 YEVETIK~~ 6-q TOU oufipmoq ~moouppm6-q~oq HLA 6ev CXEI Ka-ra- 6&it&l p6y.p~ mlyptjq K6n0la maeepfi YEVETIK~~ U U ~ ~ L - oil

Av Kal TO d o v uup6 a i ~ ~ o 6uoAa~oupyiaq q q Aq~68ou or: aut3eveiq pe xe~poupyqesloa ekdbq K O ~ -

6a eival q Aq~u8l~da, dqedpa m w v al~tdv npCna eniqq va anoKAE1mei ~ ~ O U E K T ~ K ~ . Mmaeu amwv aul.mepAapp6ve~a~ q v6ooq Crohn (Aappdvovraq un6qq Cm pm6 q v oAi~tj ~okmopf i q v6ooq T~QVO~EC Tal EK VEOU an6 ~hKd6~) ~0hiTl6a U& ~ 6 0 0 Crohn m0 10- 15% ~ w v nep~rrrdmwv), q cpkypowj TOU unok1ppm~- ~ o l j op81~olj pkwoy6vou ma daiuta EhKdbouq K O A ~ L - 6aq, q enAoipwtq an6 CMV, Kal C, difficile, q mCvwq q q E I A E O ~ ~ K T U A L K ~ ~ ~ avam6pwqq fi A~K~%ou Aye v. Crohn, ~qalpiaq tj oumpocpfiq, q epcp6v~q n u d ~ ~ t j q Wqqq pe q xwpiq 61acpuyli an6 q v avam6pwq, q pa~pa npoutoljoa an1 Atj~ueo, Kal q epcpdv~q A ~ K u ~ o - KOA~LKOU fi Aq~u806eppm~~olj ouplyyiou ma daiola v. Crohn fi p x e y p ~ p ~ ~ t j q enmAo~tjq.

H 61~pe~VT)q Kal q aVTlwdnlq TTlq A I ~ K u ~ ~ T ~ o ~ npCnet va eivai E V ~ E A E ~ ~ ~ , KaI Ta nep~edp~a q q ouw-q- pq~ i~ t jq aywyfiq npCne1 va eE,avrholjvral, acpou &6v TEAL- K& ano-rljxe~, q A l j q q onoia anop~ve~ eival q acpaipeq TTlq A ~ K ~ ~ o u Kal q KClTaUK~llfi povlpqq &LhE0~0piCl~, o-qv onoia E U T U X ~ ~ ~maAtjye~ p6v0 TO 5-10% TWV

adevdv. ME q v Cvapcq uupmwpdrrwv ouppmdv pe

Aq~u0in6a a n m i ~ a ~ E V ~ O U K ~ ~ ~ U Q , w q q ptoQthv yla ~ e ~ p q p i w q q q 6t6yvwqq Kai CvapE;rl avnpto~~Kilq ayoyilq. ITI~ neptrrrciwetq p~ apqr~ECi) E V ~ O U K ~ ~ T ) ~ ,

pe uupmwpa-roAoy(a d v q q I) unoqia oup~yyiwv Kac a n o q p h w v ouvlmCrrat oupnAqpwpa~1~6q amvoAoyc ~ 6 q h y x o q (pouchogram, mtv0qpoypacpt~6q CAEyxoq KCvwqq q q hlKd80~, MRI nuCAou). Ent UUpIITOmO- Aoylaq uuppmq pe a ~ p b t a , anarrdra~ pavop~~pt~irq - 0 ~ Tllq )vlKdeou, E V ~ UE Tt&plTlThUElq ~ V ~ E K T I K ~ ~

U& ~VTI~IOTIK~ &ll~p6?&3al UUpllhlpw/.lClT~~6$ ihEyX0~ yta CMV Kal CI. difficile.

nap6 q v CMe~qq pey6)\wv '~u~atono~qpCvwv pewhv, 17 ~ I V I I C ~ ) epn~~pLa &EL BEEEL 6 ~ 1 u q v p&y&r) nhEto$qcpia ~ w v neptmhmwv q uupmwpmoAoyia P A - TthvETal qpaVTIK6 P& q V ~ p f i q ~V@~OTIK~V, t6iwq p&~p0~06a<6Aqq fi umpocpAo~ao~vqq. I& pt~pf i crossover p&Akq, q peros xopfiyqq pmpovt6a<6Aqq 400 mg t.d.s. yla 7 q@peq, PEATL~UE q p a v r t ~ a q v a- vlM E L K ~ V ~ , &V U~EPE~XE wm6oo TOU placebo 6oov a90p6 OTIlV pEhT(Wq TT)q &V~OUKOT[LK/)~ fi TT)q l(TT0h0- y~mjq E L K ~ V ~ S . IE pla 6eLjTEpq peb5-q o-qv onoia UU~K~~~I '~KE q perOS xopqyodp&Vtl p&~povtda<6Aq (20mgikgld) Cvavr~ q q peros xopqyodpevqq u~npocpAo- €,advqq (1000mg/d), q anm~AEopa-r tK~a ~ w v 81-10 cpapp6~wv @av q ~ 6 0 v napopola doov acpop6 u q v p E h ~ i o q q q uupn-rwpa-roAoyiaq, q ompoqAocaoivq wcrr6oo E~XE wm6oo ALY~TEPE~ avenl00p~eq napevkp- YELES.

01 adeveiq nou 6ev avrano~pivovra~ o-qv xopfi- y q q pmpovt6a<6Aqq rj ompo~Ao~aoivqq, ~ ~ t h v o v r a t

PE q V d a y f i TOU ~ E ~ ~ T I E U T L K O ~ O(@.~(XTO~ ompocpAocadvq fi avrimo~xa, pmpovl6a<6Aq, fi pe q v ~alr rd~povq xopfiyqcrq Kal ~ w v 6uo ~KLPIOTLK~V. Aouq neptua6TEpouq adeveiq q oupn-rwpa-roAo$a PEATL~VE- Tat evr6q 1-2 qpCX;)v an6 q v CvapQ q q Bepaneiaq. 01 ao0eveiq pe urco~pon16~ouoa (23 uno~ponCq av6 hoq rj p~ u~rmpomj pCoa oe Cva pfiva an6 q v 61aK0mj q q Bepaneiaq) fi ~ p 6 n a evspy6 Aq~u0in6a Xpet6<0vrai oup6 pa~popbv~a Bepaneia uuvrfpqqq pe avrtp~o~i- ~ 6 . au-njv q v n e p i m q cpaivma~ 6rt eivat ano~eAE- qlClTlK6~ 660~1q ~ a p ~ h & p & q TWV ~ E ~ ~ ~ E U T L K ~ V , npo-

np6-rat 6& q o~npocpAo(aoivq A6yw ~ w v uu~vBv naps- vepyet6v q q pmpovtda<oAqq. EvaMamt~h, q ompo- cpAocaoivq 6Ovma1 va evaM6oo~~at av6 ep60p66a pe q v pmpovt6a<6Aq.

H ~pononoiqq q q cvrepc~fiq xAwpi6aq pCaw q q xopqyfioewq npopiori~hv panqpdiwv (lactobacilli, bifidobacteria, Streptococcus) CXEL avaqcp8ei an6 opc opCvouq auyypacp~iq va npoAapp6vet q v ~ ~ 6 f i h ~ q TTlq ~ ~ K U ~ ~ T L ~ O S , fi Va p0q06 Ul?lV CTumpTlUll q q ~($6 oewq m ao0eve~q pe ~p6vta ev~py6 v6ao. Ev9appuvr1- ~6 ano~ehCopa~a Cxouv eniqq avaqepeei C(E q v ~ p f i q unoKAuophv fi peros xopqyodpevqq pou6.soovi- 6 ~ 9 . IE ao0eveiq oc onoiot ~psta<onat peros m ~ p o ~ i 6 r j yla q v eni~eucq q q ucpCoewq, iowq ~ R O ~ E L X ~ E ~ anoTe- A ~ a p a ~ ~ ~ f i q xopfiyqq a<ae.sionpiwjq fi 6-pep~amo- noupivqq. IE aoeev~iq pe av8etcrc~fi m a avr@io~t~a VOUO, iawq @~~I)u&L fl TontKfi fi an6 TOU m6pmoq xopfiyqq pcrsuaAapivq$. TCAoq, a& t6ta i~~pa papeieq nep~n-rha~~q, Cxouv xopqyqeei pe ent~uxia ptoAoy~KCq Bepaneieq, 6nwq TO povodwvt~o avrioopa Cvavr~ TOU

TNF-a infliximab.

Sandborn WJ. Pouchitis following ileal pouch-anal anastomosis: definition, pathogenesis and treatment. Gastroenterology 1994; 107: 1856-60. Simchuck EJ, Thirlby RC. Risk factors and true incidence of pouchitis in patients after ileal pouch-anal anastomoses. World J Surg 2000;24:851-6 Sandborn WJ, Pardi DS. Clinical management of pouchitis. Gastroenterology 2004: 127; 1809-14. Shen B, Fazio W, Remzi FH, et al. Comprehensive evaluation of inflamma-tory and noninflammatory sequelae of ileal pouch-anal anastomoses. Am J Gastroenterol 2005;90:740-7. M. Roussomoustakaki, J. Satsangi, K. Welsh, et al. Genetic markers may predict disease behavior in patients with ulcerative colitis. Gastroenterology 1997; 112(6):1845-1853 Pardi DS, Sandborn WJ. Systematic review: the management of pouchitis. Aliment Pharmacol Ther 2006;23: 1087-96

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(EMHNIKH O M A M MEAETHZ IQNE)