Inflammatory bowel disease in children

Inflammatory bowel disease in children and adults remains the most challenging problem in gastroenterology. There is an increasing body of immunologic and genetic evidence to suggest that Crohn's disease and ulcerative colitis are different diseases, but that once inflammation begins, many common secondary pathways of inflammation are initiated. The major recent conceptual advance is the observation that mice in whom different immunoregulatory pathways are disrupted develop an inflammatory bowel disease. In the case of interleukin-2 knockout mice, the lesion restricted to the colon, is virtually identical to ulcerative colitis in humans, and is initiated by the normal bacterial flora. Yet these mice possess anticolon antibodies, long-considered to be of pathologic significance in ulcerative colitis. These animal models will allow detailed longitudinal studies to be done, and less reliance will need to be placed on cross-sectional studies of chronically inflamed gut from patients.

Immunomodulator therapy in inflammatory bowel disease

The introduction of immunomodulator therapy in the treatment of patients with inflammatory bowel disease (IBD) has provided an important tool in modifying the mucosal immune system thought to be important in the pathogenesis of IBD. Currently available immunomodulating agents include azathioprine, 6-mercaptopurine, cyclosporin, and methotrexate. Recent clinical trials have demonstrated that these agents have an important therapeutic role in the treatment of patients who are either refractory or intolerant to traditional medical therapy. They are useful in the induction and maintenance of remission for both ulcerative colitis and Crohn's disease. However, these agents have significant toxicities and limited efficacy. In addition, potential risks of malignancy and infection limit their indiscriminate use. Thus, with the better understanding of the molecular basis of mucosal immunity, innovative immune-modifying therapies, such as antagonists of cytokines and inhibitors of T-cell activation, are being developed. It is likely that these exciting developments will soon result in specific immune modulating therapy with improved efficacy and reduced toxicity in the treatment of patients with IBD.

Treatment of inflammatory bowel disease from now to the millennium

After decades of therapeutic stasis, treatment advances are occurring in inflammatory bowel disease. Recognition that mesalazine was the active moiety of sulphasalazine has led to a number of new methods of delivering mesalazine without sulphapyridine, with improved toxicity ratios. Current attempts to deliver topical steroids directly to the large bowel have yet to be established as therapeutically effective. Immunosuppressive treatment has been used for many years but recent evidence has firmly established its value and cyclosporin has recently been added to the therapeutic armamentarium. Increasing understanding of the basic processes of inflammation has yielded targets for anti-inflammatory treatments aimed both at the processes of immune activation and of attraction by chemotaxis of neutrophils from the circulation to the lamina propria. Some of these novel treatments, which will be assessed in forthcoming years, involve large molecular weight bioengineered peptides and antibodies that are likely to be expensive and difficult to administer. Other treatment, e.g. 5-lipoxygenase or thromboxane synthesis inhibitors or platelet-activating factor antagonists, are conventional lower molecular weight compounds that are easier to produce and are orally active. It is predicted that 5-lipoxygenase inhibitors will be the next therapeutic advance in inflammatory bowel disease. Such a prediction may founder if blanket suppression of multiple inflammatory mechanisms, rather than targeted actions, is required in inflammation.

Inflammatory bowel disease: diagnosis and treatment

The primary feature of IBD which distinguishes pediatric from adult patients is the presence of or potential for significant growth failure. Recognizing this complication before permanent stunting occurs is critically important. The onset of these disorders during childhood also means that many of these children will have a lifetime of disease and therapy, during both growing as well as reproductive years. The impact of this lifelong process on the psychosocial development of the child and adolescent also needs to be recognized and addressed. Treatments must be carefully considered for their chronic adverse consequences (side effects) as well as immediate benefits. This includes the risks of early, and likely repeated, bowel resections as well as potentially mutagenic or teratogenic medications. The resurgence of tuberculosis and other chronic intestinal infections, particularly in certain high-risk pediatric populations, requires a careful consideration of the differential diagnosis of IBD in children. Finally, promising therapies must be tested in children as well as adults to develop the most effective approach to controlling IBD in pediatric patients by taking advantage of potential age-related differences in intestinal immune barrier function.

Medical management of chronic inflammatory bowel disease

In the absence of a definitive cure for Crohn's disease and ulcerative colitis, the aim of therapy must be to induce and maintain clinical remission at acceptable cost to the patient in terms of adverse effects. Despite the differences in their pathogenesis, the first-line treatments for Crohn's disease and ulcerative colitis are still based upon combinations of amino-salicylic acid derivatives and corticosteroids, although the use of enteral nutrition regimes is becoming increasingly widespread in Crohn's disease. In this chapter we attempt to provide reasonably didactic guidance for the management of most cases of chronic inflammatory bowel disease. However, we have tried to go beyond this brief, motivated by the recent explosion in knowledge of inflammatory mechanisms, to suggest a rational approach to the choice of newer and less well tested therapeutic approaches in the affected child who is not responding effectively. The relative failure of cyclosporine therapy in Crohn's disease has been particularly disappointing in view of its ideal theoretical suitability. However, the encouraging early reports of treatment with anti-CD4 and anti-TNF alpha monoclonals suggest that the shift from broad spectrum immunomodulation to the targeting of critical components of the inflammatory cascade may yet field important dividends.

Growth and puberty in chronic inflammatory bowel disease

The consequences of IBD during childhood and adolescence may be devastating in terms of loss of growth potential, particularly if there has been a clinical course of frequent relapses resulting in inadequate nutrition and associated with repeated courses of steroid treatment. There is to date, however, a paucity of data recording final adult heights in such patients. The anticipation of relapse should become easier with increasing awareness of the importance of parameters of growth and pubertal development. Early and intensive nutritional support, and the use of steroid-sparing agents should help reduce the frequency and severity of any height deficit. The performance and timing of surgery must take into account the child's status in terms of height velocity and pubertal development. The importance of inducing the remission before the onset of puberty is stressed and this remission should be sustained at all costs during the pubertal years so that valuable height is not lost as a consequence of a missed pubertal growth spurt. Thus, increasing awareness of the issues of growth and development in these patients should improve the accuracy of initial diagnosis and early recognition of relapse, such that these children are ensured the best possible provision for achieving their full height potential.

Longitudinal growth in children and adolescents with inflammatory bowel disease

Weight and height were followed longitudinally from birth to adulthood in children with inflammatory bowel disease living in a defined area of Sweden, 1983 through 1987; 124 children out of a possible 128 were studied. During the year preceding diagnosis, height growth velocity was significantly reduced in both ulcerative colitis and Crohn's disease. At the time of diagnosis, weight-for-height was subnormal in both children with ulcerative colitis (p < 0.05) and those with Crohn's disease (p < 0.001), while height was reduced only in children with Crohn's disease (p < 0.05). Weight for height was normalized within one year in ulcerative colitis, after the initiation of medical therapy. In Crohn's disease, weight-for-height improved during the years following diagnosis but height remained subnormal. Children with ulcerative colitis reached puberty at the normal time and their final heights became normal. In children with Crohn's disease, puberty was delayed (p < 0.001) and final height was reduced (p < 0.01). The impact of inflammatory bowel disease on growth was substantial, but it was smaller in this study than in many other published studies. The possible reasons for this difference include use of population-based material and a relatively short interval between the first symptoms and the start of treatment. Our findings indicate that, although final height was significantly reduced in children with Crohn's disease, delayed puberty reduced the negative effects on permanent adult height, to a certain extent compensating for the period of poor growth earlier in life.

Immune mechanisms in chronic inflammatory bowel disease

Crohn's disease and ulcerative colitis are chronic inflammatory bowel diseases of unknown etiology. However, there is circumstantial evidence that immune mechanisms play an important role in the pathogenesis of the intestinal lesion, and cytokines produced by lymphoid cells may be critical for the extraintestinal sequelae of the disease. In both Crohn's disease and ulcerative colitis, activation of macrophages seems to be a key feature. Increased production of the macrophage derived cytokines TNF-alpha, IL-1 and IL-6 have been reported in both diseases. Additionally in Crohn's disease, large numbers of activated T lymphocytes can be detected in the lamina propria and the T lymphocyte derived cytokines IL-2 and IFN-gamma are secreted by a higher number of lamina propria T lymphocytes in active Crohn's disease. However, this is not the case in ulcerative colitis. The increased number of activated T lymphocytes secreting IFN-gamma may be responsible for granuloma formation in Crohn's disease, as well as for MHC class II antigen expression on colonic epithelial cells. Lamina propria T lymphocytes seem to have lost their physiological unresponsiveness to several microbial antigens. All these observations suggest that Crohn's disease may be caused by hyperreaction of the local cellular immune system to numerous microbial and nutritional antigens normally present in the intestine. The factor inducing this immune dysregulation remains unknown. Cell-mediated immunity seems to be less important in ulcerative colitis, as activated T lymphocytes are only sparse within the inflamed mucosa, and the T lymphocyte derived cytokines IL-2 and IFN-gamma cannot be detected in the gut lesion or in the serum.(ABSTRACT TRUNCATED AT 250 WORDS)

Leukocyte-endothelial cell interactions: implications for the pathogenesis and treatment of gastrointestinal disease

Evidence implicating leukocytes as mediators of tissue injury in different disease processes is accumulating rapidly. The sequestration and activation of neutrophils have been shown to be key components in the pathophysiology of chronic inflammatory bowel diseases, and in gastrointestinal lesions following hemorrhagic shock, ischemia-reperfusion, and ingestion of nonsteroidal anti-inflammatory drugs, or ethanol. Leukocyte-endothelial cell interactions also appear to be a target for the action of various drugs proven to be useful in the treatment of gastrointestinal inflammatory disorders. This review focuses on the alterations in leukocyte-endothelial cell interactions in the aforementioned conditions.

Juvenile-onset inflammatory bowel disease: predictors of morbidity and health status in early adult life

We interviewed and examined 70 young adults (50 Crohn's disease, 20 ulcerative colitis) from a geographically derived cohort of patients with juvenile-onset (< or = 16 years) inflammatory bowel disease at a mean of 14 years (range 5.2-29.5) after diagnosis. Patients with initially ileo-colonic Crohn's disease spent significantly longer in hospital than other groups. Thirty-nine Crohn's disease and 10 ulcerative colitis patients have had major surgery, with permanent stomas in 15 cases of Crohn's disease and seven of ulcerative colitis. In Crohn's disease the disease was still active at the time of review in 16 of 50 patients (10 of 20 women), whereas only two of the 20 patients with ulcerative colitis had active disease. The data show that the high early morbidity of juvenile-onset inflammatory bowel disease continues into adult life, with particularly severe and disabling manifestations in women with Crohn's disease.

Inflammatory bowel disease

Inflammatory bowel disease in children encompasses at least two forms of intestinal inflammation: ulcerative colitis and Crohn's disease. These two disease processes are differentiated based on clinical presentation, radiologic findings, endoscopic findings, histologic evaluation, and exclusion of alternative causes. The treatment and operative interventions are reviewed.

British Gastroenterologists' Care Profile for Patients with Inflammatory Bowel Disease: The Need for a Patients' Charter

The follow-up of patients with inflammatory bowel disease (IBD) was investigated using a postal questionnaire sent to 359 members of the British Society of Gastroenterology (BSG), of whom 235 replied. Of patients with IBD, 96% were weighed on each outpatient clinic review and over 60% had their full blood count checked. Although few centres (20%) have computerized recall of their patients for cancer surveillance, 96% did perform such surveillance on patients with ulcerative colitis. The mean duration of disease before surveillance was initiated was 9.6 years. Most clinicians (80%) only surveyed patients with disease extending beyond the transverse colon.

Despite recent work on cancer risk age is relatively unimportant to 76% of clinicians in their decision to screen or not. Only 24% of clinicians undertake cancer surveillance in patients with Crohn's disease but these use similar criteria in their selection of patients. Few other tests were performed regularly. Clinic services vary considerably from centre to centre, 62% offer open access to patients with IBD, 8% have a stoma nurse in clinic and 17% a dietitian. Eighty-four per cent of respondents provide educational books and 22% videos. Forty-four per cent of clinicians refer patients for advice to fellow sufferers. We believe there should be a uniform minimum standard of care and services available in clinics throughout the United Kingdom and propose a patients' charter to ensure that this occurs. Such care profiles provide guidelines to those who need to develop standards for resource management.

Review article: immunosuppressive therapy for inflammatory bowel disease

Refractory inflammatory bowel disease can be treated by surgery or using nutritional supplementation or replacement. Immunosuppressive agents may also play a role for refractory disease; they have gained widespread acceptance, due not only to trials that demonstrate efficacy but also to the realization that these side-effects are minor compared to those associated with long-term, high-dose corticosteroids. To date, 6-mercaptopurine and azathioprine remain the drugs of choice based upon extensive clinical experience, but both methotrexate and cyclosporin are promising immunosuppressants for otherwise refractory disease.

Inflammatory bowel disease: Part II. Medical and surgical management

Substantial advances have been made in the management of inflammatory bowel disease. Mesalamine and olsalazine are new anti-inflammatory agents that may serve as alternatives to corticosteroids and sulfasalazine, which have been the mainstays of medical therapy. These new agents are available in oral, enema and suppository forms. Brooke ileostomy remains the standard surgical treatment for advanced ulcerative pancolitis, but continent ileostomy procedures may be more cosmetically acceptable to selected patients.

Quality of Life in gastrointestinal disease--reports from working groups and conclusions

In this workshop Quality of Life (QOL) was discussed in relation to other measures such as treatment efficacy and cost-benefit in evaluation of clinical treatments. Demands from regulatory authorities, patients as well as nurses and doctors were believed to high-light the status of QOL measurements and use as an evaluation of medical regimens as well as of new medical treatments. Four different areas; inflammatory bowel disease, non-ulcer dyspepsia, peptic ulcer disease and surgical management of GI disease, were discussed in working groups. For inflammatory bowel disease the McMaster QOL instruments was suggested to be further developed and investigated. Non-ulcer dyspepsia was believed to differ from the other areas due to the lack of specific symptoms and evaluable factors. Peptic ulcer disease was suggested to be further evaluated by methods recently suggested by the SCUR group. Surgical management of GI disease was believed to be an important area for QOL assessment due to the fact that surgery is forever. Therefore the bases for decisions of surgical treatment has to involve such an instrument. The potential role of QOL assessments for politicians, pressure groups and health care authorities in the decision for funding, treatment regimens and individual investigators was also pointed out.

Inflammatory bowel disease in the pregnant woman

Although the woman with IBD possesses a greater potential for a complicated pregnancy, the majority of patients will experience an uneventful normal pregnancy. It is important to educate the young patient with IBD when she is planning a family. Conception at a time when IBD is quiescent offers the greatest likelihood of an uncomplicated pregnancy. Physicians must recognize and inform their patients that most medications that are necessary to suppress the disease should be continued throughout pregnancy. Although generalities can be made regarding the management of pregnant women with IBD, the individual patient may need specifically tailored therapy for her individual case.

Low bone mineral density in patients with inflammatory bowel disease

To assess the prevalence and risk factors for low bone mineral density in inflammatory bowel disease, we studied 61 consecutive patients, mean age 36 +/- 11 years. Twenty-seven had a Crohn's disease and 34 ulcerative colitis (including 13 with ileoanal anastomosis). Three patients, two women and one man (32, 70, and 45 years old, respectively) had vertebral crush fractures. Bone mineral density measured by dual energy x-ray absorptiometry at spine and femoral level was more than 2 SD below normal values in 23% of the patients, all of them having received steroid therapy. Eighteen patients (29%) had never received steroid therapy; their bone mineral density was not different than those who had. Univariate analysis showed a positive correlation between bone mineral density and body weight or oral calcium intakes, and a negative correlation with steroid daily dose. After ileoanal anastomosis, bone mineral density was not different from other groups and showed a positive correlation with time elapsed since coloproctectomy. We concluded that bone mineral density is low in patients with inflammatory bowel disease and exposes them to the risk of bone fracture. Bone mineral density after ileoanal anastomosis may increase with time after surgery.

[Chronic inflammatory bowel diseases in childhood. Case contribution and critical considerations]

The term "inflammatory bowel disease" describes 2 major categories of chronic disease: Crohn's disease and ulcerative colitis. Non specific chronic colitis and allergic colitis in childhood can usually be distinguished by clinical and histopathologic criteria. This study regards a retrospective analysis of 23 patients suffering from chronic inflammatory bowel disease. Clinical manifestations began between 4 and 18 years of age. The Authors report remarkable frequency in pediatric age and common diagnostic delay, especially in Crohn's disease. The possibility of extraintestinal symptoms (erythema nodosum, arthritis, iridocyclitis) is also showed. Moreover they analyse present diagnostic proceedings: in childhood the employ of 99 mTc-HmPAO-labelled granulocytes is a new and non invasive test useful in the follow-up of the patients. In the treatment corticosteroids and sulfasalazine are used in various combinations associated with general supportive measures. Finally the Authors confirm that chronic inflammatory bowel disease may cause, especially in childhood, remarkable involvement on the growth and several psychological disorders.

Inflammatory bowel disease in children--clinical, endoscopic, radiologic and histopathologic investigation

This paper reviews our five years' clinical experience (1987 to 1991) of 22 patients with inflammatory bowel disease (IBD). There were 12 patients with Crohn's disease and 10 patients with ulcerative colitis. The mean age at diagnosis was 8.7 years (2 to 14 years). Clinical impressions before referral were chronic diarrhea in 11, irritable bowel syndrome in 5, colon polyp in 4, lymphoma in 3, intestinal tuberculosis in 2, amoebic colitis in 2, ulcerative colitis in 2 children and other diseases. The mean interval from the onset of symptoms to the diagnosis of IBD was 18 months. Diagnosis of Crohn's disease was delayed for more than 13 months in 8 (67%), whereas that of ulcerative colitis was delayed for more than 13 months in 4 (40%). Diarrhea (50%), abdominal pain (36%) and rectal bleeding (36%) were the three most frequent presenting complaints of IBD. Moderately severe abdominal pain was a more common chief complaint in Crohn's disease (58%) than in ulcerative colitis (10%). Hematochezia (90% vs 17%) and moderately severe diarrhea (90% vs 75%) were more common gastrointestinal manifestations in ulcerative colitis than in Crohn's disease. The associated extraintestinal manifestations were oral ulcer in 7, arthralgia in 11 and arthritis in 4, skin lesions in 2, eye lesions in 2 and growth failure in 9 patients. Of 12 children with Crohn's disease, granuloma was found in 5, aphthous ulcerations in 8, cobble stone appearance in 8, skip area or asymmetric lesions in 6, transmural involvement in 7, and perianal fistula in 3. Among 10 children with ulcerative Colitis, there were crypt abscess in 8, granularity or friability in 10 and rectosigmoid ulcerations with purulent exudate in 8 children. The main sites of involvement in children with Crohn's disease were both the small and large bowels in 7 (58%), small bowel only in 2 (16%), and colon only in 3 (25%). Terminal ileum involvement was seen in 75% of Crohn's disease cases. The main sites of involvement in children with ulcerative colitis were total colon in 4 (40%), up to the splenic flexure in 2 (20%), rectosigmoid in 3 (30%) and rectum only in one (10%). Medical treatment including sulfasalazine, and systemic or topical steroid was administered initially in most patients. Seven of 12 patients with Crohn's disease and 2 of 10 patients with ulcerative colitis were operated on.(ABSTRACT TRUNCATED AT 400 WORDS)

Changes in splanchnic hemodynamics in inflammatory bowel disease. Non-invasive assessment by Doppler ultrasound flowmetry

An increase in splanchnic blood flow in both arterial and venous beds has been demonstrated in inflammatory bowel disease (IBD) by means of angiographic and scintigraphic studies. Doppler ultrasound (US) enables a non-invasive evaluation of splanchnic arterial inflow in the superior mesenteric artery (SMA) and of venous outflow in the portal vein. The aim of this study was to assess the role of Doppler US in detecting changes in the hemodynamic variables measured in patients with IBD. Forty-five patients with IBD were studied, including 22 with Crohn's disease (CD) and 23 with ulcerative colitis (UC), and compared with 45 matched normal subjects. The mean velocity of portal flow (Vmean) and the resistance index (RI) of the SMA were evaluated by Doppler US. In CD the Vmean of portal flow was significantly higher in patients with active disease than in controls (p less than 0.001) and patients with inactive disease (p less than 0.001). The RI of the SMA was significantly lower in active disease than in controls (p less than 0.005), but no significant difference was noted between active and inactive CD. Also in UC, the Vmean of portal flow was significantly higher in patients with active disease than in controls (p less than 0.01) and patients with inactive disease (p less than 0.05). The RI of the SMA was significantly lower in active disease than in controls (p less than 0.005) and in patients with inactive disease (p less than 0.005). Doppler follow-up studies were carried out in 10 patients after initiation of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

ABC of colorectal diseases. Non-specific inflammatory bowel disease

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Home hyperalimentation for inflammatory bowel disease

Total parenteral nutrition (TPN) has become a useful tool in the management of patients with inflammatory bowel disease (IBD). In the past, it was felt that TPN would have a therapeutic role in IBD, but experience has shown that it functions more as an adjunct to other therapeutic interventions. The specific roles of TPN in IBD include: (1) nutritional maintenance in the short bowel syndrome, (2) TPN as adjunctive therapy in jejunoileitis of Crohn's disease, (3) home TPN (HTPN) in Crohn's colitis, and (4) preoperative repletion of significantly depleted patients going to surgery. The adaptation of hospital techniques to the home situation has allowed patients to carry out long-term TPN therapy at home. Patients with IBD on HTPN are subject to the same mechanical and metabolic problems as are other patients on HTPN and, in addition, have a higher infection rate. When carried out appropriately, however, HTPN is a valuable technique in the management of patients with IBD and may provide an improved quality of life.

Nutritional support in patients with inflammatory bowel disease

Total parenteral nutrition with bowel rest has been used as primary therapy to reduce disease activity and achieve remission in patients with inflammatory bowel disease (IBD). However, results are short-lived and similar success can be attained through total enteral nutrition with highly specialized elemental or semielemental formulas. Enteral nutrition costs less than parenteral nutrition, maintains gut integrity, stimulates immunocompetence, and helps to control symptoms and overall disease activity. Increased use of enteral formulas can be expected in the future. The role of diet in management of IBD is currently under scrutiny. No one diet is appropriate for all patients, but restriction of fat, fiber, lactose, or oxalate may be necessary to help alleviate symptoms and minimize the risk of complications.

Malignant melanoma in inflammatory bowel disease

Malignant melanoma occurred in 11 patients with inflammatory bowel disease (IBD). Six cases occurred in patients with ileocolitis, two in regional enteritis, one in granulomatous colitis, and two in patients with ulcerative colitis. The mean age at development of IBD was 24 yr, and at development of melanoma was 40 yr: the mean duration from onset of IBD to development of melanoma was thus 16 yr. All patients for whom complete information was available, except two, had received steroids and azulfidine for approximately a decade, as well as blood transfusions, usually multiple, and on repeated occasions. Six of the 11 patients had undergone one to seven prior operations (mean 3.5). All patients had wide radical excision of the melanoma, with or without concomitant or subsequent nodal dissection. Two patients (ages 25 and 36 yr) died rapidly from widely disseminated malignant melanoma. These cases may be coincidental, or else there may be an association between IBD and melanoma, related to immunosuppression either from the disease itself, from the medical and surgical therapy, and/or from x-ray exposure.

Nutritional support in inflammatory bowel disease: current status and future directions

Malnutrition is a frequent occurrence in patients with acute inflammatory bowel disease. Total nutritional support provided either parentally (TPN) or enterally (TEN) has been advocated not only as an adjunct for improving nutrition but also as primary therapy. For patients with acute Crohn's disease, short-term rates of remission after TEN are equivalent to TPN. Coupled with certain advantages when compared with TPN, including simpler administration, fewer side effects, and preservation of the intestinal mucosal barrier, TEN may therefore be the preferred route for nutrient delivery. Controlled trials indicate equivalent or superior efficacy when enteral polymeric diets are compared with elemental diets for inducing remission in acute Crohn's disease. Moreover, when provided as an elemental diet, TEN is as effective as corticosteroids for achieving remission in acute Crohn's disease, but corticosteroids appear to be more effective than polymeric diets. Although the provision of nutritional support rather than bowel rest is the major factor contributing to symptomatic improvement, the optimal nutrient composition and the precise mechanisms whereby nutritional support achieves clinical remission remain to be clarified. In contrast to Crohn's disease, nutritional support is not effective for achieving remission in patients with ulcerative colitis. Thus, enteral nutritional support is an effective therapy for the short-term management of acute Crohn's disease. Whether long-term remission is equivalent to treatment with drugs or surgery requires prospective evaluation. Future avenues of investigation also include defining the optimal nutrient composition and the underlying mechanisms that achieve maximal nutritional repletion, promote mucosal cell renewal, and potentially directly retard production of inflammatory mediators.

A short course of intravenous nutrition in inflammatory bowel disease improves respiratory and skeletal muscle function

In malnourished patients hospitalized because of acute exacerbations of inflammatory bowel disease, a brief course of intravenous nutrition can restore skeletal and respiratory muscle function even before body protein has been repleted.

The human intestinal response to enteral nutrients: a review

This review identifies the factors which influence mucosal integrity during enteral nutrition. These include biliary and pancreatic secretions, trophic influences of endocrine and gastrointestinal polypeptides, intestinal blood flow, and innervation. Fiber, bacterial fermentation products, purines, and glutamines are potential essential nutrients which may not be provided by parenteral nutrition. However, contrary to experience in animal models, the specific advantages of intraluminal delivery of nutrients for the maintenance of mucosal integrity and structure remain unproven in the human. Current evidence in the human suggests that changes in small bowel structure and function when enteral nutrients are excluded are minor and rapidly reversible as long as general nutritional status is maintained.

Nutritional management of inflammatory bowel disease

The etiology and specific treatment of Crohn's disease and ulcerative colitis are unknown, and the treatment strategy for patients with inflammatory bowel disease is essentially symptomatic and supportive. The malnutrition that frequently accompanies inflammatory bowel disease is a manifestation of intestinal failure and should be vigorously corrected with total parenteral nutrition, elemental diets, or both. Evidence exists for the value of total parenteral nutrition and elemental diets as primary therapy for inflammatory bowel disease in selected patients. Judicious nutritional therapy remains a cornerstone in the adjunctive management of these patients.

Inflammatory bowel disease: patients' expectations in the 1990s

A group of 70 patients with inflammatory bowel disease were asked to complete a questionnaire about their disease counselling preferences, 59 replied. Seventy-five per cent wanted further advice about their disease. Of these, 60% wished to receive the advice by discussion with a trained advisor. Seventy-six per cent wanted this person to be a hospital specialist, but 50% would accept advice from a specialty trained nurse. Eighty-six per cent would like this in conjunction with 'same day' telephone advice from a hospital specialist and 85% of patients wish to be taught how to adjust their own therapy. There is an increasingly important role for nurse counsellors in the management of these diseases.

[Acute dilatation of the colon]

Dilated colon is provoked by obstructing lesions, toxic megacolon or colonic pseudoobstruction. The obstructing lesions of the colon are colonic volvulus, inflammatory bowel disease with stenosis or colonic cancer. Toxic megacolon is more often caused by I.B.D. and rarely by infectious diseases. Etiological diagnosis is possible after clinical and radiological evaluation. Colonoscopy is always indicated, except in toxic megacolon. Balloon dilatation of strictures, palliative treatment of colonic carcinoma by Laser procedures, reduction of colonic volvulus and aspiration of colonic pseudoobstruction are the principal indications of therapeutic colonoscopy in the non surgical treatment of dilated colon.