Cholesterol-lowering effect of continuous enteral nutrition in man

We have studied the effect of polymeric cholesterol-free enteral nutrition (EN) on serum lipid and apolipoprotein levels in 30 consecutive non-diabetic, non-hyperlipaemic gastrointestinal patients. EN-40 +/- (SEM) 2 kcal/kg/day including 35% vegetable lipids (50% highly polyunsaturated fat, 50% medium chain triglycerides)-was delivered continuously (24h) via the gastric route for at least 2 weeks (mean duration: 35 +/- 4 days). In the entire group, serum total cholesterol decreased by 10.5% (p < 0.01) on day 7 and 17.5% (p < 0.01) on day 28 (n = 12); this was accompanied by 21% and 20% decreases in LDL-cholesterol and apolipoprotein B (p < 0.05) levels respectively, on day 28. In the 19 patients who were normocholesterolaemic on day 0, serum total cholesterol decreased by 15% (p < 0.01) on day 7 and by 28% (p < 0.05) on day 28 (n = 7). Conversely, in the other 11 patients with a low (<3.7 mmol/L) pre-EN serum total cholesterol level, no significant changes were observed during EN. We conclude that continuous, cholesterol-free EN has, in normocholesterolaemic patients, a marked cholesterol-lowering effect; the respective role of the composition of the diet and the continuous delivery of nutrient within the gut have yet to be investigated.

Effect of a fermented milk containing Bifidobacterium animalis DN-173 010 on the health-related quality of life and symptoms in irritable bowel syndrome in adults in primary care: a multicentre, randomized, double-blind, controlled trial

BACKGROUND

Health-related quality of life (HRQoL) has been rarely evaluated as a primary endpoint in the assessment of the effect of probiotics on the irritable bowel syndrome (IBS).

AIM

To study the effects of fermented milk containing Bifidobacterium animalis DN-173 010 and yoghurt strains on the IBS in a multicentre, double-blind, controlled trial.

METHODS

A total of 274 primary care adults with constipation-predominant IBS (Rome II) were randomized to consume for 6 weeks either the test fermented milk or a heat-treated yoghurt (control). HRQoL and digestive symptoms were assessed after 3 and 6 weeks on an intention-to-treat population of 267 subjects.

RESULTS

The HRQoL discomfort score, the primary endpoint, improved (P < 0.001) in both groups at weeks 3 and 6. The responder rate for the HRQoL discomfort score was higher (65.2 vs. 47.7%, P < 0.005), as was the decrease in bloating score [0.56 +/- (s.d.)1.01 vs. 0.31 +/- 0.87, P = 0.03], at week 3 in the test vs. the control group. In those subjects with <3 stools/week, stool frequency increased (P < 0.001) over 6 weeks in the test vs. control group.

CONCLUSIONS

This study suggests a beneficial effect of a probiotic food on discomfort HRQoL score and bloating in constipation-predominant IBS, and on stool frequency in subjects with <3 stools/week.

Review article: bifidobacteria as probiotic agents -- physiological effects and clinical benefits

Bifidobacteria, naturally present in the dominant colonic microbiota, represent up to 25% of the cultivable faecal bacteria in adults and 80% in infants. As probiotic agents, bifidobacteria have been studied for their efficacy in the prevention and treatment of a broad spectrum of animal and/or human gastrointestinal disorders, such as colonic transit disorders, intestinal infections, and colonic adenomas and cancer. The aim of this review is to focus on the gastrointestinal effects of bifidobacteria as probiotic agents in animal models and man. The traditional use of bifidobacteria in fermented dairy products and the GRAS ('Generally Recognised As Safe') status of certain strains attest to their safety. Some strains, especially Bifidobacterium animalis strain DN-173 010 which has long been used in fermented dairy products, show high gastrointestinal survival capacity and exhibit probiotic properties in the colon. Bifidobacteria are able to prevent or alleviate infectious diarrhoea through their effects on the immune system and resistance to colonization by pathogens. There is some experimental evidence that certain bifidobacteria may actually protect the host from carcinogenic activity of intestinal flora. Bifidobacteria may exert protective intestinal actions through various mechanisms, and represent promising advances in the fields of prophylaxis and therapy.

Review article: bifidobacteria as probiotic agents -- physiological effects and clinical benefits

Bifidobacteria, naturally present in the dominant colonic microbiota, represent up to 25% of the cultivable faecal bacteria in adults and 80% in infants. As probiotic agents, bifidobacteria have been studied for their efficacy in the prevention and treatment of a broad spectrum of animal and/or human gastrointestinal disorders, such as colonic transit disorders, intestinal infections, and colonic adenomas and cancer. The aim of this review is to focus on the gastrointestinal effects of bifidobacteria as probiotic agents in animal models and man. The traditional use of bifidobacteria in fermented dairy products and the GRAS ('Generally Recognised As Safe') status of certain strains attest to their safety. Some strains, especially Bifidobacterium animalis strain DN-173 010 which has long been used in fermented dairy products, show high gastrointestinal survival capacity and exhibit probiotic properties in the colon. Bifidobacteria are able to prevent or alleviate infectious diarrhoea through their effects on the immune system and resistance to colonization by pathogens. There is some experimental evidence that certain bifidobacteria may actually protect the host from carcinogenic activity of intestinal flora. Bifidobacteria may exert protective intestinal actions through various mechanisms, and represent promising advances in the fields of prophylaxis and therapy.

A prospective assessment of cytomegalovirus infection in active inflammatory bowel disease

BACKGROUND

The prevalence and clinical significance of cytomegalovirus infection is reportedly high in patients with refractory inflammatory bowel disease but is unknown in unselected patients with active disease.

METHODS

In patients admitted for active inflammatory bowel disease, we prospectively studied the presence and significance of cytomegalovirus infection using anti-cytomegalovirus antibodies, cytomegalovirus viraemia and antigenaemia and cytomegalovirus inclusions and cytomegalovirus immunochemistry staining in ileocolonic biopsies.

RESULTS

A total of 64 patients were included (ulcerative colitis, n = 23; Crohn's disease, n = 41), 18 of whom had been on high-dose oral steroids and 11 on immunosuppressants. Anti-cytomegalovirus IgG and IgM were positive in 42 (66%) and 3 (5%) patients respectively. Blood or urine cytomegalovirus replication markers were found in 4 (6%) patients, all of whom had ulcerative colitis. Three patients had cytomegalovirus viraemia and received anti-viral treatment with ganciclovir. Only one of these patients had cytomegalovirus antigenaemia and also associated biopsy-proven cytomegalovirus colitis, probably as a primary cytomegalovirus infection. This patient is the only one who benefitted from anti-viral therapy.

CONCLUSIONS

Cytomegalovirus infection is infrequent in in-patients with active inflammatory bowel disease. Systematic search of cytomegalovirus replication markers should not be performed. Isolated viraemia without associated antigenaemia or direct demonstration of cytomegalovirus in ileocolonic biopsies does not warrant anti-viral therapy.

Significance of ovarian histology in the management of patients presenting a premature ovarian failure

BACKGROUND

Premature ovarian failure (POF) is a heterogeneous syndrome, possibly due to mutations of genes involved in the normal development of the ovary and/or follicles. Based essentially on animal models, these mutations are associated with various ovarian phenotypes, from a complete absence of follicles to a partial follicular maturation. The aim of the present study was to determine whether ovarian histology, compared to pelvic ultrasonography, would be helpful in identifying which patients display an impaired follicular reserve and/or growth, and in orientating the search for POF aetiology.

METHODS AND RESULTS

We studied a cohort of 61 patients suffering from POF with a normal karyotype. Their median age (range) at diagnosis was 26 years (15-39). The FSH plasma level was high, 67.0 IU/l (13-155). Estradiol and inhibin B plasma levels were low: 18.5 pmol/l (18.5-555) and 5 pg/ml (5-105) respectively. Both pelvic ultrasonography and ovarian biopsies were performed in each patient. The presence of follicles suggested at ultrasonography was confirmed at histology in 56% of the patients. Ovarian histology led to the distinction of two phenotypes: (i) small-sized ovaries, deprived of follicles; and (ii) normal-sized ovaries with partial follicular maturation. To confirm the value of ovarian biopsies, samples from 20 normal women were studied. These demonstrated that ovarian biopsy at random enables reliable assessment of follicular presence, especially when their size is <2 mm.

CONCLUSION

Ovarian histology appears to be a reliable tool in evaluating the follicular reserve, and helpful and complementary to clinical and hormonal phenotyping in orienting the search for the various genetic causes of POF syndrome.

Laparoscopic ileocecal resection in Crohn's disease: a case-matched comparison with open resection

BACKGROUND

Despite some encouraging preliminary results, the role of laparosropic surgery in the treatment of Crohn's disease (CD) is a subject of controversy and still under evaluation. The aim of this case-matched study was to compare the postoperative course of laparoscopic and open ileocecal resection in patients with CD in order to define the potential role of laparoscopic surgery in CD.

METHODS

From 1998 to 2001, 24 consecutive patients with isolated Crohn's terminal ileitis treated by laparoscopic ileocecal resection (laparoscopy group) were compared with 32 patients matched for age, gender, duration of disease, preoperative steroid treatment, fistulizing disease, and associated surgical procedure, and treated by open resection (open group).

RESULTS

In the laparoscopy group, four procedures (17%) were converted. There were no deaths. The morbidity rate was 20% in the laparoscopy group and 10% in the open group (NS). There was no significant difference between the two groups in operating time, size of bowel resection and resection margin, postoperative morphine requirement, resumption of intestinal function, tolerance of solid diet, or length of hospital stay.

CONCLUSIONS

Laparoscopic ileocecal resection in CD is safe and effective, even for fistulizing disease. There are no significant differences between laparoscopic and open ileocecal resection, especially in terms of the mortality and mortality rates. Consequently, because laparoscopic surgery seems to offer cosmetic advantages, it should be considered the procedure of choice for patients with ileocecal CD.

Long-term results of faecal diversion for refractory perianal Crohn's disease

BACKGROUND AND AIMS

Faecal diversion (FD) for refractory anoperineal Crohn's disease (APCD) is thought to be unsatisfactory with a low overall rate of defunctioning stoma closure. However, only a few patients have so far been reported in the literature. The aim of this study was to reassess the long-term efficiency of FD for APCD.

METHODS

Among 136 patients who were operated for APCD over a 18-year period, 17 underwent FD. The factors assessed were the mortality and morbidity of stoma formation, the evolution of anoperineal Crohn's disease after FD, and predictive factors of FD effectiveness.

RESULTS

Mean follow-up after FD was 135 +/- 79 months (range 20-328). Initial healing of APCD was observed in 11 patients (65%), allowing stoma closure after 14 +/- 9 months (range 3-52). The 6 other patients underwent abdominoperineal resection (APR) for persistent APCD. Three of the 11 patients with normal bowel continuity underwent secondary APR for APCD recurrence. Thus, at the end of follow up 9 (53%) patients had definitive end ileostomy and 8 (47%) continued to have normal bowel continuity with a mean follow up of 124 +/- 90 months (range 12-292) after stoma closure. The presence of rectal lesions at the time of FD was the only predictive factor of poor outcome: 8/9 (89%) patients with rectal lesions underwent APR vs 1/8 (13%) patients without rectal lesion (P < 0.01).

CONCLUSIONS

Faecal diversion for anoperineal Crohn's disease produced a high initial rate of anoperineal lesion healing. After long-term follow-up, results of faecal diversion are good (normal bowel continuity was restored in 89%) in patients without associated rectal lesions. However, in patients with associated rectal lesions, the prospects for restoring continuity were limited, thus making faecal diversion a questionable procedure.

Long-term results of ileal pouch-anal anastomosis for colorectal Crohn's disease

INTRODUCTION

The aim of this study is to report ten-year results of ileal pouch-anal anastomosis in selected patients with colorectal Crohn's disease for whom coloproctectomy and definitive end ileostomy was the only alternative.

METHODS

41 patients (22 females/19 males) with a mean age of 36 +/- 13 (range, 16-72) years underwent ileal pouch-anal anastomosis for colorectal Crohn's disease between 1985 to 1998. None had past or present history of anal manifestations or evidence of small-bowel involvement. Diagnosis of Crohn's disease was established preoperatively in 26 patients, on the resected specimen after ileal pouch-anal anastomosis, or after occurrence of Crohn's disease-related complication in 15 patients.

RESULTS

Follow-up was 113 +/- 37 months, (18-174) 20 patients having been followed for more than 10 years. There was no postoperative death. Eleven (27 percent) patients experienced Crohn's disease-related complications, 47 +/- 34 months (8-101) after ileal pouch-anal anastomosis: 2 had persistent anal ulcerations with pouchitis and granulomas on pouch biopsy and were treated medically; 2 experienced extrasphincteric abscesses and 7 presented pouch-perineal fistulas which were treated surgically. Among them, 3 patients with persistent perineal fistula despite surgery required definitive end-ileostomy. Of the 20 patients followed for more than 10 years, 7 (35 percent) experienced Crohn's disease-related complications which required pouch excision in 2 (10 percent).

CONCLUSIONS

Ten years after ileal pouch-anal anastomosis for colorectal Crohn's disease, rates of Crohn's disease-related complications and pouch excision were 35 and 10 percent, respectively. These good long-term results justify for us to propose ileal pouch-anal anastomosis in selected patients with colorectal Crohn's disease (i.e., no past or present history of anal manifestations and no evidence of small-bowel involvement) for whom the only alternative is definitive end ileostomy.

Very late onset small intestinal B cell lymphoma associated with primary intestinal lymphangiectasia and diffuse cutaneous warts

As only a handful of lymphoma cases have been reported in conjunction with primary intestinal lymphangiectasia, it is not yet clear if this association is merely fortuitous or related to primary intestinal lymphangiectasia induced immune deficiency. We report on two female patients, 50 and 58 years old, who developed small intestinal high grade B cell lymphoma a long time (45 and 40 years, respectively) after the initial clinical manifestations of primary intestinal lymphangiectasia. They presented with a longstanding history of fluctuating protein losing enteropathy, multiple cutaneous plane warts, and markedly dilated mucosal and submucosal lymphatic channels in duodenal biopsies. One had a large ulcerated tumour of the proximal ileum and the other diffuse ileal infiltration. In both, histological examination showed centroblastic high grade B cell lymphoma associated with duodenojejuno-ileal mucosal and submucosal lymphangiectasia. They were subsequently successfully treated with surgery and postoperative chemotherapy (AVmCP: adriamycin, cyclophosphamide, Vm26, and prednisolone), and chemotherapy alone (PACOB: adriamycin, cyclophosphamide, vincristine, bleomycine, and prednisolone), respectively. A three year follow up in both cases showed persistent diffuse lymphangiectasia without evidence of lymphoma. The present findings support the hypothesis that primary intestinal lymphangiectasia is associated with lymphoma development.

Refractory sprue, coeliac disease, and enteropathy-associated T-cell lymphoma. French Coeliac Disease Study Group

BACKGROUND

Adult refractory sprue is a poorly defined disorder. We did a multicentre national study of patients with refractory sprue to characterise their clinical and pathological profile and outcome, and to assess the frequency and prognostic significance of phenotypic and molecular abnormalities in the intraepithelial T-cell population.

METHODS

Patients with severe symptomatic villous atrophy mimicking coeliac disease but refractory to a strict gluten-free diet, and with no initial evidence of overt lymphoma, were diagnosed at gastrointestinal referral centres between 1974 and 1998. Fixed and/or frozen duodenojejunal biopsy samples were reanalysed and immunostained with CD3 and CD8 monoclonal antibodies to find out the phenotype of intraepithelial lymphocytes (IEL). TCRgamma gene rearrangements were assessed on frozen biopsy samples by multiplex fluorescent PCR.

FINDINGS

There were 21 patients with refractory sprue and 20 controls with coeliacs disease. 16 (84%) of 19 assessed patients had an aberrant intraepithelial lymphoid intestinal population expressing intracytoplasmic CD3 but not surface CD8. Clonal intestinal TCRgamma gene rearrangements were found in 13 (76%) of 17 patients assessed; four (out of 12 assessed) had clonal dissemination to the blood. The 16 patients with an aberrant phenotype all had uncontrolled malabsorption; three subsequently developed overt T-cell lymphoma, and eight died. The three (16%) patients without aberrant clonal IEL made a complete clinical and histological recovery with steroid therapy plus a gluten-free diet.

INTERPRETATION

An immunophenotypically aberrant clonal intraepithelial T-cell population (similar to that of most cases of enteropathy-associated T-cell lymphoma) can be found in up to 75% of patients with refractory coeliac sprue; its identification by simple diagnostic techniques represents a marker of poor outcome (including occurrence of overt T-cell lymphoma). We suggest that refractory sprue associated with an aberrant clonal IEL may be the missing link between coeliac disease and T-cell lymphoma and may be classified as cryptic enteropathy-associated T-cell lymphoma.

Distinction between coeliac disease and refractory sprue: a simple immunohistochemical method

AIMS

We recently showed that refractory sprue is distinct from coeliac disease, the former being characterized by abnormal intraepithelial T-lymphocytes expressing a cytoplasmic CD3 chain (CD3c), lacking CD3 and CD8 surface expression, and showing TCRgamma gene rearrangements. To take advantage of the abnormal phenotype of CD3c + CD8 - intraepithelial lymphocytes (IEL) in refractory sprue we developed a simple method to distinguish coeliac disease from refractory sprue.

METHODS AND RESULTS

Comparative immunohistochemical studies using anti-CD3 and anti-CD8 antibodies were applied on paraffin-embedded and frozen biopsy specimens in refractory sprue (n = 6), coeliac disease (n = 10), healthy controls (n = 5) and suspected refractory sprue (n = 6). Comparable results were obtained on fixed and frozen biopsy specimens. In four of the six patients with suspected refractory sprue, abnormal CD3c + CD8 - IEL and TCRgamma gene rearrangements were found, as in refractory sprue; the remaining two patients had normal (CD3 + CD8 +) IEL and no TCRgamma gene rearrangements. Both patients had coeliac disease, as one failed to comply with a gluten-free diet, while the other was a slow responder.

CONCLUSION

This simplified immunostaining method using anti-CD3 and anti-CD8 antibodies on paraffin sections can distinguish active coeliac disease from refractory sprue and should prove useful in clinical practice.

Selective expansion of intraepithelial lymphocytes expressing the HLA-E-specific natural killer receptor CD94 in celiac disease

BACKGROUND & AIMS

Celiac disease is a gluten-induced enteropathy characterized by the presence of gliadin-specific CD4(+) T cells in the lamina propria and by a prominent intraepithelial T-cell infiltration of unknown mechanism. The aim of this study was to characterize the subset(s) of intraepithelial lymphocytes (IELs) expanding during active celiac disease to provide insights into the mechanisms involved in their expansion.

METHODS

Flow-cytometric analysis of isolated IELs and/or immunohistochemical staining of frozen sections were performed in 51 celiac patients and 50 controls with a panel of monoclonal antibodies against T-cell and natural killer (NK) receptors. In addition, in vitro studies were performed to identify candidate stimuli for NK receptor expression.

RESULTS

In normal intestine, different proportions of IELs, which were mainly T cells, expressed the NK receptors CD94/NKG2, NKR-P1A, KIR2D/3D, NKp46, Pen5, or CD56. During the active phase of celiac disease, the frequency of CD94(+) IELs, which were mostly alphabeta T cells, was conspicuously increased over controls. In contrast, the expression of other NK markers was not modified. Furthermore, expression of CD94 could be selectively induced in vitro by T-cell receptor activation and/or interleukin 15, a cytokine produced by intestinal epithelial cells.

CONCLUSIONS

The gut epithelium favors the development of T cells that express NK receptors. In active celiac disease, there is a specific and selective increase of IELs expressing CD94, the HLA-E-specific NK receptor that may be related to T-cell receptor activation and/or interleukin 15 secretion.

[Combined transplantation of liver and small intestine in an adult. First case in France. Surgical aspects]

BACKGROUND

We report hare the first adult case of combined liver-small bowel transplantation performed in France.

CASE REPORT

A double liver + small bowel graft was transplanted in a 21-year-old patient hospitalized for 4 years for a short bowel syndrome requiring total parenteral nutrition. The patient also had severe hepatic fibrosis. The immediate post-operative period was uneventful. Two and one-half years after the double graft, the patient is on strictly oral nutrition, no longer has a stomy and lives a normal life in his home.

DISCUSSION

The advent of tacrolimus has led to long-term success of bowel grafts, developed earlier in children and now possible in adults. Combined liver-small bowel transplantation is formally indicated in patients with cirrhogenic liver disease associated with ineversible small bowel failure.

[Combined liver and small intestine transplantation in an adult. First case in France. Medical aspects: digestive and nutritional]

OBJECTIVE

We report the digestive, hepatic, intestinal and nutritional history of the first combined liver-small bowel transplantation performed in France in an adult recipient. Currently, the clinical course has been favorable at 30 months.

METHODS

In May 1997, a 21-year-old man underwent a double liver-small bowel transplantation for irreversible chronic bowel failure with severe chronic liver disease subsequent to post-surgical short-bowel syndrome. After 28 laparotomies, there were 15 cm of small bowel left for the gastric anastomosis. The patient had a terminal jejunostomy and a left colostomy, excluding a short segment of the transverse colon and the rectum. Total parenteral nutrition including lipids and been initiated in December 1992 (3500 kcal/d) and had led to severe complications. Intestinal absorption before and after the graft were studied with the balance method (input-output) and used bomb calorimetry and measurements of the steatorhhea and creatorrhea. Functional enterocyte mass was assessed from serum citrullin.

RESULTS

The postoperative period after the liver-bowel graft (220 cm small bowel with terminal ileostomy and jejunostomy) was uneventful. The immunosuppression protocol included tacrolimus, corticosteroids and azathioprin. One mild episode of acute rejection occurred at day 26 and was controlled with a corticosteroid bolus. No episode of liver rejection occurred. Moderate renal failure regressed partially after reestablishing the fluid-electrolyte balance and adapting tacrolimus dosage. Total parenteral nutrition which had sustained the patient for 4 and a half years was definitely discontinued three months after transplantation. Oral nutrition was initially associated with enteral nutrition (from day 20 to day 90) and became exclusive three months after the transplantation. Intestinal absorption coefficients measured before tranplantation, at 3 months (2200 kcal/d, ileostomy flow 1600 g/d), and at 18 months (2400 kcal/d, ileostomy flow 1300 g/d) post transplantation were, respectively, 22%, 90% and 88% for overall calorie absorption, 25%, 65% and 73% for fat absorption, and 47%, 83% and 67% for nitrogen absorption. At 18 months post-graft, there was a spectacular improvement in the patient's neurological status and his liver function was normal. Endoscopy, radiography, histology, and immunohistochemistry explorations were normal. Ileo-rectal anastomosis was re-established at 23 months post-transplantation. At 30 months the patient is living in his home and on 100% oral nutrition.

CONCLUSION

Clinical, nutritional and functional outcome at 30 months in this first French case of liver-small bowel transplantation in an adult recipient has been excellent.

Long-term survival and parenteral nutrition dependence in adult patients with the short bowel syndrome

BACKGROUND & AIMS

The short bowel syndrome (SBS) may be associated with either transient or permanent intestinal failure, presently treated by parenteral nutrition (PN). Survival and PN-dependence probabilities, taking into account both small bowel remnant length and the type of the digestive circuit of anastomosis, are not known in adult SBS patients. The aim of this study was to assess such prognostic factors.

METHODS

A total of 124 consecutive adults with nonmalignant SBS were enrolled from 1980 to 1992 at 2 home PN centers. They were analyzed for survival and PN-dependence probabilities using the Cox model and for PN dependence using linear discriminant analysis. Data were updated in April 1996.

RESULTS

Survival and PN-dependence probabilities were 86% and 49% and 75% and 45% at 2 and 5 years, respectively. In multivariate analysis, survival was related negatively to end-enterostomy, to small bowel length of <50 cm, and to arterial infarction as a cause of SBS, but not to PN dependence. The latter was related negatively to postduodenal small bowel lengths of <50 and 50-99 cm and to absence of terminal ileum and/or colon in continuity. Cutoff values of small bowel lengths separating transient and permanent intestinal failure were 100, 65, and 30 cm in end-enterostomy, jejunocolic, and jejunoileocolic type of anastomosis, respectively.

CONCLUSIONS

In adult SBS patients, small bowel length of <100 cm is highly predictive of permanent intestinal failure. Presence of terminal ileum and/or colon in continuity enhances both weaning off PN and survival probabilities. After 2 years of PN, probability of permanent intestinal failure is 94%. These rates may lead to selection of other treatments, especially intestinal transplantation, instead of PN, for permanent intestinal failure caused by SBS.

The clinicopathological features of extensive small intestinal CD4 T cell infiltration

METHODS

Four patients with clinicopathological features suggesting a new distinct entity defining extensive small intestinal CD4 T cell infiltration were observed.

RESULTS

All four patients presented with chronic diarrhoea, malabsorption, and weight loss. Biopsy specimens of the small intestine disclosed extensive and diffuse infiltration of the lamina propria by pleomorphic small T lymphocytes, which were positive for CD3, CD4, CD5, and the beta chain of T cell receptor in all three cases studied and negative for CD103 in all three cases studied. It is notable that, in all invaded areas, the infiltrating cells showed no histological change throughout the whole evolution. In three patients, lymphocyte proliferation was monoclonal and there was extraintestinal involvement. In one patient, lymphoproliferation was oligoclonal and confined to the small intestine. In all four patients, there was no evidence of coeliac disease. Although none of the four patients responded to single or multiple drug chemotherapy, median survival was five years.

CONCLUSION

Extensive small intestinal CD4 T cell infiltration is a rare entity, distinct from coeliac disease and associated with prolonged survival.

A novel phenotype related to partial loss of function mutations of the follicle stimulating hormone receptor

A single natural loss of function mutation of the follicle stimulating hormone receptor (FSHR) has been described to date. Present in the Finnish population it markedly impairs receptor function, blocking follicle development at the primary stage and presenting as primary amenorrhea with atrophic ovaries. When Western European women with this phenotype were examined for FSHR mutations the result was negative, suggesting that other etiologies corresponding to this clinical pattern are markedly more frequent. We now describe a novel phenotype related to mutations provoking a partial loss of function of the FSHR. A woman with secondary amenorrhea had very high plasma gonadotropin concentrations (especially FSH), contrasting with normal sized ovaries and antral follicles up to 5 mm at ultrasonography. Histological and immunohistochemical examination of the ovaries showed normal follicular development up to the small antral stage and a disruption at further stages. The patient was found to carry compound heterozygotic mutations of the FSHR gene: Ile160Thr and Arg573Cys substitutions located, respectively, in the extracellular domain and in the third intracellular loop of the receptor. The mutated receptors, when expressed in COS-7 cells, showed partial functional impairment, consistent with the clinical and histological observations: the first mutation impaired cell surface expression and the second altered signal transduction of the receptor. This observation suggests that a limited FSH effect is sufficient to promote follicular growth up to the small antral stage. Further development necessitates strong FSH stimulation. The contrast between very high FSH levels and normal sized ovaries with antral follicles may thus be characteristic of such patients.

Nonhepatosplenic gammadelta T-cell lymphoma: a subset of cytotoxic lymphomas with mucosal or skin localization

Human gammadelta T lymphocytes represent a minor subset of T cells in the peripheral blood, which exhibit a limited diversity and a tissue-restricted repertoire in contrast to their broad specificity. Most postthymic neoplasms that arise from this T-cell subpopulation belong to the hepatosplenic gammadelta lymphoma entity. Only a few cases of nonhepatosplenic gammadelta lymphomas have been described in detail previously. This study presents the clinicopathologic features of 11 consecutive cases of nonhepatosplenic gammadelta lymphoma. All were characterized by mucosal or skin initial involvement: nasal cavity (n = 3), gastrointestinal tract (n = 3), skin (n = 3), lung (n = 1), larynx (n = 1). Most patients presented with B symptoms (eight of 11), without peripheral lymphadenopathy and bone marrow involvement. A past history of chronic antigen exposure was noted in six cases, and four patients had features of immune deficiency. On histology, they were classified as pleomorphic tumors. Features of epitheliotropism and angiocentrism was observed in most cases. Tumor cells had a CD2+, CD3+, T-cell receptor (TCR)delta-1+), betaF1- phenotype. They were CD5- (9 of 10) and CD4-/CD8- (9 of 10) or CD8+ (1 of 10). A clonal gamma-chain gene rearrangement was detected in all tested cases (9/9). All cases had an activated cytotoxic T-cell intracellular antigen-1 (TIA-1)+, Granzyme B+ phenotype. Epstein-Barr virus (EBV) sequences were detected in six cases by in situ hybridization (ISH). Despite an aggressive clinical course, complete remission was obtained in three patients, and one of the latter required a peripheral blood stem-cell transplantation. Nonhepatosplenic gammadelta peripheral T-cell lymphoma can be regarded as a model of activated cytotoxic lymphoma, occurring in mucosae or skin. These appear to be derived from the subpopulation of tissue-restricted gammadelta lymphocytes, which are involved in the host epithelial surface surveillance. The role of chronic antigen exposure in the pathogenesis of these rare lymphomas can be suggested, in view of the past history observed in at least some patients.

[Association of a low-grade MALT lymphoma and a slightly differentiated adenocarcinoma of the stomach]

The development of synchronous gastric adenocarcinoma and primary gastric lymphoma is rare. We report a case of low grade B-cell lymphoma of mucosa associated lymphoid tissue intermingled with a gastric adenocarcinoma and without Helicobacter pylori infection. This observation leads to discuss the pathogenesis of these tumors and the role of Helicobacter pylori infection in the development of gastric lymphoma and carcinoma.

Segmental reversal of the small bowel as an alternative to intestinal transplantation in patients with short bowel syndrome

OBJECTIVE

This article reports the results of segmental reversal of the small bowel on parenteral nutrition dependency in patients with very short bowel syndrome.

SUMMARY BACKGROUND DATA

Segmental reversal of the small bowel could be seen as an acceptable alternative to intestinal transplantation in patients with very short bowel syndrome deemed to be dependent on home parenteral nutrition.

METHODS

Eight patients with short bowel syndrome underwent, at the time of intestinal continuity restoration, a segmental reversal of the distal (n = 7) or proximal (n = 1) small bowel. The median length of the remnant small bowel was 40 cm (range, 25 to 70 cm), including a median length of reversed segment of 12 cm (range, 8 to 15 cm). Five patients presented with jejunotransverse anastomosis, and one each with jejunorectal, jejuno left colonic, or jejunocaecal anastomosis with left colostomy.

RESULTS

There were no postoperative deaths. Three patients were reoperated early for wound dehiscence, acute cholecystitis, and sepsis of unknown origin. Three patients experienced transient intestinal obstruction, which was treated conservatively. Median follow-up was 35 months (range, 2 to 108 months). One patient died of pulmonary embolism 7 months postoperatively. By the end of follow-up, three patients were on 100% oral nutrition, one had fluid and electrolyte infusions only, and, in the four other patients, parenteral nutrition regimen was reduced to four (range of 3 to 5) cyclic nocturnal infusions per week. Parenteral nutrition cessation was obtained in 3 of 5 patients at 1 years and in 3 of 3 patients at 4 years.

CONCLUSION

Segmental reversal of the small bowel could be proposed as an alternative to intestinal transplantation in patients with short bowel syndrome before the possible occurrence of parenteral nutrition-related complications, because weaning for parenteral nutrition (four patients) or reduction of the frequency of infusions (four patients) was observed in the current study.

Long-term follow-up of patients with Crohn's disease treated with azathioprine or 6-mercaptopurine

BACKGROUND

Crohn's ulcerative gastrointestinal disease is presently managed through a variety of medical interventions, including-according to severity of illness-anti-inflammatory, immunosuppressive, and corticosteroid agents; and with remedial surgery to correct anatomical abnormalities caused by disease processes. The immunosuppressant azathioprine (or its metabolite, 6-mercaptopurine) is considered an efficient maintenance therapy for Crohn's, but there is always concern about bone-marrow suppression, liver damage, and other adverse effects. For how long persons with this disease should be given these drugs has not been determined.

METHODS

Patients who were treated with azathioprine or 6-mercaptopurine for more than 6 months, and who were in prolonged clinical remission (> 6 months without steroids) were followed. The time-to-relapse was analysed in those on treatment, in those who stopped treatment for reasons other than a relapse, and in the whole sample, taking into account that they could be treated with the drugs or not, as a function of time. The influence of concomitant variables on time-to-relapse rate was examined using the Cox proportional hazard model.

FINDINGS

In the 157 patients who continued to take the therapy, cumulative probabilities of relapse at 1 and 5 years were 11% and 32% respectively. Female gender, younger age, and a time for achieving remission more than 6 months were associated with a higher risk of relapse. In 42 patients who stopped therapy, probabilities of relapse at 1 and 5 years were 38% and 75%, respectively. Male gender, younger age and duration of remission less than 4 years were associated with a higher risk of relapse. After 4 years of remission on these drugs, the risk of relapse appeared to be similar, whether the therapy was maintained or stopped.

INTERPRETATION

Taking into account the potential risks of long-term immunosuppressive therapy, the usefulness of maintaining azathioprine or 6-mercaptopurine in patients who have been in remission for more than 4 years is questionable.

[Anti-endomysium and anti-reticulin antibodies in adults with celiac disease followed-up in the Paris area]

OBJECTIVES

Circulating IgA class anti-endomysium and anti-reticulin antibodies are reliable serological markers for the diagnosis of coeliac disease. The aim of this study was to evaluate their diagnostic sensitivity and specificity, and their prevalence in a group of coeliac adults taking a gluten-free diet followed in Ile-de-France.

METHODS

One hundred and forty-five sera from 134 patients were examined for IgA and IgG anti-endomysium and anti-reticulin antibodies by indirect immunofluorescence. Sixty-eight patients were confirmed coeliacs; 8 patients with noncoeliac (unresponsive to a gluten-free diet) duodenal villous atrophy and 58 patients with no villous atrophy served as controls.

RESULTS

In active coeliac disease, the sensitivity of anti-endomysium and anti-reticulin antibodies was 88% and 50%, respectively. Their specificity was 100%: they were never detected in case of noncoeliac villous atrophy. Under a strict gluten-free diet, their prevalence was 7% and 0%, respectively.

CONCLUSION

In the studied population, the diagnosis accuracy of IgA anti-endomysium antibodies confirms their usefulness in screening and follow-up of coeliac disease. The absence of anti-endomysium and anti-reticulin antibodies in those cases with noncoeliac villous atrophy suggests that in the latter, different immunopathologic mechanisms, as compared with coeliac disease, are concerned.

Techniques for the provision of parenteral nutrition

Parenteral nutrition should be provided by a regularly trained nutrition team. The objectives of nutritional support should be decided by considering both the prognosis of the disease to be treated and the risk-to-benefit ratio of parenteral nutrition. Only when other nutritional therapy has failed should the costly and complicated protocol of parenteral nutrition be implemented. Although patients' consent to artificial nutrition is usually implicit, the goals and modalities of parenteral nutrition should be explicit. This approach avoids misunderstanding and may allow patients to participate in their own care, thus decreasing the likelihood of complications, especially those of a technical type, and possibly increasing the quality and efficacy of parenteral nutrition.

Serotonin, catecholamines, and spontaneous midgut carcinoid flush: plasma studies from flushing and nonflushing sites

BACKGROUND/AIMS

Serotonin is the diagnostic hallmark of midgut carcinoids, but the pathophysiology of spontaneous flushing is unknown. The aim of this study was to assess to what extent serotonin and catecholamine blood levels are related in time with spontaneous midgut carcinoid flush.

METHODS

Using specific radioenzymatic assays, we measured prospectively before, during, and after spontaneous flushing platelet-poor plasma and whole blood serotonin and plasma catecholamines and their metabolites in 10 patients with primary midgut carcinoids. Blood was drawn simultaneously from a forearm vein and an external jugular vein draining the flushing area.

RESULTS

During flushing, plasma serotonin and norepinephrine levels increased (P < 0.001) over preflush levels at both sampling sites. Intraflush serotonin and norepinephrine were twice as high (P < 0.01) in external jugular (9.57 +/- 1.40 ng/mL and 857 +/- 33 pg/mL, respectively) than in antecubital plasma (4.59 +/- 0.73 ng/mL and 471 +/- 26 pg/mL). Preflush and postflush levels were similar at both venous sites.

CONCLUSIONS

Vein plasma serotonin and norepinephrine levels do increase during midgut carcinoid flush, especially in the flushing area. This may reflect a local release secondary to flush but also suggests a role for these bioamines in the pathogenesis of flushing.

Cyclic parenteral nutrition in hospitalized adult patients: a 9-year experience

We are reporting our 9-year experience of cyclic parenteral nutrition with 200 in-patients (mean age 52 years) treated 64 +/- (SEM)3 days (range: 15-230) for Gl diseases. During the first period (A, n = 38), all-in-one nutritive bags with intralipid 10% were used; in a second period (B, n = 135), intralipid 10% was infused separately over the first 6 h of nutrition; in the final period (C, n = 27), Intralipid 20% was used in all-in-one nutritive bags. Indications for parenteral nutrition were non-malignant digestive diseases in 89.5% of the cases. The frequency of complications appearing during cyclic parenteral nutrition was the following: catheter-related sepsis 8%, catheter obstruction 8%, hypertriglyceridemia 33%, hypercholesterolemia 14.7%, liver function test abnormalities 28% and biliary sludge and/or lithiasis 31.6%. 5 patients, with chronic obstructive small bowel disease, developed jaundice with no identifiable cause other than parenteral nutrition. The prevalence of catheter obstruction significantly decreased (P < 0.01) during period B, as compared with periods A and C. The prevalence of liver function test abnormalities decreased significantly (P < 0.01) during periods B and C, as compared with period A. Mortality rate related to cyclic parenteral nutrition was 3%. These results suggest that a) the separate infusion of lipid emulsion reduces the prevalence of catheter obstruction; b) as compared with 10% intralipid in all-in-one nutritive bags, the separate infusion of 10% Intralipid or the 20% Intralipid given in all-in-one nutritive bags is associated with a decreased prevalence of liver function test abnormalities; c) chronic small intestine obstruction seems to play a key role in parenteral-associated jaundice.