Influence of colectomy on hydrogen excretion in breath

INTRODUCTION

Hydrogen breath test is the most commonly used method to analyze carbohydrate absorption and diagnose carbohydrate malabsorption. The result of the H(2) breath test is influenced by different factors, which are mostly related to quantitative or qualitative aspects of colonic flora. A scarcely studied variable is the effect of colonic anatomical integrity on H(2) excretion in breath.

PURPOSE

The present study aims to determine whether loss of colonic integrity reduces H(2) excretion capacity after an oral load of an unabsorbable carbohydrate.

METHODS

An observational study was conducted in three patient groups: controls with preserved colon, patients with partial colectomy, and patients with complete colectomy and ileostomy. H(2) concentration in breath was measured by gas chromatography every 10 min for 3 h after oral lactulose administration.

RESULTS

Twenty-two patients with partial colectomy, 18 controls with preserved colon, and seven patients with ileostomy were included. H(2) excretion after lactulose did not differ between patients with partial colectomy and controls (basal excretion = 8.5 vs 4 ppm; delta increase = 50.0 vs 47.5 ppm; area under the curve = 4,480.0 vs 4,710.5 ppm/min). In contrast, H(2) excretion was significantly lower in the ileostomy group.

CONCLUSIONS

Partial colectomy does not influence the capacity for H(2) excretion after oral unabsorbable carbohydrate administration.

Selective inhibition of phosphodiesterase-4 ameliorates chronic colitis and prevents intestinal fibrosis

The phosphodiesterase-4 (PDE4) inhibitors may be an important target in the treatment of several inflammatory conditions. The anti-inflammatory effect of PDE4 inhibitors bears similarities with that of steroids, without interfering with the hypophysary-adrenal-axis. We compared the effect of rolipram, a selective PDE4 inhibitor, with steroids on the clinical course of experimental colitis induced by 2,4,6-trinitrobenzenesulfonic acid (TNBS). Three groups of rats (n = 20) received TNBS. One group received methylprednisolone from day 7, another group received rolipram from the same day, and control group received no further treatment. On days 14 and 21 after TNBS instillation, sets of 10 rats underwent colonic dialysis to measure eicosanoid release. Colonic lesions were blindly scored, and colons were homogenized for quantification of myeloperoxidase (MPO) activity and collagen content. Concentration of tumor necrosis factor alpha (TNF-alpha) and transforming growth factor beta1 (TGF-beta1) in colonic tissue was also measured. Both treatments reduced significantly the eicosanoid release and MPO activity. On day 14, both rolipram and methylprednisolone significantly reduced TNF-alpha content, but TGF-beta1 was only inhibited by rolipram. On day 21, lesion scores and collagen content were significantly reduced only in rolipram-treated group. In conclusion, PDE4 inhibition by rolipram markedly ameliorates the course of chronic colitis and it is superior to methylprednisolone in preventing late collagen deposition.

Response of first attack of inflammatory bowel disease requiring hospital admission to steroid therapy

INTRODUCTION

Corticoid administration is the usual treatment of Crohńs disease (CD) and ulcerative colitis (UC) attacks. However, information available on response rates and their predictive factors is scarce.

OBJECTIVE

To establish response to steroidal treatment in an homogeneous group of patients with CD or UC during their first admission to hospital.

METHODS

Restrospective analysis of 86 patients who received systemic steroidal treatment for a severe flare-up during their first hospital admission between 1995 and 2000. Patients were treated per protocol with fluid therapy, absolute diet, IV 6-methyl-prednisolone 1 mg/kg/day, and enoxaparin at prophylactic doses. Clinical response at 30 days was considered good in case of complete remission, and poor in case of partial or absent remission. Univariate and multivariate analyses according to non-parametric statistics were performed for sociodemographic and biologic variables.

RESULTS

45 patients with CD and 41 with UC were included. Good response rates were 64.4% for CD and 60.9% for UC. The univariate analysis showed that patients with good response have shorter evolution times and fewer previous flare-ups (p < 0.05) regarding CD. However, the multivariate analysis showed that none of the analyzed variables had predictive value.

CONCLUSION

The response rate of severe inflammatory bowel disease attacks to corticoids is around 60% in CD and UC. Data resulting from the current study cannot predict which patients will ultimately respond to therapy.

[Lipid control in secondary prevention: multicenter observational study in primary care]

OBJECTIVE

To assess the implementation of pharmacological and non-pharmacological treatment in coronary patients followed in primary care.

DESIGN

Observational prospective study of 6 months of follow-up.

SETTING

Primary care centers all over Spain.

PARTICIPANTS

Men and women, between 18 and 75 years old, diagnosed in the last 3 years of myocardial infarction, stable angina, and unstable angina, with cholesterol levels higher than the lipid therapeutical goal recommended by the Guía de Prevención Cardiovascular del Programa de Actividades y de Promoción de la Salud de la Sociedad Española de Medicina de Familia y Comunitaria. Patients were recruited between february of 1998 and july of 1999, and were followed for 6 months.

OUTCOME MEASUREMENTS

Total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, weight, height, body mass index, systolic and diastolic blood pressure (SBP and DBP).

RESULTS

4464 patients were included, mean age of 59 years (range, 20-96), 60% men. At 6 months, 66% of the patients had a cholesterol level higher than 200 mg/dL, 55% had LDL-C higher than 130 mg/dL, and 11% had triglycerides higher than 190 mg/dL. At 6 months a reduction of 70 mg/dL of total cholesterol, of 52 mg/dL of triglycerides, and of 51 mg/dL of LDL-C, and an increase of 4 mg/dL of HDL-Cholesterol was observed. Also, SBP and DBP were reduced 5 mm Hg and 3 mm Hg.

CONCLUSIONS

Although a clear improved was observed in the control of lipids and other risk factors, there is still a considerable potential to raise standards in secondary prevention of coronary patients followed in primary care concerning control of cardiovascular risk factors, particularly total cholesterol and lipid fractions.

[Congenital absence of the inferior vena cava as a risk factor for pulmonar thromboembolism]

The absence of the inferior vena cava is a rare congenital anomaly. Currently its diagnosis is based on non-invasive imaging techniques (computerised axial tomagraphy and nuclear magnetic resonance). In most cases, it constitutes a casual finding upon practising these image tests unrelated to this congenital anomaly. In the symptomatic patients, the complaints associated are secondary to venous insufficiency and/or deep vein thrombosis. Recently the congenital absence of inferior vena cava has been described as a risk factor of deep vein thrombosis in young patients. We present a case of congenital absence of inferior vena cava that was admitted in our hospital because of pulmonary thromboembolism.

Role of microecology in chronic inflammatory bowel diseases

Inflammatory bowel diseases (IBD) are chronic conditions of unknown etiology. Current therapy mitigates the severity of acute bouts of mucosal inflammation but an eradication therapy is lacking. Growing incidence of IBD is associated with social development. Epidemiology suggests a relationship between the establishment of the individual gut flora and the risk of developing IBD. Patients show an impaired tolerance towards commensal bacteria of the resident flora. Unrestrained activation of the intestinal immune system against some commensal bacteria appears to be responsible for the characteristic relapsing course of these diseases. Wide-spectrum antibiotic therapy reduces bacterial load and mitigates intestinal inflammation in human IBD and in animal models. Current research aims at the identification of probiotics for bacterial antagonism therapies. Probiotics are living microorganisms which upon ingestion in certain numbers exert health benefits beyond inherent basic nutrition. Colonization with a Lactobacillus reuteri strain can prevent the development of colitis in genetically susceptible mice. Other studies have used a bacterium genetically engineered to secrete the antiinflammatory cytokine IL-10 and demonstrated a therapeutic effect in animal models of colitis. Moreover, some probiotics may naturally exhibit antiinflammatory properties when interacting with the human gut mucosa. Prebiotics such as inulin have also been shown to prevent colonic inflammation in animal models. Preliminary clinical trials with probiotics in IBD are encouraging. Probiotics offer a valuable tool for the prevention and control of inflammatory bowel diseases.

[Recurrent episodes of acidosis with encephalopathy in a hemodialysis program patient with short bowel syndrome]

We present a case of a patient with short bowel syndrome in a hemodialysis program, with recurrent episodes of serious acidosis. The presence of a D-lactic acidosis peak secondary to bacterial overgrowth in the intestine was discovered during an acute episode of acidosis, with neurological affection. The detection of acidosis in predialysis measurements and the acute episodes of acidosis, made it necessary to administer bicarbonate to the patient and give him additional hemodialysis sessions.

Therapeutic effect of phenantroline in two rat models of inflammatory bowel disease

BACKGROUND

Phenantroline is a zinc-chelator that inhibits biological activities of matrix metalloproteinases (MMPs). Over-expression of MMPs can accelerate tissue destruction and disrupt subsequent tissue repair. The effects of phenantroline in two rat models of inflammatory bowel disease (IBD) are evaluated: transmural colitis induced by trinitrobenzensulphonic acid (TNBS) and distal colitis caused by dextran sulphate sodium (DSS).

METHODS

Transmural colitis was induced by TNBS in two groups of 15 rats each, and distal colitis was induced by DSS in two other groups of 15 rats each. Phenantroline was administered by oral gavage at 20 mg kg(-1) day(-1) to the test groups, whereas matched control groups received oral vehicle. On the last day of dosing, rats were subjected to intracolonic dialysis under anaesthesia for assessment of luminal eicosanoid release (PGE2, TXB2 and LTB4) and euthanized. Colons were removed and lesions were blindly scored according to macroscopic and histological scales. Myeloperoxidase (MPO) activity was measured in homogenates of colonic tissue.

RESULTS

In the TNBS model, phenantroline treatment significantly reduced colonic strictures; in the DSS model, phenantroline significantly decreased scores of epithelial injury. In both models, the levels of PGE2, TXB2 and LTB4 and tissue MPO were not significantly altered.

CONCLUSIONS

Although phenantroline did not modify the activity of inflammatory mediators, this compound substantially reduced intestinal injury associated with tissue remodelling.

Pancreatitis and haemobilia due to arterioportal fistula after percutaneous liver biopsy resolved by selective arterial embolization

Haemobilia and arterioportal fistula are uncommon complications secondary to percutaneous liver biopsy. We report the case of a patient who developed haemobilia and subsequently acute pancreatitis as a result of a liver biopsy. Selective hepatic angiogram showed an arterioportal fistula. Transcatheter arterial embolization successfully occluded the fistula. The patient remained asymptomatic 4 months later. We review the published literature concerning acute pancreatitis associated with haemobilia and draw conclusions for management of similar cases in the future.

Influence of inflammatory bowel disease on different dimensions of quality of life

OBJECTIVE

To establish the impairment of different dimensions of quality of life in inflammatory bowel disease (IBD).

DESIGN

Prospective observational study.

PARTICIPANTS

289 patients [160 with ulcerative colitis (UC) and 129 with Crohn's disease (CD)].

MEASURES

Health-related quality of life was assessed by means of the Inflammatory Bowel Disease Questionnaire (IBDQ) and the Psychological General Well Being Index (PGWBI).

RESULTS

In active IBD, all dimensions of the quality of life scored significantly lower than in inactive IBD, indicating a poor quality of life. Social impairment was the least impaired dimension of the IBDQ in active UC and CD, compared with digestive and systemic symptoms. In inactive IBD, the systemic symptoms domain received the lowest score (P < 0.01). In a subgroup of 22 patients studied before and after remission, emotional function was the most impaired dimension after achieving remission. The Psychological General Well Being Index was significantly impaired in active UC [78.5 (range 64-89)] and CD [76.5 (range 69-97)] relative inactive IBD [104 (range 93-111)] vs 106 (95-113), respectively; P < 0.05].

CONCLUSIONS

Quality of life is impaired in IBD. During relapse, clinicians should pay attention to digestive symptoms and psychological distress. In remission, they should be sensitive to systemic symptoms.

Dietary inulin improves distal colitis induced by dextran sodium sulfate in the rat

OBJECTIVES

Inulin stimulates intracolonic generation of butyrate and growth of lactic acid bacteria. This study investigated whether inulin protects against colitis.

METHODS

Rats with dextran sodium sulfate colitis received inulin either orally (1% in drinking water, or 400 mg/day) or by enema. Matched groups received vehicle. In addition, fecal water obtained from inulin-fed rats was administered by enema to rats with colitis and compared with fecal water from control rats. Finally, rats with colitis received daily enemas of either butyrate (at 40 or 80 mmol/L) or vehicle. Inflammation was assessed by eicosanoid asssay in rectal dialysates and MPO activity in colonic tissue. Mucosal lesions were blindly scored by microscopic examination. Luminal pH was measured from cecum to rectum by a surface microelectrode.

RESULTS

Oral inulin prevented inflammation, as evidenced by lower lesion scores (p < 0.05), decreased release of mediators (p < 0.05), and lower tissue MPO (p < 0.05) as compared with controls. Inulin induced acidic environment (pH <7.0) from cecum to left colon and increased counts of lactobacilli. Fecal water from inulin-fed rats also reduced scores (p < 0.05) and inflammation (p < 0.05). However, inulin or butyrate enemas had no effect.

CONCLUSIONS

Oral inulin reduces the severity of dextran sodium sulfate colitis. The effect seems to be mediated by modification of the intracolonic milieu.

Validation of the spanish version of the inflammatory bowel disease questionnaire on ulcerative colitis and Crohn's disease

The objective of this study is to validate the Spanish translation of the Inflammatory Bowel Disease Questionnaire (SIBDQ) on ulcerative colitis and Crohn's disease by assessing its convergence validity, discriminatory power, reliability and sensitivity to change. For that purpose, 211 patients with inflammatory bowel disease (116 with ulcerative colitis and 95 with Crohn's disease) completed the SIBDQ, the Psychological General Well-Being Index and the EuroQol. SIBDQ was repeated in those patients who remained in stable remission and in those with changes in clinical activity. Clinical activity was assessed by the Rachmilewitz and Harvey-Bradshaw indices. Correlations among scores of SIBDQ, EuroQol, Psychological General Well-Being Index and clinical indices of activity were all positive and comparable for both diseases (r = -0. 50 to r = -0.70, p < 0.01). Analysis of variance showed that SIBDQ discriminates between different clinical degrees of activity. Cronbach's alpha was 0.96 in ulcerative colitis and Crohn's disease. SIBDQ was also highly reliable when it was repeated in clinically stable patients with ulcerative colitis (intraclass correlation coefficient = 0.82) and Crohn's disease (intraclass correlation coefficient = 0.86). SIBDQ was sensitive to clinical changes in ulcerative colitis and in Crohn's disease, whether patients entered remission (effect size -1.88 and -1.81, respectively) or relapsed (effect size 1.70 and 8.04, respectively). In conclusion, the Spanish version of the IBDQ has proven to be a valid, reliable and sensitive instrument to detect clinical changes in patients with ulcerative colitis and Crohn's disease.

Does cyclosporin A worsen liver function in patients with inflammatory bowel disease and total parenteral nutrition?

OBJECTIVE

inflammatory bowel disease (IBD), total parenteral nutrition (TPN) and immunosuppressive treatment with cyclosporin A (CsA) are well known factors in hepatobiliary disorders. Their association, however, has been little studied.

METHOD

we retrospectively analyzed the results of liver function tests (transaminases, AST. ALT), total bilirubin, alkaline phosphatase, and gamma-glutamyltransferase (GGT) in a consecutive series of 50 patients (29 men, 21 women, mean age 32 years, range 16-78 years) hospitalized for a severe attack of IBD between January 1992 and July 1997. Basal laboratory values in all patients were normal. Thirty-eight patients had ulcerative colitis (UC) and 12 had Crohn's disease (CD), which debuted in 28% of the patients. All patients were treated with methylprednisolone (MP) (0.75-1.0 mg/kg daily i.v., and received TPN. 42% (21/50) required additional treatment with CsA (5 mg/kg daily i.v.) at the beginning or during the first week of TPN and during 7-24 days, because on nonresponse to steroid treatment. Two study groups were defined according to treatment: Group I consisted of 29 patients given MP + TPN, and group II comprised 21 patients who received MP + TPN + CsA. The groups were otherwise similar in all other variables analyzed. Liver function tests were done weekly until the end of the study period.

RESULTS

62% of the patients (31/50) showed hepatobiliary dysfunction, defined previously as a 2-fold or greater elevation of two or more parameters. There was no statistically significant difference between the two groups in the incidence of dysfunction (15/29 vs 16/21, n.s.). The parameters that showed the greatest alterations were GGT and ALT; the greatest elevation appeared during the third week of immunosuppressive treatment, and did not exceed 6-fold the normal value. The alterations disappeared once TPN and immunosuppressive treatment were discontinued.

CONCLUSIONS

the hepatobiliary dysfunction in patients treated with both TPN and CsA was no more severe than associated with TPN alone.

Impact of surgery for Crohn's disease on health-related quality of life

OBJECTIVE

When patients with Crohn's disease (CD) express concerns about their disease, they emphasize worries about surgery. However, most studies about the impact of surgery in CD on health-related quality of life (HRQOL) have compared postsurgical changes on HRQOL relative to HRQOL before surgery, not taking into account the influence of CD activity on HRQOL. Our aim was to assess whether surgical treatment of CD modifies HRQOL, compared with inactive CD, active CD, or healthy controls.

METHODS

Outcomes of 29 CD patients in remission with a previous bowel resection were compared with those from 42 clinically active CD patients and 48 patients with medically induced remission. A reference control group of 63 healthy individuals was also studied. HRQOL was measured by the Inflammatory Bowel Disease Questionnaire (IBDQ), the Psychological General Well Being Index (PGWBI), and the EuroQol.

RESULTS

Active CD patients scored the lowest on the IBDQ. Both operated and nonoperated inactive CD patients had lower HRQOL scores than controls in overall IBDQ and in all five domains. However, neither global score, digestive, systemic, emotional, social, or functional dimensions differed significantly between operated and nonoperated inactive CD patients. PGWBI and the visual analog scale of the EuroQol were also similar in both groups of inactive CD patients (103 [range, 94-107] vs. 103 [97-106] and 90 [73-87] vs. 82 [76-84]), but significantly higher than in active CD.

CONCLUSIONS

HRQOL is impaired in active CD, and improves during remission irrespective of whether it had been achieved medically or surgically. Our results suggest that to improve HRQOL it is more important to achieve remission than the approach, drugs or surgery, chosen.

Antitumor necrosis factor therapy in rat chronic granulomatous colitis: critical dose-timing effects on outcome

Inhibition of tumor necrosis fact (TNFalpha) is of potential benefit in the treatment of chronic inflammatory conditions. However, TNFalpha plays an important role in host defenses against infection, and blocking TNFalpha production may also have adverse effects. We tested the efficacy and safety of anti-TNFalpha therapy in experimental colitis induced by trinitrobenzenesulfonic acid. We cultured colonic wall specimens for bacterial growth and measured native TNFalpha protein synthesis in colonic tissue at days 0, 1, 4, 10 and 18 after induction of colitis. Anti-TNFalpha therapy (monoclonal g1 immunoglobulin, 15 mg/kg i.p., every third day) was started on either day 4 or day 10 after induction of colitis. On day 18, we measured the release of inflammatory mediators and scored colonic lesions. In acute lesions, several species of the common flora were grown, including Streptococcus, Staphylococcus, Bacteroides, clostridia and enterobacteria. In chronic lesions, only enterobacteria, clostridia and lactobacilli were isolated. TNFalpha production by inflamed colonic tissue was increased in both acute and chronic lesions. Anti-TNFalpha therapy induced a significant decrease in the release of inflammatory mediators and histopathological remission when treatment started on day 10. However, anti-TNFalpha therapy increased eicosanoid release and lesion scores when treatment started on day 4. In conclusion, acute colonic lesions showed polymicrobial infection. Anti-TNFalpha therapy induced remission of chronic intestinal inflammation, but early treatment did not prove effective.

Association between strong inflammatory response and low risk of developing visual loss and other cranial ischemic complications in giant cell (temporal) arteritis

OBJECTIVE

To identify clinical and biochemical parameters that have good predictive value for identifying giant cell (temporal) arteritis (GCA) patients who are at high or low risk of developing cranial ischemic events.

METHODS

In this multicenter study, records of patients at 3 university hospitals in Barcelona were reviewed retrospectively. Two hundred consecutive patients with biopsy-proven GCA were studied.

RESULTS

Thirty-two patients developed irreversible cranial ischemic complications. The duration of clinical symptoms before diagnosis was similar in patients with and those without ischemic events. Patients with ischemic complications less frequently had fever (18.8% versus 56.9%) and weight loss (21.9% versus 62%) and more frequently had amaurosis fugax (32.3% versus 6%) and transient diplopia (15.6% versus 3.6%). Patients with ischemic events had lower erythrocyte sedimentation rates (ESR) (82.7 mm/hour versus 104.4 mm/hour) and higher concentrations of hemoglobin (12.2 gm/dl versus 10.9 gm/dl) and albumin (37.4 gm/liter versus 32.7 gm/liter). Clinical inflammatory status and biologic inflammatory status were defined empirically (clinical: fever and weight loss; biologic: ESR > or =85 mm/hour and hemoglobin < 11.0 gm/dl). Patients not showing a clinical and biologic inflammatory response were at high risk of developing ischemic events (odds ratio [OR] 5, 95% confidence interval [95% CI] 2.05-12.2). The risk was greatly reduced among patients with either a clinical (OR 0.177, 95% CI 0.052-0.605) or a biologic (OR 0.226, 95% CI 0.076-0.675) inflammatory reaction. No patient with both a clinical and a biologic response developed ischemic events.

CONCLUSION

The presence of a strong acute-phase response defines a subgroup of patients at very low risk of developing cranial ischemic complications. Our findings provide a rationale for testing less aggressive treatment schedules in these individuals. Conversely, a low inflammatory response and the presence of transient cranial ischemic events provide a high risk of developing irreversible ischemic complications and require a prompt therapeutic intervention.

Incrimination of anaerobic bacteria in the induction of experimental colitis

Commensal bacteria may participate in the pathogenesis of bowel inflammation. We studied the role of bacteria from the rat colonic flora on transmural inflammation induced by 2,4,6-trinitrobenzenesulfonic acid (TNBS). First, bacterial translocation to the colonic wall after induction of colitis was assessed by microbiological and histological methods. Second, rats with a colonic segment excluded from fecal transit were prepared for recolonization with preselected bacteria and used to test the effects of different species on inflammation (eicosanoid release, tissue myeloperoxidase) and damage (histology). Six strains (three aerobes and three anaerobes) were identified in colonic tissue 24 h after induction of colitis. Acridine staining showed bacteria in necrotic areas of the mucosa and invading the submucosa. Rats with excluded colon and sterile culture of luminal washings showed mild inflammation and low mucosal damage in response to TNBS. Rats colonized with anaerobes showed significantly higher eicosanoid release than rats colonized with aerobes only. Moreover, submucosal-lesions were mostly observed in rats with anaerobes. Our findings suggest that colonic anaerobes play a key role in transmural inflammation.

Von Willebrand factor in the outcome of temporal arteritis

OBJECTIVE

To determine fluctuation in circulating von Willebrand factor (vWF) in the outcome of patients with temporal arteritis.

METHODS

Plasma vWF antigen concentrations were measured in 65 patients with biopsy proven temporal arteritis at different disease activity stages, in 12 with isolated polymyalgia rheumatica, and in 16 controls. Fourteen temporal arteritis patients underwent serial determinations during the course of their disease.

RESULTS

vWF concentrations were significantly raised in temporal arteritis (mean 220 [arbitrary units], range 96 to 720) and in polymyalgia rheumatica (mean 196, range 103 to 266) compared with healthy controls (mean 98, range 75 to 137) (P < 0.05). Although vWF values tended to be higher in temporal arteritis, no significant differences were found between temporal arteritis and polymyalgia rheumatica patients nor between temporal arteritis patients with ischaemic complications (mean 269, range 130 to 720) and those who presented with polymyalgia rheumatica or constitutional symptoms only (mean 179, range 140 to 220). The highest levels were obtained in patients with associated, mainly infectious, diseases (mean 631, range 240 to 1680). Raised vWF values found in active temporal arteritis patients (mean 220, range 96 to 720) persisted within the first two years after the beginning of treatment (mean 244, range 102 to 510) but tended to normalise in patients in long term remission (mean 143, range 50 to 260).

CONCLUSIONS

Persistent elevation of vWF during early remission of temporal arteritis might represent an endothelial activation status induced by a remaining inflammatory microenvironment rather than a marker of endothelial cell injury. In long term remission, decreasing vWF concentrations might reflect progression of inflammatory lesions to a healing stage.

Toxic dilatation of colon in a rat model of colitis is linked to an inducible form of nitric oxide synthase

The contribution of nitric oxide (NO) to the altered colonic contractility of acute colitis was investigated in the 2,4,6-trinitroben-zenesulfonic acid model. NO synthase was measured in colonic tissue; the effects of NO synthase inhibition on colonic contractility were studied in vitro and in vivo. Inducible NO synthase was not detected in normal colons, whereas inflamed colons showed high activity. Acute inflammation was associated with enlarged colonic perimeter. NO synthase inhibitors or selective inhibitors of the inducible enzyme prevented colonic dilatation. In vitro, contractile responses to KCl were lower in muscle from colitic than control rats. After NO synthase inhibition, however, no difference was observed between colitic and control muscle contractility. In vivo, intracolonic pressure was lower in colitic than in control rats. Selective inhibition of inducible NO synthase increased intracolonic pressure in colitic but not in control rats. In conclusion, NO generation by inducible enzymes impairs smooth muscle contractility in colitis and may be involved in the pathogenesis of toxic dilatation of the colon.

Bacterial peptides enhance inflammatory activity in a rat model of colitis

Bacterial products released within the gut lumen may alter the course of inflammatory bowel lesions. The effect of intraluminal N-formyl methionyl-leucyl-phenylalanine on mucosal release of inflammatory mediators was investigated in normal and colitis rats (at 1 and 7 days after induction of colitis by trinitrobenzenesulfonic acid). Under anesthesia, the distal colon was perfused using an isosmotic solution with or without synthetic N-formyl methionyl-leucyl-phenylalanine (100 nmol/ml). Effluents were assayed for eicosanoid (PGE2, TXB2 and LTB4) concentration. Myeloperoxidase activity was measured in colonic wall homogenates. In normal rats, peptide perfusion did not change mucosal release of PGE2, TXB2 and LTB4. Colitic rats showed high baseline release of eicosanoids. The peptide did not further increase PGE2 and TXB2 release, but significantly stimulated LTB4 both on days 1 and 7 after induction of colitis. Rats with high myeloperoxidase activity in the colonic wall showed a marked LTB4 response to the peptide. Finally, peptide perfusion increased tissue myeloperoxidase activity in colitis at day 7 but not in colitis at day 1 or in normal rats. In conclusion, bacterial products may activate inflammation. This mechanism of lumen-wall interaction might be involved in the perpetuation of inflammatory lesions of the colonic mucosa.

Eosinophilic gastroenteritis presenting as ascites and splenomegaly

A 25-year-old man with a 1 year history of episodic abdominal pain presented with splenomegaly, eosinophilic ascites and peripheral eosinophilia. Full-thickness biopsies from his gastrointestinal tract revealed intense eosinophilic infiltration involving both muscular and serosal layers and extending from his stomach to his ileum. When given oral steroids, the patient's condition improved and he was discharged without symptoms. Eighteen months later, he remains asymptomatic and without recurrence of ascites or splenomegaly. This report adds to the scarce data on extraintestinal involvement in eosinophilic gastroenteritis. Special attention is drawn to the differential diagnosis of eosinophilic ascites and to the optimal approach to its management.

Efficacy of intravenous cyclosporine for steroid refractory attacks of ulcerative colitis

The use of cyclosporine in refractory ulcerative colitis (UC) is still controversial. An 8-year-long retrospective review open-label treatment with intravenous cyclosporine in 21 patients with steroid-refractory UC is therefore in order. Intravenous cyclosporine, 5 mg/kg-1 day, was added to ongoing drug therapy. Those who responded were switched to oral cyclosporine for a mean 8.4-month period, and steroids were discontinued when possible. Sixteen out of 21 patients improved (76%). Mean latency time to onset of improvement was 9 days. Five did not improve: three underwent urgent surgery, one was switched to methotrexate, and the remainder died. While on oral cyclosporine, 10 out of 16 maintained remission and seven could discontinue steroids, five relapsed, and one went on continuous mild activity. One patient died of a Pneumocystis carinii pneumonia, while in remission. Five reversible episodes of hepatobiliary toxicity were recorded. Intravenous cyclosporine effectively and rapidly induces improvement of acute steroid-refractory flare-ups of UC and helps to prevent urgent surgery. However, major adverse events may limit its usefulness.

Induction of chronic cholangitis in the rat by trinitrobenzenesulfonic acid

We investigated the effects of the hapten trinitrobenzenesulfonic acid instilled into the rat biliary tree. The study included three groups of animals that received a single intracholedochal injection of either saline, 10% ethanol or 10 mg trinitrobenzenesulfonic acid dissolved in 10% ethanol. A fourth group of rats was subjected to common bile duct ligation and was used as control for biliary obstruction. Liver and biliary tract dysfunction was assessed 1, 10, 20 and 30 days after treatment by serum aspartate aminotransferase, alkaline phosphatase and bilirubin, and by histopathological examination of liver slices. By day 10, saline- or ethanol-treated rats did not show changes in the biochemical parameters, and light microscopy revealed no alterations. In contrast, rats treated with trinitrobenzenesulfonic acid showed significant increases in all serum markers throughout the study period. Inflammatory cell infiltrates were seen in portal areas and around bile ducts, indicating pericholangitis. Some rats presented with dilatation of extrahepatic biliary ducts; ductal proliferation and thin porto-portal fibrotic septa were observed in these cases. Bile duct ligation also induced ductal proliferation and fibrosis in all cases, but pericholangitis was not prominent. Retrograde cholangiograms in trinitrobenzenesulfonic acid rats showed distortion of the intra- and extrahepatic biliary tree. In conclusion, chronic cholangitis may be consistently induced in rats by a single intracholedochal administration of trinitrobenzenesulfonic acid.

Role of intestinal microflora in chronic inflammation and ulceration of the rat colon

Bacteria and their products stimulate inflammatory responses. The effects of different antimicrobial regimens (amoxicillin/clavulanic acid, tobramycin, imipenem, vancomycin, metronidazole) were investigated on the course of experimental colitis induced by trinitrobenzenesulphonic acid (TNB) in the rat. On day 7 and 21 after the induction of colitis, matched groups of control and antibiotic treated rats were subjected to colonic dialysis to measure eicosanoid release, and killed for morphological assessment of the colonic lesions (macro and microscopic scores). Stool samples were cultured. Selective antibiotic treatment against Gram positive, Gram negative or anaerobic bacteria had no effect on colonic lesion scores. By contrast, certain broad spectrum antibiotics (amoxicillin/clavulanic acid or the association of imipenem plus vancomycin) significantly reduced macro and microscopic scores. Rats receiving these antibiotics did not develop chronic colitis as shown by the virtual absence of colonic strictures, adhesions, fibrosis, and granulomas. On day 21 after TNB, the intracolonic release of prostaglandin E2, thromboxane B2, and leukotriene B4 was significantly higher in control than in antibiotic treated rats. Control stool cultures showed abundant colony forming units of both aerobic and anaerobic bacteria. Amoxicillin/clavulanic acid and imipenem plus vancomycin induced appreciable reductions in luminal bacteria. In conclusion, certain broad spectrum antibiotics prevent chronic colitis. The normal colonic flora seems to play an important pathogenetic part in the progression of inflammatory colonic lesions to chronicity.

[The percutaneous dissolution treatment of gallstones. Our initial experience]

OBJECTIVE

To describe our initial experience in direct contact dissolution of cholesterol gallstones with methyl-tert-butyl ether, a non surgical approach for high risk patients.

PATIENTS

Twenty symptomatic patients were preselected. They all had radiolucent stones in functioning gallbladders. Patients rejected elective surgery or were considered to be of high risk for anesthesia. Computerized tomography scan was performed to evaluate stone calcium content and liver-gallbladder anatomy. In selected patients, contact stone dissolution was carried out after transhepatic gallbladder catheterization.

RESULTS

Ten patients were excluded due to poor gallbladder contact to the liver (two patients) or stone density greater than 70 Hounsfield Units. Percutaneous transhepatic positioning of the catheter into the gallbladder was achieved in seven patients. Stone dissolution was complete in five patients and partial in one. Mean perfusion time was 6.15 hours (3.45-7.5); however, mean hospitalization stay was 7 days (4-10) mainly due to inexperienced management coordination. While on treatment, all patients experienced nausea, burning or abdominal discomfort that were easily controlled. Complications were related to catheter placement (intraperitoneal biliary leakage, external fistula) and in five patients to the dissolution procedure (severe abdominal pain, biliary colic, cholecystopancreatitis). Complications were all handled with non surgical treatment.

CONCLUSIONS

Percutaneous gallstone dissolution with methyl-tert-butyl ether is a rapid and efficacious procedure that can, nevertheless, induce relevant secondary effects and complications.

Dietary fish oil reduces progression of chronic inflammatory lesions in a rat model of granulomatous colitis

Eicosanoids are modulators of defensive and inflammatory processes in the gut mucosa, and may be involved in the pathogenesis of chronic inflammatory lesions of the bowel. As omega-3 fatty acids compete with the omega-6 as precursors of eicosanoid synthesis, we compared the effects of dietary supplementation with either sunflower (source of omega-6) or cod liver (source of omega-3) oil on the development of chronic granulomatous lesions in the rat colon. After four weeks on the supplemented diets, plasma omega-6 fatty acid content was significantly higher in the sunflower group, while omega-3 fatty acids predominated in the cod liver group. Inflammatory colitis was then induced by intracolonic administration of trinitrobenzene sulphonic acid. Luminal eicosanoid release, as measured by radioimmunoassay of intracolonic dialysis fluid, increased significantly after the challenge in both groups. Generation of prostaglandin E2 (PGE2) and leucotriene B4 (LTB4) peaked by day 3 and thereafter declined; thromboxane B2 (TXB2), instead, continued to increase from day 3 to 20 in sunflower fed rats, whereas this change was blunted in cod liver animals. The rats were killed 20, 30, or 50 days after the induction of colitis, and the colonic lesions were scored macroscopically (adhesions to surrounding tissues, strictures, ulcerations, and wall thickness) and histologically (ulceration, inflammation, depth of the lesions, and fibrosis). In cod liver animals, the damage score was markedly reduced by day 30, and inflammation and ulceration were almost absent by day 50. In conclusion, a fish oil diet prevents the increase in thromboxane in the chronic state of inflammation and shortens the course of the colonic disease by diminishing both the severity of the lesions and their progression to chronicity.

Participation of thromboxane and other eicosanoid synthesis in the course of experimental inflammatory colitis

Eicosanoids, as modulators of inflammation, may be involved in the pathogenesis of inflammatory bowel disease. We investigated their potential role in a rat model of chronic granulomatous colonic inflammation induced by trinitrobenzene sulphonic acid. Luminal eicosanoid release was quantified in vivo using a dialysis bag placed into the distal colon. We tested the effect of drugs known to modify inflammatory activity or arachidonic acid metabolism. Three days after intracolonic injection of trinitrobenzene sulphonic acid at different dose levels, the dialysates showed a highly significant increase of prostaglandin E2, 6-keto-prostaglandin F1 alpha, thromboxane B2 (TXB2), and leukotriene B4, compared with levels in controls not subjected to the toxic agent. Remarkably, the release of TXB2 continued to increase during the stage of chronic inflammation (up to day 21), whereas the levels of the remainder eicosanoids declined. Treatment with prednisone or 5-aminosalicylic acid reduced TXB2 levels in the chronic stage of the inflammatory disease and improved the morphological damage as assessed macroscopically and histologically. Moreover, two selective thromboxane synthetase inhibitors, OKY 1581 and R70416, significantly reduced the development of chronic inflammatory lesions in the colon while inhibiting the release of TXB2. Our results indicate that (1) luminal release of thromboxane increases in the chronic stage of colonic inflammation, (2) anti-inflammatory treatment reduces tissue damage and thromboxane release, and (3) selective thromboxane synthetase inhibition improves the course of the disease in our experimental model.

[Value of the serum measurement of alpha-L-fucosidase in the diagnosis of hepatocarcinoma]

The serum catalytic concentration of alpha-L-fucosidase (AFU) was measured to evaluate its usefulness for the diagnosis of hepatocarcinoma (HPC). Fifty-one patients with hepatocarcinoma, 30 with hepatic metastases, 40 with hepatic cirrhosis, 22 with other hepatic diseases and 48 healthy individuals were evaluated. The values of serum AFU were significantly higher in all groups (p less than 0.001), than in the reference group; there were also significant differences between those with HPC and hepatic cirrhosis (p less than 0.01), and between HPC and other hepatic diseases (p less than 0.05). The highest effectiveness of the test was achieved with a catalytic concentration of serum AFU of 210 nKat/l, with a 37% sensitivity and a 91% specificity. When the AFU measurement was used concomitantly with that of alpha-fetoprotein (AFP) for the diagnosis of HPC, sensitivity increased to 72% when AFI or AFP were elevated, and specificity reached 99% when both were increased. We think that the measurement of serum AFU may be helpful for the diagnosis of hepatocarcinoma.

[A study of the prevalence of alcohol consumption in the Baix Ebre region (Tarragona)]

A cross-sectional study was carried out in the Baix Ebre region about the prevalence of alcohol use, within a wider study of hypertension and other risk factors. The following characteristics were considered for the elaboration of the present study: non drinker, moderate drinker and heavy drinker, as well as the amount of alcohol intake related with demographic, socioeconomical and cultural variables such as: age, sex, urban or rural medium, marital status, place of origin, working status, social and professional level, and educational status. 64.2% of the whole population greater than or equal to 20 years were usual alcohol users, and so were 79.4% of males and 48.2% of females. According to the definition of heavy or excessive drinker, such were 21.8% of males and 2.6% of females. Males drank a higher alcohol amount, with a mean and standard deviation of 47.1 +/- 35.5. In females, these figures were 19.4 +/- 12.4 g per day. The rate of alcohol drinkers was higher in young individuals, in those with active working status, in those with medium social and professional level, and in those with medium and high educational status.

Immunohistochemical analysis of lymphoid and macrophage cell subsets and their immunologic activation markers in temporal arteritis. Influence of corticosteroid treatment

To determine the phenotype of infiltrating mononuclear cells in patients with temporal arteritis (TA), we performed immunohistochemical studies on temporal artery biopsy specimens from 24 patients with biopsy-proven TA. Interdigitating reticulum cells (IRC) were observed in 41% of the patients; disease duration was significantly shorter in these patients than in patients lacking IRC (mean 1.5 months versus 3.8 months). Infiltrating cells consisted predominantly of HLA-DR-expressing macrophages and T lymphocytes, especially of the CD4 subset. There were few B cells and no K cells. No relationship between cellular distribution and disease duration or treatment was found. Interleukin-2 receptor expression was observed in 87.5% of biopsy specimens obtained prior to or within the first 4 days of treatment with prednisone, but in only 14% of specimens obtained later. The presence of IRC in patients with TA suggests an autoimmune reaction directed against an antigenic substance that resides in the arterial wall and is presented and processed in situ. DR-expressing macrophages activated by CD4+ T lymphocytes may contribute to arterial damage in TA. Corticosteroids do not modify cellular distribution but induce important functional changes, as demonstrated by the disappearance of interleukin-2 receptor expression in patients treated for more than 4 days.

[Hypertrophic osteopathy and acropachy associated with noncirrhotic alcoholic liver disease. Apropos a case]

Hypertrophic osteoarthropathy (HOA) may be an idiopathic condition or may be secondary to other diseases, the most common of which is bronchogenic carcinoma. Among non neoplastic etiologies, it is commonly associated with chronic liver disease, usually cirrhosis and chronic active hepatitis. The concomitant occurrence of HOA and hepatic steatosis is another association that has recently been reported. We report here a 70-year-old male with periostitis, clubbing of the fingers and alcoholic hepatitis stenosis. We emphasize the need to perform observational studies to validate this association.

[Arterial hypertension in the Baix Ebre region (Tarragona)]

The results of a cross-sectional study for the evaluation of the prevalence of hypertension in the Baix Ebre region (Tarragona) are reported. 628 individuals from a randomly selected sample of 670 gave their consent to participate. The study was based on interview and examination at the patients home after getting an appointment by post. The prevalence of hypertension was 31.84 +/- 3.64%, and that of borderline hypertension 16.56 +/- 2.97%. Only 57% of hypertensives were previously known as such, and only 18.5% of these were being correctly treated. There was a significant association of hypertension with age (basically systolic blood pressure for women); also with alcohol intake, obesity and family history of hypertension or cardiovascular disease. There was no significant correlation with sex, residence in rural or urban areas, emigration, marital status, occupational status, social and professional level, education, or with the coexistence of hypertension in the spouse. The high prevalence of hypertension was a remarkable finding, consistent with its recognized importance as a first rate health problem.

Polymyalgia rheumatica: a syndrome associated with HLA-DR4 antigen

HLA class II antigens were determined in 65 patients with biopsy-proven giant cell arteritis (GCA). An increase in DR4 antigen frequency was found in the patients (40%) compared with that in 200 healthy controls (20%) (Pcorr less than 0.05). DR4 was significantly more frequent in GCA patients with polymyalgia rheumatica (PMR) than in those without PMR (58.8% versus 19.3%) (P less than 0.005). HLA-DR4 frequency in GCA patients without PMR was similar to that in the control population (20%). Patients with severe, disabling PMR had DR4 more frequently (90%) than did those with moderate symptoms who required medical care because of cranial arteritis manifestations (41.6%) (P less than 0.05). We conclude that, in GCA patients, association with DR4 is mainly related to the manifestation of the disease as PMR. We discuss clinical and immunogenetic similarities between PMR and other DR4-associated rheumatic disorders. Common immunopathogenic mechanisms leading to clinical overlap among them are suggested.

Computed tomography in reversible ischaemic attacks: clinical and prognostic correlations in a prospective study

Two hundred and nineteen patients admitted with reversible atherothrombotic ischaemic attacks were prospectively evaluated by computed tomography. Of these patients, 122 were diagnosed as suffering from transient ischaemic attacks, 58 from reversible ischaemic neurological deficits and 39 from reversible ischaemic neurological deficits with incomplete resolution. In 133 cases the ischaemic event affected the carotid system, in 63 the vertebrobasilar system and in 23 cases the system could not be determined. Brain infarctions were observed in 64 patients (29.2%), cerebral atrophy in 96 (44.4%) and dilatation of a ventricle in 17 (7.8%). The frequency of brain infarction was related to the duration of the neurological deficit, being 20.5% in those with transient ischaemic attacks, 37.9% in those with reversible ischaemic neurological deficits and 43.6% in patients with reversible ischaemic neurological deficits with incomplete resolution (P = 0.005). Ischaemic lesions were closely correlated with abnormalities on supra-aortic trunk angiography or Doppler ultrasonography. During an average follow-up period of 21 months, a higher percentage of recurrence was found in those patients with CT infarctions, but the difference was not significant.

Low-dose acetylsalicylic acid (ASA) plus dipyridamole versus dipyridamole alone in the prevention of stroke in patients with reversible ischemic attacks

A total of 243 patients who had reversible ischemic attacks (RIA) were submitted to clinical trial to determine whether dipyridamole (400 mg/day) (D) or aspirin (100 mg/48 hours) + dipyridamole (300 mg/day) (ASA + D) would produce significant reduction in the subsequent occurrence of RIA and completed stroke. One hundred and fifteen were selected for Group ASA + D and 71 were treated with dipyridamole only. The treatment groups were similar in relation to age, sex, risk factors, duration and presumed vascular territory of RIA, incidence of alterations of arterial supra-aortic trunks, cerebral infarct (CT scan), and platelet function. Patients were followed for a mean time of 21 months. At the end of the study, 21.7% of the ASA + D group and 19.7% in the D group had suffered new episodes of RIA or completed stroke (p = 0.88). Frequency of stroke (reversible ischemic neurologic deficit or completed stroke) was 7.8% in the ASA + D patients and 9.8% in the D patients (p = 0.83). Subgroup analysis did not show significant differences either. It is concluded that ASA + D has no significantly greater beneficial effect than that observed with D alone in the secondary prevention of atherothrombotic cerebral ischemia. However, a statistical Type II error cannot be excluded by the reduced number of recurrences.

Clinical usefulness of temporal artery biopsy

To assess the diagnostic usefulness of temporal artery biopsy in temporal arteritis (TA) and establish clinical features capable of predicting its positivity we have retrospectively studied the biopsy specimens and the clinical features of 103 patients who had undergone temporal artery biopsy. Temporal artery biopsy reached a positive predictive value of 90.2% with respect to the final diagnosis based on the criteria proposed by Ellis and Ralston and the clinical course. The simultaneous presence of recent onset headache, jaw claudication, and abnormalities of the temporal arteries on physical examination had a specificity of 94.8% with respect to the histological diagnosis and of 100% with respect to final diagnosis. The presence of any of these clinical features, though of little specificity (34.4%), had a sensitivity of 100% with respect to histological diagnosis, selecting a group of patients in whom temporal artery biopsy has more discriminative value.