Results of a national survey on quality of life in inflammatory bowel diseases

AIMS

Inflammatory bowel diseases (IBD) have a negative impact on patients' quality of life. The aims of this survey were to learn more about patients' concerns, and to compare their feelings with the beliefs of their close relations and physicians.

PATIENTS AND METHODS

A specific questionnaire, including the RFIPC and the MFI-20, was used. Patients' answers were compared with those given by their close relations and attending physicians.

RESULTS

This national survey included 2424 French patients. At the time of diagnosis, 73% of patients expressed having fears, but were also relieved to understand their symptoms. IBD was responsible for fatigue and weariness, and had a negative impact on daily, occupational, leisure, family and personal life. The main fears concerned unpredictable flare-ups followed by need for an ostomy bag and risk of surgery. The answers provided by close relations and physicians matched those of the patients, but physicians overestimated the patient's knowledge and underestimated disease impact.

CONCLUSION

IBD has a deleterious effect on quality of life. Close relations of the patient realize the impact the disease has on the patients' life, but attending physicians still tend to minimize patients' symptoms.

Incidence of benign upper respiratory tract infections, HSV and HPV cutaneous infections in inflammatory bowel disease patients treated with azathioprine

BACKGROUND

There are few data on the incidence of benign infections (upper respiratory tract infections, herpes lesions and viral warts) during exposure to azathioprine.

AIMS

To determine the incidence of benign infections in IBD out-patients receiving azathioprine (AZA+) and to look at the influence of leucocyte counts in the onset of these events.

METHODS

A total of 230 patients were included in a prospective cohort and observed during 207 patient-years. Episodes of benign infections were collected and incidences of benign infections were compared between the AZA+ group and patients without AZA (AZA-).

RESULTS

The incidence of upper respiratory tract infections in the cohort was 2.1 +/- 2.2 per observation-year. There was no difference between the AZA+ (n = 169) and AZA- (n = 61) groups (2.2 +/- 2.3 vs. 2.1 +/- 2.1, P = 0.77). The incidence of herpes flares was significantly increased in the AZA+ group compared to the AZA- group (1.0 +/- 2.6 vs. 0.2 +/- 0.8 per year, P = 0.04). Similarly, there were significantly more patients with appearance or worsening viral warts in the AZA+ group (17.2% (AZA+) vs. 3.3% (AZA-), P = 0.004).

CONCLUSION

This study suggests that the incidence of herpes flares and the appearance or worsening of viral warts are increased in IBD patients receiving AZA.

Simultaneous occurrence of clinical manifestations of myeloma and Waldenström's macroglobulinemia with monoclonal IgG Lambda and IgM Kappa in a single patient

This paper reports a rare case of a patient with biclonal gammopathy IGM kappa and IgG lambda corresponding to the simultaneous occurrence of the clinical manifestations of Waldenström's macroglobulinemia and multiple myeloma. Two cellular populations derived from the B lymphocyte cell line can be observed in this patient. Bone marrow aspiration revealed abnormal plasma cells with inclusions and lymph node aspiration showed immature lymphoid cells containing mu heavy chains.

A dose escalating, placebo controlled, double blind, single dose and multidose, safety and tolerability study of fontolizumab, a humanised anti-interferon gamma antibody, in patients with moderate to severe Crohn's disease

INTRODUCTION

This study was designed to evaluate the safety of fontolizumab, a humanised anti-interferon gamma antibody, in patients with moderate to severe Crohn's disease (CD).

PATIENTS AND METHODS

Forty five patients with a CD activity index (CDAI) of 250-450 were randomised in a double blind, placebo controlled, dose escalating fashion to receive single doses of fontolizumab (0.1, 1.0, and 4.0 mg/kg) or placebo. By day 29, patients with clinical response were re-randomised to receive three additional doses of one half their initial fontolizumab dose or placebo at four weekly intervals. Primary objectives were safety and tolerability. Secondary outcomes included assessments of immunogenicity, clinical activity, and potential pharmacodynamic surrogates.

RESULTS

Treatment was generally well tolerated. There were slightly more reports of chills, flu-like syndrome, asthenia, nausea, and vomiting in the 1.0 mg and 4.0 mg/kg fontolizumab cohorts. Two serious adverse events rated as worsening of CD occurred under fontolizumab. Antibodies to fontolizumab were confirmed in one patient. No differences in clinical activity parameters were noted between any of the active treatment groups and placebo, with the placebo group having a particularly favourable outcome (60% response and 40% remission). By day 29, a more enhanced decrease in median Crohn's disease endoscopic index of severity (p = 0.02) and serum C reactive protein (p<0.001) was observed in the 4.0 mg/kg (n = 14) fontolizumab cohort compared with placebo (n = 10). Pharmacodynamic effects were observed by immunohistochemistry.

CONCLUSIONS

Fontolizumab was well tolerated with minimal immunogenicity at doses of up to 4.0 mg/kg in patients with CD. A biological activity of fontolizumab is suggested.

Tomographie par émission de positons et fusion d'images de simulation virtuelle par tomodensitométrie. Impact sur la planification de la radiothérapie conformationnelle des cancers de l'œsophage

PURPOSE

To study the impact of fused (18)F-fluoro-deoxy-D-glucose (FDG)-hybrid positron emission tomography (PET) and computed tomography (CT) images on conformal radiation therapy (CRT) planning for patients with esophageal carcinoma.

PATIENTS AND METHODS

Thirty-four patients with esophageal carcinoma were referred for concomitant radiotherapy and chemotherapy with radical intent. Each patient underwent CT and FDG-hybrid PET for simulation treatment in the same radiation treatment position. PET-images were coregistered using five fiducial markers. Target delineation was initially performed on CT images and the corresponding PET data were subsequently used as an overlay to CT data to define the target volume.

RESULTS

FDG-PET identified previously undetected distant metastatic disease in 2 patients, making them ineligible for curative CRT. The Gross Tumor Volume (GTV) was decreased by CT and FDG image fusion in 12 patients (35%) and was increased in 7 patients (20.5%). The GTV reduction was >or=25% in 4 patients due to reduction of the length of the esophageal tumor. The GTV increase was >or=25% with FDG-PET in 2 patients due to the detection of occult mediastinal lymph node involvement in one patient and an increased length of the esophageal tumor in the other patient. Modifications of the GTV affected the planning treatment volume (PTV) in 18 patients. Modifications of delineation of GTV and displacement of the isocenter of PTV by FDG-PET also affected the percentage of total lung volume receiving more than 20 Gy (VL20) in 25 patients (74%), with a dose reduction in 12 patients and a dose increase in 13 patients.

CONCLUSION

In our study, CT and FDG-PET image fusion appeared to have an impact on treatment planning and management of patients with esophageal carcinoma related to modifications of GTV. The impact on treatment outcome remains to be demonstrated.

Impact of pregnancy on the clinical activity of Crohn's disease

BACKGROUND

The impact of pregnancy on Crohn's disease activity has been poorly investigated.

AIM

To determine the effect of pregnancy on Crohn's disease activity from the retrospective analysis of a cohort of women who had a regular clinical follow-up.

METHODS

Seventy pregnancies occurring in 61 women were studied. The Harvey-Bradshaw index was determined during the four quarters preceding each pregnancy, the three quarters of pregnancy and the four quarters following delivery.

RESULTS

The mean Harvey-Bradshaw index during pregnancy [0.68 (0.18), mean (S.E.M.)] was significantly lower than that of the year preceding pregnancy [0.98 (0.16), P = 0.03] and that of the year following delivery [1.10 (0.17), P = 0.04]. In non-smoking women (48 pregnancies), there was no significant change of Harvey-Bradshaw index between these intervals. Whereas in those who smoked (22 pregnancies), most of whom reduced tobacco consumption during pregnancy, the mean Harvey-Bradshaw index during pregnancy was significantly reduced compared with that of the year following delivery [0.58 (0.20) vs. 1.60 (0.33), P = 0.01]. The use of drugs was significantly lower during pregnancy.

CONCLUSIONS

Crohn's disease activity is mildly but significantly lower during pregnancy. The reduction of tobacco consumption during pregnancy in smoking women may play an important role in this improvement.

Impact of the increasing use of immunosuppressants in Crohn's disease on the need for intestinal surgery

BACKGROUND/AIM

Immunosuppressants are now used much earlier in the course of Crohn's disease; however their effect on the natural history of the disease, especially on the need for surgery, is not known. The aim of this study was to assess the evolution of the need for surgery in Crohn's disease during the last 25 years.

PATIENTS AND METHODS

The medical charts of 2573 patients were reviewed retrospectively. The use of immunosuppressants (azathioprine or methotrexate), the need for intestinal resection, and the occurrence of intestinal complications were assessed using Kaplan-Meier analysis in five consecutive cohorts of patients defined by the date of diagnosis of Crohn's disease (1978-82; 1983-87; 1988-92; 1993-97; 1998-2002).

RESULTS

In 565 patients seen in the authors' unit within the first three months after diagnosis, characteristics of Crohn's disease at diagnosis did not differ from one cohort to another. The five year cumulative probability to receive immunosuppressants increased from 0 in the 1978-82 cohort to 0.13, 0.25, 0.25, and 0.56 in the 1983-87, 1988-92, 1993-97, and 1998-2002 cohorts, respectively (p<0.001). Concomitantly, the cumulative risk of intestinal resection remained unchanged (from 0.35 to 0.34 at five years; p=0.81). The cumulative risk of developing a stricturing or a penetrating intestinal complication remained also unchanged. Similar results were obtained in the 2008 patients seen during the same period who were referred to us more than three months after diagnosis.

CONCLUSION

Although immunosuppressants have been used more frequently over the last 25 years, there was no significant decrease of the need for surgery, or of intestinal complications of Crohn's disease.

Reversal of abnormal collagen production in Crohn's disease intestinal biopsies treated with regenerating agents

BACKGROUND

Crohn's disease (CD) is characterised by inflammation, muscle layer overgrowth, and collagenous fibrosis of the intestinal tract, with no effective therapy against collagen accumulation.

AIMS

We quantified production of collagen in resection specimens from normal and CD patients and investigated the effect of regenerating agents (RGTAs) on collagen production. RGTAs are chemically substituted dextrans engineered to mimic the growth factor protecting effects of heparan sulphates. RGTAs have been shown to enhance tissue repair in various in vivo models and to modulate in vitro collagen phenotype differentially according to their structure.

PATIENTS

We studied intestinal biopsies from two groups of CD patients: treated with glucocorticoids (CD-GC group: 10 patients) or not treated (CD group: seven patients), and from seven control patients.

METHODS

After 24 hours of ex vivo incubation with (3H) proline, collagen I, III, and V were extracted by pepsin and quantitatively separated by sodium dodecyl sulphate-polyacrylamide gel electrophoresis. Biosynthesis of each collagen type was quantified on radiolabelled isolated collagen.

RESULTS

Total intestinal collagen production in CD patients compared with controls was increased up to 3.5-fold overall (p<0.001). In particular, collagen III biosynthesis was enhanced by 6.2-fold (p<0.001) in CD patients. In the CD-GC group, collagen production abnormalities were less marked. RGTAs added to the incubation medium in the CD group decreased total collagen production by 50% and decreased collagen III synthesis by 76%.

CONCLUSION

This finding offers a rationale for using RGTAs in the treatment of intestinal fibrosis in CD, thus opening up a potential new therapeutic field for this family of drugs.

Effects of appendicectomy on the course of ulcerative colitis

BACKGROUND

Appendicectomy reduces the risk of having ulcerative colitis. However, its effect on the natural history of ulcerative colitis remains uncertain.

AIM

To determine whether appendicectomy reduces the overall severity of ulcerative colitis.

PATIENTS AND METHODS

Appendicectomy status and smoking habits were specified by direct interview in 638 patients seen consecutively between 1997 and 2000. Severity of ulcerative colitis was assessed by reviewing therapeutic needs from the onset of colitis. Additionally, the annual incidence of flare up was assessed prospectively between 1997 and 2000 in patients who had not been colectomised.

RESULTS

The 10 year risk of colectomy was 16 (7)% in previously appendicectomised patients (n=49) compared with 33 (2)% in non-appendicectomised patients (n=589, p=0.05). Cox regression showed that previous appendicectomy and current smoking were independent factors protecting against colectomy (adjusted hazard ratio and 95% confidence intervals: 0.40 (0.20-0.78) and 0.60 (0.40-0.95), respectively). The respective proportions of appendicectomised and non-appendicectomised patients who required oral steroids and immunosuppressive therapy were not significantly different (67% v 70% and 27% v 19%, respectively). Between 1997 and 2000, ulcerative colitis was active for 48% of the time in appendicectomised patients (47 of 98 patient years) and for 62% of the time in non-appendicectomised patients (631 of 1024 patient years; p<0.01).

CONCLUSION

Previous appendicectomy is associated with a less severe course of ulcerative colitis. The beneficial effect of appendicectomy on the risk of colectomy is additive to that of current smoking.

Osteoporosis in inflammatory bowel disease: effect of calcium and vitamin D with or without fluoride

BACKGROUND

Previous data have indicated low bone formation as a mechanism of osteoporosis in inflammatory bowel disease. Fluoride can stimulate bone formation.

AIM

To assess the effect of fluoride supplementation on lumbar spine bone mineral density in osteoporotic patients with inflammatory bowel disease treated in parallel with calcium and vitamin D.

METHODS

In this prospective, randomized, double-blind, parallel and placebo-controlled study, 94 patients with inflammatory bowel disease (lumbar spine T score below - 2 standard deviations, normal serum 25OH vitamin D), with a median age of 35 years, were included. Bone mineral density was measured by dual-energy X-ray absorptiometry. Patients were randomized to receive daily either sodium monofluorophosphate (150 mg, n=45) or placebo (n=49) for 1 year, and all received calcium (1 g) and vitamin D (800 IU). The relative change in bone mineral density from 0 to 12 months was tested in each group (fluoride or placebo) and compared between the groups.

RESULTS

Lumbar spine bone mineral density increased significantly in both groups after 1 year: 4.8 +/- 5.6% (n=29) and 3.2 +/- 3.8% (n=31) in the calcium-vitamin D-fluoride and calcium-vitamin D-placebo groups, respectively (P < 0.001 for each group). There was no difference between the groups (P=0.403). Similar results were observed according to corticosteroid intake or disease activity.

CONCLUSIONS

Calcium and vitamin D seem to increase lumbar spine density in osteoporotic patients with inflammatory bowel disease; fluoride does not provide further benefit.

Crohn's disease clinical course and severity in obese patients

BACKGROUND AND AIMS

Obesity is unusual in Crohn's disease and the particularities of the disease in obese patients have not been studied.

METHODS

2065 patients were studied retrospectively. Obesity was defined by a BMI value >25.0 at disease onset and >30.0 at any time during the course of the disease. Disease characteristics, therapeutic needs, and year-by-year disease activity were determined in patients with and without obesity.

RESULTS

62 patients (3%) were obese. When compared with non-obese patients, obese patients did not show differences regarding sex, intestinal disease location, and disease behavior, but at diagnosis they were older (32 vs 28 years, P = 0.01) and a larger proportion had anoperineal disease (35 vs 24%, P = 0.03). When the 62 obese patients were paired for sex, location of disease at onset, date of birth, and date of diagnosis with 124 non-obese patients, the disease severity assessed by the importance of medical therapy and excisional surgery did not differ in the two groups but time to development of anoperineal abscess or fistula was shorter in obese patients, and obese patients were more prone to develop an active disease (OR 1.50, 95% CI 1.07-2.11) and to require hospitalization (OR 2.35, 95% CI 1.56-3.52)

CONCLUSION

Obesity in Crohn's disease is associated with more frequent anoperineal complications and a more marked year-by-year disease activity, but does not alter significantly the long-term course of the disease.

[Infliximab therapy for Crohn's disease anoperineal lesions]

AIM OF THE STUDY

To retrospectively evaluate the efficacy, the duration of response, and the tolerance of Remicade in anoperineal Crohn's disease.

METHODS

Fifty patients with severe symptomatic and refractory anoperineal Crohn's lesions (38 fistulae and 29 cavitating ulcers and superficial fissures) were treated with 3 intravenous infusions of Remicade (5 mg/kg) at weeks 0, 2 and 6. Efficacy was assessed using Allan's functional score and proctologic examination at 8 weeks (W8) and 24 weeks (W24) after the first infusion.

RESULTS

At W8, a response was noted for 71% (27/38) of fistulae and 79% (23/29) of ulcers and fissures. Healing rates were 39% and 49%, respectively. Efficacy of Remicade at W8 did not vary according to sex, number and type of fistulae and other treatments. At W24, 58% (15/26) of patients with fistulae and 63% (10/16) of patients with ulcers or fissures had a response. The response rate at W24 was higher in patients having anoperineal Crohn's lesions for less than one year: 77% vs 32% (P=0.004). Median Allan's score significantly decreased from 3.9 before treatment to 1.7 at W2 (P<0.001), 1.3 at W6 and 0.8 at W8. Median duration of response was 9.5 months (range: 0.5-12.5) after last infusion and was not influenced by associated treatments including immunomodulators. The relapse rate at 1 year was 64% for the responders followed at least one year (n=21). Minor adverse events occurred during 12% of all infusions. Eight patients had an infection, including one pneumonia. Eight patients developed a perineal abscess 16 weeks (range: 4-32) after the first infusion.

CONCLUSION

Remicade is rapidly effective and well tolerated in anoperineal Crohn's lesions, but the high relapse rate stresses the need for long term therapeutic strategies in these patients.

Health-related quality of life in Crohn's disease: a prospective longitudinal study in 231 patients

OBJECTIVE

The aim of this work was to assess the quality of life (QoL) of patients with Crohn's disease (CD) prospectively over 1 yr and to determine factors of influence.

METHODS

A total of 231 CD patients were included. At month 0 (M0), M3, M6, M9, and M12, patients were given a validated QoL questionnaire (self-administered) to fill in and a clinical form referring to the period of 3 months before the visit. The QoL questionnaire was made up of the Short-Form-36 and the Rating Form of Inflammatory Bowel Disease Patients Concerns. The impact on QoL of the following factors was analyzed: age, gender, CD duration and localization, presence of extradigestive manifestations or concomitant disease, disease course, medical treatments, and surgery. We studied the correlations between QoL and disease activity assessed by both patients and investigators by a visual analog scale.

RESULTS

At M0, all the scores of the Short-Form-36 were significantly lower than those of a standard population, nevertheless improving between M0 and M12. Patients' main worries were first "having an ostomy bag" followed by "uncertain nature of the disease," "energy level." and finally "having surgery." QoL was better correlated with assessment of disease course by the patient than by the investigator. Significant factors of impairment in QoL were female gender, tobacco, active CD, involvement of the colon, hospitalization, corticoid treatment, and surgery in the past 3 months. Conversely, intake of immunosuppressors improved QoL.

CONCLUSION

Patients' QoL is impaired by CD and is underestimated by doctors. Tobacco, hospitalization, and use of corticoids have a negative impact on QoL. Conversely, the use of immunosuppressors is associated with a better QoL.

Chronic use of non-steroidal anti-inflammatory drugs does not alter colonic mucosa of patients without diarrhoea

BACKGROUND

Several types of colitis can be NSAID-induced, but whether chronic use of NSAIDs alters colonic mucosa in patients without diarrhoea is not known.

PATIENTS AND METHODS

Biopsy specimens of rectal mucosa were taken in six patients with rheumatoid arthritis without diarrhoea receiving NSAIDs (group 1, n=6). Patients with rheumatoid arthritis without diarrhoea not receiving NSAIDs (group 2, n=9), and patients undergoing surveillance colonoscopy (group 3, n=23) served as controls. In all patients from the three study groups, intraepithelial lymphocyte count and apoptotic cell count were assessed, and sub-epithelial collagen band thickness was measured. Leucocyte population of lamina propria was evaluated semi-quantitatively. HLA-DR and CD25 expression of mucosal cells was appreciated by immunohistochemistry.

RESULTS

Intraepithelial lymphocyte count was in the normal range in all three group patients, and not statistically different between groups. Apoptotic epithelial cell count was not different between groups. Sub-epithelial collagen band thickness was normal in all the patients. No patient had a marked infiltration of lamina propria by leucocytes, and HLA-DR and CD25 were normally expressed in all patients.

CONCLUSION

These results from a small sample of patients suggest that patients without diarrhoea receiving NSAIDs on a long-term basis do not develop microscopic or inflammatory colitis.

[Factors associated with hyperhomocysteinemia in Crohn's disease]

AIMS

The incidence of thromboembolic disease is increased in patients with inflammatory bowel disease. Hyperhomocysteinemia is one of the risk factors for thrombosis. The aims were: 1) to assess the prevalence of hyperhomocysteinemia in a large series of patients with Crohn's disease; 2) to search for clinical and biological factors associated with hyperhomocysteinemia.

PATIENTS AND METHODS

One hundred seventy-one patients with Crohn's disease (64 males, 107 females), median age 31 years (range: 16-82), were studied. The median duration of the disease was 7 years. The concentrations of homocysteine, folate, cobalamin and C-reactive protein were measured in serum from blood sample of each patient.

RESULTS

The mean concentration of seric homocysteine was 14.8 micromol/L (N: 4.4 - 12.4 micromol/L). Hyperhomocysteinemia was observed in 89 patients (52%). It was significantly associated with age, sex, smoking habit, serum cobalamin level and history of ileal surgical resection (P<0.05). In the group of operated patients, there was a statistically significant association between hyperhomocysteinemia and the length of small bowel resected. In multivariate analysis, sex and smoking were associated with hyperhomocysteinemia.

CONCLUSION

More than half of the patients with Crohn's disease have hyperhomocysteinemia. This result stresses the need for preventing reversible factors associated with hyperhomocysteinemia, such as smoking and cobalamin deficiency, in order to lower the thrombotic risk of patients with Crohn's disease.

Impact of cessation of smoking on the course of ulcerative colitis

OBJECTIVES

The incidence and severity of ulcerative colitis (UC) are higher in nonsmokers than in smokers. The natural course of UC in smokers who stop smoking is not known. The aim of this study was to determine the impact of cessation of smoking on the course of UC among the cohort of patients regularly seen at our institution.

METHODS

The severity of UC, as judged by the occurrence of flare-ups and the need for systemic steroids, immunosuppressive drugs and colectomy, was determined in 32 patients with UC who stopped smoking after the diagnosis of UC. We compared the period after cessation of smoking (7-yr mean follow-up) with the period between the onset of the disease and the cessation of smoking (9-yr mean duration). The course of UC in this group was compared with that of 32 nonsmokers and 32 continuing smokers matched for sex, age, and age at onset.

RESULTS

In patients who quit, cessation of smoking was followed by an increase in the rate of years with active disease (p < 0.01), years with hospitalization (p < 0.05) and years with major medical therapy (oral steroids, intravenous steroids, and azathioprine, p < 0.01). After cessation of smoking, the rate of years with immunosuppressive therapy was significantly greater in ex-smokers and nonsmokers than in continuing smokers (p < 0.01). The risk of colectomy in ex-smokers after smoking cessation was similar to that of nonsmokers and continuing smokers.

CONCLUSIONS

In smokers with UC who stop smoking, the severity of the disease increases after smoking cessation, with an increase in the disease activity and the need for hospital admission and major medical therapy. In addition, the need for azathioprine therapy becomes similar to that of nonsmokers.

Smoking cessation and the course of Crohn's disease: an intervention study

BACKGROUND AND AIMS

To evaluate the benefit of smoking cessation in individuals with Crohn's disease, we performed an intervention study in a large cohort of smokers with the disease.

METHODS

Repeated counseling to stop smoking, with easy access to a smoking cessation program, was given to 474 consecutive smokers with Crohn's disease. Patients who stopped smoking for more than 1 year (quitters) were included in a prospective follow-up study, which compared disease course and therapeutic needs with 2 control groups, continuing smokers and nonsmokers, paired for age, gender, disease location, and activity.

RESULTS

There were 59 quitters (12%). Predictors of quitting were the physician, previous intestinal surgery, high socioeconomic status, and in women, oral contraceptive use. During a median follow-up of 29 months (1-54 months), the risk of flare-up in quitters did not differ from that in nonsmokers and was less than in continuing smokers (P < 0.001). Need for steroids and for introduction or reinforcement of immunosuppressive therapy, respectively, were similar in quitters and nonsmokers and increased in continuing smokers. The risk of surgery was not significantly different in the 3 groups.

CONCLUSIONS

Patients with Crohn's disease who stop smoking for more than 1 year have a more benign disease course than if they had never smoked.

Use of anti-tumour necrosis factor agents in inflammatory bowel disease. European guidelines for 2001-2003

The introduction of novel anti-tumor necrosis factor (TNF) agents has not only led to impressive new therapeutic opportunities but also resulted in uncertainty regarding their optimal use and possible side effects. Guidelines are presented here for the use of anti-TNF agents in gastrointestinal disorders. Experts were chosen from different European countries by an algorithm to avoid bias. An expert consensus on guidelines was established using a two-stage procedure of systematic Medline and abstract search for evidence and a qualifying meeting to derive recommendations. Detailed guidelines were developed for the use and the future clinical development of anti-TNF agents in inflammatory bowel disease. Grading of available evidence and grading of recommendations were performed according to AHCPR guidelines. At present infliximab is the only registered agent for Crohn's disease. Infliximab should be always used at a dose of 5 mg/kg. The guidelines define the indications both in refractory and in fistulating disease for the readministration and before surgery. Guidelines for safety and for concomitant treatments are given. Prospects, potential clinical use, and future directions for the clinical development of other anti-TNF agents are detailed. Clinical use of anti-TNF agents will be influenced by a large number of clinical trials being concluded in 2001 and 2002. It is likely that anti-TNF therapies will become an important long-term therapy for a proportion of patients with Crohn's disease. Biological agents will be followed by smaller and more stable, orally available compounds. These guidelines will be succeeded by a formal public consensus in 2002/2003.

Hepatocellular carcinoma and focal hepatic glycogenosis after prolonged azathioprine therapy

A 22-year-old woman without predisposing liver disease developed focal hepatic glycogenosis and hepatocellular carcinoma after 6 years of azathioprine therapy for Crohn's disease. Hepatocellular carcinoma without cirrhosis has previously been described during immunosuppression, but this is the first report of disseminated focal hepatic glycogenosis after long-term azathioprine therapy.

Genotypic analysis of thiopurine S-methyltransferase in patients with Crohn's disease and severe myelosuppression during azathioprine therapy

BACKGROUND & AIMS

Myelosuppression in patients with Crohn's disease (CD) treated with azathioprine has been attributed to low activity of thiopurine S-methyltransferase (TPMT). Allelic variants of the TPMT gene responsible for changes in the enzyme activity have been characterized. We investigated the distribution of mutant alleles associated with TPMT deficiency in patients with CD and myelosuppression during azathioprine/6-mercaptopurine therapy.

METHODS

Forty-one patients with CD were included. They developed leukopenia or thrombocytopenia during azathioprine or 6-mercaptopurine treatment. Polymerase chain reaction-based methods were used to search for mutations associated with TPMT deficiency.

RESULTS

Four patients (10%) had 2 mutant alleles associated with TPMT deficiency, 7 (17%) had 1 mutant allele, and 30 (73%) had no known TPMT mutation. The delay between administration of the drug and occurrence of bone marrow toxicity was less than 1.5 months in the 4 patients with 2 mutant alleles, and ranged from 1 to 18 months in patients with 1 mutant allele and from 0.5 to 87 months in patients with normal genotype.

CONCLUSIONS

Twenty-seven percent of patients with CD and myelosuppression during azathioprine therapy had mutant alleles of the TPMT gene associated with enzyme deficiency. Myelosuppression is more often caused by other factors. Continued monitoring of blood cell counts remains mandatory in patients treated with azathioprine.

Predictive factors of outcome of intensive intravenous treatment for attacks of ulcerative colitis

BACKGROUND

Intensive intravenous treatment remains the first line therapy of severe, uncomplicated attacks of ulcerative colitis.

AIM

To predict the failure of intensive intravenous treatment by combining clinical and laboratory parameters with endoscopy findings.

METHODS

Retrospective study conducted in a tertiary care referral centre. Failure of intensive intravenous treatment was defined as colectomy before day 30, intravenous cyclosporin, or death. Predictive factors of outcome were assessed using univariate and multivariate prognostic analysis.

RESULTS

Between January 1990 and May 1997, 85 consecutive patients were treated with intensive intravenous treatment for non-response to oral corticosteroids (n=59) and/or severe attack of ulcerative colitis (n=26). There were 41 successes and 44 failures (including 1 death, 13 cyclosporin and 30 colectomies before day 30). Multivariate prognostic analysis found that the presence of Truelove and Witts' criteria (P=0.018), an attack that had lasted more than 6 weeks (P=0.001), and severe endoscopic lesions (P=0.007) were associated with an increased risk of failure. Patients with severe endoscopic lesions and Truelove and Witts' criteria, or an attack of more than 6 weeks had a failure rate of 85-86%.

CONCLUSION

Clinical, laboratory and endoscopic findings can predict the risk of failure of intensive intravenous treatment. A prospective study is required to confirm these results.

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.

Oral contraceptive use and the clinical course of Crohn's disease: a prospective cohort study

BACKGROUND

Women with Crohn's disease are usually advised not to take oral contraceptives, but, unlike smoking, there is no clear association between current oral contraceptive use and more severe disease.

AIM

To assess the effect of oral contraceptive use on the clinical course of Crohn's disease.

PATIENTS

331 women, aged 16-50 years, with Crohn's disease and Crohn's disease activity index <200, were enrolled consecutively during a one year period. Patients were classified at inclusion as oral contraceptive users or non-users and smokers or non-smokers.

METHODS

A prospective 12-18 month cohort study was used. The main outcome measures were flare up rate and time to flare up.

RESULTS

In total, 134 women used oral contraceptives, in most cases low oestrogen formulations. During the study period, 61 oral contraceptive users (46%) developed a flare up, compared with 85 non-users (43%). The hazard ratio for oral contraceptive use was 1.11 (95% confidence interval 0.80 to 1.55). Variables associated with flare up were smoking status, recently active disease, baseline Crohn's disease activity index, and presence of anoperineal lesions. The same results were obtained when the analysis was restricted to patients eligible for a relapse prevention trial.

CONCLUSION

Unlike smoking, oral contraceptives have no effect on Crohn's disease activity.

[Pregnancy outcome in inflammatory bowel diseases]

OBJECTIVE

To assess pregnancy outcome in relation to disease activity and maintenance therapy in patients with inflammatory bowel disease.

METHODS

A postal questionnaire was sent to every woman of child-bearing age followed for inflammatory bowel disease in three referral centers (Rothschild, Saint-Lazare, Saint-Louis). Response rate was 65%.

RESULTS

One hundred and forty-four pregnancies (153 fetuses) in 138 women (122 had Crohn's disease) were reported. Outcome of pregnancy was normal (baby > 2500 g, without malformation) in 115 cases (77%). There were 17 cases of preterm birth (11.5%), 3 cases of hypotrophy, and 14 pregnancy losses (9 miscarriages (6%), 4 therapeutic abortions for major malformation (2.8%)). Percentages of normal pregnancy outcome were not different between patients who continued maintenance therapy and those who stopped: respective percentages were 75 vs 73% in patients receiving mesalamine or olsalazine (n = 30), and 60 vs 75% in patients receiving azathioprine (n = 22).

CONCLUSION

In a selected series of women with inflammatory bowel disease, pregnancy outcome is approaching that observed in a normal population, except for an elevated rate of preterm births. There is no need to stop maintenance therapy with 5-aminosalicylates or azathioprine during pregnancy.

Oral Crohn disease: clinical characteristics and long-term follow-up of 9 cases

BACKGROUND

Oral localization of Crohn disease is uncommon and must be differentiated from nonspecific lesions. Its natural course and its long-term prognosis are unknown.

OBSERVATIONS

We studied 9 patients (8 male, 1 female; age range, 7-52 years; median age, 16 years) with Crohn disease and specific oral lesions, including deep linear ulcers, pseudopolyps, and/or labial or buccal swelling and induration. The prevalence of such lesions was 0.5%. The median follow-up was 11 years. Oral localization developed before (n = 2), at the same time as (n = 2), or after (n = 5) the onset of the digestive disease. Noticeable associated localizations were observed in the anoperineum (n = 8) and the esophagus (n = 3). The median duration of the oral lesions was 4 years (range, 1-13 years), without necessary parallelism with the digestive localization. Five patients had complete healing after a median delay of 2 years.

CONCLUSIONS

Oral localization of Crohn disease is characterized by a marked male predominance, a young age at onset of Crohn disease, and a very protracted course. The high prevalence of associated anal and esophageal involvement suggests that Crohn lesions have a particular trophicity for squamous cell epithelium.

Crohn's disease severity in familial and sporadic cases

BACKGROUND

Having a relative with inflammatory bowel disease increases the risk for Crohn's disease but may also increase its severity in affected patients.

AIMS

To evaluate the influence of a family history on Crohn's disease course and severity.

METHODS

1316 patients followed in the same unit were studied retrospectively. Age at onset, duration of illness, site, and extent of disease were determined in patients with and without a family history. Additionally, disease severity was estimated by the need for medical therapy (steroid and immunosuppressive requirement) and the frequency and extent of excisional surgery.

RESULTS

152 (12%) patients had a family history of inflammatory bowel disease. Duration of follow up was longer in patients with a family history and there were more operations for perforating complications in familial cases. However, the importance of medical therapy, and the incidence and extent of excisional surgery were similar in familial and and sporadic cases. Kaplan-Meier estimated time to prescription of immunosuppressive drugs and first intestinal resection were similar in familial and sporadic cases. When the 152 patients with familial Crohn's disease were paired for sex, location of disease at onset, date of birth, and date of diagnosis with 152 patients sporadic Crohn's disease, the disease severity remained similar in the two groups of paired patients.

CONCLUSION

Patients with Crohn's disease and a family history of inflammatory bowel disease do not have a more severe course.

Are complicated forms of celiac disease cryptic T-cell lymphomas?

We assessed the clonality of duodenal mucosal T cells in patients with celiac disease and controls. Fifteen adult patients were studied. Four patients had a complicated celiac disease, 3 did not respond to a gluten-free diet, and 2 had an ulcerative jejunitis (including 1 patient with nonresponsive celiac disease). Seven patients had an untreated celiac disease responsive to a gluten-free diet. Histological examination of duodenal biopsies of these 11 patients showed benign-appearing celiac disease without evidence of lymphoma. Four patients with nonulcer dyspepsia and normal duodenal biopsies served as controls. TCRgamma gene rearrangements were analyzed by multiplex polymerase chain reaction on DNA extracted from duodenal biopsies. Major clonal rearrangements of the T-cell receptor were found in 4 cases, all with complicated celiac disease. Monoclonality was confirmed by DNA sequencing of the junctional region in 3 cases and by hybridization with clone-specific oligoprobes. Patients with celiac disease responsive to gluten-free diet had mainly a polyclonal pattern, with 1 of them having an oligoclonal rearrangement. An oligoclonal pattern was also observed in 2 control patients. Three patients with complicated celiac disease evolved to T-cell lymphoma with liver (n = 2) or bone marrow (n = 1) invasion. Identical clones were found in the enteropathic duodenojejunum and peripheral blood in the patient with large-cell lymphoma with bone marrow invasion. This study suggests that complicated celiac disease is a cryptic T-cell lymphoma.

[Effect of smoking on the long-term course of ulcerative colitis]

OBJECTIVE

To evaluate the effects of smoking on the long term clinical course in patients with ulcerative colitis.

METHODS

The medical charts of 556 patients with ulcerative colitis were reviewed retrospectively. Patients were classified as smokers (n = 85) or nonsmokers (n = 471) according to their smoking status during the course of the disease. Extent of colonic lesions, complications, medical requirements, and actuarial rate of colectomy were compared in smokers and nonsmokers.

RESULTS

Mean follow-up (+/- SD) was longer in smokers than in nonsmokers (116 +/- 107 mo, vs 87 +/- 94 mo.). Less smokers than nonsmokers required oral steroids (52 vs 63%, P = 0.05). No difference between the groups was observed regarding the use of salicylates, the need for intravenous steroids, for immunosuppressive drugs, for colectomy, and the occurrence of complications. The actuarial rate of colectomy was less in smokers than in nonsmokers (32 +/- 12% and 42 +/- 6% at 10 years respectively. P = 0.04). Initial and cumulative extent of the disease process did not differ between the groups. However, in the subgroup of patients with limited disease at onset, development of pancolitis was less frequent in smokers than in nonsmokers (14 and 26%, respectively, P = 0.04).

CONCLUSION

The lesser need for oral steroids and the lower actuarial rate of colectomy in smokers suggest that ulcerative colitis in smokers is characterized by a less severe clinical presentation and a better long term prognosis than in nonsmokers.

Effect of indinavir on HIV-related wasting

OBJECTIVE

To study the effect of the protease inhibitor indinavir on body weight and body composition of subjects with HIV-related wasting.

DESIGN

Prospective measurement of body weight in patients who had wasting and were treated with indinavir. A subgroup of 16 representative patients also underwent a metabolic study that included measurements of body composition (skinfolds and bioelectrical impedance) and food intake. Seven from this subgroup who did not have chronic diarrhoea also underwent indirect calorimetry for measurement of resting energy expenditure; the nine patients with wasting and chronic diarrhoea had measurements of faecal losses and intestinal permeability using the lactulose-mannitol test.

SETTING

A tertiary care university hospital.

PATIENTS

Two hundred and fourteen HIV-infected patients with wasting (less than 95% of usual body weight) had their body weight measured at day 0; 186 patients had a second body weight measurement within the first 100 days of treatment, and 160 patients were weighed a third time, at a median of 176 days.

RESULTS

Body weight increased significantly (P < 0.0001) during treatment, whatever the degree of weight loss at baseline. After a median of 176 days on treatment, body weight had increased in 119 out of the 160 patients followed (74.4%; mean weight gain, 6.3+/-SD 3.8 kg; range, 1-18 kg), had not changed in 13 (8.1%) and had fallen in 28 (17.5%; mean weight loss, 4.2+/-3.0 kg; range, 1-12 kg), relative to baseline. Overall, 119 out of the 214 patients (55.6%) from the initial population gained weight. Fat mass, fat-free mass and body cell mass increased significantly in the 16 patients who underwent metabolic studies, together with energy, protein and lipid intake. In the patients with chronic diarrhoea, intestinal permeability improved but there was no change in intestinal losses. In patients who had wasting but not chronic diarrhoea, resting energy expenditure did not change significantly. Body weight changes correlated with changes in the CD4+ cell count (r = 0.882; P = 0.00001) and, to a lesser extent, with changes in the viral load (r = -0.466; P = 0.047).

CONCLUSION

Indinavir significantly improved the nutritional status of these patients with HIV-related wasting.

Factors of weight loss in patients with HIV and chronic diarrhea

Weight loss is significant in patients with HIV and chronic diarrhea. The aim of our study was to test for the links between weight loss, the level of food intake, and the severity of diarrhea and nutrient malabsorption. One hundred and sixteen patients with HIV and chronic diarrhea underwent a standardized gastrointestinal and nutritional evaluation, which included a questionnaire on diarrhea, a prospective estimation of food intake, a measurement of blood parameters and fecal lipid and nitrogen outputs, a stool examination for bacteria and parasites, and upper and lower digestive tract endoscopy. Diarrhea resulted from an infection by Cryptosporidia, Microsporida, or other pathogens in 22%, 20%, and 13% of the patients, respectively. Diarrhea appeared idiopathic in 45% of the patients. A significant negative correlation existed between the severity of weight loss and the levels of nutrient intake (p < .005), and a significant positive correlation between the severity of weight loss and stool frequency (p < .01). Multiple linear regression identified low caloric intake and high stool frequency as predictive of weight loss. No significant correlation was found between weight loss and the parameters of malabsorption, either by bivariate study or multiple regression. These results suggest that, in patients with HIV and chronic diarrhea, the degree of wasting is significantly related to the levels of dietary intake and the clinical severity of diarrhea, but not to the extent of nutrient malabsorption.

Mycobacterium paratuberculosis and Mycobacterium avium subsp. silvaticum DNA cannot be detected by PCR in Crohn's disease tissue

BACKGROUND

The etiology of Crohn's disease remains unknown. A putative mycobacterial cause of the disease is still controversial.

AIMS

To assess the mycobacterial hypothesis in Crohn's disease using a polymerase chain reaction technique.

PATIENTS AND METHODS

Nested polymerase chain reaction with primers on the 16S-rRNA coding region (16S-rDNA) and with primers specific both to the insertion sequences (IS) 900, and IS 901/902 were used to amplify Mycobacterium paratuberculosis or Mycobacterium avium subsp. silvaticum DNA in frozen endoscopic intestinal biopsies or surgical resection specimens from patients with Crohn's disease (n = 47: 25 endoscopic biopsies and 22 surgical resection samples, +/- lymph nodes), ulcerative colitis (n = 27), and non inflammatory bowel diseases (n = 20: colonic tumors and diverticulitis). Positive as well as negative controls were used throughout the study.

RESULTS

All strains of Mycobacterium paratuberculosis and Mycobacterium avium subsp. silvaticum tested were positive for both primer systems. Of the 94 biopsies tested, 5 (2 Crohn's disease, 1 ulcerative colitis and 2 controls) were positive with the 16S-rDNA primers but did not correspond to Mycobacterium paratuberculosis or Mycobacterium avium subsp. silvaticum. None of the specimens was positive with the IS primers.

CONCLUSION

These results do not support the hypothesis that Mycobacterium paratuberculosis, or Mycobacterium avium subsp. silvaticum play a role in Crohn's disease.

[Colonic involvement in ileal Crohn's disease]

OBJECTIVES

To determine the risk and predictive factors for colonic extension in patients with ileal Crohn's disease.

METHODS

One hundred and fifty patients with ileal Crohn's disease and no specific colonic lesions on initial colonoscopy were studied retrospectively (median follow-up: 51 months).

RESULTS

Twelve patients (8%) developed colonic lesions. Ten-year cumulated risks (95% confidence interval) for colonic extension were 17.2% (range: 5.8-28.6) in the whole group, and 22.4% (range: 8.7-36.1) in the group of 86 patients with repeated colonoscopy. Young age at diagnosis was the only factor predicting colonic extension. Seven patients with colonic extension required immunosuppressive therapy but none underwent surgery.

CONCLUSION

Ileal Crohn's disease has a low tendency for colonic extension. Colonic extension has no major prognostic implications.

[Comparison of long-term course of perforating and non-perforating Crohn disease]

OBJECTIVES

To evaluate the influence of the indication of the first surgical procedure on the prognosis of Crohn's disease.

METHODS

We compared retrospectively the long-term course of 179 patients operated on for a perforating disease and 322 patients operated on for a nonperforating disease. Mean follow-up was 11 years and 2 months in the two groups.

RESULTS

Forty of 179 (25%) and 106 of 322 (33%) patients with perforating and nonperforating diseases underwent a second intestinal resection, respectively. The patients who had been operated on for a perforating disease were significantly more often reoperated on for the same indication, and conversely. Patients with perforating diseases experienced less second resections (actuarial rates: 37 +/- 11% vs 51 +/- 8% at ten years respectively), less post-surgical handicaps (mean index 24.9 vs 27.9), and fewer patients required immunosuppressive drugs (25 vs 35%).

CONCLUSION

Long-term prognosis of perforating Crohn's disease does not appear to be more severe than that of nonperforating disease.

Macronutrient intake and malabsorption in HIV infection: a comparison with other malabsorptive states

BACKGROUND

Wasting is a major complication of HIV infection. The role of malabsorption in wasting is controversial.

AIMS

To assess oral intake and malabsorption in a cohort of weight losing HIV infected patients, with or without chronic diarrhoea.

METHODS

A prospective study using a predefined protocol for HIV infected patients was performed in a gastroenterology and nutrition unit in a university hospital. A retrospective comparison was made with HIV negative patients with malabsorption due either to small bowel disease or resection. Body weight and height, serum albumin, oral intake of macronutrients, faecal weight, and faecal fat were measured.

RESULTS

Seventy nine weight losing HIV infected patients were studied. Among the 66 patients with more than 5% lipid malabsorption, wasting was significantly greater in patients with cryptosporidiosis (n = 22) than in patients with microsporidiosis (n = 18) who exhibited significantly more wasting than patients with no identified enteropathogen (n = 26) (body mass index 16.8 (14.0-20.7), 18.9 (16.5-21.3), 19.7 (15.9-23), respectively). When controlling for the level of lipid malabsorption, HIV infected patients had a significantly lower energy intake than HIV negative patients with chronic malabsorption. In HIV infected patients, but not in other categories of malabsorbers, body mass index correlated significantly with energy intake (r = 0.33, 95% confidence intervals 0.12 to 0.51).

CONCLUSION

In weight losing HIV infected patients, reduced energy intake is superimposed on malabsorption and significantly contributes to wasting.

Effects of an isotonic oral rehydration solution, enriched with glutamine, on fluid and sodium absorption in patients with a short-bowel

AIM

To compare the effects of a standard oral rehydration solution with a polymeric glucose isotonic solution enriched with glutamine on water and sodium absorption in the short bowel.

METHODS

Six patients with high jejunostomy were tested in a random order on 2 consecutive days with the standard solution (20 g/L glucose, 94 mmol/L sodium, 292 mOsm/kg osmolality) and a solution containing maltodextrins (18 g/L Glucidex 12; hydrolysis of 18 g of Glucidex 12 yields 20 g glucose) enriched with 14.6 g/L of glutamine (94 mmol/L sodium, 282 mOsm/kg osmolality). Solutions were administered via a naso-gastric tube at a rate of 2 mL/min. Jejunal effluent for each solution was collected during an 8-h period, after a 14-h equilibrium period.

RESULTS

The net 8-h fluid absorption was not significantly different between the standard solution and the solution with glutamine (333 +/- 195 and 213 +/- 251 mL, respectively (mean +/- S.E.M.)). Net sodium absorption was higher for the standard solution than for the solution with glutamine (15 +/- 15 vs. 2 +/- 20 mmol, P < 0.05). The rate of glucose absorption was not different between the solutions.

CONCLUSION

The replacement of glucose by maltodextrins and the addition of glutamine to the standard oral rehydration solution, without changing its sodium content or osmolality, results in a reduction of sodium absorption in the short-bowel syndrome.

[Morbid associations in Crohn's disease. Study of a series of 832 patients]

OBJECTIVES

Depending its frequency, the association in the same subject of Crohn's disease and another pathology can be fortuitous or the expression of genetic or environmental interrelationships. The aim of our study was to identify among a series of patients with Crohn's disease preliminary data which would be suggestive of a significant association between Crohn's disease and other pathologies.

PATIENTS AND METHODS

Personal and familial histories were collected in 832 patients with Crohn's disease who were seen consecutively in the same hospital clinic from 1974 to 1994.

RESULTS

We found 4 cases (0.5%) of associated Crohn's disease-multiple sclerosis and Crohn's disease-rheumatoid purpura in the same patient. Each of the following genetic diseases was associated with Crohn's disease in one patient (0.1%): Charcot-Marie-Tooth disease, deuteroanopia, multiple exostosis, familial ichthyosis, periodic disease.

CONCLUSION

We describe for the first time sporadic cases of associated Crohn's disease and another rare disease, Charcot-Marie-Tooth disease, familial ichthyosis and periodic disease. We suggest that there is a significant interrelationship between personal and familial histories of Crohn's disease and multiple sclerosis which should be verified in prospective studies.

Definition and diagnosis of cytomegalovirus colitis in patients infected by human immunodeficiency virus

The definition and routine diagnosis of cytomegalovirus (CMV) colitis in patients infected by human immunodeficiency virus (HIV) are controversial. In 100 consecutive HIV-infected patients who underwent colonoscopy for the investigation of diarrhea, we compared the yields of routine diagnostic tools for CMV infection and assessed the risk of further CMV organ disease in subgroups of patients with the following features: full evidence of CMV colitis (group 1), colonic CMV infection but no endoscopic lesions (group 2), and no evidence of colonic CMV infection (group 3). All biopsies taken during colonoscopy were examined immediately by routine hematoxylin and eosin (H&E) staining and viral culture and then pooled for second-line H&E staining and immunohistology. Among the 15 diagnoses of CMV colitis (group 1), two were missed during initial H&E examination, and both patients developed further CMV organ disease during follow-up. Of the 12 group 2 patients 11 were not receiving anti-CMV drugs at the time of initial colonoscopy. CMV organ disease was not significantly more common in these patients than in group 3 during follow-up. We conclude that routine H&E staining of colonic biopsy specimens for CMV inclusions is not 100% sensitive for CMV colitis. The favorable outcome of colonic CMV infection without endoscopic lesions suggests that only patients with full evidence of CMV colitis warrant specific antiviral therapy.

Results of culture form colonoscopically obtained specimens for bacteria and fungi in HIV-infected patients with diarrhea

BACKGROUND

The aim of our study was to determine the diagnostic yield of culture for bacteria and fungi from colonic biopsy specimens in 290 consecutive HIV-infected patients with diarrhea.

METHODS

During each colonoscopy, three biopsy specimens were homogenized and cultured on media for Salmonella and Shigella and for Campylobacter and Yersinia, on Loewenstein medium and on Sabouraud medium.

RESULTS

Cultures were found positive for one (n = 32) or two (n = 5) infectious agents in 37 cases, i.e., in 12.8% of the patients. Bacteria were isolated in 24 cases, and identified as Campylobacter jejunl-coli (n = 14), Salmonella (n = 2), Shigella (n = 1), or Pseudomonas aeruginosa (n = 7). Among the 14 patients with C. jejuni-coli intestinal infection, 11 had normal-appearing mucosa at colonoscopy, and 3 had a concomitant stool culture negative for Campylobacter. Mycobacterial cultures were positive for Mycobacterium avium intracellulare in 6 patients, who were already known as having a disseminated M. avium intracellulare infection from positive blood cultures. Fungal cultures were positive for Candida in 10 cases, without clear clinical significance.

CONCLUSIONS

The overall yield of culture for bacterial pathogens from colonic tissue in HIV-infected patients with diarrhea is low, but some individual cases of C. jejuni-coli infections may be detected from colonic tissue culture and not diagnosed by concomitant stool culture.

Intravenous cyclosporine in attacks of ulcerative colitis: short-term and long-term responses

The present study reports the results of intravenous cyclosporine in 32 patients with refractory and/or severe attacks of ulcerative colitis (UC). Twenty of 32 patients responded to intravenous cyclosporine; cyclosporine was clinically effective and improved colonic lesions. However, one colonic perforation and one postoperative death were observed in two patients with severe endoscopic colitis who had failed to reach clinical remission with high-dose corticosteroids and cyclosporine. Moreover, after a median follow-up of 190 days, only one-third of the patients avoided colectomy. No predictive factor of response to cyclosporine was identified. This study confirms that cyclosporine is effective in severe UC but suggests that its use could be associated with serious complications in patients with severe lesions who had failed to settle with corticosteroids and cyclosporine.

Clinical characteristics of Crohn's disease in 72 families

BACKGROUND & AIMS

Familial aggregation argues for genetic susceptibility to Crohn's disease. The aim of this study was to compare the age of onset and the clinical features of Crohn's disease between patients with familial disease and those with sporadic disease and investigate the concordance for disease location and type among relatives with Crohn's disease.

METHODS

Seventy-two families with 2 (n = 55), 3 (n = 8), 4 (n = 6), and 5 or more (n = 3) affected first-degree relatives were selected for the study. A population of 1377 patients with sporadic nonfamilial Crohn's disease was used for comparison.

RESULTS

Clinical data were obtained from 176 patients with familial Crohn's disease (79 men and 97 women). Median age at onset was younger in familial Crohn's disease than in sporadic cases: 22 vs. 26.5 years (P < 0.01). In familial cases, fewer patients had exclusively colonic involvement and more patients had both small bowel and colonic involvement. Among relatives of families with 2 affected members, 56% were concordant for disease location and 49% for disease type. These percentages reached 83% and 76%, respectively, within families with more than 2 affected members.

CONCLUSIONS

Patients with familial Crohn's disease are characterized by an early age at onset with more extensive disease and may represent a homogeneous clinical subgroup with a particularly strong genetic influence.

The role of anatomic factors in nutritional autonomy after extensive small bowel resection

BACKGROUND

It is difficult to predict which patients with a postsurgical short bowel will require long-term parenteral nutrition.

METHODS

We performed a retrospective prognostic study for the time to home parenteral nutrition or death from malnutrition (nonautonomy), on the basis of 103 patients with a residual short bowel of 17 to 150 cm. The influence of anatomic variables was summarized through the use of Cox regression model.

RESULTS

Of the 103 patients included, 24 lost nutritional autonomy. Three anatomic variables were identified as having independent predictive information; remaining small bowel length (measured on small bowel x-rays; p = .0001), and jejunoileal anastomosis (p = .01) promoted autonomy, whereas end jejunostomy (p = .002) increased the risk of losing nutritional autonomy.

CONCLUSIONS

On the basis of these results and on the relative weight of these variables, high-risk patients for loss of nutritional autonomy were defined as those with jejunoileal anastomosis and a remaining small bowel length < 35 cm, patients with jejunocolic anastomosis and remaining small bowel length < 60 cm, and patients with an end jejunostomy and remaining small bowel length < 115 cm. This classification was thereafter validated on a prospective series of 32 patients.

Methotrexate for the treatment of refractory Crohn's disease

BACKGROUND

Previous studies suggested that methotrexate has beneficial effects in patients with Crohn's disease. We report our experience with this agent in patients with chronic active Crohn's disease who previously failed to improve with conventional treatment, including azathioprine in most cases.

METHODS

Between June 1988 and June 1992, 39 patients with refractory Crohn's disease were treated with methotrexate. In patients with active disease, clinical remission was defined by a Harvey-Bradshaw index of less than 4. For patients also taking corticosteroids, the dates of remission and complete steroid withdrawal were recorded. For patients who achieved clinical remission, and those in clinical remission when methotrexate was started, the relapse rate on methotrexate therapy was noted.

RESULTS

In the 37 patients with active disease at methotrexate initiation, the probability of remission was 72% at 3 months. The probability of remission and steroid withdrawal was 42% at 12 months. In patients on clinical remission, the probability of relapse on methotrexate was 58% at 12 months. Twenty-two patients experienced side-effects, but these only warranted methotrexate discontinuation in four cases.

CONCLUSIONS

Methotrexate appears effective in most patients with refractory Crohn's disease and its short-term toxicity is acceptable, but the long-term benefit seems more limited.

[Prognosis in pancolonic forms of hemorrhagic rectocolitis]

OBJECTIVE

To assess the prognosis of pancolitis in ulcerative colitis including survival, colectomy rate, colon cancer risk, activity of disease, functional and socioprofessional impact.

METHODS

Retrospective study of 130 cases of ulcerative pancolitis referred consecutively to Rothschild Hospital from 1962 to 1993. They were 58 men and 72 women. The mean age at onset of ulcerative colitis was 30 years (range: 5-77). The extension to the right colon was secondary in 68% of patients. The period of observation ranged from 0.8 year to 46 years from the onset, with a median of 10.6 years. Three patients were lost to follow up.

RESULTS

Eight patients died, the survival rate being 93% at 10 years. Surgical treatment was performed in 85 patients. The cumulative colectomy rates were 61% and 77% at 10 and 20 years respectively. Colonic cancer developed in three patients, corresponding to a cumulative risk after 25 years of 6% in unoperated patients and 1.9% in the whole series. No cancer occurred after colectomy and ileorectal anastomosis. In the group of unoperated patients there was a decrease of activity of the disease during the first fifteen years. The quality of life of colectomized patients with reestablishment of intestinal continuity and of those treated conservatively did not differ significantly.

CONCLUSION

In this series, long term prognosis of ulcerative pancolitis was favourable. The high colectomy rate was balanced by a very low risk of colorectal cancer.

Mesalamine in Crohn's disease with steroid-induced remission: effect on steroid withdrawal and remission maintenance, Groupe d'Etudes Thérapeutiques des Affections Inflammatoires Digestives

BACKGROUND & AIMS

Steroid dependence and early relapse are frequent after a prednisolone-induces remission in Crohn's disease. The aim of this trial was to test whether mesalamine started at the onset of steroid tapering increases the rate of weaning from prednisolone and reduces the relapse rate after prednisolone cessation.

METHODS

One hundred fifty patients with active Crohn's disease were administered oral prednisolone (1 mg.kg(-1). day(-1)) x 3-7 weeks; 129 patients went into clinical remission and were randomized to Pentasa (4 g . day(-1)) or placebo, administered until weaning and for 1 year thereafter.

RESULTS

Groups were similar for clinical and biological items collected initially. Weaning failure rate was 30% and 12% in the placebo and mesalamine arms, respectively. At the end of the trial, 9 of 36 patients administered placebo and 14 of 48 administered mesalamine were in remission. Both groups had similar time to relapse curves in the postweaning year; after adjusting for risk factors (high Crohn's Disease Activity Index, white blood cell count of >9 x 10(9) /l-1 at weaning, and use of a medical treatment in the month before inclusion), Pentasa was found to be superior to placebo.

CONCLUSIONS

After a prednisolone-induces remission in Crohn's disease, mesalamine facilitates steroid withdrawal and, during the postweaning year, may reduce the relapse rate in certain patient subgroups.

Placebo-controlled clinical trial of mesalazine in the prevention of early endoscopic recurrences after resection for Crohn's disease. Groupe d'Etudes Thérapeutiques des Affections Inflammatoires Digestives (GETAID)

OBJECTIVE

Endoscopic postoperative recurrences occur early after 'curative' surgery for Crohn's disease. Pentasa has been shown to be effective in the maintenance treatment of quiescent Crohn's disease. The aim of this study was to test the efficacy of a 12-week oral intake of Claversal in the prevention of endoscopic recurrences after 'curative' resection for ileal, colonic or ileocolonic Crohn's disease. We conducted a multicentre double-blind controlled trial comparing Claversal (1g tid) with placebo, starting within 15 days after surgery. The macroscopic normality of the two anastomotic segments was assessed at surgery. Patients were clinically and biologically evaluated twice (6-week interval), and colonoscopy was performed at 12 weeks. Endoscopic relapse was defined by any anastomotic ulcerations or stenosis and staged according to a four-grade score.

RESULTS

Between May 1989 and May 1991 12 centres included 126 patients, 70 women and 56 men, aged 33 +/- 12 years (range 16-70) in the study. Disease locations were ileal, colonic and ileocolonic in 45, 6 and 49%, respectively. Claversal and placebo groups were similar at inclusion, except for ESR (37 +/- 26 vs. 27 +/- 23 mm/h in the Claversal and placebo groups, respectively; P < 0.05). Nine patients were withdrawn from the study. Adverse reactions occurred only in six patients. Five patients were excluded for protocol violation. Finally, 106 patients could be evaluated at 12 weeks (55 Claversal and 51 placebo). An endoscopic relapse was observed in 50% and 63% of the Claversal and placebo groups, respectively (P = 0.16), with a similar grade distribution. Claversal was well tolerated.

CONCLUSIONS

Our study confirms that a large proportion of endoscopic recurrences occur within 3 months of resection in Crohn's disease. There was a slight trend towards greater efficacy of Claversal; it could be worthwhile trying higher dosages and/or 5-ASA compounds with different intestinal release profiles.

Effects of cigarette smoking on the long-term course of Crohn's disease

BACKGROUND & AIMS

In Crohn's disease, smoking increases the risk for surgical procedures. The influence of smoking on the overall severity of the disease remains controversial. The purpose of the study was to examine the effects of smoking on the long-term course of Crohn's disease and the relationship between smoking and therapy.

METHODS

The medical charts of 400 consecutive patients whose smoking habits were specified by direct interview were reviewed.

RESULTS

Frequency and extent of excisional surgery were not significantly different in smokers and nonsmokers, but smokers required more glucocorticoids and immunosuppressive drugs. The effect of smoking on the need for immunosuppressive drugs was dose-dependent and was significant in women but not in men. For female smokers, the 10-year risk of immunosuppressive therapy was 52% +/- 11% compared with 24% +/- 10% for nonsmokers (P < 0.001). The risk of surgery increased only in patients who smoked and did not take immunosuppressive drugs. The surgical rate increased significantly during smoking in 19 patients who started smoking after diagnosis and decreased significantly in 34 patients who stopped compared with matched controls.

CONCLUSIONS

Patients who smoke, particularly women and heavy smokers, run a high risk of developing severe disease. Immunosuppressive therapy neutralizes the influence of smoking on surgical rates.

Identifying patients with a high risk of relapse in quiescent Crohn's disease. The GETAID Group. The Groupe d'Etudes Thérapeutiques des Affections Inflammatoires Digestives

No reliable identification of quiescent Crohn's disease (CD) patients with a high risk of relapse is available. The aim of this study was to develop a prognostic index to identify those patients. Untreated adult patients with quiescent disease (not induced by surgery) included in three phase III clinical trials were analysed retrospectively with respect to time to relapse. Nineteen factors related to biology, disease history, and topography were investigated. A relapse was defined as either a CD Activity Index (CDAI) > or = 200, a CDAI > or = 150 but over the baseline value by more than 100, or acute complications requiring surgery. The inclusion criteria were fulfilled by 178 patients. The median follow up was 23 months. The Cox model retained the following bad prognostic factors: age < or = 25 years, interval since first symptoms > 5 years, interval since previous relapse < or = 6 months, and colonic involvement (p < 0.001). Bootstrapping confirmed the variable selection. Patients were classified into three groups with an increasing risk of relapse (p < 0.001). The worst risk group was composed of patients presenting at least three of the four bad prognostic factors. These results make possible the design of clinical trials in quiescent CD patients with a high risk of relapse.

Diagnosis and prognosis of AIDS-related cholangitis

OBJECTIVE

To determine more precisely the clinical and biological characteristics of AIDS-related cholangitis, and to investigate prognostic variables of this disease.

DESIGN

Retrospective clinical and prognostic study.

SETTING

Biliary unit, Bicêtre Hospital, France.

PATIENTS

HIV-positive patients (n = 52) referred to the unit between December 1986 and June 1993 for biliary symptoms leading to the suspicion of AIDS-related cholangitis, (42 men; 10 women; mean age, 37 +/- 8 years).

INTERVENTION

Endoscopic retrograde cholangiopancreatography (ERCP) was performed in order to determine the cause of the biliary symptoms.

MAIN OUTCOME MEASURE

Clinical features and evolution of the cholangitis.

RESULTS

Among the 52 patients, 45 met the ERCP criteria of AIDS-related cholangitis (36 men; nine women). The diagnosis of cholangitis was strongly suggested by abdominal ultrasonography in 47% of the cases. ERCP showed papillary stenosis, diffuse cholangitis, extrahepatic cholangitis alone, and intrahepatic cholangitis alone in 60, 67, 7 and 27%, respectively. Endoscopic sphincterotomy was performed in 28 patients. Pain was relieved by sphincterotomy in nine patients, but the other clinical or biological features were not influenced. One-year and 2-year survival rates were 41 +/- 7% and 8 +/- 4%, respectively. Multidimensional analysis using a Cox model showed that a lymphocyte count > 500 x 10(6)/l was the only independent predictive factor of better survival.

CONCLUSION

AIDS-related cholangitis is a disease which leads preferentially to papillary stenosis or diffuse abnormalities of the biliary tract. Prognostic factors depend on the stage of the HIV infection. Another diagnosis of cholestasis was found in approximately 15% of the patients who showed biliary symptoms.

Intestinal histoplasmosis in AIDS patients: report of three cases observed in France and review of the literature

We report three cases of colonic histoplasmosis observed in a non-endemic area in patients with AIDS. The patients presented with fever, abdominal pain and an abdominal mass in the right lower quadrant. Diagnosis was obtained using Gomori-Crocott staining of endoscopic or surgical biopsies. One patient died without specific treatment and two patients had a complete remission when treated with intravenous amphotericin B but suffered a relapse when given oral itraconazole. Thus, physicians in areas where intestinal histoplasmosis is not endemic should be aware of the condition. Diagnosis can easily be obtained using Gomori-Crocott staining of colonoscopic biopsies; this should avoid unnecessary laparotomies and allow specific treatment to be instituted rapidly.

[The clinical activity of Crohn's disease in the Paris area is maximal in the spring]

The aim of this study was to look for seasonal fluctuations in the clinical course of Crohn's disease. Eighty-three patients residing in the Paris area were included in the study and they had all undergone continuous clinical monitoring throughout the first three years of the disease. During this period, the clinical activity of the disease was ranked monthly on a semi-qualitative scale ranging from 0 to 4. The dates of corticosteroid treatment and of resection surgery carried out during the first three years of the disease were also recorded. The mean clinical score varied significantly (P < 0.0001) for different months of the year, the three highest scores being recorded during the three months of Spring-time (April, May and June). The number of months of corticosteroid treatment differed significantly (P < 0.05) for the various seasons, the six highest values being reported during Spring and Summer months. The number of intestinal resections differed significantly (p < 0.05) during different seasons, the highest incidence again being reported during Spring. This study demonstrates seasonal variations in the clinical course of Crohn' disease in the Paris area, with a peak occurring in the Spring.