Multiple staging investigations may not change management in patients with high-grade dysplasia or early esophageal adenocarcinoma

The clinical value of multiple staging investigations for high-grade dysplasia or early adenocarcinoma of the esophagus is unclear. A single-center prospective cohort of patients treated for early esophageal cancer between 2000 and 2019 was analyzed. This coincided with a transition period from esophagectomy to endoscopic mucosal resection (EMR) as the treatment of choice. Patients were staged with computed tomography (CT), endoscopic ultrasound (EUS) and 2-deoxy-2-[18F]fluoro-d-glucose (FDG) positron emission tomography(PET)/CT. The aim of this study was to assess their accuracy and impact on clinical management. 297 patients with high-grade dysplasia or early adenocarcinoma were included (endoscopic therapy/EMR n = 184; esophagectomy n = 113 [of which a 'combined' group had surgery preceded by endoscopic therapy n = 23]). Staging accuracy was low (accurate staging EMR: CT 40.1%, EUS 29.6%, FDG-PET/CT 11.0%; Esophagectomy: CT 43.3%, EUS 59.7%, FDG-PET/CT 29.6%; Combined: CT 28.6%, EUS46.2%, FDG-PET/CT 30.0%). Staging inaccuracies across all groups that could have changed management by missing T2 disease were CT 12%, EUS 12% and FDG-PET/CT 1.6%. The sensitivity of all techniques for detecting nodal disease was low (CT 12.5%, EUS 12.5%, FDG-PET/CT0.0%). Overall, FDG-PET/CT and EUS changed decision-making in only 3.2% of patients with an early cancer on CT and low-risk histology. The accuracy of staging with EUS, CT and FDG-PET/CT in patients with high-grade dysplasia or early adenocarcinoma of the esophagus is low. EUS and FDG-PET/CT added relevant staging information over standard CT in very few cases, and therefore, these investigations should be used selectively. Factors predicting the need for esophagectomy are predominantly obtained from EMR histology rather than staging investigations.

Tocilizumab in the management of posttransfusion hyperhemolysis syndrome in sickle cell disease: The experience so far

BACKGROUND

Posttransfusion hyperhemolysis syndrome is a rare but life-threatening form of delayed hemolytic transfusion reaction with lysis of both transfused and autologous red cells, seen predominantly in patients with sickle cell disease. Macrophage activation is thought to play a major role in its pathophysiology. Standard treatment is with intravenous immunoglobulin and steroids but refractory cases pose a major clinical problem. Tocilizumab is a humanized monoclonal antibody against the IL-6 receptor that can inhibit IL-6 induced macrophage activation.

METHODS AND MATERIALS

We describe the case of a 33-year-old woman with sickle cell anemia and posttransfusion hyper hemolysis syndrome refractory to standard therapy, treated with Tocilizumab. We also review all cases reported in the literature where Tocilizumab was used for posttransfusion hyperhemolysis.

RESULTS

Treatment with Tocilizumab was well tolerated with no observed adverse events. There was no further drop in Hb after day 2 of treatment with subsequent continuous gradual improvement. Her bilirubin dropped significantly after the first dose and continued to improve, while ferritin and LDH reduced significantly after day 2 of treatment with Tocilizumab and continued to drop thereafter. Like in our case, all other cases in the literature where Tocilizumab was used for posttransfusion hyperhemolysis led to rapid clinical responses and no adverse events.

DISCUSSION

Even though the number of cases of posttransfusion hyper hemolysis syndrome treated with Tocilizumab are few, they have all been associated with rapid clinical responses with no observed adverse events suggesting that the role of Tocilizumab in this context needs to be further explored.

Remodelling of specialist services enables safe reduction in hospital admissions of patients with sickle cell disease: Lessons from the COVID-19 pandemic

Sickle cell disease is characterised by recurrent painful crises often leading to hospitalisation. During the COVID-19 pandemic, it was important to try to reduce the need for hospital admission for these high-risk patients while at the same time ensuring that hospital avoidance did not put them at risk of deterioration from disease-related complications. In the 3-month period between March and May 2020, there was a significant reduction in the number of hospital admissions as well as mean length of stay compared with the mean figures over the same months in the preceding 5 years (2015-19), with an overall reduction in inpatient days of 77%. There were no cases of unsafe hospital avoidance or presentations to hospital that were inappropriately delayed. Frequent telephone communication with patients and provision of ambulatory care were, among others, two very important means of supporting our patient population.

Prediction of a positive circumferential resection margin at surgery following neoadjuvant chemotherapy for adenocarcinoma of the oesophagus

Background

A positive circumferential resection margin (CRM) has been associated with higher rates of locoregional recurrence and worse survival in oesophageal cancer. The aim of this study was to establish if clinicopathological and radiological variables might predict CRM positivity in patients who received neoadjuvant chemotherapy before surgery for oesophageal adenocarcinoma.

Methods

Multivariable analysis of clinicopathological and CT imaging characteristics considered potentially predictive of CRM was performed at initial staging and following neoadjuvant chemotherapy. Prediction models were constructed. The area under the curve (AUC) with 95% confidence intervals (c.i.) from 1000 bootstrapping was assessed.

Results

A total of 223 patients were included in the study. Poor differentiation (odds ratio (OR) 2·84, 95 per cent c.i. 1·39 to 6·01) and advanced clinical tumour status (T3-4) (OR 2·93, 1·03 to 9·48) were independently associated with an increased CRM risk at diagnosis. CT-assessed lack of response (stable or progressive disease) following chemotherapy independently corresponded with an increased risk of CRM positivity (OR 3·38, 1·43 to 8·50). Additional CT evidence of local invasion and higher CT tumour volume (14 cm3) improved the performance of a prediction model, including all the above parameters, with an AUC (c-index) of 0·76 (0·67 to 0·83). Variables associated with significantly higher rates of locoregional recurrence were pN status (P = 0·020), lymphovascular invasion (P = 0·007) and poor response to chemotherapy (Mandard score 4-5) (P = 0·006). CRM positivity was associated with a higher locoregional recurrence rate, but this was not statistically significant (P = 0·092).

Conclusion

The presence of advanced cT status, poor tumour differentiation, and CT-assessed lack of response to chemotherapy, higher tumour volume and local invasion can be used to identify patients at risk of a positive CRM following neoadjuvant chemotherapy.

Dedicated Barrett's surveillance sessions managed by trained endoscopists improve dysplasia detection rate

Background and study aim Barrett's esophagus (BE)-associated dysplasia is an important marker for risk of progression to esophageal adenocarcinoma (EAC) and an indication for endoscopic therapy. However, BE surveillance technique is variable. The aim of this study was to assess the effect of dedicated BE surveillance lists on dysplasia detection rate (DDR). Patients and methods This was a prospective study of patients undergoing BE surveillance at two hospitals - community (UHL) and upper gastrointestinal center (GSTT). Four endoscopists (Group A) were trained in Prague classification, Seattle protocol biopsy technique, and lesion detection prior to performing BE surveillance endoscopies at both sites, with dedicated time slots or lists. The DDR was then compared with historical data from 47 different endoscopists at GSTT and 24 at UHL (Group B) who had undertaken Barrett's surveillance over the preceding 5-year period. Results A total of 729 patients with BE underwent surveillance endoscopy between 2007 and 2012. There was no significant difference in patient age, sex, or length of BE between the two groups. There was a significant difference in detection rate of confirmed indefinite or low grade dysplasia and high grade dysplasia (HGD)/EAC between the two groups: 18 % (26 /142) Group A vs. 8 % (45/587) in Group B (P  < 0.001). Documentation of Prague criteria and adherence to the Seattle protocol was significantly higher in Group A. Conclusion This study demonstrated that a group of trained endoscopists undertaking Barrett's surveillance on dedicated lists had significantly higher DDR than a nonspecialist cohort. These findings support the introduction of dedicated Barrett's surveillance lists.

Service provision and training for endoscopic ultrasound in the UK

Endoscopic ultrasound (EUS) is a standard procedure that plays an important role in the management of both malignant and benign disease. The development of EUS services in the UK has been haphazard and training inconsistent. The British Society of Gastroenterology has charged a working group with the task of laying down a national framework for how such services might be commissioned, structured and regulated; with particular attention to defining how endoscopist skills might be acquired, assessed and maintained. This report lays out a map for this process and its future revision.

Predicting what can go wrong at endoscopic ultrasound: a large series experience

OBJECTIVE

Although prior studies have evaluated complications following endoscopic ultrasound (EUS), data on the incidence of unplanned events at EUS, defined as any deviation from the preprocedure plan, are lacking. The aim of this study was to define the incidence, nature, clinical predictors and implications of unplanned events at EUS.

DESIGN

Case control study.

SETTING

Tertiary referral centre.

PATIENTS

4624 consecutive patients undergoing EUS during a 6 year period were enrolled. For each patient with an unplanned event, two patients with a successful EUS in the same calendar year were randomly selected as controls.

MAIN OUTCOME MEASUREMENTS

Unplanned events occurring prior to, during or after EUS procedures were prospectively recorded in a database.

RESULTS

192/4624 patients had an unplanned event (4.1%). In all, 2.1% had a failed procedure for anatomical reasons, 1.3% because of restlessness despite standard sedation and 0.5% for technical reasons. Adverse events occurred in 0.2%. There was no mortality but 4/6 patients with adverse events had to be admitted to hospital (2/4 operated). Eighty-two per cent of patients with an unplanned event had incomplete examinations, 14% had no procedure performed and 4% had complete procedures. In a multivariate analysis, only Afro-Caribbean patient origin, inpatient procedure and cancer staging procedure were independently related to unplanned events (p<0.05 for all).

CONCLUSIONS

Unplanned events at EUS are mainly due to anatomical reasons and restlessness, despite sedation. They commonly result in incomplete examination and are related to Afro-Caribbean origin, inpatient procedure and cancer staging.

Endosonographic staging of lower intestinal malignancy

The use of EUS in the assessment of rectal pathology is well established. The accurate staging of lower intestinal tumours predicts prognosis and guides the planning of individual patient treatment. Increased experience and the development of high resolution three-dimensional EUS has lead to the greater accuracy of rectal staging with EUS of rectal tumours now considered the gold standard showing T stage accuracy that ranges from 75% to 95%, with N stage accuracy ranging from 65% to 80%. The use of EUS in the staging of colonic pathology, however, is not so well established though advances in miniprobe EUS has improved the assessment of colonic tumours. EUS is also of benefit in the assessment of anal pathology though here, accurate correlation with histology has not been firmly established.

Clinicians' attitudes towards endoscopic ultrasound: a survey of four European countries

OBJECTIVE

Despite the documented effectiveness of endoscopic ultrasound (EUS) in research studies, data on the utilization of this technology in clinical practice are scarce. The aim of this study was to assess EUS availability and accessibility as well as EUS utilization among clinicians from different European countries.

MATERIAL AND METHODS

A direct mail survey was sent to members of the national gastroenterological associations in Sweden, Norway, Greece, and the United Kingdom.

RESULTS

Out of 2361 clinicians with valid addresses, 593 (25.1%) responded. Overall, EUS was available to 43% of clinicians within their practice but availability varied from 23% in Greece to 56% in the United Kingdom. More than 50% of respondents evaluating patients with esophageal cancer, rectal cancer, or pancreaticobiliary disorders had utilized EUS during the previous year, but utilization varied considerably among different countries, being more frequent in the United Kingdom. In logistic regression analyses, factors independently related to EUS utilization were mainly EUS availability and accessibility as well as perceived utility of EUS (p <0.05 for all). Respondents considered the lack of trained endosonographers (79%) and high cost (52%) as the main barriers to wider EUS use.

CONCLUSIONS

The majority of responding clinicians use EUS but overall utilization varies considerably among different countries. There is considerable variation in EUS service availability and accessibility among countries which, together with perceived usefulness of EUS, is a major determinant of EUS utilization. A shortage of trained endosonographers and the high cost are major barriers to wider EUS use. The findings of this study might help to define policies aimed at development of EUS services.

Defining the lymph node burden in a Northern European population without malignancy: the potential effect of geography in determining a need for FNA?

Data from the USA suggest that morphological specificity is insufficient to permit an assumption of malignancy in nodal staging with endoscopic ultrasound (EUS). This may not hold true elsewhere as the background lymph node burden may vary in different geographic regions. We aimed to assess the prevalence and features of mediastinal and abdominal lymph nodes at EUS in a Northern European population without malignant disease. A total of 129 consecutive patients without malignant disease referred for radial EUS were prospectively evaluated for the prevalence and echo features of lymph nodes in the mediastinum and upper abdomen. Sixty-two percent of patients had mediastinal lymph nodes and 17% had abdominal nodes at EUS. A mean of 1.4 (standard deviation 1.3, range 0-8) nodes were found per patient. No celiac nodes were seen. The majority of detected nodes were 0.5 cm or less in short axis, had oval shape, centrally echogenic pattern, and indistinct borders. The most common node locations were the subcarinal and paraesophageal areas, and the hepatoduodenal ligament. In multivariate analysis mediastinal lymphadenopathy was related to body mass index and abdominal lymphadenopathy to acute pancreatitis. The occurence of mediastinal lymphadenopathy is markedly lower in Northern Europeans than reported for US patients. Celiac nodes are extremely rare in patients without malignancy. The majority of nodes have a width of 0.5 cm or less, have oval shape, centrally echogenic pattern, and indistinct borders. The characterization of the background lymph node burden may improve the selection of lymph nodes for fine needle aspiration.

A large series, resection controlled study to assess the value of radial EUS in restaging gastroesophageal cancer following neoadjuvant chemotherapy

The true value of endoscopic ultrasound (EUS) post-neoadjuvant chemotherapy for esophageal carcinoma is not established. Superior loco-regional detail may yield useful staging and prognostic information but information on its accuracy, as compared with computed tomography (CT), remains undefined and limited by small study size. We prospectively studied 109 patients with gastroesophageal cancer; 99 of whom were undergoing surgery. All had EUS and helical CT imaging before and after neoadjuvant chemotherapy and the results were compared with pathological staging of resected specimens. Tumor response was assessed by the reduction in maximal tumor depth at EUS and correlated with patient survival. There was no difference in T and N stage accuracies between EUS and CT following neoadjuvant chemotherapy. manova showed a reduction in maximal tumor depth by > 50% at EUS to be associated with longer survival (relative risk = 0.48, P < 0.05). EUS responders had a median survival of 38 months compared to 30 months for non-responders (P < 0.05). The identification of lymphadenopathy at radial EUS was not predictive of survival. This large series study demonstrates the staging accuracy of CT and non-biopsy EUS in the setting of neoadjuvant chemotherapy for gastroesophageal cancer to be equivalent and poor. An endosonography may contribute useful clinical information in respect of potential survival. It is questionable whether radial EUS should be included in protocols for restaging.

The preferred choice for radial endosonographic staging of esophageal cancer: standard echoendoscope or nonoptic esophagoprobe?

BACKGROUND

The nonoptic esophagoprobe has been reported to be comparable to the standard echoendoscope in esophageal cancer staging, with a superior advantage of traversing more stenotic tumors because of its smaller diameter. The aim of this study was to see whether its use in a general population of esophageal cancer patients confers any significant clinical benefit.

METHODS

Five hundred seventy-seven consecutive patients referred for initial locoregional staging of esophageal cancer were analyzed retrospectively. Comparisons were made between the standard echoendoscope and the esophagoprobe.

RESULTS

Complete staging (95.2% vs 77.5%; p < 0.001) was significantly higher in the esophagoprobe group compared with that of the standard echoendoscope group (315 and 262 patients, respectively). In 146 patients with histopathologic verification without prior chemotherapy or radiotherapy, the esophagoprobe was comparable in T-staging accuracy to the standard echoendoscope in those with traversable tumors (89.2% vs. 82.8%; p = 0.213). However, the presence of a nontraversable stricture significantly decreased standard echoendoscope T-staging accuracy compared with a traversable stricture (33.3% vs. 82.8%, respectively; p < 0.001). The esophagoprobe also picked more advanced tumors and distal nodes.

CONCLUSIONS

The esophagoprobe is more accurate than the standard echoendoscope in the T staging of esophageal cancer because of its higher likelihood of traversing tumor stenosis. It can potentially reduce the necessity for dilation in stenotic tumors by four to five times. We propose using the esophagoprobe as the first choice for radial endoscopic ultrasound staging of esophageal cancer.

A prospective control study of the safety and cellular yield of EUS-guided FNA or Trucut biopsy in patients taking aspirin, nonsteroidal anti-inflammatory drugs, or prophylactic low molecular weight heparin

BACKGROUND

Although the ASGE recommends that high-risk endoscopic procedures can safely be performed on patients taking aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) in standard doses, there is a paucity of data on EUS-FNA per se in this setting.

OBJECTIVE

We studied the safety and cellular yield of EUS-FNA and/or Trucut biopsy (TCB) in patients taking aspirin, NSAIDS, or prophylactic low molecular weight heparins (LMWH).

DESIGN

Prospective control study.

PATIENTS

Consecutive patients undergoing EUS-FNA and/or TCB were recruited over an 18-month period. The usage of aspirin, NSAIDS, or LMWH were recorded and patients who were not taking these medications served as controls.

MAIN OUTCOME MEASUREMENTS

The bleeding events (endosonographic findings of extraluminal bleeding, intraluminal bleeding requiring hemostatic procedures, hematemesis, or melena) and cellular yield were compared between patients and controls.

RESULTS

Two hundred fourteen patients (8 had repeat procedures) underwent EUS-FNA and/or TCB on 241 lesions. Bleeding events occurred in none (0 of 26), 33.3% (2 of 6), and 3.7% (7 of 190) of the patients in the aspirin/NSAIDS, LMWH, and control groups, respectively (p = 0.023). The mean numbers of FNA passes, applications of suction, bloody specimens, and cellular yield were not significantly different between patients who were or were not receiving medications. No significant difference in bleeding events was noted between the FNA and TCB groups.

CONCLUSION

EUS-FNA or TCB is safe in patients taking aspirin or NSAIDS. Consideration should be given to stopping LMWH before the procedure. The cellular yield and blood contamination of the specimen from FNA are similar to those in controls.

Duodenal EUS to identify thickening of the extrahepatic biliary tree wall in primary sclerosing cholangitis

BACKGROUND

Diagnosing primary sclerosing cholangitis (PSC) is problematic and requires meeting a burden of proof through clinical, biochemical, radiologic, and histological features. Endoscopic ultrasound yields detailed images of the extrahepatic biliary tree, but its value in contributing to the diagnosis of this condition is unknown.

OBJECTIVES

To determine the potential for transduodenal EUS to detect common bile duct wall thickening in PSC.

DESIGN

A prospective, controlled study with retrospective, blinded data analysis.

SETTING

Single tertiary referral center for inflammatory bowel disease and EUS.

PATIENTS

Four groups of patients were assessed with radial endosonography: PSC (n = 9); inflammatory bowel disease (IBD) with abnormal liver blood tests (n = 21); choledocholithiasis (n = 15); and normal controls (n = 50). Measurements were made of the common bile duct diameter and wall thickness.

INTERVENTIONS

Transduodenal radial EUS of the biliary tree.

MAIN OUTCOME MEASUREMENTS

Common bile duct diameter and wall thickness.

RESULTS

The mean diameter (SD) of the common bile duct for the PSC, IBD, choledocholithiasis, and normal control groups measured 8.9 mm (2.8), 5.4 mm (1.7), 7.2 mm (2.2), and 5.0 mm (1.9), respectively (PSC and choledocholithiasis groups compared to the IBD group, P < .05 for a single test of hypothesis, but correction for the multiple testing of data removed this significance; normal control group P < .005). Mean ductal wall thickness (SD) was 2.5 mm (0.8) for the PSC group, 0.7 mm (0.4) for the IBD group, 0.8 mm (0.4) for the choledocholithiasis group, and 0.8 mm (0.4) for the normal control group, respectively (PSC group compared to the other 3 groups, P < .005).

LIMITATIONS

Assessment of intrahepatic PSC is problematic.

CONCLUSION

Thickening (>1.5 mm) of the common bile duct wall is seen in patients with PSC but not in those with apparently uncomplicated IBD or choledocholithiasis. The results of this study suggest that standard endosonography contributes to the imaging and potentially to the diagnosis of PSC.

Endoscopic ultrasound-guided fine needle aspiration cytology of pancreatic neuroendocrine tumours: cytomorphological and immunocytochemical evaluation

OBJECTIVES

Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) is increasingly used in preoperative localization and diagnosis of pancreatic neoplasms including neuroendocrine tumours (NETs). The objective of the present study was to identify the cytological features of pancreatic NETs obtained by EUS-FNA.

METHODS

The study group consisted of nine cases of pancreatic tumours correctly diagnosed or strongly suggestive of NETs based on EUS-FNA. Cytological smears were retrospectively reviewed. The clinical data and immunocytochemical stains applied to the cell block preparations were also reviewed and examined.

RESULTS

All cases except one showed characteristic cytomorphological features sufficient for their recognition and separation from pancreatic adenocarcinoma and other lesions. The most helpful cytological features that facilitated the cytological diagnosis of NET were a richly cellular aspirate with a monotonous, poorly cohesive population of small cells with a speckled or dusty chromatin pattern and plasmacytoid morphology. The neuroendocrine differentiation of these tumours was further confirmed by immunocytochemistry.

CONCLUSION

EUS-FNA is a valuable method in the recognition of pancreatic NETs. By adherence to the characteristic cytomorphological criteria of pancreatic NET together with collection of suitable material for ancillary immunocytochemical stains, cytopathologists could reach a correct diagnosis in most instances.

Cytologic diagnosis of pancreatic endocrine tumors by endoscopic ultrasound-guided fine-needle aspiration: A review

Precise localization and diagnosis of pancreatic endocrine tumors (PETs) is important, because pancreatic PETs have different clinical and biological behavior and treatment modalities than do exocrine pancreatic tumors. In contrast to the much more common exocrine adenocarcinomas, cytologic studies of PET are relatively rare and many cytopathologists lack experience with the cytomorphologic features of these tumors.During the last 10 yr, endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) has matured into an accurate, highly sensitive, and cost-effective modality for the preoperative localization of pancreatic PETs. This has resulted in an increased number of PETs first sampled as cytology specimens. This manuscript focuses on the cytomorphologic features most suggestive of pancreatic PETs, differential diagnosis, and diagnostic pitfalls of PETs. The technical development of EUS-guided FNA and the ancillary studies for pancreatic PETs are also reviewed. The data summarized in this review indicate that EUS-FNA is a valuable method in the recognition of pancreatic PETs and in most cases cytopathologists could reach a correct diagnosis of these tumors, including their hormone producing capability on aspirated cytologic material.

Metastatic lymph node impostor in pancreatic cystadenocarcinoma

CONTEXT

Lymph node involvement in pancreatic cancer is a predictor of poor patient long-term survival. The detection of multiple metastatic peri-pancreatic nodes by EUS-FNA may dissuade the surgeon from undertaking a curative pancreatic resection.

CASE REPORT

We report an interesting case of a man with chronic lymphocytic leukemia, who presented with the diagnostic problem of a pancreatic solid-cystic lesion and multiple malignant-looking peri-pancreatic lymphadenopathy on EUS. EUS-FNA yielded chronic lymphocytic leukaemia involvement in the peri-pancreatic lymph nodes and a markedly elevated CEA in the cystic fluid. The absence of adenocarcinoma involvement of the lymph nodes prompted surgery on the pancreatic lesion with a curative intent. Pancreatic mucinous cystadenocarcinoma was diagnosed and a sub-total pancreatectomy was performed with clear resection margins. All 30 resected peri-pancreatic lymph nodes showed chronic lymphocytic leukemia involvement only.

CONCLUSIONS

This case illustrates that abnormal lymphadenopathy adjacent to a primary pancreatic lesion may not necessarily be due to the latter. Systemic lymphoproliferative disease, as in this case, can masquerade as metastatic adenocarcinoma lymph nodes on EUS. EUS-FNA is useful in diagnosing lymphoproliferative disease.

The substitution of endoscopic ultrasound for endoscopic retrograde cholangio-pancreatography: implications for service development and training

OBJECTIVES

Choledocholithiasis and other benign conditions of the biliary tree are difficult to define clinically. Endoscopic retrograde cholangio-pancreatography (ERCP) is increasingly being replaced as the investigation of choice by other imaging modalities. The aim of this study was to measure the impact of substituting endoscopic ultrasound (EUS) for ERCP in terms of case throughput and the proportion of therapeutic ERCPs performed.

METHODS

Over a 12-month period, cases with a low/medium likelihood for biliary pathology were triaged to EUS rather than ERCP. Data were collected on the proportion of ERCPs performed with diagnostic or therapeutic intent and compared with data from the preceding 12-month period.

RESULTS

In the 12 months to April 2001, 518 cases were referred for ERCP; 140 underwent EUS and 378 underwent ERCP. The proportions of diagnostic and therapeutic ERCP were 14% and 86%, respectively. Benign biliary disease represented 33% of all referrals for EUS, and calculi were identified in 6% of these cases. During the preceding year, 637 ERCPs were performed. The proportion of diagnostic (33%) and therapeutic (67%) cases differed from the index year (P < 0.001).

CONCLUSIONS

The substitution of EUS for ERCP results in significant quantitative and qualitative change to ERCP practice, which has direct consequences for training and service development.

Efficacy and safety of endoscopic dilation of esophageal strictures in epidermolysis bullosa

BACKGROUND

Epidermolysis bullosa is a rare genetically determined disorder of the stratified squamous epithelium. Patients with the most severe forms develop scarring of the esophagus after ingestion of food. This results in dysphagia, which severely compromises the ability to eat. Maintenance of adequate nutritional intake is a central aim, but the most appropriate method is unknown.

METHODS

The results of endoscopic through-the-scope balloon dilation under propofol anesthesia in 53 patients with epidermolysis bullosa and esophageal strictures are reported.

RESULTS

Seventy-five percent of patients had a single stricture (range 1 to 6 strictures), most often in the proximal esophagus (median 20 cm from incisors). A total of 182 dilations were performed (median two per patient) over a median follow-up period of 3.5 years. For all but 3 patients, there was an improvement in the dysphagia score. There was a mean increase in weight after the procedure of 2.9 kg: 95% CI[2.0, 3.8]; p<0.001, over a median 29 days. There was no significant post-procedure morbidity.

CONCLUSIONS

Endoscopic balloon dilation is a safe and effective treatment for the esophageal strictures of epidermolysis bullosa. In the majority of patients, dilation relieves dysphagia and improves nutritional status.

Training in radial EUS: what is the best approach and is there a role for the nurse endoscopist?

BACKGROUND AND STUDY AIMS

The aim of this study was to determine the relative contribution of previous endoscopic experience, case observation, and hands-on experience to skill acquisition in radial EUS.

METHODS

In EUS trainees, four senior gastroenterology fellows, and a nurse endoscopist, the ability to reproduce set views from the mediastinum, stomach, and duodenum was assessed. Points were ascribed to static and dynamic stations and to the use of console controls.

RESULTS

Trainees observed 55 - 170 cases and conducted 25 - 124 examinations. Competence was demonstrated after performing approximately 25 examinations in the mediastinum, 35 examinations in the stomach, and 78 examinations in the duodenum. The number of previous examinations conducted correlated with the ability to scan the duodenum ( P < 0.01). Observation of 100 or more further procedures early in training did not accelerate learning. The nurse endoscopist showed a comparable degree of competence in mediastinal scanning to that of the other trainees after performing a similar number of examinations.

CONCLUSIONS

Proficiency in radial endosonography is greatly influenced by the numbers of examinations performed. Observing large numbers of cases early in training does not appear to translate into competence. A background in advanced therapeutic endoscopy is not a prerequisite for acquiring endoscopic ultrasound skills. Nurse endoscopists may be expected to train successfully in mediastinal imaging at the same pace as senior gastroenterology fellows.

Bone density improves with disease remission in patients with inflammatory bowel disease

BACKGROUND AND AIMS

Patients with inflammatory bowel disease (IBD) are at risk of low bone mineral density (BMD). The aim of this cross-sectional study was to investigate (i) whether patients with IBD in long-term remission have greater bone density relative to patients with active disease, (ii) the effect of remission on BMD in ulcerative colitis and Crohn's disease, and (iii) the effect of azathioprine treatment, used to induce remission, on BMD.

PATIENTS AND METHODS

BMD relative to the age-standardised mean (Z-score) was measured by dual-energy X-ray absorptiometry at the left femoral neck and lumbar spine in consecutive patients with IBD. Patients were divided into the following groups: (i) active disease, (ii) remission of less than one year, (iii) remission of one to three years, and (iv) remission of more than three years. Active disease was defined as three or more bowel motions per day, treatment with oral or rectal corticosteroids, and/or presence of a fistula. The subgroups with ulcerative colitis and Crohn's disease and the effect of taking azathioprine were compared. All results were controlled for confounding variables. RESULTS A total of 137 (64 ulcerative colitis, 73 Crohn's disease) patients were evaluated. Patients in remission for more than three years had a normal mean Z-score that was significantly higher than those with active disease at both the femoral neck and the lumbar spine for both ulcerative colitis and Crohn's disease. Patients taking azathioprine and in remission had significantly higher mean Z-scores at the lumbar spine than patients with active disease and who were not taking azathioprine.

CONCLUSION

In patients with ulcerative colitis and Crohn's disease, age-matched BMD is higher with increasing duration of disease remission and induction of remission by azathioprine.

Thiopurine methyltransferase activity and the use of azathioprine in inflammatory bowel disease

BACKGROUND

Azathioprine therapy is discontinued in one-third of patients with inflammatory bowel disease because of toxicity or a lack of clinical response. Patients with thiopurine methyltransferase (TPMT) deficiency are intolerant to azathioprine, whilst carriers are at increased risk of side-effects.

AIM

To evaluate the importance of TPMT activity in the management of azathioprine therapy in inflammatory bowel disease.

METHODS

Clinical response, adverse effects and haematological parameters were determined and correlated with TPMT enzyme activity and genotype in 106 patients with inflammatory bowel disease.

RESULTS

Ninety-six patients had high TPMT activity, and 10 had intermediate activity. Nineteen patients (18%) were intolerant to azathioprine. Fifteen (16%) of those with high TPMT activity were intolerant, compared with five (50%) with intermediate activity [odds ratio (OR), 5.4; 95% confidence interval (CI), 1.5-19.8]. Complete remission was achieved in 63% of cases, and complete or partial remission in 79%. Interestingly, very high TPMT activity (> 14 units/mL red blood cells) was significantly associated with non-response, irrespective of the time on azathioprine (OR, 0.21; 95% CI, 0.07-0.68). TPMT gene mutations correlated with TPMT activity.

CONCLUSIONS

Inflammatory bowel disease patients with intermediate TPMT activity have an increased risk of azathioprine toxicity. Conversely, very high TPMT activity predicts treatment failure. TPMT genotype predicted TPMT phenotype in this study.

Vancomycin and ceftazidime bioactivities persist for at least 2 weeks in the lumen in ports: simplifying treatment of port-associated bloodstream infections by using the antibiotic lock technique

The residual antibiotic concentration of vancomycin (2 mg/ml)- or ceftazidime (2 mg/ml)-heparin solutions instilled in ports in pediatric hematology-oncology patients 1 to 34 days earlier was measured. Antibiotic concentrations of > or = 100 microg of either antibiotic per ml persisted for at least 21 days. For treatment of lumenal port infections, antibiotic-heparin dwell times of > or = 2 weeks may be appropriate.

Variation in gut-homing CD27-negative lymphocytes in inflammatory colon disease

Prolonged antigenic stimulation results in lymphocyte shedding of CD27, a member of the tumour necrosis factor receptor (TNFR) family, and transformation to a stable phenotype capable of synthesizing interleukin-4 (IL-4). Co-expression of alpha4beta7 identifies those cells with gut-homing potential. We have investigated these cell populations in patients with inflammatory colonic disease. Circulating and lamina propria mononuclear cells were isolated from patients with Crohn's disease (CD), ulcerative colitis (UC), non-inflammatory bowel disease (non-IBD) colonic inflammation and healthy controls. Double and triple colour flow cytometry for CD3, CD4, CD27, alpha4beta7 and intracellular cytokines was performed. Circulating CD4+ CD27- populations were increased in patients with CD (8.8 +/- 0.8%, P < 0.001), UC (12.2 +/- 1.9%, P < 0.001) and non-IBD colitis (10.5 +/- 1.3%, P < 0.01) as compared with controls (6.1 +/- 0.5%). CD4+ CD27- alpha4beta7+ cells were increased in CD (P < 0.01). Lamina propria CD4+ CD27- populations were depressed significantly in CD (P < 0.05), UC (P < 0.02) and non-IBD colitis (P < 0.03). Mucosal CD4+ CD27- cells synthesized IL-4 in preference to interferon-gamma. Thus, colonic inflammation is associated with alterations in gut-tropic circulating and mucosal populations of differentiated memory T cells with the phenotype of predominantly IL-4-synthesizing cells.

Ferric trimaltol corrects iron deficiency anaemia in patients intolerant of iron

BACKGROUND

Oral iron supplements, which are usually in the form of ferrous (Fe2+) salts, are toxic to the gastrointestinal mucosa, and so intolerance is common, resulting in poor compliance and failure of treatment. The sugar derivative maltol strongly chelates iron, rendering it available for absorption and stabilized in the less toxic ferric (Fe3+) form.

AIM

To test whether ferric trimaltol could correct iron deficiency anaemia in patients intolerant of ferrous sulphate.

METHODS

Twenty-three patients were recruited from gastroenterology clinics, of whom 1 5 had inflammatory bowel disease, a group often difficult to treat with oral iron. Patients with iron deficiency anaemia and documented intolerance to ferrous sulphate were given 3 months of treatment with ferric trimaltol.

RESULTS

Nineteen of 23 patients completed the treatment and anaemia was fully corrected in 14 of these, mean haemoglobin increased from 106 +/- 15 to 126 +/- 16 g/L, and there was a particularly low incidence of side-effects. Of 11 patients with inflammatory bowel disease who completed the study, nine fully corrected their anaemia.

CONCLUSION

The results demonstrate that in patients intolerant of ferrous compounds, ferric trimaltol corrects iron deficiency and has a low incidence of side-effects.

Anti-inflammatory effect of interleukin-10 in rabbit immune complex-induced colitis

BACKGROUND

Interleukin-10 (IL-10) is an anti-inflammatory cytokine that downregulates the secretion of pro-inflammatory cytokines and additionally induces the secretion of anti-inflammatory cytokines, thus possibly leading to reduction of chronic inflammation in inflammatory bowel disease. In this study we evaluated the anti-inflammatory effect of IL-10 in a model of acute colitis in rabbits.

METHODS

Colitis was induced by rectal instillation of formalin, 0.65%, followed by intravenous infusion of 0.85 ml heat-aggregated rabbit immunoglobulin. Rabbits were treated with an intravenous bolus of recombinant human IL-10 (SCH52000), 100 microg/kg (n=14) or 500 microg/kg (n=14), 1 h before induction of colitis (control group, n=12).

RESULTS

High-dose IL-10 improved macroscopic scores of inflammation and decreased tissue myeloperoxidase levels and leukotriene B4 levels in dialysate fluid. Thromboxane B2 and prostaglandin E2 levels remained unaffected.

CONCLUSION

IL-10 ameliorates acute colitis in this model. Consequently, this anti-inflammatory cytokine may have a role in the therapy of acute inflammatory bowel disease.

Phenotypical characterization of cells in the thoracic duct of patients with and without systemic inflammatory response syndrome and multiple organ failure

The subset composition and recirculation properties of the migrating lymphocyte pool in humans is largely unknown. The present study was conducted in order to phenotypically characterize cells in human thoracic duct lymph of patients under non-inflammatory and inflammatory conditions. These data were compared with data from peripheral blood, with special emphasis on those cells homing to the gut. Thoracic duct lymph and peripheral blood contained comparable proportions of B and T lymphocytes and CD8+ cells. Thoracic duct lymph contained proportionally more CD4+ cells, more CD4+CD45RO+ that express alpha 4 beta 7 cells and more CD8+CD45RO+ that express alpha 4 beta 7, as compared to peripheral blood. These data suggest an equal recirculation rate of B and T lymphocytes; a more active recirculation of CD4+ cells compared to CD8+ cells; and a more active recirculation of memory cells to the gut as compared to other extra-lymphoid sites in patients under non-inflammatory conditions. Data were also obtained in patients with the system inflammatory response syndrome and multiple organ failure. Although it is generally assumed that granulocytes and monocytes do not recirculate, lymph of multiple organ failure patients contained significantly more granulocytes than monocytes, indicating that in severe generalized inflammatory states these cells re-enter the circulation through the thoracic duct. Furthermore, no increased activation of cells homing to the gut was found in these patients.

Epithelial cell folate depletion occurs in neoplastic but not adjacent normal colon mucosa

BACKGROUND & AIMS

Restricted folate supply is associated with the development of carcinoma, and folate supplements have a protective effect in colorectal carcinoma. This effect may be mediated through correction of local folate deficiency. The aim of this study was to define the folate content of neoplastic colonic epithelial cells and its relation to that of adjacent normal tissue and circulating levels.

METHODS

Epithelial cells were isolated from endoscopic biopsy specimens of normal, adenocarcinoma, adenoma, and adjacent normal colonic mucosa by ion chelation. Intracellular folate levels were determined by microbiological assay.

RESULTS

Folate levels in carcinoma specimens were lower than in adjacent normal tissue (P < 0.02). Levels in adenoma epithelial cells were lower than in adjacent normal tissue, although this did not reach statistical significance (P < 0.06). Epithelial cells from normal tissue and mucosa adjacent to tumors and adenomata had similar folate contents. Blood folate and vitamin B12 indices for all groups were normal.

CONCLUSIONS

Malignant colon epithelial cells show a relative localized folate deficiency. However, there is no evidence for the occurrence of generalized mucosal folate deficiency. This finding suggests that folate supplements do not inhibit carcinogenesis through correction of localized folate depletion.

Preferential expression of the mucosal homing receptor integrin alpha 4 beta 7 in gastrointestinal non-Hodgkin's lymphomas

Recent studies have identified the integrin alpha 4 beta 7 as a mucosal homing receptor that mediates lymphocyte migration to the intestinal mucosa by binding to MAdCAM-1, a vascular recognition molecule (addressin) selectively expressed on mucosal endothelium. In the present study, we have assessed the expression of alpha 4 beta 7 on B- and T-cell non-Hodgkin's lymphomas of different primary localization and on related normal lymphocytes. Among B-lineage lymphomas, expression of alpha 4 beta 7 was present in the majority of cases of malignant lymphomatous polyposis of the intestine and low-grade lymphoma of the mucosa-associated lymphoid tissue/monocytoid B-cell lymphoma and in some cases of precursor B-cell lymphoma. CLL/small lymphocytic lymphoma, (nodal) mantle cell lymphoma, follicular center cell lymphoma, Burkitt's lymphoma, and diffuse large B-cell lymphoma were virtually always alpha 4 beta 7 negative, as was the case when localized in the mucosa-associated lymphoid tissue. The normal B cells of the follicle mantles and part of the B cells of the extrafollicular B-cell compartment of lymphoid tissues expressed moderate levels of alpha 4 beta 7. By contrast, follicular center cells were alpha 4 beta 7 negative. Among T-lineage lymphomas, expression of alpha 4 beta 7 was also strongly related to the primary localization; in mucosal, nodal, and cutaneous T cell lymphomas the percentage of positive cases was 56%, 17%, and 0%, respectively. All cases of precursor T-cell lymphoma were alpha 4 beta 7 negative. High expression of alpha 4 beta 7 was found on a subset of peripheral blood memory T cells as well as on lymphocytes in the intestinal mucosa. We conclude that non-Hodgkin's lymphomas that are related to mucosa-associated B- and T-lymphocyte populations selectively express the mucosal homing receptor alpha 4 beta 7. The presence of this receptor underscores their distinctive character and may play an important role in determining their characteristic mucosal dissemination pattern.

Altered expression of alpha 4 beta 7, a gut homing integrin, by circulating and mucosal T cells in colonic mucosal inflammation

BACKGROUND AND AIMS

Expression of alpha 4 beta 7 on memory T lymphocytes identifies a cell population that preferentially migrates to the gut. Detection of alpha 4 beta 7 on circulating lymphocytes may permit the identification of specific subsets trafficking between the circulation and the gut in inflammatory bowel diseases.

PATIENTS

Samples and clinical details were taken from patients with Crohn's disease (CD), ulcerative colitis (UC), diverticulitis/ infectious colitis, and healthy controls.

METHODS

Peripheral blood and lamina propria mononuclear cells were isolated. Cells were labelled with CD3, CD4, CD25, CD45RO or alpha 4 beta 7.

RESULTS

Median levels of circulating total memory T cells (CD4+CD45RO+) were increased in CD (p < 0.01) and UC (p < 0.05). However, the proportion of systemic gut homing T cells (CD4+CD45RO+ alpha 4 beta 7+) was decreased in CD (p < 0.05), UC (p < 0.002), and inflammatory controls (p < 0.05). Levels of activated gut homing T cells (CD4+CD25+ alpha 4 beta 7+) were increased in CD (p < 0.01) and UC (p < 0.05). For both CD4+CD45RO+ and CD4+CD25+ cells, the proportion of lymphocytes coexpressing alpha 4 beta 7 was decreased compared with controls. In small and large intestine lamina propria, expression of alpha 4 beta 7+ on CD3+ cells was extensive, although it was decreased in CD (p < 0.03), UC (p < 0.05), and inflammatory controls (p < 0.05).

CONCLUSIONS

Circulating and mucosal gut homing lymphocyte populations are changed in patients with colonic inflammation. This may arise due to a dilution effect from recruited naive T cells, or from integrin down regulation. Changes in general CD4+ lymphocyte populations mask more subtle variations in those cells with gut homing potential.

Mediators of mucosal inflammation: implications for therapy

Treatment of inflammatory bowel disease remains a challenge. The major shortcoming in the development of new therapeutic approaches is the fact that the cause of inflammatory bowel disease is still unknown. Recognition of the importance of the arachidonic acid cascade of inflammatory mediators presents the opportunity to specifically inhibit or antagonize leukotriene B4, thromboxane, platelet activating factor, or phospholipase. Interleukins and cytokines have more recently been defined as targets for specific therapy. The results of these specific immune modulating studies are not only important from a therapeutic point of view, but substantially contribute to our understanding of the pathogenic cascades in IBD. In this review, several targets for novel therapeutic intervention are discussed.

Efficacy of recombinant granulocyte colony-stimulating factor (rhG-CSF) in experimental colitis

Inflammatory bowel disease is associated with mucosal neutrophil recruitment and activatation, mediated in part by arachidonic acid metabolites. G-CSF attenuates the immune response to sepsis and ameliorates glycogen storage disease Ib-related colitis. These actions may be effected through the shedding of neutrophil adhesion molecules, or inhibition of proinflammatory mediator synthesis. Immune complex colitis was used to evaluate the effect of rhG-CSF on colonic mucosal inflammation, neutrophil recruitment and the generation of eicosanoids. Immune complex colitis was induced in White New Zealand rabbits. Animals were pretreated with rhG-CSF either 24 h before induction, or at induction, with dosages of 50 and 200 micrograms/kg. rhG-CSF caused a time- and dose-dependent neutrophilia in all animals. Pretreatment with rhG-CSF resulted in increased tissue myeloperoxidase levels, despite a histologically similar mucosal polymorphonuclear cell infiltrate between treated and control colitis groups. Leukotriene B4 (LTB4) and thromboxane B2 (TXB2) dialysis fluid levels were lower in treated animals, in particular in the groups receiving two doses (LTB4: both P < 0.01; TXB2: both P < 0.01. Prostaglandin E2 (PGE2) levels in dialysis fluid of the rhG-CSF-treated animals showed no difference from controls. In this model of experimental colitis, high-dose therapy with G-CSF resulted in a marked decrease of proinflammatory mediators, but mucosal generation of the protective PGE2 was preserved. These results suggest that prolonged high-dose therapy with G-CSF may have anti-inflammatory effects in colitis.

Duodenal intraepithelial and lamina propria T lymphocytes in human immunodeficiency virus-infected patients with and without diarrhoea

BACKGROUND

Diarrhoea is an important problem in human immunodeficiency virus (HIV)-infected patients. Intestinal pathologic conditions may arise from changes in local immunocyte populations. The aims of our study were to establish the histologic features of the duodenal mucosa of HIV-infected patients and to determine a) the phenotype of small-intestinal-intraepithelial (IELs) and lamina propria (LPLs)-lymphocytes; b) their degree of activation and differentiation within the lamina propria; and c) their relation to the presence of diarrhoea.

METHODS

Distal duodenal biopsy specimens were obtained prospectively from 29 HIV-infected patients-11 patients with diarrhoea (group 1) and 18 patients without diarrhoea (group 2)- and from 42 patients who had neither any risk factor for HIV nor diarrhoea (group 3). Histopathologic and immunohistochemical studies were combined with flow cytometric analysis, after separation of the mucosal intraepithelial compartment from the lamina propria.

RESULTS

The median number of IELs and the percentage of gamma delta IELs were both unchanged in HIV-infected patients as compared with controls. In HIV-infected patients LP CD4 cells were decreased, and LP CD8 cells increased. No significant difference was found in the expression of CD25 or CD27 within the LP CD8 populations of HIV-infected patients in groups 1 and 2.

CONCLUSIONS

These findings suggest that the occurrence of diarrhoea in HIV-infected patients is unrelated to IEL and LPL phenotype.

Dieulafoy's disease: endosonographic detection and endosonography-guided treatment

BACKGROUND

To investigate whether endosonography can help in the detection and treatment of Dieulafoy's disease, we examined eight patients with suspicion of Dieulafoy's disease.

METHODS

Between December 1992 and April 1995, eight patients were referred because of suspicion of Dieulafoy's disease. Seven presented with upper gastrointestinal bleeding and one with a tiny ulcer. In all eight patients the stomach was examined with an Olympus GF-UM20 echoendoscope. The stomach was filled with 200 to 400 ml of water after which the body, fundus, and cardia were carefully visualized.

RESULTS

In all eight patients a clearly visible, relatively large caliber (2 to 3 mm) vessel was seen to penetrate the muscularis propria and could be followed running through the submucosa for 2 to 4 cm. Subsequently four patients received sclerotherapy, three under endosonographic guidance. Follow-up of all patients (median 10 months), showed recurrent bleeding in two patients, 3 and 5 months after sclerotherapy. One was then diagnosed with a duodenal ulcer and one with recurrent bleeding from the Dieulafoy's lesion.

CONCLUSIONS

Endosonography is useful in the detection of Dieulafoy's disease in patients with unexplained upper gastrointestinal bleeding. Sclerotherapy can be performed during the same procedure, with endosonography-guided injection of the sclerosing agent near the abnormal vessel.

Attenuation of the inflammatory response in an animal colitis model by neutrophil inhibitory factor, a novel beta 2-integrin antagonist

BACKGROUND

Neutrophils are significant effector cells in acute inflammatory bowel disease. Recruitment of these cells is dependent on beta 2-integrin-mediated adhesion and transmigration. The efficacy of neutrophil inhibitory factor (NIF), an antagonist of the beta 2-integrin CD11b/CD18, in ameliorating inflammation was tested in an animal model of acute colitis.

METHOD

Immune-complex colitis was induced in groups of rabbits by using various formalin concentrations (2%, 0.75%, and 0.5%). Animals were treated with rNIF, 10 mg/kg. After they had been killed the mucosal appearance was scored, and tissue saved for histology and quantitation of myeloperoxidase (MPO), leukotriene B4 (LTB4), prostaglandin E2 (PGE2), and thromboxane B2 (TXB2).

RESULTS

In the 2% formalin group therapy with rNIF resulted in lower LTB4 (p < 0.05) levels. For the 0.75% and 0.5% groups, MPO was lower with rNIF treatment (p < 0.03 and p < 0.05, respectively), as were LTB4 concentrations (both, p < 0.04). PGE2 and TXB2 levels remained unchanged. Histology showed polymorphonuclear cell infiltration to be reduced by rNIF in the 2% and 0.75% formalin-treatment groups (p < 0.05).

CONCLUSION

These results suggest that blockade of CD11b/CD18-mediated mucosal neutrophil recruitment may form part of a strategy for targeted therapeutic intervention in inflammatory bowel disease.

Lexipafant (BB-882), a platelet activating factor receptor antagonist, ameliorates mucosal inflammation in an animal model of colitis

OBJECTIVE

To assess the anti-inflammatory action of lexipafant (BB-882), a platelet activating factor antagonist, in an animal model of acute colitis.

DESIGN

An animal intervention study.

METHODS

Following the rectal instillation of formalin 0.75% into male New Zealand White (NZW) rabbits, 0.85 ml of aggregated immunoglobulin was administered i.v. Treatment groups (0.8 mg/kg, n = 6; 2.4 mg/kg, n = 13; 3.2 mg/kg, n = 10) were given bolus doses of BB-882 two-hourly i.v. (control group, n = 25). Rectal dialysis was performed before induction of colitis and sacrifice. Dialysate leukotriene B4 (LTB4), prostaglandin E2 (PGE2) and thromboxane B2 (TXB2) levels were determined. Tissue was saved for histology and measurement of myeloperoxidase content.

RESULTS

There was a dose-dependent improvement in macroscopic scores (2.4 and 3.2 mg/kg: P < 0.02, P < 0.001) and myeloperoxidase levels (3.2 mg/kg: P < 0.04). Dialysate LTB4 levels fell (2.4 and 3.2 mg/kg: P < 0.03, P < 0.02) as did PGE2 levels. TXB2 concentrations remained unaffected.

CONCLUSION

The PAF receptor antagonist BB-882 shows efficacy in treating inflammation in an animal model of acute colitis as evidenced by a dose-dependent fall in macroscopic mucosal damage, neutrophil infiltration and reduced generation of inflammatory mediators.

Soluble Fc gamma receptor III (CD 16) and eicosanoid concentrations in gut lavage fluid from patients with inflammatory bowel disease: reflection of mucosal inflammation

BACKGROUND

Activated neutrophils cause tissue injury in inflammatory bowel disease (IBD). Upon activation, they shed soluble Fc gamma IIIb receptors (sFc gamma RIIIb). The subsequent inflammatory response is modulated by several mediators, including neutrophil derived leukotriene B4 (LTB4), thromboxane B2 (TXB2), and prostaglandin E2 (PGE2). The aim of this study was to determine the value of gut lavage sFc gamma RIII and eicosanoid measurements for the assessment of mucosal inflammation in IBD.

METHODS

A total of 18 patients with active IBD, 10 ulcerative colitis (UC), and eight Crohn's disease (CD), and 12 control patients underwent whole gut lavage. Disease activity, endoscopic appearance, and histopathology were graded. Samples were processed for the determination of sFc gamma RIIIb, LTB4, PGE2, and TXB2.

RESULTS

Soluble Fc gamma RIIIb concentrations were increased in both IBD groups. Significant correlations were seen between sFc gamma RIIIb and LTB4 values with histology scores. Mean eicosanoid lavage fluid concentrations in control patients were 14.1 pg/ml for LTB4, 5.6 pg/ml for PGE2, and 397 pg/ml for TXB2. Concentrations of all eicosanoids in IBD patients were significantly increased: LTB4 in UC: mean 73.2 pg/ml, in CD: 96.4 pg/ml (both p < 0.01 v controls). PGE2 in UC: 20.2 pg/ml, in CD: 43.4 pg/ml (p < 0.01). TXB2 in UC: 719.3 pg/ml, in CD: 180.6 pg/ml (both p < 0.05).

CONCLUSIONS

Whole gut lavage fluid analysis is an effective method to study mucosal eicosanoid production. Soluble Fc gamma RIIIb concentrations in gut lavage fluid closely correlate with histological signs of mucosal inflammation and with lavage LTB4 concentration. These data suggest that lavage Fc gamma RIIIb assessment may be used as a simple assay to estimate mucosal neutrophil infiltration in IBD.