[Food bolus obstruction of the oesophagus or ingestion of a foreign body; what should you do?]

A food bolus obstruction of the oesophagus and foreign body ingestion are frequently encountered in common clinical practice. There is currently no guideline in the Netherlands for management of these problems. We present two cases to illustrate how these can be managed in line with European and American guidelines. The first patient was a 36-year-old female with total obstruction of the oesophagus by a food bolus. Biopsies taken following endoscopic removal showed eosinophilic infiltration of the mucosa and a subsequent diagnosis of eosinophilic oesophagitis. Symptoms resolved following medical treatment. The second patient, a 23-year-old male with psychomotoric retardation, presented following ingestion of a steel fork. The patient had a previous history of three laparotomies because of ingestion of a foreign body. Endoscopic removal was not possible, and a fourth laparotomy was performed to remove the fork. Food bolus obstruction is a gastroenterological emergency that warrants swift endoscopic removal. In cases of ingestion of a foreign body, the characteristics of the object must be taken into account when determining timing of endoscopic removal.

High detection rate of adenomas in familial colorectal cancer

BACKGROUND AND AIMS

Subjects with one first-degree relative (FDR) with colorectal cancer (CRC) <50 years old or two FDRs with CRC have an increased risk for CRC (RR 4-6). Current guidelines recommend colonoscopic surveillance of such families. However, information about the yield of surveillance is limited. The aim of the present study was to evaluate the outcome of surveillance and to identify risk factors for the development of adenomas.

PATIENTS AND METHODS

Subjects were included if they fulfilled the following criteria: asymptomatic subjects aged between 45 and 65 years, with one FDR with CRC <50 years old (group A) or two FDRs with CRC diagnosed at any age (group B). Subjects with a personal history of inflammatory bowel disease or colorectal surgery were excluded.

RESULTS

A total of 551 subjects (242 male) met the selection criteria. Ninety-five subjects with a previous colonoscopy were excluded. Two of 456 remaining subjects (0.4%) were found to have a colorectal tumour (one CRC and one carcinoid). Adenomas were detected in 85 (18.6%) and adenomas with advanced pathology in 37 subjects (8.1%). 30 subjects (6.6%) had multiple (>1) adenomas. Men were more often found to have an adenoma than women (24% vs 14.3%; p=0.01). Adenomas were more frequent in group B compared with group A (22.0% vs 15.6%; p=0.09).

CONCLUSION

The yield of colonoscopic surveillance in familial CRC is substantially higher than the yield of screening reported for the general population.

[Acute abdominal and back pain in a patient with an aortic aneurysm and a duodenum perforation on CT-scan]

An 82-year old man with a known aneurysm of the abdominal aorta (AAA) presented with a history of acute onset abdominal and back pain of a few hours. He was haemodynamically stable and had pain on pressure over the aneurysm. Ultrasound confirmed the AAA, but could not demonstrate or exclude rupture. Subsequent CT-scan confirmed a non-ruptured AAA and demonstrated a small, curvilinear, hyperdense structure thought to be a fish bone or chicken bone which had perforated the duodenum. On gastroduodenoscopy, a fish bone was found and removed. The patient's symptoms resolved completely within two days. In patients with a possible ruptured AAA, echographic or CT-scan investigations can confirm or exclude the condition thus avoiding unnecessary surgery. These investigations also gather preoperative data for potential endovascular reconstruction. Before the introduction of new visualization techniques a duodenum perforation resulting from the unnoticed swallowing of a sharp object could only be diagnosed by explorative laparotomy. Delay in diagnosis leads to high mortality.

Detection of ileocecal Crohn's disease using ultrasound as the primary imaging modality

At our hospital ultrasound (US) is used as an initial screening procedure in all patients with abdominal symptoms. The purpose of this study was to assess the effect of this policy on the detection of ileocecal Crohn's disease. We retrospectively studied all patients with a new diagnosis of ileocecal Crohn's disease from our institute over the period 1990-2001. The final diagnosis was based on clinical follow-up and pathological, surgical, US, and other radiological findings. We noted who referred the patient to the radiology department, what the initial clinical presumption was, and what the first imaging study was. US diagnoses were determined from the initial US report and US findings were registered from the images. There were a total of 47 patients (20 men, 27 women) with a mean age of 30 years and a median age of 27 years (range 14-75 years). In all patients the initial imaging study was an abdominal US. Using US, a confident diagnosis of ileocecal Crohn's disease was made in 35 of the 47 patients, Crohn's disease was suggested among the differential diagnosis in 10, and an incorrect diagnosis was made in 2 patients. In 28 of 47 patients, the referring physician did not consider Crohn's disease when requesting the initial US examination. In eight patients with appendicitis-like symptoms, the US findings strongly influenced the decision to refrain from operation at that point in time. US, when used as a low-threshold diagnostic procedure, is a reliable and noninvasive means for making an early diagnosis of ileocecal Crohn's disease in patients who present with atypical symptoms. It may prevent both unnecessary therapeutic delay as well as unnecessary surgery.

A Gly15Arg mutation in the interleukin-10 gene reduces secretion of interleukin-10 in Crohn disease

BACKGROUND

Genetic susceptibility, probably involving cytokines and their receptors, plays an important role in inflammatory bowel disease (IBD). In this study we examine the potential role of the interleukin-10 (IL-10) gene as a susceptibility gene in IBD.

METHODS

We studied 17 sib-pairs with either Crohn disease (CD) or ulcerative colitis. After microsatellite analysis for allele-sharing, the IL-10 gene of sib-pairs who shared alleles was screened for nucleotide alterations in and around exons and the promoter region. The IL-10 promoter polymorphism at position -1082 was also determined. Function was evaluated by measuring IL-10 secretion by peripheral blood mononuclear cells stimulated with lipopolysaccharide or phorbol ester. The activity of recombinant immature wild-type and mutated IL-10 was tested in a proliferation assay with a human monocytic leukaemia cell line (HL60 cells).

RESULTS

DNA sequencing revealed a G --> A point mutation in exon 1 at base position 43 in one sib-pair, both affected with CD. It was also found in 2 of their healthy siblings, but not in 75 unrelated healthy controls. This mutation results in a glycine to arginine substitution at amino acid position 15 of the leader sequence (Gly15Arg). The in vitro IL-10 secretion by mononuclear cells of the IL-10 Gly15Arg carriers was about 50% of healthy controls, matched for the -1082 polymorphism in the IL-10 promoter region. Incubation of HL60 cells with recombinant mutated IL-10 showed a markedly reduced cell proliferation compared to wild-type IL-10.

CONCLUSION

A Gly15Arg mutation in the leader sequence of IL-10 was found in a multiple CD-affected family. This altered leader sequence decreases IL-10 secretion, thereby reducing the anti-inflammatory effect.

A Gly15Arg mutation in the interleukin-10 gene reduces secretion of interleukin-10 in Crohn disease

BACKGROUND

Genetic susceptibility, probably involving cytokines and their receptors, plays an important role in inflammatory bowel disease (IBD). In this study we examine the potential role of the interleukin-10 (IL-10) gene as a susceptibility gene in IBD.

METHODS

We studied 17 sib-pairs with either Crohn disease (CD) or ulcerative colitis. After microsatellite analysis for allele-sharing, the IL-10 gene of sib-pairs who shared alleles was screened for nucleotide alterations in and around exons and the promoter region. The IL-10 promoter polymorphism at position -1082 was also determined. Function was evaluated by measuring IL-10 secretion by peripheral blood mononuclear cells stimulated with lipopolysaccharide or phorbol ester. The activity of recombinant immature wild-type and mutated IL-10 was tested in a proliferation assay with a human monocytic leukaemia cell line (HL60 cells).

RESULTS

DNA sequencing revealed a G --> A point mutation in exon 1 at base position 43 in one sib-pair, both affected with CD. It was also found in 2 of their healthy siblings, but not in 75 unrelated healthy controls. This mutation results in a glycine to arginine substitution at amino acid position 15 of the leader sequence (Gly15Arg). The in vitro IL-10 secretion by mononuclear cells of the IL-10 Gly15Arg carriers was about 50% of healthy controls, matched for the -1082 polymorphism in the IL-10 promoter region. Incubation of HL60 cells with recombinant mutated IL-10 showed a markedly reduced cell proliferation compared to wild-type IL-10.

CONCLUSION

A Gly15Arg mutation in the leader sequence of IL-10 was found in a multiple CD-affected family. This altered leader sequence decreases IL-10 secretion, thereby reducing the anti-inflammatory effect.

Interleukin-2-Deficient mice: effect on cytokines and inflammatory cells in chronic colonic disease

Mice deficient in interleukin-2 (IL-2-/-) develop inflammatory bowel disease resembling human ulcerative colitis. After death, macroscopic and microscopic scores were used to determine colonic inflammation. Both scores were significantly increased in the colon of IL-2-/- mice as compared to wild types mice. The level of IL-1beta 24-week-old was increased in IL-2-/- mice produced by the colon as compared with IL-2+/+ controls. However, the concentrations of IL-6 and IL-10 were not changed. The spleen weight of IL-2-/- mice was significantly increased compared with IL-2+/+ controls. We used immunochemical techniques in low-temperature paraffin-embedded spleen of IL-2-/- mice to examine pathological changes of CD4+ T cells, CD8' T cells, and CD11b+ cells. The tissue was successfully stained and was well preserved. The percentage CD4+ T cells was not significantly changed, while the percentage CD8+ T cells was significantly decreased in IL-2-/- mice compared with IL-2+/+ controls. On the other hand, the percentage CD11b+ cells was significantly increased in the spleen of IL-2-/- mice compared with IL-2+/- controls. As well as the marked difference in CD8+ and CD11b+ cells in the spleen, the increased level of IL-1beta in colonic tissue might indicate that cytotoxic T cells as well as macrophages are involved in the development and/or perpetuation of the inflammatory reactions in IL-2-/- mice.