Azathioprine in the maintainance remission in inflammatory bowel disease patients: 7-year follow up

Background

Azathioprine (AZA) and thiopurine are widely used for induction and maintenance of remission in steroid dependent patients with inflammatory bowel disease (IBD).

Methods

Aim of this study has been to investigate its efficacy and safety in maintaining steroid-free remission in steroid dependent IBD patients seven year after the institution of treatment. Data from consecutive IBD outpatients referred in our Institution, between 1985-2016, were reviewed and all patients treated with AZA were included in this retrospective study. AZA was administered at the recommended dose of 2-2.5 mg/kg.

Results

Out of 2802 consecutive IBD outpatients visited in the index period, AZA was prescribed to 433 patients, 236 (54.5%) were affected by Crohn's disease (CD) and 197 (45.5%) by ulcerative colitis (UC). One hundred and seventy-nine patients with a follow-up < 84 months were excluded from the study. Two hundred and fifty-four patients were evaluated, 141 (55.5%) with CD and 113 (44.5%) with UC. One hundred and thirty-nine (54.7%) were male and 115 (45.3%) female (average age of 35.62 ± 14.20 SD years, range 14-74 y.). Seven year after the institution of treatment, 127 (50%) patients still were in steroid-free remission (83 CD vs 44 UC, 58.8% and 38.9%, respectively, p = 0.0024), 71 (27.9%) had a relapse requiring retreatment with steroids (29 CD vs 42 UC, 20.6% and 37.2%, respectively, p = 0.0047), 56 (22.1%) discontinued the treatment due to side effects (29 CD vs 27 UC, 20.6% and 23.9%, respectively). Loss of response from 1st to 7th year of follow-up was low, about 20%.

Conclusions

Seven year after the onset of treatment 50% of patients did not require further steroid courses. After the first year loss of response was low in six subsequent years. In the present series the maintenance of steroid-free remission was significantly higher in CD than in UC patients. The occurrence of side effects leading to the withdrawal of AZA treatment has been low.

Key messages

An important therapeutic moment of IBD is mantaining remission in steroid dipendent patients. AZA can be a viable and inexpensive alternative to treath these patients.

Patient with chest pain refractory to proton pump inhibitor: report of a case of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is the most common form of gastrointestinal disorders associated with eosinophilia. Typically, an inappropriate accumulation of eosinophils is found in the esophageal mucosa. EoE can be well managed and treated with several options that include an elimination diet, drug therapy (oral and topical steroids) and esophageal dilatations. We herein, report a case of a 49-year-old male affected by EoE associated to chest pain, treated with proton pump inhibitor without clinical response. The patient suffered from long lasting postprandial fullness and gastroesophageal reflux disease-like symptoms. He had a history of episodic asthmatic attacks and allergic rhinitis but had not dysphagia or food impaction. The patient recovered completely after an adequate treatment.

Azathioprine treatment in inflammatory bowel disease patients: type and time of onset of side effects

BACKGROUND

Azathioprine (AZA) and 6-mercaptopurine (6-MP), purine analogues, are the immunosuppressant drugs most frequently used for inducing and maintaining remission in inflammatory bowel disease (IBD). The occurrence of adverse effects is a major drawback in the use of these drugs, and short- and long-term toxicity represent a major limitation to their use.

AIM

The present study investigated the prevalence, type and time of onset of AZA-related adverse events, in a cohort of IBD patients in a single referral Centre.

PATIENTS AND METHODS

The records of consecutive IBD outpatients, referred to our Institution between 1987-2009, were retrospectively evaluated.

RESULTS

We reviewed 2014 patients, in whom AZA was prescribed in 302 of them, 139 (46%) with ulcerative colitis (UC) and 163 (54%) with Crohn's disease (CD). Side-effects were complained by 98 (32.4%) out of 302 patients, 50 UC and 48 CD, (36% UC vs 29.4% CD, p = 0.26). In 20 (20.4%) patients, 11 UC and 9 CD, side-effects recovered after dosage reduction whilst in 78 (79.6%), 39 UC and 39 CD, the treatment was discontinued (dose-dependent side-effects in 42 patients and dose-independent in 36). Overall, side-effects were observed after a mean period of 14.5 ± 7.8 months (range 0.5-123) of AZA treatment. The majority (76%) of the dose-dependent adverse events were reported between 12-18 months after the beginning of treatment.

CONCLUSIONS

The prevalence of side effects leading to withdrawal of AZA treatment, in our series of Italian patients, was higher respect to data reported in the literature (25.8%).

Hydrogen breath test--diet and basal H2 excretion: a technical note

BACKGROUND

Hydrogen breath tests are widely used in clinical practice. For a correct evaluation of data, low basal H2 excretion is required, thus, 12-hour fasting is usually prescribed. An additional reduction in the intake of complex carbohydrates in the preceding 24 h is suggested in some centers. The issue, however, has never been directly investigated.

AIM

The aim of the present study was to analyze the effect of the pretest diet on the basal H2 excretion and the number of subjects excluded from the test due to high basal H2 excretion.

METHODS

Two cohorts of 500 consecutive patients undergoing a lactose tolerance test in the years 1997-1998 (when 12-hour fasting was required) and in 2007-2008 (when a low-carbohydrate diet in the preceding 24 h was also prescribed) were retrospectively reviewed.

RESULTS

The mean basal H2 excretion was significantly lower (p < 0.0001) in the low-carbohydrate diet group (2.46 +/- 6.8 vs. 4.73 +/- 3.3 ppm). In 1997-1998, 46/500 patients (9.2%) were excluded from the test due to basal H2 values as compared to 7/500 (1.4%) in the period 2007-2008.

DISCUSSION

To the best of our knowledge, ours is the first study to provide objective data on the advantage offered by reducing the intake of complex carbohydrates before H2 breath tests.

Methodology and indications of H2-breath testing in gastrointestinal diseases: the Rome Consensus Conference

BACKGROUND

Breath tests represent a valid and non-invasive diagnostic tool in many gastroenterological conditions. The rationale of hydrogen-breath tests is based on the concept that part of the gas produced by colonic bacterial fermentation diffuses into the blood and is excreted by breath, where it can be quantified easily. There are many differences in the methodology, and the tests are increasingly popular.

AIM

The Rome Consensus Conference was convened to offer recommendations for clinical practice about the indications and methods of H2-breath testing in gastrointestinal diseases.

METHODS

Experts were selected on the basis of a proven knowledge/expertise in H2-breath testing and divided into Working Groups (methodology; sugar malabsorption; small intestine bacterial overgrowth; oro-coecal transit time and other gas-related syndromes). They performed a systematic review of the literature, and then formulated statements on the basis of the scientific evidence, which were debated and voted by a multidisciplinary Jury. Recommendations were then modified on the basis of the decisions of the Jury by the members of the Expert Group.

RESULTS AND CONCLUSIONS

The final statements, graded according to the level of evidence and strength of recommendation, are presented in this document; they identify the indications for the use of H2-breath testing in the clinical practice and methods to be used for performing the tests.

Effect of predominant methanogenic flora on the outcome of lactose breath test in irritable bowel syndrome patients

BACKGROUND

The relationship between hydrogen and methane production is a possible confounding factor in the interpretation of H(2) breath tests (HBT), but is usually disregarded for the interpretation of HBT and, in most instances, only H(2) excretion is measured. The present study was designed to evaluate the effect of predominant fasting methane CH(4) or H(2) production on the outcome of lactose HBT, in a large, homogeneous series of adult patients with irritable bowel syndrome (IBS).

PATIENTS AND METHODS

A lactose HBT was performed in 237 IBS patients with predominant fasting methane production (CH(4)>H(2)), recording the outcome of the test, amount of gas excreted and occurrence of clinical symptoms. Data were compared to those of 237 age- and sex-matched IBS patients with low fasting CH(4) excretion.

RESULTS

The test was positive in 124 predominant CH(4) producers (52.3%) (PMP), as compared to 201 (84.8%) low methane producers (LMP) (P<0.0001). Peak hydrogen concentration and area under the curve of H(2) were significantly (P<0.001) lower, and the occurrence of symptoms during the test less frequent, in PMP vs LMP patients. During the test, CH(4) excretion doubled in 57/113 (50.4%) patients with negative HBT, and in 49/124 (39.5%) with positive HBT.

CONCLUSIONS

Patients with predominant fasting methane production excrete less H(2) than LMP, after an oral load of lactose. The lower prevalence of severe lactose intolerance in PMP, as well as lower incidence of symptoms during the test, is, indeed, related to lower and slower H(2) excretion. The assumption that H(2) excretion is an effective means of quantifying the amount of malabsorbed carbohydrates is questionable in PMP. Methane-producing patients likely have a higher 'false negative' rate as compared to LMP after an oral load of lactose. Nonetheless, as symptoms are related to the amount of gas produced in the colon, HBT identifies patients with 'lactose intolerance', irrespective of the presence of lactose malabsorption, and helps in predicting the effect of lactose-restricted diet.

Infliximab in refractory pouchitis complicated by fistulae following ileo-anal pouch for ulcerative colitis

AIM

To determine the efficacy of infliximab in the treatment of chronic refractory pouchitis complicated by fistulae following ileal pouch-anal anastomosis for ulcerative colitis.

METHODS

This open study included seven patients (four females, three males) with chronic refractory pouchitis complicated by fistulae. Pouchitis was diagnosed by clinical, endoscopic and histological criteria. The sites of the fistulae were as follows: pouch-bladder in one, vaginal in three, perianal in two, and both vaginal and perianal in one. Extra-intestinal manifestations (erythema nodosum, arthralgia) were present in four patients. Crohn's disease was carefully excluded in all patients after re-evaluation of the history, re-examination of the original proctocolectomy specimen and examination of the proximal small bowel. All patients had been treated with antibiotics and three with steroids. Patients received infliximab, 5 mg/kg, at 0, 2 and 6 weeks. Azathioprine (2.5 mg/kg) was also started for all patients as bridge therapy. Clinical response was classified as complete, partial or no response. Fistulae closure was classified as complete (cessation of fistulae drainage and total closure of all fistulae), partial (a reduction in the number, size, drainage or discomfort associated with fistulae) or no closure. The pouchitis disease activity index and quality of life were also used as outcome measures.

RESULTS

Clinically, all patients improved. At the 10-week follow-up, six of the seven patients had a complete clinical response, and five had complete fistulae closure. At the 10-week follow-up, the median pouchitis disease activity index decreased from 12 (baseline) (range, 10-15) to 5 (range, 3-8); the median quality of life decreased from 37 points (range, 33-40) to 14 (range, 9-18). Erythema nodosum and arthralgia showed complete remission soon after the first infusion of infliximab.

CONCLUSIONS

These preliminary results indicate that infliximab may be recommended for the treatment of refractory pouchitis complicated by fistulae following ileal pouch-anal anastomosis for ulcerative colitis.

Infliximab in refractory pouchitis complicated by fistulae following ileo-anal pouch for ulcerative colitis

AIM

To determine the efficacy of infliximab in the treatment of chronic refractory pouchitis complicated by fistulae following ileal pouch-anal anastomosis for ulcerative colitis.

METHODS

This open study included seven patients (four females, three males) with chronic refractory pouchitis complicated by fistulae. Pouchitis was diagnosed by clinical, endoscopic and histological criteria. The sites of the fistulae were as follows: pouch-bladder in one, vaginal in three, perianal in two, and both vaginal and perianal in one. Extra-intestinal manifestations (erythema nodosum, arthralgia) were present in four patients. Crohn's disease was carefully excluded in all patients after re-evaluation of the history, re-examination of the original proctocolectomy specimen and examination of the proximal small bowel. All patients had been treated with antibiotics and three with steroids. Patients received infliximab, 5 mg/kg, at 0, 2 and 6 weeks. Azathioprine (2.5 mg/kg) was also started for all patients as bridge therapy. Clinical response was classified as complete, partial or no response. Fistulae closure was classified as complete (cessation of fistulae drainage and total closure of all fistulae), partial (a reduction in the number, size, drainage or discomfort associated with fistulae) or no closure. The pouchitis disease activity index and quality of life were also used as outcome measures.

RESULTS

Clinically, all patients improved. At the 10-week follow-up, six of the seven patients had a complete clinical response, and five had complete fistulae closure. At the 10-week follow-up, the median pouchitis disease activity index decreased from 12 (baseline) (range, 10-15) to 5 (range, 3-8); the median quality of life decreased from 37 points (range, 33-40) to 14 (range, 9-18). Erythema nodosum and arthralgia showed complete remission soon after the first infusion of infliximab.

CONCLUSIONS

These preliminary results indicate that infliximab may be recommended for the treatment of refractory pouchitis complicated by fistulae following ileal pouch-anal anastomosis for ulcerative colitis.

Topical butyrate improves efficacy of 5-ASA in refractory distal ulcerative colitis: results of a multicentre trial

BACKGROUND

The treatment of distal ulcerative colitis, refractory to conventional 5-ASA/steroid treatment, is still a matter of debate. The present study aimed at confirming, with adequate statistical power, previous data indicating the usefulness of topical butyrate and 5-ASA in the treatment of this condition.

DESIGN

Double-blind, placebo-controlled, multicentre study. A total of 51 patients with distal (< 65 cm) ulcerative colitis, refractory to topical 5-ASA/cortisone, were randomly allocated to receive topical 5-ASA 2 g and 80 mM L-1 sodium-butyrate bid (Group A; 24 patients) or 5-ASA 2 g and 80 mL saline bid (Group B; 27 patients) for 6 weeks. Sigmoidoscopy with biopsies, as well as clinical and laboratory evaluations, were carried out at enrollment and at the end of the trial. Primary endpoints: remission or marked improvement in endoscopic, histologic and clinical findings.

RESULTS

Most parameters showed a significant improvement vs. baseline in both groups. Remission in six patients and improvement in 12 patients in Group A vs. one remission and 13 with improvement in Group B (P < 0.05). A significant difference in favour of Group A was recorded regarding the number of bowel movements (P < 0.01), urgency (P < 0.05) and the patients' self evaluation (P < 0.01).

DISCUSSION

The combined treatment with topical butyrate and 5-ASA is significantly more effective than 5-ASA alone in the management of refractory distal colitis. Further improvements in the treatment of refractory distal ulcerative colitis may be feasible based on the identification of patient subgroups and the association of two or more active drugs. Butyrate may well be one of them.

Lactose malabsorption, irritable bowel syndrome and self-reported milk intolerance

BACKGROUND

The relationship between lactose malabsorption, irritable bowel syndrome and development of intestinal symptoms is unclear, especially when the ingested dose of milk is small. Thus, the role of hydrogen breath testing in the diagnostic work-up of patients with nonspecific intestinal symptoms is still debated.

AIMS

To establish the relationship between lactose malabsorption, severe self-reported milk intolerance, irritable bowel syndrome and related symptoms.

METHODS

The prevalence of lactose malabsorption was prospectively assessed by means of a hydrogen breath test in 839 patients (503 with irritable bowel syndrome, based on the Rome criteria, regularly consuming milk, and 336 subjects who identified themself as milk intolerant, after an oral load of 25 g lactose). The test was considered "positive" when a hydrogen peak exceeding 20 ppm over baseline values was observed in two or more samples. Attempts were also made to establish whether the predominant presenting symptom (diarrhoea, constipation, alternating diarrhoea and constipation, pain and gaseousness) might be helpful in predicting the outcome of the breath test.

RESULTS

The prevalence of a positive breath test was comparable in the two groups (337 patients with irritable bowel syndrome (66.9%) vs 240 patients with milk intolerance (71.4%)). The same holds true for the first peak of hydrogen excretion, total hydrogen output and prevalence of symptoms during, and in the four hours after, the test. The predominant presenting symptom was not useful for predicting outcome of the test either in regular milk users or in milk intolerant subjects.

CONCLUSIONS

The almost identical results of the lactose breath test of patients with irritable bowel syndrome and subjects with self-reported milk intolerance suggests that the two conditions overlap to such an extent that the clinical approach should be the same. A lactose breath test should always be included in the diagnostic work-up for irritable bowel syndrome, as fermentation of malabsorbed lactose is likely responsible for triggering symptoms. Conversely, lactase deficiency is probably irrelevant in most subjects not affected by irritable bowel syndrome, within a moderate milk consumption.

Topical butyrate for acute radiation proctitis: randomised, crossover trial

BACKGROUND

No available therapy has, as yet, proven effective to treat acute radiation proctitis (ARP) following radiation therapy for malignant pelvic disease. We assessed whether sodium butyrate enemas, at a dose of 80 mmol/L (80 mL/24 h), might offer effective treatment for this condition.

METHODS

20 patients presenting with ARP after completing a cycle of 35-52 Gy external-beam radiation therapy for pelvic malignant disease, were treated for 3 weeks with topical sodium butyrate and saline enemas according to a randomised, double-blind, crossover protocol. Clinical, endoscopic, and histological findings were assessed at enrollment, at week 3, and then at the end of the study. Data were analysed by two-tailed t test for paired data (continuous variables) and a logistic-regression model with variable multiple response for ordered categorical data.

FINDINGS

Topical butyrate, but not saline, led to remission of symptoms (clinical score from 8.2 [SE 1.6] to 1.5 [0.7] vs 7.9 [1.8] to 8.1 [3.4]). When the treatment regimen was switched, eight out of nine of the previously placebo-treated patients went into remission, whereas three patients relapsed when switched to saline. The advantage of butyrate over placebo, expressed as CI, odds ratio, and p value was significant for almost all the clinical, endoscopic and histological factors taken into consideration.

INTERPRETATION

Topical sodium butyrate, unlike other therapeutic regimens used so far, proved effective in the treatment of ARP.

Combined oral sodium butyrate and mesalazine treatment compared to oral mesalazine alone in ulcerative colitis: randomized, double-blind, placebo-controlled pilot study

Butyrate represents the main source of energy for colonic epithelial cells; however, its availability/utilization is impaired in ulcerative colitis (UC). In the present randomized, double-blind, placebo-controlled pilot study, the safety and efficacy of colonic targeted oral sodium butyrate tablets, coated with a pH-dependent soluble polymer, have been evaluated in ulcerative colitis. Thirty patients with mild to moderate colitis underwent a six-week course of oral sodium butyrate (4 g/day) plus oral mesalazine (2.4 g/day), (Group A) or of oral mesalazine plus placebo (Group B). Clinical, endoscopic, and histologic data were collected at the beginning and the end of the study. Twenty-five patients completed the study (12 in group A, 13 in group B). No untoward side effects were reported. In group A, seven patients underwent remission and four improved; in Group B the numbers were 5 and 5, respectively. After treatment, all clinical parameters had significantly improved in both treatment arms compared to pretreatment findings. The UC disease activity index (UCDAI) score decreased from 7.27 +/- 2.02 to 2.58 +/- 2.19 (P < 0.05) in the combined treatment group and from 6.07 +/-1.60 to 3.46 +/- 1.98 (P < 0.05) in group B. The endoscopic and histologic scores also significantly improved after treatment in both groups (P < 0.05). The difference between the two treatment arms was not significant, but a significantly better improvement vs baseline values (P < 0.05) was observed in the combined treatment group vs the mesalazine group, when considering both the clinical index (delta9.58 +/- 4.19 vs 5.92 +/- 3.48) and the UCDAI score (delta4.67 +/- 2.19 vs 2.54 +/- 2.18). A more favorable trend, although not significant, was observed for all individual parameters in group A. In conclusion, results of the present pilot study indicate that oral butyrate is safe and well tolerated. These data also suggest that oral butyrate may improve the efficacy of oral mesalazine in active ulcerative colitis and prompt the need of a large scale investigation to confirm the present findings.

Multiple organ dysfunction in ulcerative colitis

OBJECTIVE

The mortality rate in severe ulcerative colitis (UC) is commonly attributed to major colonic complications or surgical procedures. Early recognition of the severity of the colitis, intensive medical treatment, and prompt surgery have all contributed to improving its outcome over the past 40 yr. Recently, we have observed some fatal cases of severe UC in which death was related to multiple organ dysfunction syndrome (MODS). This complication, associated with a very high mortality rate, may occur in several acute critical diseases, both infectious and noninfectious, but has so far not been reported in UC. The aim of this study was to evaluate the prevalence and outcome of MODS in severe UC.

METHODS

The records of 180 consecutive patients admitted to the Gastrointestinal Unit, University of Rome for an acute severe attack of UC during the period 1976-1998 were retrospectively analyzed. Severity of UC was defined according to the criteria of Truelove and Witts. MODS was defined according to the original criteria of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference 1992. All patients were on a standard intensive regimen consisting of total parenteral nutrition and hydrocortisone 100 mg q.i.d. Colectomy was performed according to the timing of the Oxford intensive regimen.

RESULTS

Of these 180 severe UC patients, 11 (6.1%) experienced clinical and laboratory features of MODS. The lung was involved in five patients, the kidney in three, the liver in seven, the central nervous system in three, the hematological system in three, and the pancreas in one. MODS was preceded by toxic megacolon in five patients and by so-called "impending megacolon" in four, whereas in two patients no previous complications of UC were observed. MODS developed during the first attack of colitis in seven patients and during relapse in four. The overall mortality rate was 12/180 (6.6%). Of the 12 patients who died, eight (72.7%) had MODS.

CONCLUSIONS

These data indicate that UC must be included among the causes of MODS. In our referral center for inflammatory bowel diseases, MODS was responsible for the majority of UC cases with a fatal outcome. The timely identification of signs of MODS should prompt admission to an intensive care unit and emergency surgery.

Effect of rifaximin on intestinal bacterial overgrowth in Crohn's disease as assessed by the H2-Glucose Breath Test

The occurrence of intestinal bacterial overgrowth in patients with Crohn's Disease (CD) has been described and antimicrobial treatment has been shown to be effective in reversing this condition. However, the mechanisms underlying the efficacy of antimicrobial therapy are still only partially known. The aim of the present study was to evaluate the effect of a non-absorbable antibiotic (rifaximin) in comparison to placebo on bacterial overgrowth in patients with CD.

METHODS

Fourteen patients with inactive CD of the ileum and bacterial overgrowth, as assessed by the hydrogen breath test, were blindly allocated to receive rifaximin (1200 mg/day) or placebo t.i.d. for one week. A hydrogen breath test, and clinical and biochemical parameters were further performed 14 days and 30 days after starting treatment.

RESULTS

After 14 days, the hydrogen breath test proved to be negative in seven out of seven patients treated with rifaximin (p < 0.05), and in two out of seven in the placebo group (p = ns). After 30 days, the hydrogen breath test was positive in all patients of the rifaximin and placebo group, respectively. No changes in the CDAI score were documented in any patients.

CONCLUSIONS

Short-term administration of rifaximin is effective in the therapy of bacterial overgrowth in patients with inactive CD of the ileum, thus suggesting that the control of luminal bacterial growth could be useful in the management of these patients. However, since we observed a decline with time in this positive effect, further studies are needed to identify the most appropriate therapeutic strategies.

Circulating soluble factor-inhibiting natural killer (NK) activity of fresh peripheral blood mononuclear cells (PBMC) from inflammatory bowel disease (IBD) patients

This study was performed in order to assess the cytotoxic activity, both natural (NK) and antibody-dependent (ADCC), of PBMC from 38 IBD patients and correlate it with their clinical features. Cytotoxicity assays were performed using sensitive target cells for NK and ADCC activities. In some experiments, highly purified NK cells, obtained both by Percoll density gradient and by co-culturing non-adherent PBMC with RPMI 8866 feeder cells, were used as effector cells. Furthermore, we evaluated NK cell parameters such as number, surface expression of adhesion molecules (CD11a/CD18, CD49d and CD54) and response to different stimuli. We observed a decreased NK cytotoxicity of PBMC from IBD patients, both in ulcerative colitis (UC) and Crohn's disease (CD), independently of the clinical activity of disease. In contrast, the ADCC lytic activity was within normal range. The lower NK cytotoxic activity observed in our IBD patients cannot be related to a decreased number of NK cells, surface expression of adhesion molecules, defective response to IL-2 and maturative defect. Decreased NK activity was induced in PBMC of controls when serum of patients was added and this was unrelated to monocyte-derived modulating factor(s). Our data show a decreased natural killing by fresh PBMC from IBD patients. This lower activity seems to be unrelated to a primary NK cell defect, since purified NK cells exhibited normal levels of killing. It might be hypothesized that serum factors, possibly derived from lymphocytes, with inhibitory properties on NK activity, might be functionally active in the blood of IBD patients, thus modulating NK activity.

Quantitative analysis of stool losses in adult celiac disease: use of near-infrared analysis reconsidered

BACKGROUND

An attempt has been made to establish whether near-infrared stool analysis is more suitable for quantifying malabsorption than the traditional stool fat analysis. A group of celiac disease (CD) patients was used as index population.

METHODS

Stool fat, nitrogen, and water were measured with near-infrared analysis of 1- and 3-day stool collections in 96 celiac disease patients on a free diet (in 39 also on gluten-free diet) and in 96 matched controls and 14 patients with latent CD.

RESULTS

The fecal output of fat, nitrogen, and water was significantly increased in free-diet CD, whereas their percentage content was only slightly modified compared with controls. None of the variables under consideration differed significantly between the 24-h and 72-h stool specimens.

CONCLUSION

Our data show that the high value of fecal fat, nitrogen, and water, in celiac disease, are mainly due to the fecal weight, whereas the percentage composition of stool does not offer additional diagnostic information. Furthermore, 3-day stool collection is not necessary to confirm or rule out malabsorption in most patients. Near infrared analysis of 24-h specimens is time- and cost-effective and may increase the use of stool analysis and be usefully employed to monitor the clinical follow-up of patients with chronic diarrhea.

Serum levels of soluble CD30 are increased in ulcerative colitis (UC) but not in Crohn's disease (CD)

Imbalance in Th1 and Th2 subsets and their derived cytokines seems to be involved in the immune abnormalities underlying UC and CD. CD30 is a member of the tumour necrosis factor/nerve growth receptor superfamily expressed on T cells producing Th2 cytokines and released as a soluble form. In this study high levels of soluble CD30 were found in sera of UC patients independently of disease activity. Furthermore, increased titres of soluble CD30 molecule were shown, in the same patients, by mitogen-stimulated cultures of peripheral blood mononuclear cells. Our data seem to indicate that an activation of Th2 immune response is involved in the pathogenesis of UC, but not of CD. Furthermore, this finding indicates that serum soluble CD30 measurement may be helpful for differentiating these two forms of inflammatory bowel disease.

Doppler sonography of the superior mesenteric artery in Crohn's disease

OBJECTIVE

The aim of this study was to evaluate blood flow in the superior mesenteric artery (SMA) in patients with active and inactive Crohn's disease (CD) using Doppler sonography to dynamically assess the changes of resistance in both fasting and postprandial states.

SUBJECTS AND METHODS

Doppler sonography of the SMA was performed on 15 patients (mean age, 38 +/- 4 years) with active CD and on 15 patients (mean age, 41 +/- 5 years) with inactive CD. Imaging was performed at both fasting and 15 min after an 1890-kJ meal. A preliminary examination of 10 healthy volunteers with no signs of intestinal disease (mean age, 28 +/- 2 years) was necessary to define the parameters of normality. Because we wanted to express the postprandial resistive change in the SMA, we introduced a parameter called resistive difference (RD), defined as the mathematic difference between the resistive index measured at fasting (highest value) and measured at 15 min after the meal (lowest value).

RESULTS

By evaluating the relationship between the RD and extension of disease, we found a direct correlation between progressive extension of disease and reduction of the RD in patients with active CD (correlation coefficient, .98) whereas we found no such correlation in patients with inactive CD (correlation coefficient, .05).

CONCLUSION

We believe that Doppler sonography of the SMA is a promising noninvasive method to detect inflammatory disease of the small bowel, to evaluate its extension, and to document resolution of disease after therapy.

Short-chain fatty acid topical treatment in distal ulcerative colitis

BACKGROUND

Some evidence indicates that short-chain fatty acid (SCFA) enemas are effective in the treatment of distal ulcerative colitis.

METHODS

In a randomized, double-blind, placebo-controlled study, we tested the efficacy of a 6-week course of topical SCFA (100 mL, twice daily enemas of sodium acetate 80 mmol/L, sodium propionate 30 mmol/L and sodium butyrate 40 mmol/L) in 40 patients with mild to moderate distal colitis. Clinical, endoscopic and histological data were collected at the beginning and end of the study.

RESULTS

Fourteen patients on SCFA improved (overall score 11.3 +/- 2.0 vs. 7.4 +/- 3.5) as compared to five in the placebo group (overall score 10.0 +/- 1.9 vs. 8.9 +/- 2.5). In the SCFA-treated group all parameters significantly improved except the number of bowel motions, whereas no significant changes were recorded in the control group. A statistically significant difference between the two treatment regimens, however, was observed only for intestinal bleeding (P < 0.05), urgency (P < 0.02) and the patient self-evaluation score (P < 0.05). This was probably due to the random inclusion of more patients with moderate disease into the SCFA-treated group, thus causing pretrial differences between the two groups.

CONCLUSION

The present study confirms that irrigation with SCFA enemas is effective in distal colitis, and may represent an alternative therapeutic tool in the treatment of the disease.

Sorbitol malabsorption and nonspecific abdominal symptoms in type II diabetes

Some data suggest that sorbitol intake may be responsible for diarrhea in diabetic patients. One hundred thirteen hydrogen breath tests were performed in type II diabetics (72) and normal controls (41) after oral loads of sorbitol ranging from 2.5 to 20 g in iso-osmolar solutions to assess the role of malabsorption of this compound in the genesis of abdominal symptoms. The prevalence of sorbitol malabsorption and abdominal symptoms, peak (Cmax H2) and total (Ctot H2) hydrogen production, and mouth to cecum transit time (MCTT) did not differ in type II diabetics and controls. Malabsorption was observed more frequently with the highest doses of sorbitol (10% of patients at a dose of 2.5 g and approximately 75% at 20 g). Symptoms, usually consisting of mild discomfort and abdominal distension, were observed only after sorbitol loads of 10 and 20 g in 27.2% of the diabetics and in 36.3% of the controls. Diarrhea was present in three subjects (two diabetics and one control) only at a dose of 20 g. These data indicate that it is highly unlikely for sorbitol to play a role in inducing diabetes diarrhea. A moderate (up to 10 g) sorbitol intake is not contraindicated in type II diabetics.

Lactose malabsorption and irritable bowel syndrome. Effect of a long-term lactose-free diet

Lactose malabsorption may induce abdominal symptoms indistinguishable from those of the irritable bowel syndrome (IBS), however the exact relationship between the two conditions and the optimal differential diagnostic workup are still to be defined. We prospectively studied the prevalence of lactose malabsorption (by means of a hydrogen breath test) and the clinical effect of a long-term lactose-free diet in 230 consecutive patients with a suggested diagnosis of irritable bowel syndrome, no organic disease of the GI tract, and no history of milk intolerance. Lactose malabsorption was diagnosed in 157 patients (68.2%). In 48 (43.6%) of the 110 patients who complied with the diet symptoms subsided, in 43 they were somewhat reduced and in 17 they remained unchanged. Symptoms never fully subsided in lactose malabsorbers non-compliant with the diet or in normal lactose absorbers who adhered to a lactose-free regimen. Partial improvement was observed in 20% of these subjects. No relation was demonstrated between pre-trial symptoms and the outcome of the diet. The occurrence of symptoms during the lactose breath test strongly suggested a favorable response to diet, but did not help in predicting whether symptoms would subside or be reduced. Conversely, their absence during the test was not associated with an acceptable negative predictive value. The high prevalence of lactose malabsorption in the patients under study suggests that in Italy IBS and lactose malabsorption are frequently associated. A test for diagnosing lactose malabsorption should always be included in the diagnostic workup for IBS and a long-term lactose-free regimen recommended if the test is positive.

Topical treatment of refractory distal ulcerative colitis with 5-ASA and sodium butyrate

Nine patients with distal ulcerative colitis refractory to standard therapy were treated with intrarectal instillation of a sodium butyrate solution and 5-ASA. A marked clinical, endoscopical and, to a smaller extent, histological improvement was observed in seven of nine patients. The clinical improvement usually occurred within the second week of therapy, and thus earlier than in previous cases treated with butyrate alone. This preliminary experience suggests that the combined butyrate-5-ASA treatment may prove a useful therapeutic tool in refractory distal ulcerative colitis and possibly increase the effectiveness of the individual therapeutic regimens.

Rectal irrigation with short-chain fatty acids for distal ulcerative colitis. Preliminary report

Colon cells from patients with ulcerative colitis utilize short-chain fatty acids inefficiently and may be exposed to decreased concentrations of these compounds. To test whether irrigation of the inflamed mucosa with short-chain fatty acids is useful, we conducted a six-week preliminary trial in 12 patients with distal colitis. Each patient used twice daily rectal irrigations with 100 ml of a solution containing acetate (80 mM), propionate (30 mM), and butyrate (40 mM). Two patients stopped at three weeks, one because of no improvement and the other because of complete resolution of symptoms. Of the 10 who completed the trial, nine were judged to be at least much improved and showed a change in a mean disease activity index score from 7.9 +/- 0.3 (SE) to 1.8 +/- 0.6 (SE) (P less than or equal to 0.002) and in a mucosal histology score from 7.7 +/- 0.7 (SE) to 2.6 +/- 0.7 (SE) (P less than or equal to 0.002). Thus, ulcerative colitis patients appear to benefit from increased contact with or higher than usual levels of these critical energy substrates.

Fecal lactate and ulcerative colitis

Impaired metabolism of short-chain fatty acids, as well as a modified fecal ionogram, have been reported in ulcerative colitis. Fecal water samples from 62 patients with ulcerative colitis were analyzed in the present investigation to evaluate changes in SCFAs and lactic acid in relation to activity and severity of disease. Short-chain fatty acid levels were high in quiescent and mild disease (162.6 +/- 63.6 and 147.8 +/- 63.2 mM/L, respectively), but significantly decreased in the severe form (64.7 +/- 46.9 mM/L). Lactate showed a progressive increase from mild colitis (3.0 +/- 1.8 mM/L) to severe colitis (21.4 +/- 18.6 mM/L). It thus appears that mild colitis displayed a fecal pattern characterized by normal pH and bicarbonate, slightly impaired electrolyte handling, high short-chain fatty acid values, and only moderately increased lactate. Severe colitis, on the other hand, was characterized by low fecal pH, bicarbonate, and potassium, high sodium and chloride, low short-chain fatty acid levels, and very high lactate levels. A critical lowering of intraluminal pH, which shifts bacterial metabolism from short-chain fatty acid to lactate production, may be responsible for the intraluminal pooling of lactate.

Organic anions and the diarrhea of inflammatory bowel disease

To determine if organic anions contribute to the diarrhea of inflammatory bowel disease, we measured osmolality, electrolytes, short-chain fatty acids, lactic acid, and some Krebs cycle anions in 24-hr fecal collections from 18 patients with chronic ulcerative colitis, 20 with Crohn's disease of the colon, and 16 normals. Mean lactic acid concentration was significantly elevated in ulcerative and Crohn's colitis, but values correlated with fecal weight only in the former syndrome. In ulcerative colitis, concentrations of each short-chain fatty acid, especially butyrate, were decreased compared with those from normals or Crohn's disease. Lactate and short-chain fatty acids accounted for nearly half the variability in fecal weight in ulcerative colitis. Crohn's patients had elevated mean fecal water osmolality and osmotic gap not observed in ulcerative colitis. Increased lactic acid and/or deficient short-chain fatty acids may modulate the diarrhea of ulcerative colitis. This mechanism seems less important in Crohn's colitis where an additional osmotic component may be significant.

Seeking clues for a positive diagnosis of the irritable bowel syndrome

Despite its high prevalence the irritable bowel syndrome (IBS) lacks acceptable pathophysiological markers and its diagnosis largely depends on the exclusion of underlying organic disease. Systemic acid-base balance, serum electrolytes and the composition of faecal water (electrolytes and organic anions), were studied in thirty-eight diarrhoeal patients out of a series of ninety-three consecutive IBS patients. Only patients with diarrhoea as the predominant symptom were included in the study to evaluate whether this subgroup could provide the clue for a positive diagnosis of the syndrome. Serum electrolytes and systemic acid-base balance were within the normal range. Faecal electrolytes were also normal (Na 26.6 +/- 19.3 SD; K 66.8 +/- 28.3; Cl 19.1 +/- 15.2 mEq 1(-1)), despite the finding of a moderately increased 24-h faecal output. The K:Na ratio was also within the normal range. These data are in agreement with the lack of systemic changes observed in IBS patients even with profuse or longstanding diarrhoea. Both faecal short chain fatty acids and lactic acid were increased in patients vs. controls, but a considerable overlap with normal values was observed (131.4 +/- 62.6 SD vs. 108.5 +/- 58.3 mEq 1(-1). Only lactic acid concentration was significantly higher than in controls (1.3 +/- 1.2 vs. 0.5 +/- 0.2). Despite these findings it is concluded that the subgroup of IBS patients with diarrhoea also appears to lack a pathophysiological marker and does not provide clues for a positive diagnosis of this syndrome.

Early recognition of toxic megacolon

Increased amounts of small bowel gas are a frequent finding on plain abdominal films in toxic megacolon (TMC), but they may also be found in patients with severe colitis. We studied 69 consecutive patients with severe ulcerative colitis to evaluate whether an increased gas content of the small intestine may identify patients prone to TMC. The intestinal gas was measured on plain abdominal films by means of a planimeter. On the basis of gas values, 38 patients showed a normal and 31 an increased amount of small intestinal gas. The outcome of the disease (complications, need for surgery, and mortality rate) and 18 clinical and hematochemical findings were compared in the two groups. Of the 31 patients with increased gas, seven developed TMC, whereas this complication was not observed in the 38 patients with normal gas. The only other different features between the two groups were blood pH and base excess, which were significantly higher in the patients with increased small bowel gas content. We therefore suggest that persistent abnormal gaseous distension of the small bowel, together with severe metabolic alkalosis, characterizes a subgroup of patients with severe colitis at high risk for the development of TMC. The strict surveillance of these patients led to early recognition of seven cases of TMC and prompt institution of aggressive medical treatment. Since all these patients survived, the early detection of TMC may improve prognosis.

Faecal excretion of bicarbonate in ulcerative colitis

The normal colon absorbs water, sodium and chloride and secretes potassium and bicarbonate. In ulcerative colitis (UC), modifications occur in the absorption of water, sodium and chloride, whereas the secretion of potassium remains unchanged. There appear to be no data in the literature on bicarbonate secretion. Since some 25% of chloride absorption is coupled with bicarbonate secretion by an anion exchange mechanism, the impairment in chloride absorption should be accompanied by modifications in bicarbonate secretion. Faecal bicarbonate was therefore measured in 20 patients with active UC and 15 normal control subjects. Faecal pH, pCO2 and electrolytes (Na+, K+, Cl-, HCO3-), blood acid-base balance, urinary pH and bicarbonate were determined on the same day in all patients. Faecal pH and bicarbonate were significantly reduced in UC versus controls: pH 6.06 +/- 0.39 versus 6.52 +/- 0.43; HCO3- 8.4 +/- 5.2 versus 34.6 +/- 12.3 mEq/l (mean +/- SD), whereas sodium and chloride were increased. Faecal potassium concentration was normal, but potassium output was increased. Metabolic alkalosis was observed in 8 patients and a normal acid-base balance in the remaining 12. Urinary pH was acid and urinary bicarbonate negligible in all patients. No correlation was observed between plasma, faecal and urinary bicarbonate. Data emerging from this study show that the faecal excretion of bicarbonate is reduced in patients with active UC. A possible explanation for this finding may be impairment of the colonic anion exchange mechanism induced by inflammation of the mucosa. The role of organic anions is also hypothesized. The acid-base balance does not seem to be directly affected by the decrease in faecal bicarbonate loss.

Consequence of colonic involvement on electrolyte and acid-base homeostasis in Crohn's disease

We evaluated the relationship existing between the site of intestinal lesions and systemic acid-base balance in 78 patients with active Crohn's disease. Patients with enteritis had a normal acid-base balance, while mild and moderate metabolic alkalosis were present in enterocolitis and colitis. These findings appeared to be related to the electrolyte fecal losses. In enteritis fecal sodium and chloride concentrations were within the normal range (Na 29.2 +/- 18.5; Cl 16.6 +/- 11.2 mEq/l) while in colitis they were significantly higher (Na 52.8 +/- 20.8; Cl 29.6 +/- 12.7 mEq/l). Intermediate values were observed in enterocolitis. The fecal potassium concentrations were similar in the three groups of patients, with a slightly lower concentration in enterocolitis and colitis. The fecal K/Na ratio was normal in enteritis and reversed in enterocolitis and colitis. This study suggests that a relationship exists between the site of lesions, fecal electrolyte losses, and systemic acid-base balance in Crohn's disease. Systemic metabolic alkalosis and an abnormal fecal K/Na ratio occurred in patients with colonic involvement, indicating the important role played by the colon in acid-base and electrolyte homeostasis.

Composition of fecal water. Comparison of "in vitro" dialysis with ultrafiltration

We describe a simple method for the collection of stool water using dialysis membrane tubing placed directly into the feces. When the membrane was placed in pure aqueous solutions or in homogenized feces stored at 4 degrees C, equilibration for solutes was complete in 24 h. Exchangeable ions, short chain fatty acids, osmolality, and pH were measured in the fecal water of 8 normal subjects and 36 patients affected by different diarrheal diseases. The composition of fecal water collected by this method was almost identical to that obtained by ultrafiltration of feces immediately after collection. Differences, when present, were minimal (about 4%) and practically irrelevant. This in vitro dialysis method is simple, inexpensive, and seems particularly suitable for the measurement of osmolality, electrolytes, and short chain fatty acid concentrations in large numbers of fecal samples.

Risk factors in toxic megacolon

A retrospective analysis of data from a series of 22 patients with toxic megacolon complicating ulcerative colitis was performed in an attempt to detect factors associated with the fatal outcome of the attack. Of the 25 clinical findings studied, significant differences between survivors (17) and nonsurvivors (5) were observed in only seven. In nonsurvivors, duration of the disease was longer and blood pH and standard bicarbonate levels higher, whereas serum potassium, calcium, phosphorus, and beta-globulins were lower. Discriminant analysis showed that three pairs of features, namely potassium-beta-globulins, potassium-bicarbonate, and potassium-blood pH provided a good discrimination between survivors and nonsurvivors. Results of this study indicate that the severity of the electrolyte and metabolic disorder appears to be an important risk factor in toxic megacolon. Intensive fluid and electrolyte replacement should therefore be considered a crucial point for successful management of toxic megacolon.

Intestinal gas in ulcerative colitis

Intestinal gas was measured planimetrically on plain abdominal films from 25 healthy subjects and 47 patients with active ulcerative colitis (mild, moderate, severe and toxic megacolon). Compared with controls, significant colonic distention was found in toxic megacolon. Gas in the small bowel was significantly increased in toxic megacolon and in severe colitis but was within the normal range in the mild and moderate forms. Two groups of patients with severe colitis were identified, showing either normal or increased gas content in the small bowel. Two of seven patients in the latter group developed toxic megacolon in spite of intensive medical treatment. Intestinal gas values showed a linear correlation with arterial blood pH, ESR and body temperature. No correlation was found between intestinal gas and other features of severity. It is suggested that an abnormal collection of gas in the small bowel loops associated with metabolic alkalosis corresponds to an early stage of a toxic complication ("impending megacolon").

Blood pH: a test for assessment of severity in proctocolitis

Acid base balance was studied in 58 patients with active idiopathic proctocolitis; the condition of 10 of them was complicated by toxic megacolon. Arterial blood pH increased progressively with increased severity of the colitis and as the lesions became more widespread. Statistically significant differences were observed in pH values between the mild/moderate and severe forms and between the severe and complicated forms ('toxic megacolon'). A linear correlation was found between pH and the amount of intestinal gas, pulse rate, and plasma albumin.

Effects of bombesin and bombesin-like peptides on gastrointestinal myoelectric activity

Gastrointestinal myoelectric activity was studied during intravenous infusion of bombesin and bombesin-like peptides in conscious dogs with electrodes chronically implanted at different levels between the stomach and the rectum. The peptides used were bombesin, the COOH-terminal hepta- octa-, and nonapeptide of bombesin, and litorin, a new natural peptide isolated from the skin of Litoria aurea. Bombesin significantly increased the frquency of pacesetter potentials (PP) in tha antrum, duodenum, jejunum, and ileum. In the duodenum and jejunum the increase of PP frequency showed linear correlation with the reduction of PP amplitude. The propagation velocity of PP was clearly reduced. Spikes were not affected in the antrum and ileum, whereas they were abolished in the duodenum and jejunum. In the duodenum the increase of PP frequency and the slowing down of propagation velocity was followed by the loss of PP phase lock and the appearance of a characteristic electric pattern, consisting of an irregular sequence of small and slow potentials ("electric disorganization"). The mechanical counterpart was the disappearance of intraluminal pressure activity. In the colon the effect of bombesin on electric activity was not consistent. Neither the COOH-terminal heptapeptide nor the octapeptide of bombesin showed a significant effect on myoelectric activity, whereas the effect of COOH-terminal-nonapeptide and litorin was similar to that of bombesin. Thus, the characteristic electric changes of PP produced by bombesin appear to be related to the sequence of the nine amino acids in the COOH-terminal residue of the bombesin molecule.