Allelic variation at the interleukin 1beta gene is associated with decreased bone mass in patients with inflammatory bowel diseases

BACKGROUND

Interleukin 1beta (IL-1beta) and its natural antagonist have been implicated in the pathogenesis of inflammatory bowel disease (IBD). Both cytokines influence bone formation. IL-1beta stimulates osteoclast activity while interleukin 1 receptor antagonist (IL-1ra) enhances bone formation.

AIMS

To determine whether the decreased bone mass in IBD is related to gene polymorphisms coding for IL-1beta and IL-1ra, and thus identify patients with an increased risk.

METHODS

Bone mineral densitometry was performed at the femoral neck, lumbar spine, and the distal third of the radius in 75 IBD patients (34 men/41 women; 40.3 (1.6) years) and in 58 healthy controls (HC; 28 men/30 women; 32.4 (1.2) years). Values were correlated with the TaqI and AvaI gene polymorphisms in the IL1B and the variable number of tandem repeats gene polymorphism in the IL1RN gene.

RESULTS

In IBD patients, but not in HC, carriers of allele 2 at the AvaI gene polymorphism (IL1B-511*2) had significantly lower Z scores at the lumbar spine (-0.82 (0.13) v -0.29 (0.21) p=0.03) and the femoral neck (-0.59 (0.14) v 0.15 (0.19); p=0.003) than non-carriers. These patients also had a higher risk for osteopenia or osteoporosis at the femoral neck (odds ratio 3.63 (95% confidence interval 0.95-13.93)). No association was found between bone mass and the other gene polymorphisms analysed in IBD patients or in HC.

CONCLUSIONS

Our results suggest that genetic variability may be a major determinant of bone loss in IBD. Carriers of IL1B-511*2, who are hypersecretors of IL-1beta, have a higher risk of presenting with low bone mass in IBD. Screening for this allele may contribute to determination of the risk of bone loss at the time of disease onset.

[Serum bone marker measurements in bone metabolism disorders associated with inflammatory bowel diseases]

Patients with inflammatory bowel disease (IBD) have decreased bone mineral density (BMD), which is usually much more remarkable in patients with Crohn's disease (CD) than those with ulcerative colitis (UC). The aim of the present study was to investigate the usefulness of serum beta-Crosslaps (bCL) and osteocalcin (OC) determinations to assess bone metabolism in patients with IBD. Forty-nine patients with IBD (23 UC, 26 CD) and 46 healthy controls were studied. Serum bCL and OC were measured by Elecsys immunoassay. Compared to controls (0.275 +/- 0.14 ng/ml) the mean bCL concentration was significantly higher in the CD (mean = 0.489 +/- 0.25 ng/ml; p < 0.001) and UC groups (mean = 0.439 +/- 0.3 ng/ml; p < 0.01). The mean OC concentration was significantly higher in the CD group (28.52 +/- 14.75 ng/ml) than in controls (21.42 +/- 7.43 ng/ml) but OC level was not significantly increased in the UC group (24.89 +/- 15.08 ng/ml). There was no significant difference in bCL or OC concentrations between the CD and UC groups. These results indicate that the accelerated bone resorption is not associated with increased bone formation in patients with IBD. These two marker of the bone metabolism could be a good laboratory parameter of bone pathology in patients with IBD, especially in CD.

Effect of Helicobacter pylori infection and eradication on gastric epithelial cell proliferation and apoptosis

OBJECTIVES

the effect of Helicobacter pylori infection on gastric epithelial cell proliferation and apoptosis is still controversial. Our aim was to evaluate the effect of H. pylori infection on cell kinetic parameters in normal gastric epithelium, gastritis with/without intestinal metaplasia and gastric cancer.

PATIENTS AND METHODS

antral biopsies were taken from 121 patients (61 women, 60 men, mean age 58.5+/-14.3 years of age) who underwent routine gastroscopy for upper gastrointestinal symptoms. Sections were scored for normal epithelia (n=15), gastritis without intestinal metaplasia (n=74), gastritis with intestinal metaplasia (n=24), and gastric adenocarcinoma (n=8). Fifty-two patients had H. pylori positive gastritis, and success of H. pylori eradication therapy was controlled in 12 cases, all with intestinal metaplasia. To characterize cell proliferation and assess apoptosis, immunohistochemistry [Proliferating Cell Nuclear Antigen (PCNA)], histochemistry [Argyrophil Nucleolar Organizer Regions (AgNOR)], and terminal deoxynucleotidyl transferase (TdT)-mediated deoxyuridinetriphosphate (dUTP) nick end-labeling (TUNEL) were used, respectively.

RESULTS

both cell proliferation and apoptosis is was higher in chronic gastritis when compared with normal epithelia, but neither PCNA LI (54.79+/-19.1 vs. 53.20+/-20.7) nor AgNOR counts (291.43+/-44.3 vs. 277.8+/-57.54) were different in H. pylori positive versus negative chronic gastritis. A significant positive correlation (P<0.05) was found in this group between PCNA and AgNOR techniques. Apoptosis was significantly higher (P<0.05) in H. pylori positive cases only when intestinal metaplasia was not present. Cell proliferation in intestinal metaplasia decreased to the activity of normal epithelium after successful eradication of H. pylori but remained high if eradication therapy failed.

CONCLUSIONS

epithelial cell proliferation does not depend on H. pylori status in chronic gastritis. H. pylori increases apoptosis only in the absence of intestinal metaplasia.

[Effect of Helicobacter pylori infection and eradication on proliferative kinetics of the gastric mucosa]

Helicobacter pylori infection is associated with an increased cell proliferation activity, however the exact mechanisms have not been elucidated. Our aim was to study the effect of Helicobacter pylori infection on normal gastric epithelia, gastritis, intestinal metaplasia and carcinoma by the expression of proliferating cell nuclear antigen and nucleolus organizer regions. Antral biopsies were taken from 121 patients (61 women, 60 men; mean age 58.5 y.). Sections were scored for normal epithelia (n = 15), gastritis without intestinal metaplasia (n = 74), gastritis with intestinal metaplasia (n = 24) and gastric carcinoma (n = 8). 52 patients had H. pylori positive gastritis, and success of eradication therapy was controlled in 34 cases. To characterize cell proliferation immunohistochemistry (PCNA) and histochemistry methods (AgNOR) were used. Results of PCNA and AgNOR significantly correlated except of that in the intestinal metaplasia group. PCNA LI and AgNOR counts were not significant higher in H. pylori positive compared to the H. pylori negative gastritis. Presence of H. pylori caused higher proliferation rate in intestinal metaplasia group measured by PCNA. In the group of intestinal metaplasia the proliferation activity decreased to the activity of the normal epithelia after the successful eradication, but remained high if eradication therapy was failed. Our results suggest, that H. pylori infection plays only as a co-factor in gastric carcinogenesis. Results were controversial in the intestinal metaplasia group, that can be explained by the heterogeneity of the bacteria.

[Celiac disease today: review of the growing knowledge]

Coeliac disease is the most common disorder with malabsorption of the small intestine, caused by the gluten fraction of cereals in genetically predisposed individuals. T-cell mediated autoimmune processes are initiated by gluten exposure, leading to both intestinal and extraintestinal manifestations, therefore coeliac disease is nowadays considered to be a systemic disorder. More and more diseases are proved to be associated with coeliac disease, in these conditions screening is strongly recommended. The studying of the recently explored autoantibodies against tissue transglutaminase brought us further in the understanding of the pathophysiology of coeliac disease. The spreading of reliable serologic methods modified our knowledge on the clinical picture and prevalence of the disease. In case of long-term dietary abuse the most common complications are decreased bone mineral density and development of lymphomas. Sustained glutenfree diet results in clinical and histological restitution, affects the course of associating diseases beneficially and decreases the risk for malignancies.

Spiral CT colonography in inflammatory bowel disease

OBJECTIVE

Most of the studies on virtual colonoscopy are dealing with the role of detecting colorectal polyps or neoplasms. We have undertaken this study to evaluate the value of CT colonography in patients with colonic Crohn's disease.

METHODS AND MATERIAL

Five patients (three males, two females, 23-51 years, mean age 42 years) with known (4) or suspected (1) Crohn's disease of the colon underwent fiberoptic colonoscopy and CT colonography in the same day or during a 1-week period. The images were evaluated with the so called zoomed axial slice movie technique and in some regions intra- and extraluminal surface shaded and volume rendered images were generated on a separate workstation. The results were compared to those of a colonoscopy.

RESULTS

The final diagnosis was Crohn's disease in four patients and colitis ulcerosa in one. Total examination was possible by colonoscopy in two cases, and with CT colonography in all five cases. The wall of those segments severely affected by the disease were depicted by the axial CT scans to be thickened. The thick walled, segments with narrow lumen seen on CT colonography corresponded to the regions where colonoscopy was failed to pass. Air filled sinus tracts, thickening of the wall of the terminal ileum, loss of haustration pseudopolyps and deep ulcers were seen in CT colonography. Three dimensional (3D) endoluminal views demonstrated pseudopolyps similar to endoscopic images None of the colonoscopically reported shallow ulcerations or aphtoid ulcerations or granular mucosal surface were observed on 2- or 3D CT colonographic images.

CONCLUSION

CT colonography by depicting colonic wall thickening seems to be a useful tool in the diagnosis of Crohn's colitis, which could be a single examination depicting the intraluminal, and transmural extent of the disease.

Comparison of a tissue transglutaminase ELISA with the endomysium antibody test in the diagnosis of gluten-sensitive enteropathy

BACKGROUND

Tissue transglutaminase (tTG) has recently been found to be the major if not the only autoantigen of gluten-sensitive enteropathy (GSE).

OBJECTIVES

To further determine the significance of this finding for diagnostic (screening) and follow-up purposes, we performed tTG-based ELISAs, and compared the results to the endomysium antibody test (EMA).

PATIENTS

We examined 120 serum samples from patients with celiac disease (CD) including 72 on a gluten-free diet (GFD) and eleven on a gluten challenge, 47 with dermatitis herpetiformis (DH) including 16 on a GFD and one on a gluten challenge, 96 with non-CD gastrointestinal diseases, and 117 with others; i.e. 380 serum samples altogether. Follow-up sera from 13 patients were included.

METHODS

Results of an ELISA with guinea pig liver tTG were compared with the EMA test using monkey esophagus. Inhibition of endomysial staining was performed with sera positive on the EMA test but negative with the guinea pig tTG ELISA.

RESULTS

The specificity and sensitivity of the tTG ELISA are high (98.6% and 92.5%). The serum IgA antibody titers against tTG decrease after introduction of a GFD. In one case, endomysial staining could not be inhibited.

CONCLUSIONS

Our results show that the guinea pig tTG ELISA is suitable for use as a simple diagnostic screening and follow-up method for GSE. Further studies are necessary to identify possible additional minor antigens in GSE.

[Comparison of various methods in the detection of Helicobacter pylori infection]

There are several possible methods to detect H. pylori in the gastric mucosa. The aim of our prospective study was to evaluate the diagnostic value of these tests and to define their place in the clinical practice. 109 (45 male, 64 female) patients who underwent upper GI endoscopy were included. Before endoscopy, whole blood was collected for serological test and 13C-UBT (13C-urea breath test) was performed. During endoscopy, multiple biopsies were collected from the antrum and corpus for the examination of H. pylori status by histology and rapid urease test. Patients with positive histology and a positive result of any other examinations, or--in case of negative histology--with two positive results of the remaining examinations were considered to be H. pylori-positive. 50 patients (46%) proved to be H. pylori-positive. Sensitivity and specificity, respectively, were as follows [in brackets: negative predictive value (NPV) and positive predictive value (PPV), respectively]: histology, 98% and 92% (98% and 91%); 13C-UBT, 93% and 98% (94% and 98%); rapid urease test, 83% and 100% (86% and 100%); serological examination, 86% and 74% (88% and 70%). The sensitivity and the clinical role of the methods used for the detection of H, pylori infection is different. Histology is the most reliable method if endoscopy in performed. The positive result of the rapid urease test is also of good diagnostic value. The 13C-UBT is the method of choice if no endoscopy is performed and the clarification of H. pylori status is necessary. This method can be useful to control the success of bacterium eradication as well. The serological examination provides instant result, therefore this method is proposed for screening and epidemiological studies.

[Detection of aneuploidy from gastrointestinal biopsy samples]

Aim of the present work was the development of a mechanic cell separation protocol for gastrointestinal biopsy analysis. Evaluation of the technique was performed on selected group of patients who underwent routine endoscopy. Routine gastrointestinal biopsies were obtained after informed consent. 23 gastric (6 healthy, 14 gastritis, 3 adenocarcinoma) and 15 colon samples (5 healthy, 7 colitis ulcerosa, 3 adenocarcinoma) were evaluated. The mechanic disruption of the biopsies was performed by Medimachine (DAKO, Denmark), a commercially available system using a 30 microns miner and a 30 microns mesh. The cell solution was centrifuged for 5 minutes by 250 g. The cells were fixed in paraformaldehide and stained by propidium iodide. The flow cytometry analysis was performed on a BD FacStar Plus flow cytometer. The DNA data were evaluated using the Winlist software. All of the preparations were appropriate for flow cytometric analysis. The coefficient of variation of the DNA histograms (n = 7) (CV mean +/- SD. 6.45% +/- 1.21) were acceptable for analysis. In the gastric biopsy samples aneuploidy was determined only in malignant cases. In four of the seven colitis ulcerosa samples and in one of the three adenocarcinoma aneploidy was found. The histologically healthy specimen were all diploid. Mechanic cell separation and disaggregation is a useful method for preparing fresh biopsy specimen for flow cytometry.

Quantitative DNA and morphometric analysis of gastroscopic brush smears by TV image analysis

OBJECTIVES

To determine quantitative nuclear morpho-and densitometric classifiers and classification techniques for analysis of gastric, Feulgen-stained brush smears.

DESIGN

TV image analysis-based quantitative DNA and morphometric analysis of gastric brush smears in a prospective study.

PATIENTS AND METHODS

Ninety-eight (11 normal, 77 gastritis (17 with intestinal metaplasia) and 10 adenocarcinoma) Feulgen-Schiff-stained gastric brush smears were analysed by TV image analysis. The classification of the smears was based on parallel histological examination. For standards, DNA content of lymphocyte cell cultures was determined by the image and by flow cytometry. From every nucleus, six morphometric (surface, layers, minimum diameter, maximum diameter, perimeter and form factor) and six densitometric (integrated optical density (IOD), average density, sigma density, minimum and maximum density and density range) parameters were simultaneously determined. The smear parameters (object cells CV, DNA index, 2c deviation index, 5c exceeding rate, G1 -S-G2 ratio) were analysed together with the mean and SD values of the nuclear parameters by discriminant analysis and back-propagation neural networks.

RESULT

The normal smears were all diploid and their S + G2 ratio was 15.24+/-7.75% (mean +/- SD). The gastritis smears were all diploid with a proliferation fraction of 20.89+/-6.75%. The tumours were aneuploid in eight of the ten cases with 5c exceeding rate > 6.23%, the S + G2 fraction ratio was 34.72+/-10.12%. The mean nuclear surface area was 46+/-20, 58+/-20 and 74+/-22 microm2 in normal, gastritis and malignant groups, respectively. Significant differences (P<0.05) were found in nuclear surface, minimum and maximum diameter, and perimeter parameters. Using linear discriminant analysis, 100% of the non-malignant cases and 70% of the tumour cases were correctly classified. Using 30 non-malignant and five malignant cases as a training set, the neural networks classified 95% of the remaining cases correctly. The DNA index increased significantly (P<0.05) in Helicobacter pylori-positive cases compared to the negative ones. In gastritis with intestinal metaplasia, the proliferation ratio decreased significantly (P<0.05).

CONCLUSIONS

The image analysis is a useful tool for quantitative gastric cytology. The combination of nuclear morphometric parameters and neural network classifiers with multivariate quantitative DNA analysis is suggested for gastric brush smear quantitative cytology analysis.

Antibodies to tissue transglutaminase as serologic markers in patients with dermatitis herpetiformis

Dermatitis herpetiformis is a gluten-sensitive disease with a symmetrically distributed blistering over extensor surfaces. The association with celiac disease is further supported by the high rate of immunoglobulin A autoantibodies to endomysium in patients with dermatitis herpetiformis, which are highly specific and sensitive indicators of celiac disease. Therefore, we determined immunoglobulin A antibodies to tissue transglutaminase, the recently discovered endomysial autoantigen in celiac disease, in patients with dermatitis herpetiformis and controls. Sera of 61 patients with dermatitis herpetiformis, as characterized by granular immunoglobulin A deposits in the subepidermal basement membrane and known endomysial antibody titers (determined by indirect immunofluorescence) as well as 84 control sera of patients with dermal or intestinal diseases unrelated to dermatitis herpetiformis, were analyzed for circulating immunoglobulin A antibodies to tissue transglutaminase by enzyme-linked immunosorbent assay. Immunoglobulin A anti-tissue transglutaminase titers in patients with dermatitis herpetiformis were significantly elevated above the controls. Furthermore, the immunoglobulin A anti-tTG titers showed a positive correlation with semiquantitative endomysial antibody data. Compared with endomysial antibodies, determination of immunoglobulin A anti-tissue transglutaminase reached a specificity and sensitivity of 97.6% and 89.1%. Patients with dermatitis herpetiformis have elevated immunoglobulin A autoantibodies to tissue transglutaminase, confirming its pathogenic relation with celiac disease and further supporting the usefulness of this novel assay for screening and therapy control.

Octreotide in the prevention of pancreatic injury associated with endoscopic cholangiopancreatography

BACKGROUND

Data on whether long-acting somatostatin analogue octreotide causes or prevents pancreatic injury following endoscopic retrograde cholangiopancreatography (ERCP) are controversial.

AIM

This multicentre, prospective trial studied the effect of octreotide on pancreatic injury in a large unselected group of patients after ERCP and endoscopic sphincterotomy.

METHODS

The study was carried out in a prospective random manner on 2102 patients in 11 endoscopic centres. Patients in the study received 0.1 mg octreotide acetate and those in the control group received isotonic sodium chloride, subcutaneously before and 45 min after ERCP. Pancreatic injury was assessed by clinical symptoms such as pain, fever and abdominal tenderness. Serum amylase and blood sugar were determined prior to, and 6 and 24 h after the endoscopic procedure.

RESULTS

Data from 599 patients in the study group and 600 in the control group were included in the final evaluation. When all the patients were considered, octreotide did not induce pancreatic injury as assessed by clinical symptoms, and diminished the increase of serum amylase levels following ERCP. However, when subgroups of patients were studied, the frequency of increased amylase levels decreased significantly in patients with chronic obstructive pancreatitis and in patients who underwent endoscopic sphincterotomy (P < 0.01). The peak serum glucose level was higher in the treated group when compared to the controls.

CONCLUSION

The prophylactic use of long-acting somatostatin does not alter the frequency of post-ERCP pancreatic injury, but it may diminish the rate of increased serum amylase levels in patients with chronic obstructive pancreatitis and also in those with an endoscopic sphincterotomy.

[Computerized speech recognition-based endoscopic findings]

Discrete, Hidden Markov model based speech recognition and phoneme based speech synthesis techniques were applied for gastroscopy reporting and machine control. The authors developed a special program for grammatical analysis of the sentences. Altogether 100 patient findings were grammatically analysed. The sentences were grouped according to the topographical order of the investigation: oesophagus, cardia, fundus, corpus, antrum, pylorus, bulbus, postbulbar section, and the pathological findings: erosion, ulceration, malignancy. Speech samples from 3 deep voiced male investigators were collected. The recognition rate was above 95%. A simulation program was also developed for dictation and controlling of the different equipment (monitor, printer, video, endoscope) in the gastroscopy laboratory by speech recognition. Speech synthesis was applied for the evaluation of understanding. This module artificially synthesizes the answer of the system giving backup for the understood information. With additional developments the discrete word speech 'recognition' achieved the level of routine application in medical reporting. However, ready-to-use developments need the joint activity of speech technology and endoscopy industry with end-user teams.

[Experience with endoscopic diagnosis and treatment of acute biliary pancreatitis]

Acute biliary pancreatitis may be a grave illness with a fatal outcome in some instances. Its etiology is unclear so far. The diagnosis is difficult even with the help of conventional diagnostic methods and the most up to date imaging techniques. The most sensitive method among laboratory investigations is the elevation of ALT (serum alanine transferase) while endoscopic cholangiopancreatography has the highest accuracy rate of invasive diagnostic procedures. There is a chance of spontaneous remission in cases with mild symptoms while invasive measures-endoscopy or surgery-are needed in cases with grave symptoms. In the present study we evaluate 23 of our cases.

Comparison of single-dose and 7-day fluconazole treatment of fungal esophagitis in alcoholic liver disease

The aim of the study was to assess the effectiveness of a single-dose fluconazole treatment of fungal esophagitis in patients with alcoholic liver disease. Twenty-two alcoholic liver disease patients with fungal esophagitis were randomly assigned to receive either a single-dose of 150 mg fluconazole or a 7-day treatment of daily 50 mg fluconazole. Control esophagoscopy was performed in both groups on days 9-11. Direct smears and cultures on Sabouraud's medium were performed at both endoscopies. Patients' sera were tested for Candida antigens and for antibodies against Candida albicans on days 1, 8 and 15. Twenty patients (18 C. albicans, 1 C. tropicalis, 1 C. pseudotropicalis) completed the study, there were two drop-outs from the single-dose group. Antibodies against C. albicans were found in four cases, Candida antigens in five. There were no significant differences in the treatment outcome between the two groups, clinical cure was recorded in eight out of nine patients in the single-dose group and nine out of eleven patients in the 7-day group, mycological eradication in four out of nine, and in three out of eleven, respectively. Single-dose fluconazole treatment seems to be an effective therapy of fungal esophagitis in alcoholic liver disease patients.

[Diagnostic value of abdominal ultrasonography and endoscopic retrograde cholangiopancreatography in obstructive jaundice]

The diagnostic value of ultrasonography (US) and endoscopic retrograde cholangio-pancreatography (ERCP) was compared, in 66 patients with bile duct obstruction, who underwent subsequent biliary surgery. The level of the blockage was diagnosed by US with a 80%, by ERCP with a 95.4% sensitivity, while the cause of the obstruction was determined with a 50% and a 89% sensitivity, respectively. Predictive value of these examinations is over 90%. Based on the clinical results and on the high diagnostic value of the above mentioned examinations, it is essential to fill up the bile ducts with direct contrast material.