Oral rehydration solution normalizes plasma renin and aldosterone levels in patients with ulcerative colitis after proctocolectomy

Objectives: The possible effects and benefits of oral rehydration solution (ORS) on chronic dehydration after total proctocolectomy. Methods: To evaluate the effect of ORS on the renin-angiotensin system after remnant proctocolectomy in patients with ulcerative colitis (UC), we selected 20 patients after remnant proctocolectomy, ileal J pouch-anal anastomosis, and construction of a diverting ileostomy for UC. Patients were randomly divided into two groups, A (n=9) or B (n=11), 2 weeks after the surgery. In group A, ORS (1000 mL/day) was given for the first 7 days and mineral water (1000 mL/day) for the next 7 days. In group B, mineral water (1000 mL/day) was given for the first 7 days and ORS (1000 mL/day) for next 7 days. Plasma levels of renin, aldosterone and excretion of sodium in urine were evaluated at days 0, 7, and 14. We defined day 0 as the day of beginning this study. Results: Mean plasma renin levels on day 0 were six to eight times greater than the upper normal limit. In group A, ORS lowered plasma renin levels. In group B, plasma levels of renin and aldosterone after ORS were lower than those at days 0 and 7. Conclusions: ORS corrected increased plasma levels of renin and aldosterone to within the normal range in patients after proctocolectomy.

Pouch functional outcomes after restorative proctocolectomy with ileal-pouch reconstruction in patients with ulcerative colitis: Japanese multi-center nationwide cohort study

BACKGROUND

Although several complications capable of causing pouch failure may develop after restorative proctocolectomy (RPC) for ulcerative colitis (UC), the incidences and causes are conflicting and vary according to country, race and institution. To avoid pouch failure, this study aimed to evaluate the rate of pouch failure and its risk factors in UC patients over the past decade via a nationwide cohort study.

METHODS

We conducted a retrospective, observational, multicenter study that included 13 institutions in Japan. Patients who underwent RPC between January 2005 and December 2014 were included. The characteristics and backgrounds of the patients before and during surgery and their postoperative courses and complications were reviewed.

RESULTS

A total of 2376 patients were evaluated over 6.7 ± 3.5 years of follow-up. Twenty-seven non-functional pouches were observed, and the functional pouch rate was 98.9% after RPC. Anastomotic leakage (odds ratio, 9.1) was selected as a risk factor for a non-functional pouch. The cumulative pouch failure rate was 4.2%/10 years. A change in diagnosis to Crohn's disease/indeterminate colitis (hazard ratio, 13.2) was identified as an independent risk factor for pouch failure.

CONCLUSION

The significant risk factor for a non-functional pouch was anastomotic leakage. The optimal staged surgical procedure should be selected according to a patient's condition to avoid anastomotic failure during RPC. Changes in diagnosis after RPC confer a substantial risk of pouch failure. Additional cohort studies are needed to obtain an understanding of the long-standing clinical course of and proper treatment for pouch failure.

The functional outcome and factors influencing the quality of life after ileal pouch anal anastomosis in patients with ulcerative colitis

PURPOSE

The aim of this study was to assess the bowel function and quality of life (QOL) in patients with ulcerative colitis (UC) after total proctocolectomy with ileal pouch anal anastomosis (IPAA).

METHODS

Two questionnaires ["Questionnaire sheet on the bowel function" and "Inflammatory bowel disease questionnaire (Japanese IBDQ)"] were sent to 121 patients with UC who underwent IPAA at Tohoku University Hospital. Seventy-nine patients (65%) participated in the study.

RESULTS

The median number of daily bowel movements was 6.5, which significantly decreased with postoperative time (≤ 1, 1-5, 5-15 years) and increased with age (< 45, ≥ 45 years at colectomy). The ratio of patients who usually had bowel movements at night also significantly decreased with postoperative time and increased with age. The median total IBDQ score was 180. A multivariate analysis showed that "trip activity", "care about where the restroom is", and "bowel movements in the day" were significant independent risk factors for the daily life satisfaction score.

CONCLUSIONS

The bowel function and QOL were acceptable in patients with UC after IPAA; however, patients with a short postoperative time or older age had a lower functional outcome than others.

Current State of and Problems Related to Cancer of the Intestinal Tract Associated with Crohn's Disease in Japan

BACKGROUND/AIM

Cancer of the intestinal tract (small and large intestine) associated with Crohn's disease has a low incidence but can be fatal if it develops. Thus, the key question is how to deal with this type of cancer. The current study surveyed major medical facilities that treat inflammatory bowel disease (IBD) surgically in Japan in order to examine the clinical features of cancer of the intestinal tract associated with Crohn's disease and explore ways to deal with this cancer in the future.

PATIENTS AND METHODS

Sixteen major medical facilities that treat IBD surgically were surveyed regarding cancer of the intestinal tract associated with Crohn's disease. The medical facilities had treated 3,454 patients with Crohn's disease, 122 of whom had developed intestinal cancer. The medical facilities were surveyed regarding those 122 patients.

RESULTS

The incidence of intestinal cancer associated with Crohn's disease has increased yearly. Cancer most often developed in the left side of the colon and, particularly, in the rectum and anal canal. Seventy-six percent of cases were diagnosed preoperatively, 4% were diagnosed intraoperatively, while the remaining 20% were diagnosed pathologically after surgery. The most prevalent histological type of cancer was mucinous carcinoma (50%). Forty-two percent of cancers were differentiated, with 4% being poorly differentiated. The surgical procedure performed most often (67%) was abdominoperineal resection. The 5-year survival rate by stage was 88% for Stage I, 68% for Stage II, 71% for Stage IIIa, 25% for Stage IIIb and 0% for Stage IV. Overall, the 5-year survival rate was 52%.

CONCLUSION

Gastrointestinal (GI) cancer associated with Crohn's disease had an incidence of 3.5%, but also involved a poor prognosis with a 5-year survival rate of 52%. Early detection through surveillance is crucial to improving the prognosis for patients. However, surveillance of the intestinal tract with endoscopy or contrast studies is technically and diagnostically hampered by Crohn's disease and intestinal strictures. A biopsy of the anal canal, a common site of cancer, can readily be performed and constitutes the first step in surveillance.

Parastomal hernia repair with the Sugarbaker technique using e-PTFE mesh

PURPOSES

Although surgery is commonly used to treat parastomal hernia, it is very difficult and has shown poor results. Recently, repair with prosthetic materials has been thought to be a more promising method.

METHODS

The Sugarbaker technique with e-PTFE mesh (Dualmesh^®) performed via open surgery was adopted for seven patients with parastomal hernia. Two of them were recurrent cases. Three of the patients experienced incarceration of the intestine and recovered conservatively before surgery. The median age of the patients at the parastomal hernia repair was 77.6 years old (range 37.7-84.7).

RESULTS

The median operative time was 211 min (range 147-256). The median hernia size was 28 cm² (range 7.5-60 cm²). The median amount of blood loss during the operation was 158 g (range 0-370 g). Surgical site infection was not observed. The postoperative median hospital stay was 17 days (range 13-40) and the median follow-up was 2.4 years (range 1.0-3.7). During the follow-up period, we did not observe recurrence or readmission.

CONCLUSIONS

The surgical results were satisfactory with minimal morbidity and no recurrences. The Sugarbaker technique for parastomal repair using e-PTFE mesh may be suitable as a standard method for treating parastomal hernia.

[Surgical management of intestinal Crohn's disease]

Various intestinal conditions such as stricture, fistula, abscess, perforation, and hemorrhage are complications of Crohn's disease. Surgical intervention remains important, even in the era of biologic therapy. Limited surgical resection is essential to avoid short bowel syndrome after massive resection or multiple operations. Strictureplasty is effective for short, isolated stricture of the small intestine and provides good results equivalent to those of intestinal resection. Fecal diversion in the case of very complicated lesions not suitable for immediate resection can offer patients general and local improvement. Although bypass surgery is currently not performed because of the possibility of deterioration or carcinogenesis of the bypassed segment, bypass surgery is useful for avoiding stoma. Laparoscopic surgery is indicated for patients with nonperforating, localized ileocecal lesions, and for those presenting initially. The cumulative postoperative reoperation rate is about 50% to 60% at 10 years. The risk factors for early recurrence are smoking, perforating type, previous reoperation, and small intestinal disease. During postoperative follow-up and maintenance treatment, the importance of an algorithm comprising regular check-ups with ileocolonoscopy and the use of thioprines and biologics has been proposed.

Long-term incidence and characteristics of intestinal failure in Crohn's disease: a multicenter study

BACKGROUND

The aim of this study was to clarify the risk and characteristics of intestinal failure (IF) in patients with Crohn's disease (CD).

METHODS

The present study was a retrospective study in 12 hospitals. CD patients who underwent initial surgery at any of the 12 hospitals between 1970 and 2009 were collected (n = 1,703). Those who developed IF were reviewed (n = 68), and the cumulative risk of IF was analyzed by the Kaplan-Meier method. In addition, IF patients who underwent initial surgery at other hospitals and were then treated at any of the 12 hospitals were also reviewed (n = 33). Thus, a total of 101 IF patients were collected, and the cumulative risk of IF-related death was analyzed.

RESULTS

The cumulative risk of IF after the initial surgery was 0.8 % (5 years), 3.6 % (10 years), 6.1 % (15 years), and 8.5 % (20 years). In CD patients with IF, mean age at initial surgery, IF occurrence, and present age at the time of the study were 28.2, 38.2, and 46.1 years, respectively. The mean number of surgeries per patient was 3.3. The mean length of the remnant small bowel was 163 cm. Twelve IF patients (12 %) had died and the cumulative risk of IF-related death by the time from the occurrence of IF was 1.1 % (3 years), 3.7 % (5 years), 6.5 % (7 years), and 8.9 % (10 years).

CONCLUSION

The occurrence of IF and IF-related death in CD patients is not rare over the long term. There is a pressing need to develop strategies for the prevention and management of IF.

Risk factors for surgical site infection in Japanese patients with ulcerative colitis: a multicenter prospective study

PURPOSE

A prospective, multicenter, observational study was performed to investigate the risk factors of surgical site infection (SSI) in patients with ulcerative colitis (UC).

METHODS

From 2009 to 2010, perioperative clinicopathological data were collected from patients who had undergone surgery for UC within the research period, for up to 6 consecutive months in 13 hospitals in Japan. The primary outcome was the development of SSI.

RESULTS

A total of 195 patients with UC who underwent colorectal surgery were enrolled. SSI was diagnosed in 38 (19.5 %) patients, in the form of incisional infection in 23 (11.8 %), organ/space infection in 16 (8.2 %), and both in 1 (0.5 %). There were no significant risk factors associated with an increased risk of development of incisional SSI. An American Society of Anesthesiologists physical status of ≥ 3 was indicated as the only significant risk factor for organ/space SSI (P = 0.02) compared with other factors, such as a neutrophil count of >100 × 10(2)/mm(3), albumin level of <3.5 g/dl, perioperative packed red blood cell transfusion, fair or poor colonic cleanliness, and therapeutic use of antibiotics.

CONCLUSION

Poor general physical status was the significant independent risk factor for organ/space SSI in patients with UC in Japan.

A shift from colon- to ileum-predominant bacteria in ileal-pouch feces following total proctocolectomy

BACKGROUND

We previously investigated fecal flora of the pouch after total proctocolectomy using terminal restriction fragment polymorphism analysis. Although the results of the cluster analysis demonstrated clearly that bacterial populations, including an unidentified bacteria generating a 213-bp PCR fragment, moved toward a colon-like community in the pouch, it did not track changes in the individual species of fecal bacteria.

AIMS

The aim of the present study was to estimate genome copy number of ten bacterial species, clusters, groups, or subgroups (including the bacteria generating 213-bp fragment in the previous study) in feces samples from pouches at various times following ileostomy closure.

METHODS

A total of 117 stool samples were collected from patients with ulcerative colitis after surgery as well as healthy volunteers. We used real-time polymerase chain reaction of the 16S rRNA gene to estimate genome copy numbers for the nine bacterial populations and the bacteria generating 213-bp fragment after identification by DNA sequencing.

RESULTS

We demonstrated a time-dependent increase in the number of anaerobic and colon-predominant bacteria (such as Clostridium coccoides, C. leptum, Bacteroides fragilis and Atopobium) present in proctocolectomy patients after stoma closure. In contrast, numbers of ileum-predominant bacterial species (such as Lactobacillus and Enterococcus faecalis) declined.

CONCLUSIONS

Our data confirm previous findings that fecal flora in the pouch after total proctocolectomy changes significantly, and further demonstrate that the number and diversity of ileal bacteria decreases while a more colon-like community develops. The present data are essential for the future analysis of pathological conditions in the ileal pouch.

Cross-resistance to antineoplastic agents in a human small-cell lung-cancer subline resistant to okadaic Acid

We report on a human small cell lung cancer subline (H69/OA100) resistant to okadaic acid, an inhibitor of protein phosphatases. H69/OA100 showed cross-resistance to cis-diamminedichloroplatinum(II) (CDDP), adriamycin, and vinca alkaloids. Intracellular retention of adriamycin and CDDP in H69/OA100 was the same as those in H69. H69/OA100 was not shown to express MDR-1 by the reverse transcription polymerase chain reaction method. Expression level of mRNA of multidrug resistance-associated protein (MRP) in H69/OA100 was the same as that in H69. These data suggest that the mechanism of drug resistance in H69/OA100 might be due to a new mechanism of non-P-glycoprotein mediated multidrug resistance.

[A case with local recurrence of rectal cancer that responded to S-1 and PSK with long-term complete response]

The patient was a 65-year-old male, who underwent low anterior resection for rectal cancer. The pathological diagnosis showed mucinous adenocarcinoma, pSS, and pN0. He complained of diarrhea and melena 4 months after the surgery. Abdominal computed tomography and colonofiberscopy showed a local recurrence of rectal cancer. Because the tumor was diagnosed as unresectable, combined chemotherapy of S-1 (100 mg/day, per os, 4 weeks of treatment and 2 weeks of rest) and PSK (3 g/day, per os, the same schedule as S-1) was started. After the 2 courses of chemotherapy, computed tomography and colonofiberscopy showed a complete disappearance of the tumor. The chemotherapy was continued until the 9th course and then stopped. Five years and 4 months since the induction of a complete response, the patient is still alive without disease recurrence. Combined chemotherapy of S-1 and PSK may be one of useful choices for recurrent colorectal cancer.

[A case of anal cancer with rapidly rising CEA in longstanding perianal Crohn disease after infliximab administration]

Infliximab is effective in the treatment of steroid-resistant Crohn disease. However, there is clinical concern about a possible correlation between an increased risk of anorectal cancer and infliximab treatment. We report a case of anorectal cancer in long-standing perianal Crohn disease. A 34-year-old patient with a long-standing perianal lesion of Crohn disease underwent 3 sessions of infliximab therapy. After therapy, the concentration of plasma CEA was 36.5ng/ml and rose to 91.4ng/ml. We suspected anorectal cancer, so abdominoperineal resection was performed. The histological findings indicated mucinous adenocarcinoma. Monitoring of patients with long-standing perianal Crohn disease is considered essential for early diagnosis of anal cancer after obtaining biopsy samples from perianal lesions. Additionally, when infliximab is started for perianal Crohn disease, thorough examination for perianal lesion should be performed.

[A case of multiple metachronous metastases of colon cancer to the small intestine preoperatively diagnosed by double balloon enteroscopy and radically resected]

The patient was a 75-year-old woman who had undergone resection of a transverse colon cancer two years before. She had anemia and intestinal obstruction, and a diagnosis of multiple metastases to the small intestine was made by double balloon enteroscopy. Eleven metastatic foci were resected by partial resection of the jejunum and ileum. Adjuvant FOLFOX chemotherapy was given, achieving a 26-month disease-free survival. The double balloon enteroscopy was useful in the definitive diagnosis of this case, and aggressive resection with adjuvant chemotherapy contributed to the good outcome.

The effect of growth hormone releasing peptide-2 on upper gastrointestinal contractile activity and food intake in conscious dogs

BACKGROUND

The aim of this study was to evaluate the effect of growth hormone releasing peptide (GHRP)-2, a synthetic ligand for the growth hormone secretagogue receptor, on upper gastrointestinal motility and food intake.

METHODS

Five neurally intact dogs and five dogs with vagotomy and pyloroplasty were equipped with strain gauge force transducers on the stomach, duodenum and jejunum. GHRP-2 (0.5-10 microg/kg) was administered intravenously in neurally intact dogs in the interdigestive state and after feeding. To study the mechanism of GHRP-2-induced inhibition on postprandial contractions, various antagonists were administered intravenously prior to GHRP-2. The effect of GHRP-2 on postprandial contractions was also studied in dogs with vagotomy. GHRP-2 was also administered immediately before feeding in each group, and its effect on food intake was assessed.

RESULTS

GHRP-2 did not evoke gastrointestinal contractions in the interdigestive state. GHRP-2 induced contractile inhibition continuing for 2-3 min in neurally intact dogs and dogs with vagotomy. This inhibitory effect was reversed by the alpha- and alpha(2)-blockers. GHRP-2 increased food intake in neurally intact dogs, but not in dogs with vagotomy.

CONCLUSIONS

These results indicate that in the upper gut GHRP-2 inhibits postprandial contractions via alpha(2)-receptors on the enteric nervous system, whereas an intact vagal nerve is necessary for a GHRP-2-induced increase in food intake.

Quality of life of patients and medical cost of "half elemental diet" as maintenance therapy for Crohn's disease: secondary outcomes of a randomised controlled trial

BACKGROUND/AIM

Quality of life (QOL) of the patients and medical costs are important in current medical treatments, especially those for chronic diseases. We have reported the effectiveness of 'half elemental diet (ED)' as maintenance therapy for patients with Crohn's disease (CD). The aim of this study was to evaluate the QOL of CD patients and medical costs of half-ED.

METHODS

Fifty-one CD patients in remission were randomly assigned to a half-ED group (n=26) or a free diet group (n=25). The primary outcome measure was the occurrence of relapse during a 2-year period. This time, we investigated the QOL of the patients and medical costs of half-ED, as secondary outcomes. QOL was evaluated using the Japanese version of the IBDQ scoring system, and medical costs were calculated monthly from the receipts.

RESULTS

IBDQ score was not significantly different between the two groups at 1 and 13 months after the start of maintenance treatment. Medical costs were not significantly different between them either. This study showed that half-ED therapy did not affect the treatment of CD patients, neither regarding their QOL nor medical costs.

CONCLUSION

This study has confirmed this half-ED therapy is beneficial for patients with Crohn's disease.

[An operative case of ulcerative colitis associated with hyperthyroidism]

We encountered a rare operative case of hyperthyroidism followed by ulcerative colitis (UC). A 26-year-old mam was referred to our department to undergo an operation. We suspected the possible complication of adrenal insufficiency, since he suffered from severe weight loss, a high fever and palpitation on admission. We diagnosed hyperthyroidism, however, based on the presence of high serum free T3 and T4 levels and a decreased TSH level. After improving the symptoms and the thyroid function by administering thiamazole, we then performed a total proctocolectomy. Although a high rate of association of autoimmune thyroid diseases with UC has been suggested, only 9 cases of hyperthyroidism coexisting with UC have so far been reported in Japan. A common immunological process has been suggested to be implicated in the pathogenesis of this association, however, the exact mechanism needs to be elucidated in the future.

Bacterial population moves toward a colon-like community in the pouch after total proctocolectomy

BACKGROUND

Colonic transformation is defined by phenotypic alterations in the ileum after total proctocolectomy. Changes in microbiota of the ileal pouch and the roles of these microbes in colonic transformation, however, have not been addressed.

METHODS

A total of 151 stool samples were collected from patients with ulcerative colitis patients and an ileostomy, those with an ileal pouch, and healthy control volunteers. Bacterial DNA was extracted from stool, and the diversity of complex bacteria was assessed by terminal restriction fragment length polymorphism (T-RFLP) analysis, a novel DNA-based approach that enables us to investigate the presence of nonculturable bacteria. To determine whether ileal pouch bacterial communities shift to a more colon-like distribution, the relative abundance of terminal restriction fragments that could be classified as "colonic," "ileal," or "common" was investigated.

RESULTS

Cluster analysis demonstrated that most of the ileostomy samples were categorized into Cluster I or II and that less than 10% of ileostomy samples were classified into Cluster IV. In contrast, more than 90% of control samples were grouped in Cluster IV. In further analyses, the median lifetimes of pouches in Clusters I, II, III, and IV were significantly different at 11, 56, 265, and 310 days, respectively. T-RFLP patterns of the ileal pouch were characterized by a time-dependent decrease in "ileal" and increase in a part of "colonic" fragments, which represented mainly nonculturable bacteria such as the Clostridium coccoides group.

CONCLUSION

T-RFLP analysis demonstrated that a time-dependent shift to a "colon-like" bacterial community, including nonculturable bacteria, in the ileal pouch after total proctocolectomy.

Early diagnosis and early corticosteroid administration improves healing of peristomal pyoderma gangrenosum in inflammatory bowel disease

PURPOSE

To evaluate the efficacy of early diagnosis and early administration of corticosteroid for peristomal pyoderma gangrenosum, a prospective study was carried out.

METHODS

In April 1998, we began studying a new treatment regimen of peristomal pyoderma gangrenosum in which prednisone at a dose of 20 to 40 mg was administered systemically immediately after diagnosis. Early-stage peristomal pyoderma gangrenosum was treated concurrently with topical cadexomer iodine, and at the granulation stage, treatment with clobetasol ointment was started. Healing of peristomal pyoderma gangrenosum was determined by complete epithelialization of ulcer without pain or exudates. Patients were assigned to group A (n = 7) before April 1998 and group B (n = 10) after April 1998, and historical comparison was done between the 2 groups.

RESULTS

In group A, all patients had ulcerative colitis, and in group B, 7 patients had ulcerative colitis, 2 had Crohn's disease, and one had indeterminate colitis. In group B, significantly earlier diagnosis (P = 0.0093), earlier start of treatment (P = 0.0057), higher initial dose of corticosteroid (P = 0.0052), and earlier healing of peristomal pyoderma gangrenosum (P = 0.0023) were observed.

CONCLUSIONS

Early diagnosis and early corticosteroid administration appeared to be effective for promoting healing of peristomal pyoderma gangrenosum.

Giant T4 rectal carcinoma mimicking urinary bladder adenocarcinoma accurately diagnosed by immunohistochemistry and successfully treated with total pelvic exenteration: report of a case

A 54-year-old man, with the chief complaints of hematuria, pollakisuria, and pneumaturia, was referred to our hospital, with a diagnosis of giant urinary bladder adenocarcinoma with massive invasion to the rectum. On the basis of the radiological diagnosis and findings of hematoxylin and eosin (H&E) of biopsy specimens, it was difficult to conclude whether the adenocarcinoma originated in the bladder or in the rectum. The immunohistochemical staining of the biopsy specimens showed cytokeratin 7 (CK7)(-) and CK20(+), which supported the notion that the adenocarcinoma possibly originated from the rectum. Although the prognosis of T4 bladder adenocarcinomas has been reported to be quite poor in comparison with that of transitional cell carcinomas, the postoperative prognosis of T4 rectal adenocarcinomas has been reported to be more favorable and such tumors are recommended to be surgically resected. Because no distant metastasis was detected, the patient underwent total pelvic exenteration with a reconstruction of the ileal conduit. Although the resected tumor measured 12 cm in diameter with n1 metastasis, the radial margin was cancer-negative, and the tumor was curatively resected. The immunohistochemical diagnosis of the resected tumor showed carcinoembryonic antigen(+), CK7(-), CK20(+), thrombomodulin(-), and uroplakin(-), which supported the rectal origin. At present the patient is undergoing postoperative adjuvant chemotherapy for rectal cancer.

Stoma-related complications in inflammatory bowel disease

BACKGROUND

This study was designed to evaluate the incidence and details of stoma-related complications in patients with ulcerative colitis and Crohn's disease who underwent permanent enterostomas, and to analyze the specific problems in these diseases.

METHODS

Permanent enterostomas constructed for ulcerative colitis and Crohn's disease between 1984 and 2004 in our institution were included. The incidence and details of stoma-related complications were investigated retrospectively. The cumulative probability of complications and stoma reconstruction was also estimated by the Kaplan-Meier life-table analysis.

RESULTS

43 patients with ulcerative colitis and 59 patients with Crohn's disease underwent 46 and 76 stoma constructions, respectively. Stoma-related complications, including fistula, retraction and stenosis, were significantly more frequent in patients with Crohn's disease (36.8%) than ulcerative colitis (17.4%) (p < 0.05). The cumulative risk of complications and the necessity for stoma reconstruction was significantly higher in patients with Crohn's disease (p < 0.05). Among the patients with Crohn's disease, colostomies were likely to receive revisional surgery earlier than ileostomies (p < 0.05).

CONCLUSION

In the surgical therapy of inflammatory bowel disease, special attention should be paid in the high incidence of stoma-related complications in patients with Crohn's disease, which needs revisional surgery more frequently.

Pouchitis atlas for objective endoscopic diagnosis

"Pouchitis" is a term for nonspecific mucosal inflammation of the pouch after total proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis. Pouchitis is the most frequent complication of the pelvic pouch at the late stage. To improve the accuracy of the pouchitis diagnosis, sets of clinical symptoms and endoscopic findings (with or without histology of biopsy samples) have previously been evaluated. Endoscopic findings are central to the diagnosis, and a universal consensus of various endoscopic findings must be the initial step toward an objective diagnosis of pouchitis. Since a proper signpost for the endoscopic evaluation of pouchitis has been absent, we developed this pouchitis atlas to minimize the diagnostic variation inherent among individual endoscopists. We also propose new criteria for the diagnosis of pouchitis: the Japanese criteria for diagnosis of pouchitis. These criteria are based on clinical symptoms and endoscopic findings that are clearly categorized in the atlas, and exclude infectious enteritis, anastomotic insufficiency, pelvic infection, anal dysfunction, and Crohn's disease. Advantages of the new criteria include ease of bedside diagnosis, without the calculation of points required by the other criteria for pouchitis. This pouchitis atlas, together with our new criteria, should contribute to the establishment of a clear-cut diagnosis for pouchitis and promote better evaluation and treatment of this novel intestinal inflammation.

[Carcinoma arising from ileorectal fistula in a patient with Crohn's disease]

A 72-year-old man was given a diagnosis of Crohn's disease in 1976 at age 44, and partial resection of is ileum was performed. In November 1982, barium enema examination revealed on ileorectal fistula. As he had no complaint, conservative therapy was chosen. In August 2003, he had high fever and CT scan revealed presacral abscess. Ileocecal resection, partial resection of is small intestine and loop sigmoid colostomy were performed. In December 2004, the serum level of CEA was gradually elevated and he complained of anal mucus discharge. Endoscopic examination showed a fistula orifice in the rectum and biopsy of the fistula revealed mucinous adenocarcinoma. We performed abdominoperineal resection of the rectum with partial resection of the sacrum. We thought that careful observation helped the detection of such a rare case of carcinoma arising from a fistula tract.

Role of alpha-2 adrenoceptors in regulation of giant migrating contractions and defecation in conscious dogs

The aim was to investigate the effects of alpha(2)-adrenoceptor antagonist yohimbine on colonic motility and defecation. The effects of yohimbine (0.5, 1.0, and 3.0 mg/kg) on colonic motility and defecation were studied in neurally intact dogs (N=6), dogs with extrinsic denervation of the ileocolon (N=4), and dogs with enterically isolated ileocolnic loops (N=5) equipped with strain gauge force transducers on the ileocolon. The effects of yohimbine on colonic motility and defecation were also studied in the presence of various antagonists (atropine, hexamethonium, ondansetron, FK224, and naloxone). Yohimbine evoked giant migrating contractions and defecation in a dose-independent manner in neurally intact dogs. These stimulatory effects of yohimbine were abolished by atropine and hexamethonium. In dogs with extrinsic denervation, yohimbine induced giant migrating contractions in the colon but did not stimulate defecation. In dogs with ileocolonic loops, yohimbine induced colonic motor complexes but not giant migrating contractions in the enterically isolated colon. These results indicate that alpha(2)-adrenoceptors in the peripheral nervous system regulate giant migrating contractions by controlling the release of acetylcholine, while those in the central nervous system must be important in the regulation of defecation.

Effect of calcium polycarbophil on bowel function after restorative proctocolectomy for ulcerative colitis: a randomized controlled trial

The aim of the present study was to determine if calcium polycarbophil ameliorates diarrhea after ileal J-pouch anal anastomosis for ulcerative colitis. Twenty-one randomized patients were given either bifidobacterium (3 g/day) plus calcium polycarbophil (3 g/day), in the polycarbophil group (11 patients), or bifidobacterium (3 g/day), in the control group (10 patients), p.o. for 6 months. Anal manometry was performed and bowel function (stool frequency, stool consistency, and nighttime soiling) was assessed via a questionnaire before and 1, 3, and 6 months after drug administration. Eight patients were deemed eligible in each group; five patients were excluded from the study, including two patients whose stool consistency was too firm and who experienced difficulty in defecating attributed to polycarbophil. Anal manometry and stool consistency did not change with time and did not differ between the polycarbophil and the control groups. Stool frequency decreased with time in both groups and did not differ between the groups. Nighttime soiling improved with time in the polycarbophil group but did not change in the control subjects. These results suggest that polycarbophil might be able to improve nighttime soiling without obviously affecting stool frequency and consistency after ileal J-pouch anal anastomosis for ulcerative colitis.

A new drug delivery system targeting ileal epithelial cells induced electrogenic sodium absorption: possible promotion of intestinal adaptation

We previously demonstrated the induction of the epithelial sodium channel, prostasin, and 11beta-hydroxysteroid dehydrogenase type 2 and activation of sodium transport mediated by those molecules in the remnant ileum after total proctocolectomy. The aims of the present study were to develop a new drug delivery system that targets ileal epithelial cells and to enhance local mineralocorticoid action without systemic effects. Orally administered D-aldosterone-containing D,L-lactide/glycolide acid copolymer microspheres are absorbed in the rat terminal ileum and released aldosterone. Blood and terminal ileal tissues were collected 2 weeks after the administration of the microspheres, and the aldosterone concentrations, mRNA, and protein expressions of the above molecules and sodium transport were evaluated. Significantly high levels of tissue aldosterone in the absence of elevated plasma levels were detected in the microspheres-treated rats. Epithelial mRNA and protein expression of the above molecules increased significantly in the microspheres-treated animals. Electrogenic sodium transport in the ileum was enhanced in the microspheres-treated rats. Aldosterone-containing microspheres successfully induced the expression of the above molecules and activated sodium transport in the ileal mucosa, both of which are essential for intestinal adaptation. Pre- and/or postoperative treatment with this drug may compensate for the excessive loss of sodium and water following proctocolectomy.

Pregnancy and delivery in patients with enterostomy due to anorectal complications from Crohn's disease

BACKGROUND AND AIMS

Enterostomy is often undergone by patients with Crohn's disease (CD) due to severe anorectal lesions such as rectovaginal fistula (RVF). Reports of successful pregnancy and delivery, which are important determinants of quality of life for female CD patients with stoma, are limited. Thus, we investigated problems associated with pregnancy and delivery in female CD patients at our hospital.

MATERIALS AND METHODS

Between 1985 and 2003, five female CD patients with enterostoma carried seven pregnancies and delivered eight babies in our hospital. For this study, we investigated CD activity, fetal growth, stoma complications, and the outcome of delivery in these seven pregnancies.

RESULTS

Among the five patients, four underwent loop ileostomy and one loop sigmoidostomy for treatment of RVF or severe stricture of the rectum or sigmoid colon. Except for one case, no fertility treatment was done. During pregnancy, a flare-up was observed in one patient and was successfully treated with corticosteroids. Although home enteral or parenteral nutrition was required in two cases, fetal growth was within the normal range in all pregnancies. Preterm delivery occurred in one case with a twin pregnancy. The mean diameter of stoma increased during pregnancy (p<0.01), and a mucosal laceration of stoma by the edge of an ostomy appliance occurred in one case. All deliveries were safe, with six cesarean sections and one transvaginal delivery. After each delivery, the stoma returned to pre-pregnancy size.

CONCLUSIONS

Pregnancy and delivery in CD patients with stoma is safe and should be encouraged. However, special attention to disease activity, nutritional support, and stoma-related complications is recommended.

An international, multicenter, prospective, observational study of the side-to-side isoperistaltic strictureplasty in Crohn's disease

PURPOSE

The side-to-side strictureplasty is a bowel-sparing alternative to resection in the treatment of stricturing Crohn's disease. This study was initiated to review the adoption of the side-to-side strictureplasty as a new surgical technique and the relative outcomes a decade after its description.

METHODS

A total of 184 unique patients from six centers in the United States, Italy, and Japan served as the basis for this study. A questionnaire instrument was used to assemble prospectively acquired preoperative, intraoperative, perioperative, and postoperative data from each center into a computer-generated database.

RESULTS

Average age at surgery for patients selected for a side-to-side strictureplasty varied significantly between centers (minimum, 31.0 years; maximum, 39.5 years, P < 0.006). Use of the side-to-side strictureplasty technique for primary Crohn's disease vs. surgically recurrent disease also varied significantly by center (primary minimum, 16.7 percent; maximum, 68.6 percent, P < 0.03). Furthermore, length of diseased bowel selected for construction of a side-to-side strictureplasty was significantly different among centers (minimum, 20.8 +/- 9.9 cm; maximum, 64.3 +/- 29.3 cm, P < 0.001). Use of synchronous bowel resection away from the site of the side-to-side strictureplasty was relatively common (minimum, 21.1 percent; maximum, 66.7 percent) as it was with the use of additional synchronous strictureplasties (minimum, 41.9 percent; maximum, 83.3 percent). The six centers experienced a low number of complications (minimum, 5.7 percent; maximum, 20.8 percent). Forty-one of 184 total patients required surgery for recurrent disease, with an average time to recurrence of 35 months. The difference of reoperation-free five-year survival experienced by the patients in the six centers was not statistically significant, with a cumulative reoperation-free five-year survival of 77 percent across all centers.

CONCLUSIONS

Worldwide implementation of the side-to-side strictureplasty technique and its variations has occurred. This procedure carries a very low mortality and morbidity rate, with acceptable recurrence rates.

Effectiveness of an 'half elemental diet' as maintenance therapy for Crohn's disease: A randomized-controlled trial

BACKGROUND

Although thiopurines have a proven role in maintenance therapy for Crohn's disease, an alternative therapy is needed for patients intolerant or resistant to thiopurines.

AIM

To evaluate the effectiveness of home enteral nutrition as a maintenance therapy regimen in which half of the daily calorie requirement is provided by an elemental diet and the remaining half by a free diet. We refer to this home enteral nutrition therapy as 'half elemental diet'.

METHODS

Between 2002 and 2005, 51 patients in remission from two hospitals were randomly assigned to a half elemental diet group (n = 26) or a free diet group (n = 25). The primary outcome measure of this study was the occurrence of relapse over the 2-year period.

RESULTS

The relapse rate in the half elemental diet group was significantly lower [34.6% vs. 64.0%; multivariate hazard ratio 0.40 (95% CI: 0.16-0.98)] than that in the free diet group after a mean follow-up of 11.9 months. Compliance was similar in the two groups. No adverse event occurred in any of the patients throughout the study.

CONCLUSION

This randomized-controlled trial shows the effectiveness of an half elemental diet, which is a promising maintenance therapy for Crohn's disease patients.

Role of selective arterial secretin injection test in treatment of gastrinoma

BACKGROUND/AIMS

To study whether use of the selective arterial secretin injection test increased the rate of tumor localization and curative resection in patients with gastrinoma.

METHODOLOGY

Nine patients with gastrinoma were divided into 2 groups, before and after introduction of selective arterial secretin injection test; 4 patients before 1987 (Group 1) and 5 patients after 1988 (Group 2). Clinical results were compared retrospectively between groups.

RESULTS

Localization of primary gastrinoma was made with conventional imaging studies in 1 of the 4 patients in Group 1 and 3 of the 5 patients in Group 2. In contrast, use of the selective arterial secretin injection test was able to localize the primary tumor in 4 of the 5 patients in Group 2. Total gastrectomy was carried out in the 4 patients in Group 1, and pancreatoduodenectomy was the most frequently performed procedure (3 patients) in Group 2. Rate of curative resection was 25% and 80% in Groups 1 and 2, respectively.

CONCLUSIONS

These results indicate that combining selective arterial secretin injection test with conventional imaging studies contributes to increasing rate of curative resection of gastrinoma.

Fecal stream is essential for adaptive induction of glucose-coupled sodium transport in the remnant ileum after total proctocolectomy

Our previous studies demonstrated that sodium glucose cotransporter 1 (SGLT-1) was induced in the remnant ileum of total colectomized rats via the action of factors other than hyperaldosteronism. The aim of the present study was to clarify whether fecal stream is required for the enhancement of SGLT-1-mediated sodium transport. Twenty-seven pairs of ileal tissues were obtained from the proximal and distal side, respectively, of loop ileostomy after total proctocolectomy. Mucosae were mounted in an Ussing chamber to evaluate glucose-coupled sodium transport. Levels of SGLT-1 mRNA in proximal and distal mucosae were compared by Northern blotting. Villous height and crypt depth were measured to test for correlations between mucosal structure and SGLT-1-mediated sodium transport or mRNA expression levels. Both glucose-coupled sodium transport and expression of SGLT-1 mRNA were significantly lower in distal mucosae relative to proximal mucosae. In distal mucosae, villous height, but not crypt depth, was significantly lower than in proximal mucosae, demonstrating a positive correlation between villous height and SGLT-1 function and expression. Comparative studies of proximal and distal mucosae demonstrated that in addition to hormonal changes, fecal stream is required for full induction of the sodium transport system (which includes SGLT-1-mediated transport) in the remnant ileum following total proctocolectomy.

Assessment of the Japanese Inflammatory Bowel Disease Questionnaire in patients after ileal pouch anal anastomosis for ulcerative colitis

BACKGROUND

The Inflammatory Bowel Disease Questionnaire (IBDQ) is the most widely used disease-specific health-related quality of life questionnaire for patients with inflammatory bowel disease. However, little has been reported about the validation of IBDQ for patients with ulcerative colitis after surgery. The aim of this study was to assess the validity and reliability of the Japanese version of IBDQ in patients with ulcerative colitis after total proctocolectomy and ileal pouch anal anastomosis (IPAA).

METHODS

The validity and reliability of the Japanese IBDQ were assessed in patients with ulcerative colitis who had received IPAA in our hospital. We mailed them the Japanese IBDQ and a supplemental questionnaire on bowel function, which was developed at our institution. Internal consistency, discriminative validity, and factor validity were assessed.

RESULTS

Of the 121 patients to whom we sent the questionnaires, 64 patients (53%) participated in this study. The Japanese IBDQ scores correlated well with Cronbach's alpha value (0.800 to 0.923) and daily life satisfaction score (Pearson's r, 0.492 to 0.700). The total IBDQ score and two subscale scores of the IBDQ, "bowel symptoms" and "systemic symptoms," correlated well with daily bowel-movement frequency (Pearson's r, -0.256 to -0.329). Factor analysis revealed a four-factor structure, and all correlations among factors were moderately positive (0.337 to 0.465). Although the factor distribution was not clearly divided into the four IBDQ subscales, these four factors showed a marked tendency to represent the IBDQ subscales independently.

CONCLUSIONS

The Japanese IBDQ is a valid and reliable instrument for the assessment of Japanese patients with ulcerative colitis after IPAA.

Factors affecting the bowel function after proctocolectomy and ileal J pouch-anal anastomosis for ulcerative colitis

The aim was to study determinants of postoperative bowel function after restorative proctocolectomy for ulcerative colitis. Medical records of patients who underwent proctocolectomy with ileal J pouch-anal anastomosis (IPAA) in two- or three-stage operations and whose status of defecation was known via a questionnaire were retrospectively reviewed. Bowel function, including stool frequency, stool consistency, and degree of nighttime soiling, was correlated with age at the time of surgery, time after ileostomy closure, mean resting anal pressure, longitudinal length of ileal J pouch, and duration of fecal diversion by using univariate and multivariate analyses. Stool frequency decreased significantly with time after ileostomy closure in both univariate and multivariate analyses. Stool frequency tended to be less in patients having a long J pouch, but the correlation was not significant (P = 0.071) in univariate analysis. Nighttime soiling ameliorated with time after ileostomy closure in multivariate, but not univariate, analysis. Deterioration of nighttime soiling was seen in patients whose duration for fecal diversion was long, both in univariate (P = 0.068) and multivariate (P = 0.052) analyses. Stool consistency was related to none of the five factors investigated. These results indicate that as the time after surgery increases, stool frequency decreases and nighttime soiling ameliorates. Delaying ileostomy closure because of anticipated postoperative incontinence does not significantly alter postoperative continence.

Molecular analysis of colonic transformation in the ileum after total colectomy in rats

BACKGROUND

Colonic transformation is thought to be a phenotypic alteration in the ileum after total colectomy (TC) but has not been well addressed at the molecular level. We previously demonstrated roles of aldosterone in enhancement of ileal sodium absorption after TC. However, the significance of aldosterone in intestinal adaptation has been unknown.

METHODS

Rat epithelial gene expression was compared between the ileum and distal colon by complementary DNA microarray. Genes were categorized into "colonic," "common," and "ileal" genes according to signal intensity. Ileal gene expressions in (1) the control and TC rats and (2) the control and aldosterone-infused rats were compared to detect altered genes or to assess the role of aldosterone in intestinal adaptation. Differential expression of MUC3 and lysozyme was confirmed by quantitative reverse transcriptase-polymerase chain reaction.

RESULTS

A total of 6109 genes were categorized into "colonic," "common," or "ileal" gene pools. A comparison of the control and TC rats yielded 82 and 91 genes that were induced and suppressed in the ileum after TC, respectively. Thirty-five percent of them were associated with colonlike transformation (ie, the induction of colonic genes or the suppression of ileal genes). The expressions of MUC3 and lysozyme messenger RNAs were enhanced significantly in the TC ileum, compared with the control. In comparison, aldosterone infusion modulated a total of only 21 genes in the ileum.

CONCLUSION

Those data demonstrate that altered gene expression after TC is, in part, characterized by colonlike transformation. Furthermore, circulating aldosterone appears to play a part in the altering and/or adapting of gene expression in intestinal epithelium.

An approach to analyze mechanisms of intestinal adaptation following total proctocolectomy

We hypothesized that epithelial cells of the remnant small intestine display "colonic" phenotype after total proctocolectomy. The aims of the present study were to identify preferentially expressed molecules in the colon or in the small intestine and to evaluate mRNA levels of those in the ileal pouch. Differential gene expression was investigated between the small intestine and the colon by using cDNA microarray and was confirmed by Northern blotting. Expression of three colonic mRNAs (3-hydroxy-3-methylglutaryl-coenzyme A synthase 2, deleted malignant brain tumors 1, carcinoembryonic antigen-related cell adhesion molecule 1) and one "small intestinal" (microsomal triglyceride transfer protein) mRNA were compared between the control and the ileal pouch mucosae by quantitative reverse transcriptase-polymerase chain reaction. Seventy-four clones were differentially expressed with more than a threefold difference. Differential expression was confirmed in all mRNAs examined, including 3-hydroxy-3-methylglutaryl-coenzyme A synthase 2 and microsomal triglyceride transfer protein. The mucosal expression of carcinoembryonic antigen-related cell adhesion molecule 1 mRNA in the ileal pouch was enhanced in humans. The remnant ileum develops some, but not all, colonic phenotype after total proctocolectomy. Comparative study of epithelial gene expression between the small intestine and the colon enables us to analyze mechanisms of intestinal adaptation after total proctocolectomy.

Aldosterone enhances 11beta-hydroxysteroid dehydrogenase type 2 expression in colonic epithelial cells in vivo

OBJECTIVE

[corrected] 11beta-hydroxysteroid dehydrogenase type 2 (11beta-HSD2) metabolizes glucocorticoids, thus enabling aldosterone to bind to the mineralocorticoid receptor. However, little is known about the regulatory mechanism of epithelial 11beta-HSD2 expression in the gut.

MATERIALS AND METHODS

Sprague-Dawley rats were maintained on a sodium-depleted diet or subjected to continuous aldosterone infusion for 4 weeks. Plasma aldosterone and arginine-vasopressin (AVP) levels were measured by radioimmunoassay. Expression of 11beta-HSD2 in colonic epithelia was evaluated by Northern blotting and immunohistochemistry. T84 and Caco2 cells were stimulated with aldosterone, dexamethasone and AVP alone or in combination, and 11beta-HSD2 mRNA was measured by quantitative reverse transcription polymerase chain reaction (RT-PCR).

RESULTS

Sodium-depleted and aldosterone-infused rats showed an increase of plasma aldosterone and AVP. Both treatments resulted in induction of 11beta-HSD2 in the colonic epithelia at mRNA and protein levels. Positive immunoreactivity was detected in the cytoplasm of the surface epithelia in control rats. In contrast, epithelial cells in the crypt also showed immunoreactivity for 11beta-HSD2 in the proximal colon of dietary sodium-depleted and aldosterone-infused rats. Induction of 11beta-HSD2 mRNA was observed when T84 cells were stimulated with corticosteroids plus AVP.

CONCLUSIONS

Aldosterone has a pivotal role by increasing expression of 11beta-HSD2 in epithelial cells of the colon. AVP may act as a synergistic hormone in aldosterone-mediated 11beta-HSD2 induction.