Crohn's disease patients with chronic intestinal failure receiving long-term parenteral nutrition: a cross-national adult study

BACKGROUND

Chronic intestinal failure (CIF) is a very rare Crohn's disease (CD) complication.

AIM

  To determine incidence of CIF treated with home parenteral nutrition (HPN) in adult CD patients and to isolate factors associated with severe CIF.

METHODS

This retrospective multicentre study included 38 patients with CD-related CIF treated with HPN for at least 12 months in French HPN centres. Severe CIF was defined by a length of remnant small bowel of less than 100 cm or CIF occurrence within the 15 years following CD diagnosis.

RESULTS

Median delay between CD diagnosis and CIF was 15 years. CIF incidence did not decrease over time (1.4/year before 1995 vs. 2.2/year after). Median number of small bowel resections per patient was three (range 1-8). Median small bowel resection, remnant and initial lengths were 160, 80 and 260 cm, respectively. Twenty-four per cent of patients developed stenosis within 1 year after CD diagnosis and 76% developed perforative complications within 2 years. In multivariate analysis, severe CIF, defined as CIF onset <15 years after CD diagnosis, was associated with a more recent CD diagnosis (odds ratio, 0.785; 95% confidence interval, 0.623-0.989). CIF occurred despite frequent use of immunosuppressants. Course of CD remained severe during HPN: immunosuppressants prescription occurred in 11 patients, surgery in six. Six patients died from CD (n = 2), HPN complications (n = 2) or other causes (n = 2).

CONCLUSIONS

Chronic intestinal failure requiring HPN is rare during CD. Incidence remained stable over time. Surgical procedures play a minor role in the occurrence of severe chronic intestinal failure compared to CD severity.

Fistulizing perianal Crohn's disease: contrast-enhanced magnetic resonance imaging assessment at 1 year on maintenance anti-TNF-alpha therapy

BACKGROUND

The aim of the study was to assess perianal fistulas by magnetic resonance imaging (MRI) in patients with severe fistulizing Crohn's disease (CD) using maintenance antitumor necrosis factor alpha (TNF-α) therapy and to correlate MRI changes with clinical outcome.

METHODS

Perineal MRI before and after a 1-year scheduled anti-TNF-α maintenance therapy was performed in 20 patients (14 females; mean age = 33.7). The Van Assche score (i.e., number of fistulas, localization, and extension, importance of T2 hyperintensity, presence of abscess) was calculated. Fistula track contrast enhancement was also used. Clinical outcome was defined as no response, response, or remission.

RESULTS

Response and remission were observed in respectively 40% and 35% of cases. The Van Assche score varied from 13.8 (7-20) to 6.13 (0-12) in patients with a response or remission (P < 0.05). The T2 hyperintensity follow-up value decreased in patients in response or remission (P < 0.01). T2 hyperintensity disappeared or decreased in 14 out of 15 patients in clinical response or remission as compared to one among the five nonresponding patients (P < 0.01). The decrease in Van Assche score and hyperintensity value was not significantly different in patients in remission compared to those with response. Only one patient in clinical remission had a persisting contrast enhancement on MRI, whereas contrast enhancement persisted in all other patients not in remission (P = 0.002).

CONCLUSIONS

The clinical benefit of maintenance anti-TNF-α therapy in perianal CD is associated with a significant improvement of the Van Assche score, particularly T2 hyperintensity. The disappearance of contrast enhancement was the only semiological MR feature associated with remission.

The changing pattern of Crohn's disease incidence in northern France: a continuing increase in the 10- to 19-year-old age bracket (1988-2007)

BACKGROUND

Crohn's disease incidence rates have stabilised in industrialised countries since the 1980s. Conversely, a continuing increase in childhood-onset Crohn's disease incidence has been reported.

AIM

To confirm trends in inflammatory bowel disease (IBD) incidence in northern France over an extended time period (1988-2007) with a focus on childhood-onset Crohn's disease.

METHODS

The IBD patients recorded in the EPIMAD registry between 1988 and 2007 were included. Standardised incidence rates were calculated for Crohn's disease and ulcerative colitis in the entire population, and separately according to age. Evolution of phenotypes at diagnosis was also studied.

RESULTS

A total of 12 084 incident IBD cases (7428 Crohn's disease and 4656 ulcerative colitis) were recorded. Crohn's disease incidence rates increased from 5.2 cases/100 000 persons in 1988-1990 to 6.7 in 2006-2007 (+29%), stabilising after a peak at 7.1 in 1997-1999. Crohn's disease incidence rates in the 10-19-year age category increased by 71%, from 6.5 (1988-1990) to 11.1 (2006-2007). The frequency of initial ileo-colonic localisation increased from 52.9% in 1988-1990 to 68.6% in 2006-2007 (P<0.0001). Ulcerative colitis incidence rates decreased during the same period.

CONCLUSIONS

From 1988 to 2007, Crohn's disease incidence increased by 29% in northern France and by 71% in the 10-19-year-old age group. Consequently, studies on Crohn's disease risk factors should focus on the population under 20 years of age.

Outcome of patients with obscure gastrointestinal bleeding after negative capsule endoscopy: results of a one-year follow-up study

BACKGROUND

Capsule endoscopy (CE) is an effective method for investigating the small bowel, especially in cases of obscure gastrointestinal bleeding (OGIB), although the long-term outcome of patients with a negative CE is generally not known.

PATIENTS AND METHODS

For 49 patients with OGIB and a negative CE, their referring physicians filled out a follow-up questionnaire to assess bleeding recurrence and any repeat investigations after negative video capsule endoscopy (VCE).

RESULTS

A minimum follow-up duration of one year (median: 15.9 months) was available for 35 patients with an overall rebleeding rate of 23% (n=8). Of these eight patients, four women presented with recurrence prior to new investigations. In the four remaining patients, repeat endoscopy work-ups after negative CE were performed and revealed previously missed lesions with bleeding potential, mainly in the stomach. Overall, 13 patients, with or without rebleeding, had repeat endoscopy work-ups after a negative CE, leading to a definitive diagnosis in nine patients, with lesions located in the stomach and colon in eight of them.

CONCLUSION

Patients with OGIB and a negative CE had a low rate of rebleeding. This study highlights the importance of the initial endoscopy work-up, and suggests that CE be proposed after a minimum of two gastroscopies and one complete colonoscopy.

Irritable bowel syndrome is more frequent in patients hospitalized for ischaemic colitis: results of a case-control study

It has been suspected that there is an epidemiological link between irritable bowel syndrome (IBS) and ischaemic colitis (IC). We performed a retrospective case-control study to compare the frequency of IBS in patients hospitalized for IC compared with that of patients with peptic ulcer bleeding. Cases were patients with a first episode of IC and controls were patients with a first episode of peptic ulcer bleeding, matched to cases for sex and 10-year age-class. Diagnosis of IBS was based on medical information extracted from hospital medical files and a standard self-questionnaire. The association between IBS and IC was tested using Mc Nemar's paired odds ratio (OR); confidence interval at 95% (CI 95%) was calculated; Mantel-Haenzel's Chi(2) was applied. A total of 113 cases and 113 matched controls were studied. There were 37 males and 76 females and the mean age was 69 +/- 15 years in each group. The prevalence of IBS in cases was 16.9%vs 1.8% in controls. The risk of IBS was 11.05 times higher among cases than in controls (P < 0.001); CI 95%: (2.45-49.74). A total of 87 pairs with complete data were used for OR calculation. The risk of IBS was 7.5 times higher in cases than in controls (P = 0.002); CI 95%: (1.72-32.80). This case-control study shows that IBS is more frequent in IC patients than in controls.

Efficacy and safety of ornithine alpha-ketoglutarate in heel pressure ulcers in elderly patients: results of a randomized controlled trial

OBJECTIVE

Pressure ulcers affect predominantly the elderly and nutritional status is a known risk factor. Guidelines on pressure ulcers provide recommendation on nutritional management. Ornithine alpha-ketoglutarate (OKG) is an adjuvant treatment in undernourished elderly patients or in patients with hypercatabolism states. It is a precursor of different amino-acids which play a role in the process of healing. The objective of the study is to determine the efficacy of OKG on pressure ulcer area reduction after six weeks of treatment.

DESIGN

Multi-centre, international, randomized, comparative, double blind, parallel groups, placebo-controlled study.

PARTICIPANTS

160 patients (ITT population) aged over 60 years with a heel pressure ulcer at stage II or III.

INTERVENTION

Patients received OKG (n=85) or placebo (n=75) once a day for 6 weeks.

MEASUREMENTS

Ulcer area was measured each week, using a tracer. The primary endpoint was the percentage reduction of the surface at the final visit: [(Wound areatn - Wound areat0)/ (Wound areat0)].

RESULTS

At inclusion, ulcer area distribution deviated from normal distribution (median ulcer area OKG 6.6 cm(2), placebo 3.9 cm2, p=0.044, Mann-Whitney test). As healing is strongly related to baseline ulcer area, the abnormal distribution was a major bias. Therefore it was decided to perform the analysis on 2 sub-groups of patients according to the mean ulcer area, i.e. above or below 8 cm2. The mean wound area reduction for baseline area 8 cm2 no between group differences on either parameter was detected. When closure rate is considered, a significant difference in favor of OKG group is observed (- 0.07 cm2/day in the OKG group and - 0.04 cm2/day in the placebo groups respectively p=0.007, Mann-Whitney test). Thirty serious adverse events were reported in 28 patients (15 allocated to OKG and 13 to placebo). None of them was considered treatment related.

CONCLUSION

This clinical trial supports a potential benefit of OKG 10g daily in the subgroup of patients with pressure ulcers Collapse

Key Words Collapse

MESH Headings

• Aged
• Aged, 80 and over
• Double-Blind Method
• Female
• Foot Ulcer/drug therapy
• Foot Ulcer/pathology
• Heel/pathology
• Humans
• Male
• Ornithine/adverse effects
• Ornithine/analogs & derivatives
• Ornithine/therapeutic use
• Pressure Ulcer/drug therapy
• Pressure Ulcer/pathology
• Reference Values
• Skin/drug effects
• Skin/pathology
• Statistics, Nonparametric
• Wound Healing/drug effects

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Grants Collapse

Affiliation(s)

S Meaume Department of Gerontology, Charles Foix Hospital, Ivry-sur-Seine, Paris
J C Kerihuel
T Constans
L Teot
E Lerebours
J Kern
I Bourdel Marchasson

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Ganglioneuromatosis: an unusual cause of ileal stricture mimicking Crohn's disease

Ileal idiopathic forms of ganglioneuromatosis in adults are extremely rare and represent a challenging pathologic condition for the clinician. We present two cases of ileal ganglioneuromatosis consisting of stricturing lesions that mimicked clinical and radiologic features commonly observed in Crohn's disease patients with ileal involvement.

Double stenting of oesophagus and airways in palliative treatment of patients with oesophageal cancer is efficient but associated with a high morbidity

BACKGROUND

Double stenting of oesophagus and airways may be required in palliative treatment of patients with locally advanced oesophageal cancer.

AIM

To assess feasibility, efficacy and complications occurring in patients with locally advanced oesophageal cancer receiving both oesophagus and airways stenting.

METHODS

In one single centre between 1997 and 2005, among 180 patients with locally advanced oesophageal cancer treated by the palliative placement of a self-expanding metal stent, patients requiring double stenting of oesophagus and airways were identified. Clinical efficacy, complications and survival were retrospectively collected.

RESULTS

Fifteen patients (8.3% of 180) required a double stenting at follow-up. Symptomatic efficacy of oesophagus and airways stenting was 86.7% for dysphagia and 100% for dyspnoea. Median survival after the second stent insertion was 99 days. Life-threatening early complications occurred in three patients after double stenting (20%), including two deaths following oesophageal perforation and massive haemoptysis, respectively. Procedure-related mortality was 13.3%.

CONCLUSIONS

Double stenting of oesophagus and airways is feasible in patients with locally advanced oesophageal cancer, with a relevant clinical efficacy. However, early major complications including procedure-related death may occur in as many as 20% of patients. This treatment should be reserved to very selected patients with severe symptoms and end-stage disease.

Wireless capsule endoscopy versus ileocolonoscopy for the diagnosis of postoperative recurrence of Crohn's disease: a prospective study

BACKGROUND AND AIMS

Following ileocolonic resection for Crohn's disease (CD), early endoscopic recurrence predicts recurrence of symptoms. The aim of the study was to compare ileocolonoscopy and wireless capsule endoscopy (WCE) for the detection of postoperative recurrence in CD.

METHODS

WCE and ileocolonoscopy were performed within six months following surgery in 32 prospectively enrolled patients. Two independent observers interpreted the results of WCE. Recurrence in the neoterminal ileum was defined by a Rutgeerts score>or=1. When observers at WCE did not concur, WCE results were considered as either true negative or true positive and sensitivity and specificity were calculated according to both assumptions.

RESULTS

Recurrence occurred in 21 patients (68%) and was detected by ileocolonoscopy in 19 patients. Sensitivity was 90% and specificity 100%. Sensitivity of WCE was 62% and 76% and specificity was 100% and 90%, respectively, depending on assumptions. There was a correlation between the severity of the lesions measured by both methods (p<0.05). Lesions located outside the scope of conventional endoscopy were detected by WCE in two thirds of patients with excellent interobserver agreement (kappa>0.9) for all lesions with the exception of ulceration (kappa=0.7).

CONCLUSIONS

The sensitivity of WCE in detecting recurrence in the neoterminal ileum was inferior to that of ileocolonoscopy. In contrast, WCE detected lesions outside the scope of ileocolonoscopy in more than two thirds of patients. Additional follow up studies are needed to assess the clinical relevance of such lesions. At the present time, it seems that WCE cannot systematically replace ileocolonoscopy in the regular management of patients after surgery.

Endoscopic markers of villous atrophy are not useful for the detection of celiac disease in patients with dyspeptic symptoms

BACKGROUND AND STUDY AIMS

Celiac disease can manifest with nonspecific symptoms, including functional gastrointestinal disorders such as dyspepsia. The aim of our study was to assess the usefulness of duodenal endoscopic markers of villous atrophy for the selection of dyspeptic patients for histological assessment.

PATIENTS AND METHODS

Esophagogastroduodenoscopy was performed in dyspeptic patients, in patients considered to be at risk of having celiac disease, and in healthy controls. At least three duodenal biopsies were performed for histological assessment of villous atrophy in all patients and controls. We looked for the following four duodenal endoscopic markers of celiac disease: reduction in the number of folds, scalloping of folds, mosaic-pattern mucosa, and nodular mucosa.

RESULTS

A total of 175 people were enrolled (75 patients with dyspepsia; 75 patients who were "at risk" of having celiac disease; and 25 healthy volunteers, or "controls"). Of the dyspeptic patients, four had endoscopic markers of celiac disease with no histologically confirmed villous atrophy, while one patient without endoscopic markers was found to have Marsh type I villous atrophy. Of the patients at risk of having celiac disease, 16 had at least one endoscopic marker and 10/16 were found to have histological villous atrophy. In this group, the sensitivity and specificity of the endoscopic markers were 100 % and 90.8 % respectively. "At-risk" patients with two or more endoscopic markers all had histologically confirmed villous atrophy. Neither endoscopic markers nor villous atrophy were found in any of the control patients.

CONCLUSIONS

Additional endoscopic markers are valuable for diagnosis in patients with clinical symptoms suggestive of celiac disease. In contrast, endoscopic markers of villous atrophy are not useful for selecting a subgroup of dyspeptic patients for screening for celiac disease by duodenal histological assessment. These patients should be screened using other protocols.

Prior chemoradiotherapy is associated with a higher life-threatening complication rate after palliative insertion of metal stents in patients with oesophageal cancer

BACKGROUND

Self-expanding metal stents are used routinely to palliate dysphagia due to oesophageal cancer.

STUDY AIM

To compare the frequency of life-threatening complications after self-expanding metal stent insertion, depending on whether patients received prior chemoradiotherapy or no treatment.

PATIENTS AND METHODS

During 7 years, 116 consecutive patients were treated at a single centre in a palliative intent by insertion of self-expanding metal stent for dysphagia due to an oesophageal cancer. Patients were retrospectively separated into two groups: patients with chemoradiotherapy before self-expanding metal stent insertion (group 1, n = 56) and patients with no treatment before or after self-expanding metal stent insertion (group 2, n = 60). Life-threatening complications were compared and predictive risk factors of postprocedure complications were identified.

RESULTS

Median dysphagia was significantly improved during the first month (grade 3 to grade 1 in the two groups). Early and late major complications occurred more frequently in group 1 (23.2% vs. 3.3%; P < 0.002 and 21.6% vs. 5.1%; P < 0.02 respectively). Prior chemoradiotherapy was the only independent predictive factor of postprocedure major complications, with an odds ratio of 5.59 (CI 95% 1.7-18.1).

CONCLUSIONS

Life-threatening complications after palliative self-expanding metal stent placement seem to occur more frequently in patients with prior chemoradiotherapy. Prevention of these severe complications should be considered before stenting.

Ineffectiveness of Lactobacillus johnsonii LA1 for prophylaxis of postoperative recurrence in Crohn's disease: a randomised, double blind, placebo controlled GETAID trial

BACKGROUND AND AIMS

Early endoscopic recurrence is frequent after intestinal resection for Crohn's disease. Bacteria are involved, and probiotics may modulate immune responses to the intestinal flora. Here we tested the probiotic strain Lactobacillus johnsonii LA1 in this setting.

PATIENTS AND METHODS

This was a randomised, double blind, placebo controlled study. Patients were eligible if they had undergone surgical resection of <1 m, removing all macroscopic lesions within the past 21 days. Patients were randomised to receive two packets per day of lyophilised LA1 (2 x 10(9) cfu) or placebo for six months; no other treatment was allowed. The primary endpoint was endoscopic recurrence at six months, with grade >1 in Rutgeerts' classification or an adapted classification for colonic lesions. Endoscopic score was the maximal grade of ileal and colonic lesions. Analyses were performed primarily on an intent to treat basis.

RESULTS

Ninety eight patients were enrolled (48 in the LA1 group). At six months, endoscopic recurrence was observed in 30/47 patients (64%) in the placebo group and in 21/43 (49%) in the LA1 group (p = 0.15). Per protocol analysis confirmed this result. Endoscopic score distribution did not differ significantly between the LA1 and placebo groups. There were four clinical recurrences in the LA1 group and three in the placebo group.

CONCLUSION

L johnsonii LA1 (4 x 10(9) cfu/day) did not have a sufficient effect, if any, to prevent endoscopic recurrence of Crohn's disease.

Clinical evaluation of the use of the M2A patency capsule system before a capsule endoscopy procedure, in patients with known or suspected intestinal stenosis

BACKGROUND AND STUDY AIM

The main complication of video capsule endoscopy (VCE) is the blocking of the capsule by a gastrointestinal stenosis. The "patency capsule" is a self-dissolving capsule that is the same size as the video capsule. It contains a radiofrequency identification (RFID) tag that allows it to be detected by a scanning device placed on the abdominal wall. When its passage is blocked by a stenosis, the patency capsule dissolves in 40-80 hours after ingestion. The aim of this study was to evaluate the usefulness of this system in patients with suspected intestinal stenosis but also requiring VCE.

PATIENTS AND METHODS

22 patients (16 men; 46 +/- 18 years; 15 with diagnosed or suspected Crohn's disease, two with suspected intestinal tumor, and two on nonsteroidal anti-inflammatory drugs) were first investigated with an abdominal CT plus enteroclysis (entero-CT, n = 15) or a small-bowel follow-through (SBFT, n = 7). The patency capsule was then administered at around 09.00 to fasting patients. The presence of the patency capsule in the digestive tract was assessed 30 hours later using the hand-held scanner. When the patency capsule was detected, a plain abdominal film was obtained, and this was repeated every 24 hours until capsule expulsion.

RESULTS

At 30 hours after ingestion, the patency capsule was detected in 17 patients (72.3 %): in the area of the small intestine (n = 6) and in the colon (n = 11). In all the patients in whom the capsule was blocked in the small intestine, the stenosis had been suspected on CT or SBFT. In three patients, the delay in progression of the patency capsule led to cancellation of the VCE procedure. In three patients, the patency capsule induced a symptomatic intestinal occlusion, which resolved spontaneously in one and required emergency surgery in two. Although these two patients would have been obliged to undergo operation for their primary disease in any case, the procedure had to be brought forward. In one patient, the capsule passed through the stenosis without symptoms. All patients in whom the progression of the patency capsule was delayed had an established or suspected diagnosis of Crohn's disease.

CONCLUSIONS

The current technical development of the patency capsule limits its use in clinical practice, as it did not detect stenoses undiagnosed by CT or SBFT. The start of dissolution at 40 hours after ingestion is too slow to prevent episodes of intestinal occlusion. Patients with Crohn's disease are most likely to be at risk of blockage of progression of the capsule and should benefit from a CT investigation before VCE. However, a careful interview eliciting the patient's medical history and symptoms remains the most useful indicator with regard to suspicion of an intestinal stenosis.

Clinical evaluation of the use of the M2A patency capsule system before a capsule endoscopy procedure, in patients with known or suspected intestinal stenosis

BACKGROUND AND STUDY AIM

The main complication of video capsule endoscopy (VCE) is the blocking of the capsule by a gastrointestinal stenosis. The "patency capsule" is a self-dissolving capsule that is the same size as the video capsule. It contains a radiofrequency identification (RFID) tag that allows it to be detected by a scanning device placed on the abdominal wall. When its passage is blocked by a stenosis, the patency capsule dissolves in 40-80 hours after ingestion. The aim of this study was to evaluate the usefulness of this system in patients with suspected intestinal stenosis but also requiring VCE.

PATIENTS AND METHODS

22 patients (16 men; 46 +/- 18 years; 15 with diagnosed or suspected Crohn's disease, two with suspected intestinal tumor, and two on nonsteroidal anti-inflammatory drugs) were first investigated with an abdominal CT plus enteroclysis (entero-CT, n = 15) or a small-bowel follow-through (SBFT, n = 7). The patency capsule was then administered at around 09.00 to fasting patients. The presence of the patency capsule in the digestive tract was assessed 30 hours later using the hand-held scanner. When the patency capsule was detected, a plain abdominal film was obtained, and this was repeated every 24 hours until capsule expulsion.

RESULTS

At 30 hours after ingestion, the patency capsule was detected in 17 patients (72.3 %): in the area of the small intestine (n = 6) and in the colon (n = 11). In all the patients in whom the capsule was blocked in the small intestine, the stenosis had been suspected on CT or SBFT. In three patients, the delay in progression of the patency capsule led to cancellation of the VCE procedure. In three patients, the patency capsule induced a symptomatic intestinal occlusion, which resolved spontaneously in one and required emergency surgery in two. Although these two patients would have been obliged to undergo operation for their primary disease in any case, the procedure had to be brought forward. In one patient, the capsule passed through the stenosis without symptoms. All patients in whom the progression of the patency capsule was delayed had an established or suspected diagnosis of Crohn's disease.

CONCLUSIONS

The current technical development of the patency capsule limits its use in clinical practice, as it did not detect stenoses undiagnosed by CT or SBFT. The start of dissolution at 40 hours after ingestion is too slow to prevent episodes of intestinal occlusion. Patients with Crohn's disease are most likely to be at risk of blockage of progression of the capsule and should benefit from a CT investigation before VCE. However, a careful interview eliciting the patient's medical history and symptoms remains the most useful indicator with regard to suspicion of an intestinal stenosis.

Renal impairment in patients with inflammatory bowel disease: association with aminosalicylate therapy?

BACKGROUND

In recent years, several case reports have been published suggesting an association between the use of 5-aminosalicylic acid (5-ASA) in patients with inflammatory bowel disease (IBD) and the development of chronic tubulo-interstitial nephritis. Apart from lesions associated to 5-ASA treatment, however, it is clear that IBD itself may also induce renal impairment, albeit the frequency is unknown.

METHODS

During 1 year, all IBD patients seen at the outpatient clinic of 27 European centres of gastro-enterology were registered and screened for renal impairment controlling for a possible association with 5-ASA therapy. Patients were questioned about their medical and drug history and their IBD disease activity. Renal screening (calculated creatinine clearance) was performed at baseline, after 6 and 12 months.

RESULTS

Included patients (n = 1,529) had a mean age of 39 (range 14-98), 56% had Crohn's disease, 42% ulcerative colitis and 2% indeterminate colitis. Half of the patients used 5-ASA during the study period. Decreased creatinine clearance was observed in 34 patients, among them 13 with chronic renal impairment. Comparing patients with and without renal impairment, no difference could be observed in 5-ASA consumption. In contrast, patients with renal impairment were significantly older, had a lower body mass index and showed a higher frequency of male sex, bowel resection and stoma.

CONCLUSION

Although the association between 5-ASA therapy and chronic tubulo-interstitial nephritis is clearly described in several case reports, this prospective study came to the reassuring conclusion that renal impairment in IBD patients is not frequently observed and is rarely associated with 5-ASA therapy.

Environmental risk factors in paediatric inflammatory bowel diseases: a population based case control study

BACKGROUND

Environmental exposures in early life have been implicated in the aetiology of inflammatory bowel disease.

OBJECTIVE

To examine environmental risk factors prior to the development of inflammatory bowel disease in a paediatric population based case control study.

METHODS

A total of 222 incident cases of Crohn's disease and 60 incident cases of ulcerative colitis occurring before 17 years of age between January 1988 and December 1997 were matched with one control subject by sex, age, and geographical location. We recorded 140 study variables in a questionnaire that covered familial history of inflammatory bowel disease, events during the perinatal period, infant and child diet, vaccinations and childhood diseases, household amenities, and the family's socioeconomic status.

RESULTS

In a multivariate model, familial history of inflammatory bowel disease (odds ratio (OR) 4.3 (95% confidence interval 2.3-8)), breast feeding (OR 2.1 (1.3-3.4)), bacille Calmette-Guerin vaccination (OR 3.6 (1.1-11.9)), and history of eczema (OR 2.1 (1-4.5)) were significant risk factors for Crohn's disease whereas regular drinking of tap water was a protective factor (OR 0.56 (0.3-1)). Familial history of inflammatory bowel disease (OR 12.5 (2.2-71.4)), disease during pregnancy (OR 8.9 (1.5-52)), and bedroom sharing (OR 7.1 (1.9-27.4)) were risk factors for ulcerative colitis whereas appendicectomy was a protective factor (OR 0.06 (0.01-0.36)).

CONCLUSIONS

While family history and appendicectomy are known risk factors, changes in risk based on domestic promiscuity, certain vaccinations, and dietary factors may provide new aetiological clues.

Argon plasma coagulation in the treatment of hemorrhagic radiation proctitis is efficient but requires a perfect colonic cleansing to be safe

AIMS

We evaluate prospectively effectiveness, tolerance, predictive factors of failure and complications of argon plasma coagulation (APC) in the treatment of hemorrhagic radiation proctitis (HRP).

PATIENTS AND METHODS

Twenty-seven patients were treated by APC for HRP. Eight patients needed blood transfusion before APC. Six patients were anti-coagulated and one had severe thrombocytopenia. APC was performed without sedation in 25/27 patients. Before APC treatment, bowel preparation was performed by enema (n = 19 sessions), polyethylene glycol or sodium phosphate (n = 53 sessions). APC treatment was performed every 5 weeks. Effectiveness of APC was based on clinical and endoscopic score and biological status before and after APC treatment.

RESULTS

The mean follow-up was 13.6 months (range, 3-31 months). After one to seven sessions of APC (average, 2.66 sessions), twenty-five patients (92%) had no recurrence of bleeding. The bleeding score decreased from 3.03 to 0.42 (P < 0.001) and the endoscopic score from 3.08 to 0.73 (P < 0.001). Out of the eight patients requiring blood transfusion prior to APC sessions, only one required blood transfusion after APC (P < 0.05). One late relapse was observed and successfully re-treated by APC. Side effects were anal or rectal pain (n = 3) and vagal symptoms (n = 2). Three colonic explosions occurred, with perforation leading to surgery in one case. The incidence of bowel explosion was higher after local preparation (3/19 sessions) compared with oral preparation (0/53 sessions) (P < 0.05). No stricture due to APC appeared, even if telangiectasias coagulated during a session were circumferential.

CONCLUSION

Coagulation by APC is an effective and safe treatment of HRP if a complete cleansing preparation is performed to avoid explosion.

Opposite evolution in incidence of Crohn's disease and ulcerative colitis in Northern France (1988-1999)

BACKGROUND

Northern France was characterised by a high incidence of Crohn's disease (CD) and a low incidence of ulcerative colitis (UC) according to the first inquiry undertaken in the late 1980s.

AIMS

To assess the trends in the incidence of inflammatory bowel disease (IBD) over a 12 year period (1988-1999) in the same area of Northern France.

PATIENTS

Patients living in Northern France (Nord, Pas-de-Calais, Somme, and Seine Maritime--total of 5,790,526 inhabitants) between 1988 and 1999 were included in the study. Case ascertainment was established according to methodology previously described.

METHODS

Trends in incidence were studied using a Poisson regression model in four three year periods (1988-90, 1991-93, 1994-96, and 1997-99) adjusted for age at diagnosis and sex. Incidence rates were standardised for age with the European standard population.

RESULTS

During 1988-99, 7066 cases of IBD were recorded (56.8% CD, 37.7% UC, and 5.5% indeterminate colitis). Mean annual incidence rate of CD increased from 5.2/100,000 inhabitants in 1988-90 to 6.4 in 1997-99 (adjusted p for trend <0.001). In contrast, the incidence of UC decreased from 4.2 to 3.5 (adjusted p for trend <0.001). The ileocolonic subtype of CD increased by 25% even though median age at diagnosis and frequency of digestive investigations were not different.

CONCLUSIONS

Contrary to what has been reported in other countries in Northern Europe, the incidence of CD increased by 23% in 12 years in Northern France while that of UC decreased by 17% during the same period. This indicates that some factors which influence IBD frequency (in both directions) are still at work in this area of Europe, and that further studies aimed at identifying these should be performed. The rising incidence of CD could enhance the burden of this disease on the public health system in France.

Osteoporosis in inflammatory bowel disease: effect of calcium and vitamin D with or without fluoride

BACKGROUND

Previous data have indicated low bone formation as a mechanism of osteoporosis in inflammatory bowel disease. Fluoride can stimulate bone formation.

AIM

To assess the effect of fluoride supplementation on lumbar spine bone mineral density in osteoporotic patients with inflammatory bowel disease treated in parallel with calcium and vitamin D.

METHODS

In this prospective, randomized, double-blind, parallel and placebo-controlled study, 94 patients with inflammatory bowel disease (lumbar spine T score below - 2 standard deviations, normal serum 25OH vitamin D), with a median age of 35 years, were included. Bone mineral density was measured by dual-energy X-ray absorptiometry. Patients were randomized to receive daily either sodium monofluorophosphate (150 mg, n=45) or placebo (n=49) for 1 year, and all received calcium (1 g) and vitamin D (800 IU). The relative change in bone mineral density from 0 to 12 months was tested in each group (fluoride or placebo) and compared between the groups.

RESULTS

Lumbar spine bone mineral density increased significantly in both groups after 1 year: 4.8 +/- 5.6% (n=29) and 3.2 +/- 3.8% (n=31) in the calcium-vitamin D-fluoride and calcium-vitamin D-placebo groups, respectively (P < 0.001 for each group). There was no difference between the groups (P=0.403). Similar results were observed according to corticosteroid intake or disease activity.

CONCLUSIONS

Calcium and vitamin D seem to increase lumbar spine density in osteoporotic patients with inflammatory bowel disease; fluoride does not provide further benefit.

Efficacy of antibiotic-lock technique with teicoplanin in staphylococcus epidermidis catheter-related sepsis during long-term parenteral nutrition

BACKGROUND

The antibiotic-lock technique has been suggested to treat catheter-related sepsis in parenteral nutrition and to avoid catheter removal.

METHODS

To determine the incidence of catheter-related sepsis, the bacteria involved, and the efficacy of the antibiotic-lock technique with teicoplanin, all patients (n = 263) undergoing parenteral nutrition from January 1997 to December 1999 in one center, with patients at the hospital (n = 209) and at home (54) were retrospectively studied. The antibiotic-lock technique with teicoplanin was systematically used in all suspected infections and maintained in staphylococcus epidermidis (SE) infections.

RESULTS

A total of 21 of 263 patients had 34 infections (0.11/patient per year): 12 of 209 hospitalized and 9 of 54 home patients. A total of 10 of 34 infections were due to non-SE, and the catheter was immediately removed. The other 24 of 34 infections were due to SE; in 5 of 24, the catheter was removed after 48 hours of the antibiotic-lock technique because of persistent fever or thrombosis. A total of 5 of 12 patients had 2 or more infections on the same catheter. The antibiotic-lock technique prevented short-term catheter removal in these cases, but a second infection occurred within a median of 50 days. In 4 of 5 cases, a third infection occurred in a mean delay of 90 days so that the catheter was removed. In 3 of 5 patients, bacteria was analyzed with pulsed field gel electrophoresis, which showed that recurrent infections were due to the same strain in all cases.

CONCLUSIONS

In this study, the incidence of catheter-related sepsis was low and mostly related to SE. Our results do not support the use of the teicoplanin antibiotic-lock technique in SE infections.

Low levels of gastric mucosal glutathione during upper gastric bleeding associated with the use of nonsteroidal anti-inflammatory drugs

OBJECTIVES

To investigate the glutathione concentrations in gastric mucosa from patients with acute gastric bleeding related to nonsteroidal anti-inflammatory drugs (NSAIDs), and to test the influence of nutritional status on mucosal glutathione. Glutathione protects the gastrointestinal mucosa against reactive oxygen species, and glutathione content in various tissues may be depleted during malnutrition.

METHODS

Endoscopic biopsies were obtained from 39 patients. Eighteen of these (9 well-nourished, 9 malnourished) presented with gastric bleeding ulcers related to NSAIDs. Twenty-one other patients (12 well-nourished, 9 malnourished) underwent normal routine diagnostic endoscopy and served as controls. Malnutrition was defined as a loss of over 10% of normal body weight and/or plasma albumin levels below 30 g/l. Gastric biopsies were taken from the fundus and antrum (controls) and from the region of the ulcer (patients with acute bleeding) and frozen quickly until glutathione analysis by high-performance liquid chromatography (HPLC) coulometric detection. Results were expressed as nmol/mg wet tissue.

RESULTS

Gastric mucosal glutathione levels were significantly (P < 0.05) lower in both the antrum (0.81 +/- 0.34 v. 1.41 +/- 0.88 nmol/mg tissue) and the fundus (1.04 +/- 0.54 v. 1.43 +/- 0.92 nmol/mg tissue, P < 0.05) in malnourished than in well-nourished control patients. Glutathione mucosal concentrations were decreased significantly in patients with NSAID-induced gastric bleeding compared with control patients (0.38 +/- 0.36 v. 1.12 +/- 0.56 nmol/mg tissue, P < 0.001), and the lowest glutathione levels were observed in malnourished patients (0.28 +/- 0.20 v. 0.48 +/- 0.15 nmol/mg tissue in well-nourished patients, not significant).

CONCLUSION

Malnutrition is associated with low levels of gastric glutathione. This may contribute to the severity and the onset of haemorrhage in NSAID-induced gastric ulcers.

Magnetic resonance cholangiographic assessment of a delayed radiation-induced bile duct stricture

Radiation-induced bile duct strictures are rare since bile ducts are considered to be resistant in radiation injury. We report a case of bile duct stenosis where evidence is presented that bile duct stricture was the result of radiation injury and which illustrates the major contribution of magnetic res-onance cholangiography in biliary tract disease evaluation.

Increase in cyclooxygenase-2 and nitric oxide-synthase-2 mRNAs in pouchitis without modification of inducible isoenzyme heme-oxygenase-1

OBJECTIVES

The pathophysiology of pouchitis occurring after ileal pouch-anal anastomosis remains controversial. Prostaglandins and nitric oxide synthesized in excess by cyclooxygenase-2 and nitric oxide synthase-2 are thought to be involved in the inflammatory process. Because heme oxygenase-1, by its antioxidant properties, could modulate inflammatory reaction, we analyzed mRNAs of the three enzymes (cyclooxygenase-2, nitric oxide synthase-2, and heme oxygenase-1) in patients with ileal pouch-anal anastomosis.

METHODS

Endoscopic biopsies were obtained in eight patients with normal ileal pouch-anal anastomosis, in eight patients with pouchitis, and in normal ileum of six healthy subjects. A relative quantitative RT-PCR was performed to determine the levels of cyclooxygenase-2, nitric oxide synthase-2, and heme oxygenase-1 mRNAs.

RESULTS

Cyclooxygenase-2 and nitric oxide synthase-2 mRNAs were increased both in normal ileal pouch-anal anastomosis and in pouchitis, compared with healthy subjects. Pouchitis disease activity index was correlated with mRNA levels of cyclooxygenase-2 (r = 0.71; p < 0.01) and nitric oxide synthase-2 (r = 0.51; p < 0.05). Heme oxygenase-1 mRNA levels were not significantly different in patients versus healthy subjects.

CONCLUSIONS

The increase in cyclooxygenase-2 and nitric oxide synthase-2 mRNA levels both in pouchitis and normal ileal pouch-anal anastomosis demonstrates that a latent inflammatory process occurs in the ileal pouch mucosa. This inflammatory process was not found to be associated with an induction of heme oxygenase mRNA, a possible regulator of the inflammatory response.

Chronic hepatitis C with normal or abnormal aminotransferase levels: is it the same entity?

OBJECTIVE

The features of hepatitis C virus (HCV) infection with persistently normal serum alanine aminotransferase (ALT) activity levels are not well defined. This study evaluated the characteristics of HCV infection according to the presence or absence of elevated ALT.

METHODS

Demographic data, liver histology and HCV genotype were studied in a group of 80 HCV-RNA-positive subjects with persistently normal ALT (PNALT) (group 1), and compared with a second group of 455 HCV-RNA-positive patients with elevated ALT (group 2). The annual progression of liver fibrosis was also calculated.

RESULTS

A higher proportion of women was found in group 1:64% vs 42% in group 2 (P< 0.0002). The HCV genotype 1 was less frequent in group 1:49% vs 60% in group 2 and genotype 2 was more frequent: 16% in group 1 vs 4% in group 2 (P< 0.002). Cirrhosis was less frequent in group 1 (4% vs 13% in group 2 (P< 0.0001)). Normal liver was more frequent in group 1:9% vs 1% in group 2 (P< 0.0001). The Knodell score was significantly different between the two groups: 3.2 +/- 0.27 vs 7.15 +/- 0.22 (P< 0.0001). The progression of liver fibrosis was lower in group 1: 0.053 +/- 0.14 units/year vs 0.13 +/- 0.24 in group 2 (P < 0.007).

CONCLUSION

HCV infection with PNALT is associated with less severe histological liver disease and a lower fibrosis progression rate. This suggests that the natural history of HCV infection in these patients is different from that in patients with abnormal ALT.

Prothrombotic inherited abnormalities other than factor V Leiden mutation do not play a role in venous thrombosis in inflammatory bowel disease

OBJECTIVES

Because the incidence of thromboembolism is increased in patients with inflammatory bowel disease, we attempted to assess the role of prothrombotic inherited coagulation abnormalities in the development of thrombosis.

METHODS

Four populations were compared: 15 patients with inflammatory bowel disease and a previous venous thrombosis, 58 control patients with inflammatory bowel disease but without thrombosis, 110 patients without inflammatory bowel disease but with previous deep venous thrombosis, and 84 healthy subjects. Inherited and acquired risk factors of venous thrombosis, e.g., factor V Leiden and prothrombin 20210A mutations, C677T methylenetetrahydrofolate reductase polymorphism, a polymorphism located in exon 13 of factor V gene, inflammatory and hypercoagulability markers were studied in each population.

RESULTS

In the study, 14.3% of thrombotic patients with inflammatory bowel disease had factor V Leiden mutation versus 0% of control patients with inflammatory bowel disease (p = 0.04), 15.5% of thrombotic patients without inflammatory bowel disease (NS) and 3.6% of the healthy controls. A total of 14% of thrombotic patients with inflammatory bowel disease and 11.8% of thrombotic patients without inflammatory bowel disease carried prothrombin 20210A mutation, compared to 1.7% of control patients with inflammatory bowel disease; however, the difference was just below significance. Other inherited coagulation abnormalities were not statistically significantly different among the four populations.

CONCLUSIONS

Our study confirms that factor V Leiden mutation increases the risk for thrombotic events but is not more frequent in patients with inflammatory bowel disease. Our results do not support the role of other thrombotic risk factors.

[Expandable metal stents in palliative treatment of malignant colorectal stricture. A report of 17 consecutive patients]

OBJECTIVE

Several endoscopic procedures have been used to avoid a colostomy in palliative treatment of occlusive colorectal cancer. The aim of this study was to evaluate in intent to treat the long term effectiveness and safety of self-expanding metal stents as a palliative treatment in patients with neoplastic colonic obstruction.

PATIENTS AND METHODS

From December 1997 to June 2000, seventeen patients were treated with 21 colonic stents. Sites of obstruction were high rectum in 3, sigmoid in 11 and left colon in 3.

RESULTS

Stent placement was successful in 16/17 patients (94%). Relief of bowel obstruction occurred in 13 patients (74%) in the first 48 hours. Expandable metal stent achieved an effective bowel transit until death in 9 of the 17 patients (53%). Clinical complications occurred in 6 patients (35%): 2 perforations, 2 migrations, 1 rectal bleeding and 1 dislocation of the stent. Subsequent colostomy was done in 5 patients.

CONCLUSION

Colonic stenting is an alternative palliative treatment in malignant colorectal stricture. However, morbidity and need for subsequent colostomy should be taken into account.

Inflammatory bowel disease in spouses and their offspring

BACKGROUND & AIMS

The rarity of inflammatory bowel disease (IBD) in both husband and wife is often given as an argument against an infectious origin. We registered conjugal instances of IBD in Northern France and in Belgium between 1989 and 2000.

METHODS

Couples were assigned to group A if both partners had symptoms of IBD before cohabitation, to group B if one spouse had IBD before cohabitation and the other experienced first symptoms afterwards, and to group C if both partners got the disease after cohabitation. Risk of IBD was assessed in their offspring.

RESULTS

Thirty conjugal instances were registered. Seventeen were concordant for Crohn's disease and 3 for ulcerative colitis; 10 were mixed. Two belonged to group A, 6 to group B, and 22 to group C. In group C, IBD occurred in the first affected spouse an average of 9 years after cohabitation and in the second spouse an average of 8.5 years later. Group C conjugal forms were more frequent than expected by chance (P < 0.02). Fifty-four children were born to 25 couples; among them 9, of whom 4 were siblings, developed Crohn's disease at a median age of 15 years.

CONCLUSIONS

The frequency of conjugal forms of IBD suggests an etiologic role for environmental factors. Offspring of 2 affected parents have a high risk of developing IBD.

Influence of glutamine on cytokine production by human gut in vitro

BACKGROUND

glutamine modulates cytokine production by immune cells in vitro and protects the gut from experimental enterocolitis, but data on the effect of glutamine on cytokine production in human gut are lacking.

AIM

to assess the effect of glutamine pre-treatment in vivo and in vitro on cytokine production by intestinal mucosa.

METHODS

nine fasted volunteers received either enteral glutamine or saline over 6 h in a cross-over design. Duodenal biopsies were cultured for 24 h with or without glutamine. Cytokine content of culture media was analysed by ELISA, and the expression of cytokine mRNA in biopsies was assessed by semi-quantitative RT-PCR.

RESULTS

glutamine given in vivo and in vitro significantly decreased IL-6 [1.4 (0.8-8.5) vs 8.9 (1.0-43.9)] and IL-8 production [5.8 (0-51.4) vs. 53.0 (2.5-114.6), pg/mg wet tissue], median (range), both P< or =0.01, in comparison to no glutamine experiments. Glutamine did not influence IL-4 production. IL-1beta, IL-10 and TNF-alpha were not detectable in culture media. The expression of any cytokine mRNA was not influenced by glutamine.

CONCLUSIONS

glutamine reduces pro-inflammatory cytokine production by human intestinal mucosa, probably by a post-transcriptional pathway. Glutamine could be useful to modulate inflammatory conditions with imbalanced cytokine production.