Budesonide enema in pouchitis--a double-blind, double-dummy, controlled trial

BACKGROUND

Pouchitis has been suggested to be a recurrence of ulcerative colitis in a colon-like mucosa. Topical steroids are a valid therapeutic alternative for distal forms of ulcerative colitis.

AIM

To investigate the efficacy and tolerability of budesonide enema in the treatment of pouchitis compared with oral metronidazole.

MATERIALS AND METHODS

Twenty-six patients with an active episode of pouchitis (defined as a pouchitis disease activity index score >or= 7) and no treatment during the previous month were randomized to receive either budesonide enema (2 mg/100 mL at bedtime) plus placebo tablets or oral metronidazole (0.5 g b.d.) plus placebo enema in a prospective, double-blind, double-dummy, 6-week, controlled trial.

RESULTS

Based on the intention-to-treat principle, we detected a significant improvement in disease activity at the end of the first week with both drugs (P < 0.01). After that, improvement was moderated until stabilization at 4 weeks in both treatments. The per protocol analysis showed that both drugs had similar efficacy in terms of disease activity, clinical and endoscopic findings. Fifty-eight per cent and 50% of patients improved (decrease in pouchitis disease activity index >or= 3) with budesonide enema and metronidazole, respectively (odds ratio, 1.4; confidence interval, 0.2-8.9). Adverse effects were observed in 57% of patients given metronidazole and in 25% of patients given budesonide.

CONCLUSIONS

Budesonide enemas are an alternative treatment for active pouchitis, with similar efficacy but better tolerability than oral metronidazole.

Serum transforming growth factor-beta1 levels increase in response to successful anti-inflammatory therapy in ulcerative colitis

OBJECTIVE

To investigate serum levels of transforming growth factor-beta1 and interferon-gamma in active ulcerative colitis and to assess changes during treatment.

METHODS

We prospectively evaluated serum from 25 patients with untreated active ulcerative colitis and 19 healthy controls. Disease activity score (DAI), serum transforming growth factor-beta1 and interferon-gamma levels were measured at baseline and after 7 days of conventional treatment. Disease activity score and transforming growth factor-beta1 were also assessed at 42 days.

RESULTS

Baseline transforming growth factor-beta1 levels were significantly higher in patients than in controls (P < 0.02). On the 7th day, transforming growth factor-beta1 levels increased only in patients who responded (P < 0. 01); variations in transforming growth factor-beta1 levels and disease activity score were inversely correlated (r=- 0.72, P < 0. 001). At day 42, serum transforming growth factor-beta1 decreased significantly compared with the 7th day (P < 0.05). While in controls, interferon-gamma was undetectable; untreated patients had higher, widely variable, levels. At day 7, responders had higher interferon-gamma values than unresponsive cases. Variations in interferon-gamma correlated moderately with changes in transforming growth factor-beta1 (r=0.53, P < 0.05). Cytokine response did not depend upon the type of treatment.

CONCLUSIONS

Both transforming growth factor-beta1 and interferon-gamma may play a role in the injury-repair process in active ulcerative colitis. Variations in circulating transforming growth factor-beta1 levels in the first week of treatment seem to be related to the therapeutic response.

High frequencies of telomeric associations, chromosome aberrations, and sister chromatid exchanges in ulcerative colitis

OBJECTIVE

Chromosome instability provides a predisposing background to malignancy, contributing to the crucial genetic changes in multistep carcinogenesis. The aim of this work was to analyze chromosome instability in patients with ulcerative colitis (UC) to achieve a better understanding of the increased risk for colorectal cancer.

METHODS

Peripheral blood lymphocyte cultures from 20 untreated UC patients and 24 controls were used to study chromosome instability by assessing telomeric associations (TAS), chromosome aberrations (CA), and sister chromatid exchanges (SCE).

RESULTS

Mean frequencies of TAS and CA were significantly increased in UC patients compared to controls (p < 0.001). Chromosomes 10, 11, 21, 16, and 19 were the most frequently involved in TAS. A total of 104 CA clustered in 66 breakpoints could be exactly localized. Seven nonrandom bands significantly affected in UC patients were found (p < 0.004), showing a significant correlation with the location of cancer breakpoints (p < 0.003), particularly with colorectal carcinoma rearrangements. SCE analysis showed higher levels in patients compared to controls (p < 0.006), but no differences were observed in cell cycle kinetics.

CONCLUSIONS

Our results demonstrate the presence of an unstable genome in UC patients that could be related to the cancer development observed in this disease.

[Absence of bleeding recurrence of peptic ulcer after long term follow-up of successful eradication of Helicobacter pylori]

Helicobacter pylori (HP) eradication reduces dramatically the peptic ulcer relapse rate, but information regarding recurrence of peptic ulcer bleeding after eradication is still scanty. Available data show rebleeding rates of 0-3% per year in successfully eradication patients, compared with figures between 12 and 33% among the non eradicated ones. The aim of this study was to determine the rebleeding rate among successfully eradicated patients with a prior history of rebleeding peptic ulcer. 42 patients (34 male, mean age 49, range 18-74) hospitalised for Hp positive bleeding peptic ulcer undergoing conservative treatment, were given as soon as oral route was re-established, a one-week eradication treatment, followed by the same proton pump inhibitor for three or five weeks for duodenal and gastric ulcer healing respectively. No maintenance antiulcer therapy was indicated. Patients were advised not to take nonsteroideal anti-inflammatory drug. Ulcer healing and Hp eradication was confirmed in all 42 patients by means of endoscopy and biopsies for urease rapid test and histology four weeks after completion of the treatment. After this patients were invited to enter a long-term follow-up program with periodical visits. End point of the study was occurrence of rebleeding. Further endoscopies were planned when rebleeding or symptomatic relapse. Median follow-up time was 24.02 months, ranging from 3 up to 27 months. All patients were compliant with the follow-up visits. None of the patients presented with symptoms suggestive of ulcer relapse or upper gastrointestinal bleeding. Our data suggest, that Hp eradication can prevent bleeding relapses in patients with Hp positive bleeding peptic ulcers.

[Helicobacter pylori detection by polymerase chain reaction in gastric juice and its correlation with the histology (Giemsa)]

HP infection is involved in the pathogenesis of several gastroduodenal diseases, as type B chronic gastritis, duodenal and gastric ulcer, MALT lymphoma and gastric cancer. The recent availability of molecular techniques, specifically the PCR, allow us to detect very low amounts of the bacterium. The aim of the study is to evaluate the presence of HP in gastric juice by PCR technique and to correlate this findings with histology (Giemsa) of gastric mucosa. Gastric juice PCR positive findings were found in 10/31 (32.3%) HP positive patients at histology. We concluded that HP in gastric juice is possible to detect by molecular techniques. In our study 32.3% of the patients showed the presence of HP in gastric juice.

Successful treatment of retractile mesenteritis with oral progesterone

Retractile mesenteritis is a rare inflammatory mesenteric disorder that involves the intestine secondarily. The natural history of this process is diverse, but most patients require some empiric therapeutic measures. Up to now, pharmacological therapy has included corticosteroids, colchicine, and immunosuppressive drugs. Although these drugs are successful in most patients, some have been refractory to these therapies and, in others, the beneficial effects were counterbalanced by adverse reactions. Many patients require surgery, but most have poor results. This report describes a 42-year-old man with histologically proven retractile mesenteritis refractory to surgical intervention who had a good response to oral progesterone (10 mg/day for 6 months) with complete disappearance of tumor mass and clinical symptoms. No adverse effects were detected. Current knowledge about the mechanism by which progesterone affects fibrogenesis is scanty. It seems likely that progesterone down-regulates proliferation and metabolism of fibroblasts and fibrogenesis.

Pre- and post-treatment serum levels of cytokines IL-1beta, IL-6, and IL-1 receptor antagonist in celiac disease. Are they related to the associated osteopenia?

OBJECTIVE

Decreased bone mineral density is a common finding in untreated celiac disease patients. However, the precise pathophysiology of osteopenia remains incompletely understood. Pathological features of gluten sensitivity are associated with local release of proinflammatory and antiinflammatory cytokines. We investigated the serum levels of IL-1beta, IL-6, and IL-1 receptor antagonist in celiac patients and correlated them with bone density measurements.

METHODS

We assessed serum samples of 16 female patients at the time of diagnosis (on an unrestricted diet) and after a mean time of 37 months on a gluten-free diet. At the same time, bone mineral density in the lumbar spine and total skeleton was determined by DEXA.

RESULTS

Untreated patients had high serum levels of IL-1beta and IL-6 and normal IL-1-RA. Treatment produced a decrease in median IL-1beta levels (p = NS) and a significant diminution of IL-6 (p < 0.05). On the contrary, IL-1-RA increased significantly after treatment (p < 0.05). Baseline lumbar spine Z-score and IL-6 levels exhibited a significant inverse correlation (r = -0.61; p < 0.01). Patients with more severe baseline osteopenia (< -2 Z-scores) had a significantly lower IL-1-RA than those with less bone compromise (> -2 Z-scores).

CONCLUSIONS

Our data demonstrate that the inflammatory process observed in active celiac disease is associated with high serum levels of IL-1beta and IL-6 and normal levels of IL-1-RA. Treatment significantly reduces both proinflammatory cytokines and significantly increases the antiinflammatory one. We also suggest that these cytokines might have a role in the osteopenia associated with celiac disease.

Gluten sensitivity in patients with primary biliary cirrhosis

OBJECTIVE

Whereas celiac disease and primary biliary cirrhosis have been reported to coexist in the same patient, the frequency of this relationship has not been clarified. Nowadays, the concept of celiac disease has been extended from that of a severe enteropathy to a broader concept of gluten-driven intestinal immunological response. In this study we assessed features of gluten sensitivity in a cohort of patients with primary biliary cirrhosis.

METHODS

Ten patients with primary biliary cirrhosis were evaluated a mean of 2 yr after diagnosis. The following features of gluten sensitivity were assessed: serum antigliadin and endomysial antibodies, small bowel histology (degree of atrophy and quantitative histological parameters), the presence of the typical celiac HLA genotype (DQ2), and intraepithelial lymphocyte response in the rectal mucosa after local gluten instillation (rectal gluten challenge).

RESULTS

Overall, three patients presented evidence of gluten sensitivity. All three had abnormal titers of antigliadin antibody type IgA and one was positive for endomysial antibody. Two patients had partial villous atrophy. The rectal gluten challenge showed a celiac-like response, evidenced by an increase in intraepithelial lymphocyte infiltration after gluten exposure, in the three patients. The characteristic celiac HLA genotypes (DQA1 0501 and DQB1 0201) were identified in three patients. One of them also exhibited other features of gluten sensitivity. However, despite evidence of gluten intolerance, patients had minimal or no symptoms characteristic of celiac disease.

CONCLUSION

We detected features of gluten sensitivity in a high proportion of patients with primary biliary cirrhosis. Further studies should be performed to elucidate the clinical significance of this association.

Gluten sensitivity in the rectal mucosa of first-degree relatives of celiac disease patients

BACKGROUND/AIMS

Rectal gluten challenge is a simple, sensitive, and specific test of mucosal gluten sensitivity. Our aims in this study were to evaluate gluten sensitivity in a group of relatives of celiac patients and to compare these findings with those obtained on small bowel histology, celiac disease-related serology, and HLA typing.

METHODS

A 4-h rectal gluten challenge was performed with 6 g of crude gluten in saline solution in 29 first-degree relatives, 20 well-diagnosed celiac patients, and 10 subjects in whom celiac disease had been excluded. The number of intraepithelial lymphocytes in pre- and postchallenge frozen rectal biopsies (pan T-cell immunocytochemistry) was quantified by computerized image analysis.

RESULTS

The intraepithelial lymphocyte response after gluten instillation was significantly higher in celiac disease patients (median, 126% increase above the baseline count; 95% confidence interval: 61-213%) compared with control subjects (median, -5%; 95% confidence interval: -29-5%). Using a cut-off of 20% change in intraepithelial lymphocyte count, 14 relatives (48%) showed a celiac-like response. Two of these subjects had partial villous atrophy and increased lymphocyte counts in the small bowel mucosa. One of them also exhibited a positive celiac disease-related serology and the typical celiac human lymphocyte antibody (HLA) DQ2. The remaining 12, and all those relatives with a negative challenge, had normal small bowel mucosa and were negative for antigliadin and endomysial antibodies. The characteristic celiac HLA (DQA1 0501 DQB1 0201 heterodimer) was identified in five relatives with positive challenge (including the patient with more severe mucosal atrophy) but was also present in eight relatives with no evidence of gluten sensitivity in the rectal mucosa.

CONCLUSIONS

Our study characterizes a subgroup of relatives of celiac patients who show mucosal evidence of sensitization after local instillation of gluten in the rectum but who have no other features of celiac disease.

Bone mineral density in patients with pancreatic insufficiency and steatorrhea

OBJECTIVES

Low bone mineral density (BMD) has been demonstrated in some patients with chronic intestinal disorders accompanied by diarrhea and malabsorption. However, very few studies have evaluated BMD in patients with pancreatic insufficiency due to cystic fibrosis. Our aim was to assess the prevalence and severity of bone loss in a cohort of patients with pancreatic insufficiency as a consequence of chronic pancreatitis.

METHODS

Fourteen patients with chronic pancreatitis were studied. All of them presented with severe pancreatic insufficiency (secretin test: bicarbonate < or = 40 mEq/L) and steatorrhea (fecal fat > 7 g/day) and had been abstinent from alcohol for a median of 2.5 yr (range 1-15 yr). BMD was measured with a total-body scanner for dual-energy x-ray absorptiometry. Results were expressed as T-score (number of SD by which a patient density differs from the mean of sex-matched 30-yr-old healthy controls) in lumbar spine (L2-L4) and femoral neck. Total serum calcium, 25-(OH)D3, alkaline phosphatase, and midmolecular parathyroid hormone were determined.

RESULTS

Ten patients demonstrated osteopenia (T-score -1 to -2.5) in the lumbar spine and in the femoral neck. Three patients displayed osteoporosis (T-score < -2.5) in the lumbar spine and two in the femoral neck. Mean T-scores (+/- SEM) were -1.44 +/- 0.37 in the lumbar spine and -1.79 +/- 0.27 in the femoral neck. Total and ionic serum calcium, serum parathyroid hormone, and alkaline phosphatase were in the normal range in all patients. Serum 25-(OH)D3 was below normal range in 7 of 12 patients. T-scores of patients with pancreatitis of alcoholic etiology (n = 10) were similar to those of nonalcoholic patients (n = 4). BMD did not correlate with age, bicarbonate secretion, fecal fat excretion, stool volume, parameters of mineral metabolism, duration of alcoholism, or mean alcohol intake.

CONCLUSIONS

Most patients with pancreatic insufficiency as a consequence of chronic pancreatitis exhibit osteopenia, and some show evidence of osteoporosis. Identifying the intimate mechanisms for low BMD are beyond the limitations of the present study. More in-depth metabolic studies are necessary to define the pathogenic mechanism of osteopenia associated with chronic pancreatic disorders.

Gastrointestinal permeability in celiac disease

BACKGROUND & AIMS

Intestinal permeability is increased in patients with active celiac disease. The measurement of sucrose permeability is proposed as a novel means to detect upper gastrointestinal damage, with potentially greater use than conventional methods. The aim of this study was to evaluate the effectiveness of sucrose in the detection of celiac disease.

METHODS

Permeability tests were performed in 27 newly diagnosed patients, at diagnosis, after upper gastrointestinal endoscopies were performed to exclude macroscopic gastric lesions, and after 2 months on a gluten-free diet. Results were compared with those obtained in 30 healthy subjects and 7 patients with chronic diarrhea but no evidence of celiac disease.

RESULTS

At diagnosis, 25 of 27 patients had increased urinary excretion of sucrose. Mean sucrose excretion in patients with untreated celiac disease was significantly increased compared with healthy controls and controls with disease. Sucrose excretion decreased significantly after treatment and completely normalized in 60% of patients. The lactulose-mannitol ratio was abnormal in 26 of 27 patients, with a mean value significantly greater than that observed in healthy controls. This ratio also significantly declined after treatment; however, no values returned to the normal range.

CONCLUSIONS

Increased sucrose permeability is a sensitive marker for advanced celiac disease. Moreover, it decreases rapidly in response to a gluten-free diet and therefore is potentially useful to follow response to therapy.

Gastrointestinal permeability in celiac disease

BACKGROUND & AIMS

Intestinal permeability is increased in patients with active celiac disease. The measurement of sucrose permeability is proposed as a novel means to detect upper gastrointestinal damage, with potentially greater use than conventional methods. The aim of this study was to evaluate the effectiveness of sucrose in the detection of celiac disease.

METHODS

Permeability tests were performed in 27 newly diagnosed patients, at diagnosis, after upper gastrointestinal endoscopies were performed to exclude macroscopic gastric lesions, and after 2 months on a gluten-free diet. Results were compared with those obtained in 30 healthy subjects and 7 patients with chronic diarrhea but no evidence of celiac disease.

RESULTS

At diagnosis, 25 of 27 patients had increased urinary excretion of sucrose. Mean sucrose excretion in patients with untreated celiac disease was significantly increased compared with healthy controls and controls with disease. Sucrose excretion decreased significantly after treatment and completely normalized in 60% of patients. The lactulose-mannitol ratio was abnormal in 26 of 27 patients, with a mean value significantly greater than that observed in healthy controls. This ratio also significantly declined after treatment; however, no values returned to the normal range.

CONCLUSIONS

Increased sucrose permeability is a sensitive marker for advanced celiac disease. Moreover, it decreases rapidly in response to a gluten-free diet and therefore is potentially useful to follow response to therapy.

Chromosome instability in untreated adult celiac disease patients

Spontaneous chromosome aberrations (CAs) and induced fragile sites (FSs) were analysed in 12 untreated adult coeliac disease (CD) patients and 8 healthy controls. Blood lymphocytes from each individual were cultured for 72 h at 37 degrees C in F-10 medium with 5% fetal calf serum and 0.1 ml phytohemagglutinine. FSs were induced by FudR (10 micrograms/ml, 24 h before harvesting) and caffeine (2.2 mM. 6 h before harvest). Spontaneous CAs and FSs were analysed on 30-50 Giemsa-stained and G-banded metaphases. The mean frequencies of spontaneous CAs (abnormal cells, gaps/cell and breaks/cell) of CD patients (0.24 +/- 0.02, 0.21 +/- 0.02 and 0.13 +/- 0.02, respectively) were significantly higher than those of controls (0.04 +/- 0.01, 0.02 +/- 0.01 and 0.02 +/- 0.01, respectively) (p < 0.001). Fourteen spontaneous CAs and 5 FSs specific for CD patients presented a strong coincidence (70%) with bands involved in T- and B-cell malignant lymphoma rearrangements. These findings suggest that CD has chromosome instability affecting specific points that could be related to the high prevalence of malignancies in this disorder.

Early changes of body composition in asymptomatic celiac disease patients

BACKGROUND/AIM

This is a study of patients with asymptomatic celiac disease. The aims of this study were: 1) To evaluate the nutritional status of asymptomatic patients with newly diagnosed celiac disease, and 2) to compare these findings with those of untreated/symptomatic and treated patients.

MATERIAL

We examined 41 patients with celiac disease divided into three groups: a) 8 asymptomatic (diagnosed in a study of first-degree relatives of probands), b) 20 untreated/symptomatic patients, and c) 13 treated patients. Nutrition of patients from groups A and B was assessed at the time of diagnosis.

METHODS

Nutritional status was evaluated by: 1) body composition (fat and lean mass) by dual energy x-ray absorptiometry (DEXA), and 2) anthropometric measurements.

RESULTS

Compared with sex and age matched controls (n = 153), asymptomatic patients presented a moderate but significant reduction of the fat compartment (-29%; p < 0.001), but not of the lean-tissue mass (p = NS). Untreated/symptomatic patients showed a more severe depletion of fat (-46%; p < 0.001) and lean mass (-9.0%; p < 0.05) compared with healthy controls. Although fat mass of treated patients was significantly reduced with respect to controls (-24%; p < 0.003), lean mass was not affected. The anthropometric measurements of fat showed a significant correlation with the evaluation by DEXA (multiple regression analysis r = 0.918).

CONCLUSION

Asymptomatic patients in our study with an unequivocal diagnosis of celiac disease established by mucosal biopsy exhibited a modified body composition.

[Botulinum toxin is effective in the short-term treatment of esophageal achalasia. Preliminary results of a randomized trial]

Botulinum toxin (BoTox) is a potent inhibitor of the release of acetylcholine from terminal nerves and has been used successfully in spastic disorders of skeletal muscle. Its used for the treatment of disorders of gastrointestinal smooth muscle has recently been explored. In this study we evaluated the efficacy of transendoscopic injection of BoTox in 13 symptomatic patients with achalasia G II (Siewert classification) without previous treatment of an ongoing randomized-controlled trial. Patients were blindly randomized to administrate: a) 8OU of BoTox were injected in four quadrants (1 ml in each quadrant-20 U/ml) (n = 8), b) normal saline solution as placebo injected in the same way (n = 5). Patients who did not respond were retreated in an open design with the same schedule of BoTox. BoTox or placebo were injected directly into the lower esophageal sphincter (LES), located by manometric and endoscopic procedures, via sclerotherapy injector. Response to treatment was assessed by changes in symptoms score, weight, LES pressure, barium esophagograms and endoscopy. All determinations were repeated at basal and after 7-30-60 and 90 days of treatment. Post treatment response was considered positive if at one month, 3 of 4 parameters were improved. No evidence of response to BoTox were assessed in 3 patients. At 90 days, 10 patients remain well and data are as follows: (mean +/- SD) symptoms score: (Pre: 3.23 +/- 0.44) (Post: 1.31 +/- 0.95); LES pressure (mmHg) (Pre: 53, 15 +/- 66.31 +/- 7.49); % reduction of esophageal diameter 55% (p < 0.0001) (pair T-test). Relaxation of LES did not change after treatment. There were no side effects related to BoTox injection.

CONCLUSIONS

Endoscopic intrasphincteric BoTox injection is safe, simple and effective in the short term treatment for achalasia. Further studies are necessary for evaluation of long term effects.

Gynaecological and obstetric disorders in coeliac disease: frequent clinical onset during pregnancy or the puerperium

BACKGROUND AND AIM

While gynaecological and obstetric disorders have been reported among women with coeliac sprue, their true prevalence and relationship to the coeliac disease process has not been completely elucidated. Our aims were to determine: (1) the prevalence of gynaecological and obstetric problems in patients with coeliac disease and the influence of strict gluten restriction on their occurrence, (2) the effect of pregnancy on the clinical course of coeliac disease and (3) the clinical features of those patients with onset of coeliac disease during pregnancy and the puerperium.

PATIENTS AND METHODS

The gynaecological and obstetric history of 130 coeliac patients and 130 age-matched healthy female controls were compared in a case-control study.

RESULTS

In comparison to the controls, untreated coeliac disease patients exhibited significantly later menarche, an earlier menopause, an increased prevalence of secondary amenorrhoea and a greater incidence of spontaneous abortions. Patients who had adhered, in the long term, to a gluten-free diet had gynaecological and obstetric history indistinguishable from controls. Clinical deterioration of coeliac disease was observed in untreated patients during 17% of their pregnancies. In 14% of those untreated patients who were pregnant symptoms related to coeliac disease were manifested for the first time during either pregnancy (n = 7) or the puerperium (n = 4). Nine of these patients had underestimated features suggestive of coeliac disease.

CONCLUSION

The early diagnosis and treatment of coeliac disease may avoid significant gynaecological and obstetric complications in affected women. Celiac sprue must always be borne in mind among patients who develop diarrhoea and weight loss during pregnancy and/or the puerperium.

Screening for asymptomatic celiac sprue in families

We evaluated the reliability of IgA and IgG antigliadin antibodies (AGA-A, AGA-G), antireticulin antibody (ARA), endomysial antibodies (EmA), and alpha 1-antitrypsin clearance (alpha 1-AT CL) in the detection of celiac sprue (CS) in 59 first-degree asymptomatic relatives of celiac patients who had duodenal biopsy. Twenty-four relatives who had normal results of screening tests were selected at random for biopsy; 35 relatives with at least one abnormal test result were biopsied. Eleven relatives were noted to have villous atrophy at biopsy; the diagnosis of celiac sprue was confirmed by histological improvement after gluten-free diet in six. AGA-G, alpha 1-AT CL, and EmA had sensitivities of 73%, 73%, and 64%, respectively, with very high levels of specificity. Sensitivity was improved by the combination of two serological markers (AGA-G + alpha 1-AT CL = 91%; AGA-G + EmA = 82%; EmA + ARA = 82%). Furthermore, combination of EmA and ARA has shown the best specificity and positive predictive value. AGA-G, alpha 1-AT CL, and EmA are reliable individual markers for the detection of asymptomatic celiac sprue. However, a combination of two of them, including ARA, was more sensitive than the individual tests.

Bone mineral affection in asymptomatic adult patients with celiac disease

OBJECTIVES

Osteopenia is a well-known complication of overt celiac disease, but whether such defective bone mineralization is present among asymptomatic or silent patients is not known. Our objectives were: 1) to examine bone mineralization of a group of asymptomatic celiac patients; 2) to compare these results with those of symptomatic patients.

METHODS

Bone mineral density of the spine and total skeleton by dual energy x-ray absorptiometry and serum parameters of mineral metabolism of eight recently diagnosed asymptomatic patients with celiac disease were studied. Results were compared with those obtained in 20 untreated symptomatic celiacs, 14 patients treated with gluten-free diet for a mean time of 15 yr, and 153 healthy adult subjects, matched by sex and age.

RESULTS

Four and five out of eight asymptomatic patients presented with reduced mineralization of the spine and the total skeleton, respectively (> 1 SD below normal values for sex and age). Two patients presented with severe osteopenia of the spine, and the other three presented with severe osteopenia of the whole skeleton (> 2 SD below mean normal values). Osteopenia at plane bone level (total skeleton) was significantly lower when compared to healthy controls (p < 0.02). Symptomatic untreated patients had significantly more severe deterioration of bone mineralization than did asymptomatics (p < 0.05) and treated patients (p < 0.05). No difference in bone mineral density was observed between treated patients and asymptomatic celiacs. Serum levels of calcium, alkaline phosphatase, 25-OH vitamin D, and parathormone did not show conclusive abnormalities.

CONCLUSIONS

Our findings provide direct evidence that reduced bone mineralization occurs in asymptomatic celiac patients before any other symptom becomes evident. Only early diagnosis and treatment of celiac disease can avoid the deterioration of the bone structure observed in all clinical status of celiac disease.

Value of endoscopic markers in celiac disease

Duodenoscopy in celiac disease has identified several markers of the disease. Our aim was to evaluate, in a prospective study, the usefulness of the different endoscopic features in 100 consecutive cases referred to endoscopy for intestinal biopsy. Histological examination of duodenal samples showed severe villous atrophy (grade III/IV) in 36 patients. Of these patients, 34 had endoscopic markers suggestive of celiac disease. These were reduction in number or loss of Kerkring's folds (in 27), mosaic pattern (14), scalloped folds (12), and visibility of the underlying blood vessels (5). Endoscopic visualization of these markers had a sensitivity of 94%, a specificity of 92%, and a positive predictive value of 84%. Reduction in number, or loss of, Kerkring's folds was the most sensitive (76%) and specific (98%) single endoscopic change indicating celiac disease. Duodenoscopy permitted diagnosis in three of four asymptomatic patients in a group of 24 first-degree relatives of celiac disease patients. We conclude that endoscopy of distal duodenum is a sensitive and specific indicator of celiac disease.

Superior mesenteric artery blood flow in celiac disease

Measurements of the hemodynamic parameters of the superior mesenteric artery were performed in 18 patients with celiac disease. Ten were studied at the time of diagnosis, when a small bowel biopsy showed a flat mucosa. The remaining eight patients were studied after complete clinical and histological recovery induced by a gluten-free diet. Doppler ultrasound flowmetry was used to measure blood flow in physiological and fasting conditions and after a mixed liquid test meal (Ensure-Plus). The results were compared with those of healthy subjects (N = 7). Mean basal flow was 50% higher in untreated celiac disease patients than in healthy controls and patients with chronic pancreatitis (P = NS). Postprandial mesenteric blood flow was significantly increased (P < 0.002) and delayed in time (P < 0.005) in celiac disease as compared to controls. Successful treatment reduced the mesenteric blood flow in celiac disease to normal values. Our study demonstrates that pathophysiological changes in the small bowel mucosa during the active clinical phase of celiac disease induce an abnormal splanchnic circulation.

Dextran administration avoids hemodynamic changes following paracentesis in cirrhotic patients. A safe and inexpensive option

Paracentesis associated with albumin administration has been shown to be a safe and useful procedure in the treatment of patients with cirrhosis and ascites. Given the high cost of albumin, 20 patients with cirrhosis and ascites were treated in an open study, with daily paracentesis using dextran 70, an inexpensive volume expander, instead of albumin. In the first 10 patients, hemodynamic evaluation was performed in basal conditions, after each paracentesis (5 liter), and after dextran infusion. Twelve hours after each paracentesis without expansion, a significant drop in pulmonary capillary wedge pressure from 9.5 +/- 1.0 to 7.1 +/- 1.7 (P less than 0.01) and a reduction in cardiac output from 6.6 +/- 1.0 to 5.0 +/- 1.9 (NS) were observed. Moreover, the hematocrit rose significantly from 36.8 +/- 5.6 to 39.2 +/- 4.8 (P less than 0.01). These parameters returned to baseline values after the administration of 84 +/- 14 ml of dextran 70 for each 1000 ml of ascites removed. The other 10 patients received dextran 70 simultaneously with the paracentesis without hemodynamic control. No significant changes in renal and hepatic functions were observed at the end of the study. The mean volume of ascites removed was 12.3 +/- 4.6 liter. Two patients developed hyponatremia that required no treatment. No patient developed renal failure. One patient died because of gastrointestinal bleeding.(ABSTRACT TRUNCATED AT 250 WORDS)

Celiac sprue after surgery of the upper gastrointestinal tract. Report of 10 patients with special attention to diagnosis, clinical behavior, and follow-up

The clinical onset of celiac sprue (CS) may be precipitated by upper digestive tract surgery. We report a series of 10 patients who developed CS after diverse types of peptic ulcer surgery. Six were male and 4 female. Gastrectomy with Billroth II anastomosis was performed in 5 patients, truncal vagotomy and pyloroplasty in 2, parietal cell vagotomy and pyloroplasty in 1, and vagotomy with gastrojejunal anastomosis in 2. We found that eight patients had had previous symptoms that suggested CS. Symptoms occurred early in the postoperative period. Severe diarrhea and striking weight loss were the most prominent clinical findings. The response to gluten-free diet was independent of the type of surgical procedure performed and was similar to that observed in the general celiac population.

Alpha 1-antitrypsin clearance as an aid in the management of patients with celiac disease

One hundred and thirty-two different intestinal alpha 1-antitrypsin clearance tests were performed in 48 untreated adult celiac patients, 64 patients taking a gluten-free diet, and 20 adult healthy controls. In the untreated group, 95% of patients had enteric protein loss with values higher than the upper limit of normality (mean +/- 2 SD). In the treated group of patients, only 22% had abnormal levels of alpha 1-antitrypsin clearance. Sixteen patients who had elevated clearance before treatment had decreased clearance after an average of 7.4 months on a gluten-free diet. There was a significant relation (p less than 0.05) between the alpha 1-antitrypsin clearance and the degree of alteration of the jejunal histological structure. We conclude that enteric protein loss is a very frequent finding in celiac patients and the measurement of alpha 1-antitrypsin clearance may be a reliable method to evaluate the activity of the disease and useful in following the efficacy of treatment.

Fecal fat concentration in the differential diagnosis of steatorrhea

Many approaches have been proposed to differentiate between steatorrhea due to pancreatic insufficiency and intestinal disease. Bo-Linn and Fordtran recently suggested that fecal fat concentration (FFC) is a useful screening test for this distinction. Our aim was to validate their result in a large group of patients. Fecal fat concentrations were calculated for 613 fecal fat tests in 538 patients. Included were 88 patients with pancreatic steatorrhea (13 pancreatic carcinoma, 6 cystic fibrosis, and 69 chronic pancreatitis) and 525 with nonpancreatic steatorrhea. The mean FFC of patients with pancreatic disease (15.0 +/- 1.9 g%, mean +/- SEM) was significantly higher than that of patients with other diseases causing malabsorption (8.9 +/- 0.3 g%, p less than 0.001). Forty-two percent of patients with pancreatic steatorrhea had an FFC below 10 g%. The overlapping of the FFC of steatorrhea due to pancreatic disease and that produced by celiac disease, gastric resection, and other conditions suggests that this approach does not differentiate between pancreatic and intestinal steatorrhea.

[Value of the breath test with cholylglycine C14 in the diagnosis of bacterial contamination in patients with gastric surgery]

The TAE C14 has been evaluated as a diagnostic method of small bowel contamination in a group of patients operated for gastric disturbances. It has been compared with bacterial culture and bile salts chromatogrpahy of jejunum liquid and therapeutic response. 36 patients have been studied and divided in 3 groups: a) negative control: 8 subjects without pathology; b) positive control: 6 patients with intestinal resection and 1 with intestinal scleroderma, all of them with steatorrhea; c) gastric operated patients: 16 BII with and without vagotomy, 3 gastroenteroanastomosis and vagotomy, 1 superselective vagotomy and pyloroplasty and 1 B I, all the patients had steatorrhea, except one with BII. The period elapsed between the operation and the studies varied from 1 to 17 years (X: 4.9 +/- 4.1). The average value of steatorrhea was 23.9 +/- 10.2 g/24 hs. 100% of group b and 80% of group c had abnormal TAE C14. In 80% of the patients of the group c chromatogrpahy was performed and it agreed with TAE C14 in 80% of the studies. Bacteriology was positive in 100% of 18 studies, coinciding with TAE C14 in 70% patients. Therapeutic control of 100% of group c was positive in 90%.