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Does preoerative ileitis predispose to pouchitis?
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AGA ABSTRACTS
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GASTROENTEROLOGY, Vol. 108, No. 4
• SMALL B O W E L E N T E R O S C O P Y : S H O U L D JEJUNAL BIOPSY BE ROUTINE? ' = Morris A J , Lee F D, MacKenzie J F. G a s t r o e n t e r o l o g y a n d P a t h o l o g y D e p t s , Royal I n f i r m a r y , G l a s g o w , UK Introduotion, Small bowel enterosoopy allows direct endoscopic examination of the small bowel. Push enteroaeopes offer the facility for jejunal biopsy but the additional diagnostic yeild from routine enterosc0pie biopsy is unknown. Estimates of the prevalence of non steroidal anti inflammatory drug (NSAiD) small bowel enteropathy vary widely depending on the method of small bowel assessment employed~ This may be explained by failure to detect miorosoopic disease if no biopsy is obtained at diagnostio enterosoopy. We have therefore examined the role of enteroscopic jejunal biopsy in "the diagnosis Of suspected NSAID enteropathy in patients with rheumatoid arthritis (RA) and ankylosing spondylitia (AS). Patients/Methods. 27 patients on long term NSAID (15RA:12AS), 10 p a t i e n t s n o t on NSAID (SRA:5AS) a n d 7 oontl-ola n e t on NSAID w e r e e x a m i n e d u s i n g t h e O l y m p u s SIF-10L p u s h e n t e r o s o o p e . All macresoopio j e j u n a l l e s i o n s w e r e d o c u m e n t e d . J e j u n a l b i o p s i e s w e r e o b t a i n e d from n o r m a l muoosa i n p r o x i m a ! a n d d i s t a l jejunum a n d mucosa a d j a c e n t to u l o e r a t i v e l e s i o n s . H i s t o l o g i c a l a s s e s s m e n t was c a r r i e d o u t b y a s i n g l e p a t h o l o g i s t who w a s b l i n d e d t o e n t e r o s o o p y r e s u l t and drug therapy. Results. I n t h e NSAID g r o u p 9 ( 2 2 % ) p a t i e n t s h a d l e s i o n s obaerved (3 ulcers: 3 ereaiona) at enterosoopy whilst in the n o n NSAID g r o u p 1 ( ! e r o s i o n ) (10%) p a t i e n t h a d l e s i o n s aeen. None of t h e c o n t r o l p a t i e n t s h a d j e j u n a l u l o e r a t i o n . I n 30 (8 ! %) p a t i e n t s t h e e n t e r o s c o p i o f i n d i n g s a n d h i s t o l o g y were compatible. I n ? (19%) p a t i e n t s , all on NSAID, t h e r e s u l t s of e n t e r o s e o p y a n d h i a t o l o g y w e r e i n c o m p a t i b l e , 5 (71 %) of t h e s e p a t i e n t s h a d normal e n t e r o e o o p y a n d a b n o r m a l histology consistent with NSAID enterepathy. Coneluaions: We c o n o l u d e t h a t NSAID e n t e r o p a t h y is a diffuse mucosal disease Whose prevalence may be underestimated by endoscopic inspection only. The finding of additional mioroacopic abnormalities in 19% of patients suggest that jejunal biopsy should be considered an essential part 'of diagnoatic enteroscopy.
• DISEASE RELATED CONCERNS OF PATIENTS "WITH INFLAMMATORY BOWEL DISEASE AND THE USE OF UNCONVENTIONAL THERAPIES.. G. Moser. W. Tlllinger, H. Vogeisang, J. Wyatt, Th. Maier, H. Lochs, A. Gangl, DepartmentofIn,realMedicine W, UniversityHospitalVienna,Aus~ia
O DOES PREOERATIVE ILEITIS P R E D I S P O S E T O POUCHITIS? RG Moslev, J Madsen, M Reichelderfer, BA H a r m s . Departments of Medicine, Pathology, and S u r g e r y , Univ of Wisconsin, Madison WI. ' '
O STIMULATION OF TRANSFORMING GROWTH'FACTOR ~ (TGFI~i)
Inflammation of the ileal pouch ("pouchitis") i s a frequent complication of total colectomy with ileal pouch-anal anastomosis (IPAA) and is particularly common in patients with ulcerative colitis (UC)~ A l t h o u g h bacterial o v e r g r o w t h and immune'injury have been suggested as possible mechanisms, t h e etiology remains unknown. We explored the possibility that p o u c h i t i s is related to p r e existing ileal inflammation (so-called ',backwaSh ileitis,), which is present in up to 25% of U C patients. METHODS= We reviewed all colectomy specimens of UC patients undergoing a IPAA by a single surgeon f r o m 1990 to' 1993. When adequate ileum was present (47 of I08 patients), inflammation was evaluated by one of us (blinded to clinical outcome) and quantified by the following scale: grade O, absence; grade i, mild acute cryptitis; grade 2, extensive cryptitis; grade 3 , crypt abscesses. Clinical fol!owup w a s p e r f o r m e d by chart review and mailed surveys, with pouchitis diagnosed by standard clinical criteria (diarrhea, hematochezia, fever). PJSULTS= Of our 47 patients r i0 (21%) had evidence of ileitis: 3 with grade i,~2 with grade 2, and 5 with grade 3. Five of i0 (50%) developed pouchitis, whereas only 11 of 37 patients without ileitis (30%) had subsequent pouchitis. Although suggestive, the difference between patients with and without ileitis was not significant (p=0.27, Fisher's exact test ) . Interestingly, n o n e o f 6 evaluable polyposis ! patients undergoing IPAA for familial polyposis had ileitis or subsequentpouchitis. CONCLUSIONS: o u r data suggest that pouchitis is more common i n uC patients with pre-existing ileitis. Larger prospective studies a r e needed to evaluate this association.
Introduction: Patients' disease related concerns and information level about inflammatory bowel disease (IBD) are important for their Coping with the illness. We investigated the relationsinp between IBD patients' concerns with disease related and sociodemographic data, their perceived information level about IBD and the use of alternative medicine in 105 consecutive outpatients with IBD (72 Croim's disease, 33 ulcerative colitis). Methods: Disease t;elated concerns were measured with the Rating Form of IBD Patient Concerns (RFIPC, Drossman 1991), actual disease activit~ was assessed by physicians with the CDAI and CAI. A severe course of the disease was assumed if the patient fullfilled one or more of the following criteria: continuous medicationwith immonenppr~sives and/or coninosteroi& a~l/or more tim, 2 opcratinas aad/or malnutrition, or inability to work more than 50% of the time within the year precc~Eag the L~rvinw. h~orm~on level about IBD was assessedby the patient using a visual an~og scale (0 = "totally unin£ormed", 100 = "very well informed") Results:The issuesof greatest coacem were "having an ostomy bag" (mcan-scorceSD: 63.6-+-38),.the "effects of medication" (53.1-~34),~"havmgsurgery" (51.6-+-35),and "the oncertain nature of the disease" (46.5±32), Disease related concerns (mean o f RFI~Csumscore: 33-H9) correlated pcorly with the disease related data assessedby physicians but sigmficantly with patients' perceived m/'omatien level about IBD: Lower information level was associated with .greater concerns (Kendall Tau x = -0.20, p<0.004). Of 97 (92.4%) patients 33 (34%) reported that they have used unconventional therapies. Additional 16 (16.5%) patients followed special diets. Homeopathy was the alternative therapy most frequently tried by the patients (n=22). Except for disease duration, there were no differences between patients who used alternative treaUnents and those who did not in their sociodemographic and disease-related data, concerns (RFlPC-sumscore) or level of information about IBD. Patients with longer disease duration used unconventional therapies more often (~ = 0.33, p<0,0001). Patients who used altsmative treatments were more concerned about "having surgery" (p<0.001) and "being treated as dif~rent" (p<0.04). Conclusion: Patients' concerns and their perceived information level about IBD as well as their skepticism towards conventional therapies have to be considered in clinical care. Better infi3rmation about IBD and psychosomatic cotmselling for patients who show high levels of concerns may improve their quality of life and help these patients to avoid using unproven alternative therapies.
BY ENTERIC BACTERIA INDUCES CHRONIC FIBROTIC LESIONS IN THE RAT INTESTINE. M. Mourelle, F. Guarner, A. Salas,' J-R. Malagelada. Digestive System Research Unit, Hospital General Vail d'Hebr0n, Barcelona and Hospital Mutua, Terrasa, Spain. TGFf~I promotes wound repair by deposition of extracellular matrix and could play a role in the pathogenesis of bowel strictures. We measured plasma TGFf~i(elisa) and colonic wall collagen:(hydroxyproline) in the course of experimental colitis. In Protocol I, colitis was induced by trinitr0benzenesulfonic acid (60 mg i n 20% EtOH) in c0ntrol~(TNB) and antibiotic pretreated (TNB-Ab) rats. Antibiotics (oral imipenem+vancomycin, 5 0 + 5 0 mg/kg/d).were broad spectrum, unabsorbable and aimed at bowel sterilization. T e n ~tS Per group. were killed on days 0, 1 and 21 , f o r blood and colon tissue sampling. In Protocol II, filtrates of colonic contents from 4 normal rats were prepared; and aliquots cultured for aerobes and anaerobes prior to and after 10 rain aonication. After sonication, anaerobic cultures became negative and only a few aerobic colonies remained. Under anesthesia, 3 group:s 0f rats were laparotomized and injected into the colonic w a l l with either 200 pL of filtrate prior tO (BAC group) or after sonicatibn (SON group) or 200 pL saline (SAL group). Ten rats per group wer e ~ killed 0 and 7 days after, and samples Obtained. In TNB, TGFI~1 increased from day 0 (m ± sd 18 + 10 ng!mL) tO 1 (89 ± 10) and 21 (129 ± t 5, p < 0.05); the response was blunted in TNB-Ab (day 1: 11±=2; day 2 1 : 6 5 ± 2 4 p<0.O5). Collagen in the colonic wall increased in TNB from day O (2.1 ± 0.7 #g/rag) to day 2 1 (23.4 ± 1.0}. Again, Collagen was significantly lower in TNB,Ab (day 21: 1 0 . 3 ± 0 . 3 L At day 21, 7 Out of 10 TNB rats presented colonic strictures but only I of 10 TNB'Ab (p
AGA ABSTRACTS
.
.
.
.
GASTROENTEROLOGY, Vol. 108, No. 4
• SMALL B O W E L E N T E R O S C O P Y : S H O U L D JEJUNAL BIOPSY BE ROUTINE? ' = Morris A J , Lee F D, MacKenzie J F. G a s t r o e n t e r o l o g y a n d P a t h o l o g y D e p t s , Royal I n f i r m a r y , G l a s g o w , UK Introduotion, Small bowel enterosoopy allows direct endoscopic examination of the small bowel. Push enteroaeopes offer the facility for jejunal biopsy but the additional diagnostic yeild from routine enterosc0pie biopsy is unknown. Estimates of the prevalence of non steroidal anti inflammatory drug (NSAiD) small bowel enteropathy vary widely depending on the method of small bowel assessment employed~ This may be explained by failure to detect miorosoopic disease if no biopsy is obtained at diagnostio enterosoopy. We have therefore examined the role of enteroscopic jejunal biopsy in "the diagnosis Of suspected NSAID enteropathy in patients with rheumatoid arthritis (RA) and ankylosing spondylitia (AS). Patients/Methods. 27 patients on long term NSAID (15RA:12AS), 10 p a t i e n t s n o t on NSAID (SRA:5AS) a n d 7 oontl-ola n e t on NSAID w e r e e x a m i n e d u s i n g t h e O l y m p u s SIF-10L p u s h e n t e r o s o o p e . All macresoopio j e j u n a l l e s i o n s w e r e d o c u m e n t e d . J e j u n a l b i o p s i e s w e r e o b t a i n e d from n o r m a l muoosa i n p r o x i m a ! a n d d i s t a l jejunum a n d mucosa a d j a c e n t to u l o e r a t i v e l e s i o n s . H i s t o l o g i c a l a s s e s s m e n t was c a r r i e d o u t b y a s i n g l e p a t h o l o g i s t who w a s b l i n d e d t o e n t e r o s o o p y r e s u l t and drug therapy. Results. I n t h e NSAID g r o u p 9 ( 2 2 % ) p a t i e n t s h a d l e s i o n s obaerved (3 ulcers: 3 ereaiona) at enterosoopy whilst in the n o n NSAID g r o u p 1 ( ! e r o s i o n ) (10%) p a t i e n t h a d l e s i o n s aeen. None of t h e c o n t r o l p a t i e n t s h a d j e j u n a l u l o e r a t i o n . I n 30 (8 ! %) p a t i e n t s t h e e n t e r o s c o p i o f i n d i n g s a n d h i s t o l o g y were compatible. I n ? (19%) p a t i e n t s , all on NSAID, t h e r e s u l t s of e n t e r o s e o p y a n d h i a t o l o g y w e r e i n c o m p a t i b l e , 5 (71 %) of t h e s e p a t i e n t s h a d normal e n t e r o e o o p y a n d a b n o r m a l histology consistent with NSAID enterepathy. Coneluaions: We c o n o l u d e t h a t NSAID e n t e r o p a t h y is a diffuse mucosal disease Whose prevalence may be underestimated by endoscopic inspection only. The finding of additional mioroacopic abnormalities in 19% of patients suggest that jejunal biopsy should be considered an essential part 'of diagnoatic enteroscopy.
• DISEASE RELATED CONCERNS OF PATIENTS "WITH INFLAMMATORY BOWEL DISEASE AND THE USE OF UNCONVENTIONAL THERAPIES.. G. Moser. W. Tlllinger, H. Vogeisang, J. Wyatt, Th. Maier, H. Lochs, A. Gangl, DepartmentofIn,realMedicine W, UniversityHospitalVienna,Aus~ia
O DOES PREOERATIVE ILEITIS P R E D I S P O S E T O POUCHITIS? RG Moslev, J Madsen, M Reichelderfer, BA H a r m s . Departments of Medicine, Pathology, and S u r g e r y , Univ of Wisconsin, Madison WI. ' '
O STIMULATION OF TRANSFORMING GROWTH'FACTOR ~ (TGFI~i)
Inflammation of the ileal pouch ("pouchitis") i s a frequent complication of total colectomy with ileal pouch-anal anastomosis (IPAA) and is particularly common in patients with ulcerative colitis (UC)~ A l t h o u g h bacterial o v e r g r o w t h and immune'injury have been suggested as possible mechanisms, t h e etiology remains unknown. We explored the possibility that p o u c h i t i s is related to p r e existing ileal inflammation (so-called ',backwaSh ileitis,), which is present in up to 25% of U C patients. METHODS= We reviewed all colectomy specimens of UC patients undergoing a IPAA by a single surgeon f r o m 1990 to' 1993. When adequate ileum was present (47 of I08 patients), inflammation was evaluated by one of us (blinded to clinical outcome) and quantified by the following scale: grade O, absence; grade i, mild acute cryptitis; grade 2, extensive cryptitis; grade 3 , crypt abscesses. Clinical fol!owup w a s p e r f o r m e d by chart review and mailed surveys, with pouchitis diagnosed by standard clinical criteria (diarrhea, hematochezia, fever). PJSULTS= Of our 47 patients r i0 (21%) had evidence of ileitis: 3 with grade i,~2 with grade 2, and 5 with grade 3. Five of i0 (50%) developed pouchitis, whereas only 11 of 37 patients without ileitis (30%) had subsequent pouchitis. Although suggestive, the difference between patients with and without ileitis was not significant (p=0.27, Fisher's exact test ) . Interestingly, n o n e o f 6 evaluable polyposis ! patients undergoing IPAA for familial polyposis had ileitis or subsequentpouchitis. CONCLUSIONS: o u r data suggest that pouchitis is more common i n uC patients with pre-existing ileitis. Larger prospective studies a r e needed to evaluate this association.
Introduction: Patients' disease related concerns and information level about inflammatory bowel disease (IBD) are important for their Coping with the illness. We investigated the relationsinp between IBD patients' concerns with disease related and sociodemographic data, their perceived information level about IBD and the use of alternative medicine in 105 consecutive outpatients with IBD (72 Croim's disease, 33 ulcerative colitis). Methods: Disease t;elated concerns were measured with the Rating Form of IBD Patient Concerns (RFIPC, Drossman 1991), actual disease activit~ was assessed by physicians with the CDAI and CAI. A severe course of the disease was assumed if the patient fullfilled one or more of the following criteria: continuous medicationwith immonenppr~sives and/or coninosteroi& a~l/or more tim, 2 opcratinas aad/or malnutrition, or inability to work more than 50% of the time within the year precc~Eag the L~rvinw. h~orm~on level about IBD was assessedby the patient using a visual an~og scale (0 = "totally unin£ormed", 100 = "very well informed") Results:The issuesof greatest coacem were "having an ostomy bag" (mcan-scorceSD: 63.6-+-38),.the "effects of medication" (53.1-~34),~"havmgsurgery" (51.6-+-35),and "the oncertain nature of the disease" (46.5±32), Disease related concerns (mean o f RFI~Csumscore: 33-H9) correlated pcorly with the disease related data assessedby physicians but sigmficantly with patients' perceived m/'omatien level about IBD: Lower information level was associated with .greater concerns (Kendall Tau x = -0.20, p<0.004). Of 97 (92.4%) patients 33 (34%) reported that they have used unconventional therapies. Additional 16 (16.5%) patients followed special diets. Homeopathy was the alternative therapy most frequently tried by the patients (n=22). Except for disease duration, there were no differences between patients who used alternative treaUnents and those who did not in their sociodemographic and disease-related data, concerns (RFlPC-sumscore) or level of information about IBD. Patients with longer disease duration used unconventional therapies more often (~ = 0.33, p<0,0001). Patients who used altsmative treatments were more concerned about "having surgery" (p<0.001) and "being treated as dif~rent" (p<0.04). Conclusion: Patients' concerns and their perceived information level about IBD as well as their skepticism towards conventional therapies have to be considered in clinical care. Better infi3rmation about IBD and psychosomatic cotmselling for patients who show high levels of concerns may improve their quality of life and help these patients to avoid using unproven alternative therapies.
BY ENTERIC BACTERIA INDUCES CHRONIC FIBROTIC LESIONS IN THE RAT INTESTINE. M. Mourelle, F. Guarner, A. Salas,' J-R. Malagelada. Digestive System Research Unit, Hospital General Vail d'Hebr0n, Barcelona and Hospital Mutua, Terrasa, Spain. TGFf~I promotes wound repair by deposition of extracellular matrix and could play a role in the pathogenesis of bowel strictures. We measured plasma TGFf~i(elisa) and colonic wall collagen:(hydroxyproline) in the course of experimental colitis. In Protocol I, colitis was induced by trinitr0benzenesulfonic acid (60 mg i n 20% EtOH) in c0ntrol~(TNB) and antibiotic pretreated (TNB-Ab) rats. Antibiotics (oral imipenem+vancomycin, 5 0 + 5 0 mg/kg/d).were broad spectrum, unabsorbable and aimed at bowel sterilization. T e n ~tS Per group. were killed on days 0, 1 and 21 , f o r blood and colon tissue sampling. In Protocol II, filtrates of colonic contents from 4 normal rats were prepared; and aliquots cultured for aerobes and anaerobes prior to and after 10 rain aonication. After sonication, anaerobic cultures became negative and only a few aerobic colonies remained. Under anesthesia, 3 group:s 0f rats were laparotomized and injected into the colonic w a l l with either 200 pL of filtrate prior tO (BAC group) or after sonicatibn (SON group) or 200 pL saline (SAL group). Ten rats per group wer e ~ killed 0 and 7 days after, and samples Obtained. In TNB, TGFI~1 increased from day 0 (m ± sd 18 + 10 ng!mL) tO 1 (89 ± 10) and 21 (129 ± t 5, p < 0.05); the response was blunted in TNB-Ab (day 1: 11±=2; day 2 1 : 6 5 ± 2 4 p<0.O5). Collagen in the colonic wall increased in TNB from day O (2.1 ± 0.7 #g/rag) to day 2 1 (23.4 ± 1.0}. Again, Collagen was significantly lower in TNB,Ab (day 21: 1 0 . 3 ± 0 . 3 L At day 21, 7 Out of 10 TNB rats presented colonic strictures but only I of 10 TNB'Ab (p