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Survey questionnaire and serologic screening for celiac sprue in first-degree relatives of patients with celiac sprue
AJG – September, Suppl., 2002
e.The patient was started on mesalamine, metronidazole, and prednisone and improved. It is well established that Crohn’s disease is associated with a high risk of small bowel and colorectal carcinoma. There are only a few case reports of adenocarcinoma as an initial presentation of Crohn’s. It appears to be more common in males, always develops in areas involved by Crohn’s, and is thought to follow a dysplasia carcinoma sequence. Most lesions are high grade and present clinically with obstructive symptoms. Physicians should consider inflammatory bowel disease in patients with small bowel adenocarcinoma who have persistent gastrointestinal symptoms.
239 SURVEY QUESTIONNAIRE AND SEROLOGIC SCREENING FOR CELIAC SPRUE IN FIRST–DEGREE RELATIVES OF PATIENTS WITH CELIAC SPRUE Robert D. Hower, D.O., David L. Limauro, M.D., David V. Glorioso, M.D. and Tony Colatrella, M.D.*. Internal Medicine, Mercy Hospital, Pittsburgh, PA. Purpose: The purpose of this study was to more accurately assess the prevalence of Celiac Sprue in first degree relatives and to evaluate their associated symptoms and diseases with a survey and serologic screening. The study population was a western Pennsylvania population in a mixed urban–suburban setting. Methods: A Celiac Disease seminar was held at the Mercy Hospital of Pittsburgh in conjunction with the Pittsburgh Celiac Sprue Association. Interested participants voluntarily underwent a serologic tissue transglutaminase (tTG) assay along with a survey consisting of general questions concerning age, sex, symptoms, and concurrent medical illnesses. The participants that had a positive tTG assay were contacted for future endoscopic evaluation and counseling. Results: A total of 182 people participated in the study, 77 male and 105 female. There were 128 participants that had a first degree relative with CS. Nine of 128 persons (7%) with first– degree relatives tested positive for the tTG antibody. The ratio of male to female positives was 1.75 to 1. The most common symptoms reported in the tTG positive population were abdominal gas (56%), bloating (33%), and diarrhea (22%). Forty–four percent of tTG positive persons reported having no subjective symptoms. The prevalence of concurrent disease states in the tTG positives were asthma (33%), depression (22%), and anemia, eczema, alopecia, each with (11%). The most prevalent symptoms in the entire tTG negative group were: abdominal gas 92 (50.5%), malaise 62 (34%), and bloating 56 (30.7%). The most common disease states of the entire tTG negative group were asthma 23 (13%), and anemia 16 (9%). Conclusions: Positive serology for the tTG antibody was more common in first– degree relatives of patients with CS than would be expected in a general population. Nonspecific gastrointestinal symptoms, while common in the tTG positive persons, were also common in subjects without CS. Practitioners need to be aware of the increased prevalence of CS in family members of those with CS, and testing should not be limited to only those with gastrointestinal symptoms.
240 HYPERBARIC OXYGEN THERAPY FOR PNEUMATOSIS CYSTOIDES INTESTINALIS Waqar A. Qureshi, M.D., FACG, Gregory Shannon, M.D., Fife Caroline, M.D. and Atilla Ertan, M.D., FACG*. Gastroenterology, Baylor College of Medicine and VAMC, Houston, TX and Hyperbaric Medicine, University of Texas, Houston, TX. Purpose: Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by the presence of multiple gas–filled cysts in the gastrointestinal tract. Many theories have been proposed to explain the pathogenesis of PCI. The mechanical theory postulates that intestinal gas dissects
Abstracts
S79
into the bowel wall through a breach in the intestinal mucosa. The pulmonary theory suggests that air released from ruptured alveoli dissects through the mediastinum, along the aorta and mesenteric arteries to the bowel. The bacterial theory proposes that gas–forming organisms, such as Clostridium perfringens, cause gaseous dissection within the bowel wall. The rationale for using hyperbaric oxygen is that breathing pure oxygen at enhanced atmospheric pressure causes resorption of gases such as nitrogen by increasing the driving force for gas diffusion. Methods: A 69 yr. old man presented with incapacitating abdominal pain, diarrhea and weight loss for over 2 years. About 2 yr. ago the patient underwent a laparotomy for acute abdominal pain and pneumoperitoneum, and was diagnosed with PCI. He failed to respond to supportive therapy including dietary changes, use of antidiarrheals and antacids. PMH was significant for hypertension, atrial fibrillation, Bell’s palsy, and diabetes. At the time of the present admission, in addition to chronic diarrhea the patient showed signs of wasting with marked weight loss and cachexia. The patient was treated with three sessions of hyperbaric oxygen therapy, each delivered at 2.4 times atmospheric pressure for 110 minutes in an oxygen chamber. A comprehensive Medline search identified fourteen cases of PCI managed by this approach but without standardized recommendations. Results: There was dramatic improvement in symptoms with complete resolution of the abdominal pain and distention by the second treatment. Radiological studies revealed resolution of the cysts at week two post therapy. At six months follow up, the patient was completely asymptomatic and his weight had returned to baseline. Conclusions: Hyperbaric oxygen appears to be an effective treatment for symptomatic patients with pneumatosis cystoides intestinalis. However, more studies are needed to define the ideal atmosphere level and duration of hyperbaric oxygen therapy required in symptomatic patients with pneumatosis cystoides intestinalis.
241 A NOVEL GAS CHROMATOGRAPHIC METHOD FOR DETECTION OF URINARY SUCRALOSE: APPLICATION TO THE ASSESSMENT OF INTESTINAL PERMEABILITY Ashkan Farhadi, M.D., Ali Keshavarzian, M.D.*, Earle W. Holmes, Ph.D., Jeremy Fields, Ph.D., Lei Zhang, M.D., PH.D. and Ali Banan, Ph.D. Department of Internal Medicine, Section of Gastroenterology and Nutrition, Rush Medical College, Rush University, Chicago, IL and Department of Pathology, Loyola University, Chicago, IL. Purpose: The most direct and accurate method to quantitatively assess intestinal barrier function is by measurement of intestinal permeability. To assess human intestinal permeability, we developed a highly–sensitive gas chromatography (GC) method for the measurement of urinary sucralose (S) along with three other sugar probes, including sucrose, lactulose (L) and mannitol (M). We also investigated the intestinal bacterial metabolism of these sugar probes to evaluate whether these probes are suitable for assessement of the whole gut permeability. Methods: To this end, 14 healthy controls were enrolled. 5– h and 19 – h urine samples were collected after ingestion of a water– based solution containing 7.5g L, 2.0 g M, 1 g S and 40 g sucrose. These sugar probes were then measured using a unique capillary column GC technique. Metabolism of sugar probes by intestinal bacteria was also evaluated by in vitro incubation of an iso– osmolar mixture of M, L and S with fecal bacteria at 37° C for 19 hours. Sugar concentration and pH of the mixture were monitored for 19 h. Results: All 4 sugars were detected in the urine samples without interference (see Table 1). The capillary column substantially enhanced the sensitivity of detection of sugar probes by 200 –2000 times as compared to a Packed Column GC method. It also lowered the coefficient of variation from 15% to 3.95%. The detection limit was 0.2 and 0.5 mg/L for S and L, respectively. While intestinal bacteria metabolized L by 51% and acidified the environment (pH 7.2 to 4.8) during incubation, they did not metabolize S or M.
e.The patient was started on mesalamine, metronidazole, and prednisone and improved. It is well established that Crohn’s disease is associated with a high risk of small bowel and colorectal carcinoma. There are only a few case reports of adenocarcinoma as an initial presentation of Crohn’s. It appears to be more common in males, always develops in areas involved by Crohn’s, and is thought to follow a dysplasia carcinoma sequence. Most lesions are high grade and present clinically with obstructive symptoms. Physicians should consider inflammatory bowel disease in patients with small bowel adenocarcinoma who have persistent gastrointestinal symptoms.
239 SURVEY QUESTIONNAIRE AND SEROLOGIC SCREENING FOR CELIAC SPRUE IN FIRST–DEGREE RELATIVES OF PATIENTS WITH CELIAC SPRUE Robert D. Hower, D.O., David L. Limauro, M.D., David V. Glorioso, M.D. and Tony Colatrella, M.D.*. Internal Medicine, Mercy Hospital, Pittsburgh, PA. Purpose: The purpose of this study was to more accurately assess the prevalence of Celiac Sprue in first degree relatives and to evaluate their associated symptoms and diseases with a survey and serologic screening. The study population was a western Pennsylvania population in a mixed urban–suburban setting. Methods: A Celiac Disease seminar was held at the Mercy Hospital of Pittsburgh in conjunction with the Pittsburgh Celiac Sprue Association. Interested participants voluntarily underwent a serologic tissue transglutaminase (tTG) assay along with a survey consisting of general questions concerning age, sex, symptoms, and concurrent medical illnesses. The participants that had a positive tTG assay were contacted for future endoscopic evaluation and counseling. Results: A total of 182 people participated in the study, 77 male and 105 female. There were 128 participants that had a first degree relative with CS. Nine of 128 persons (7%) with first– degree relatives tested positive for the tTG antibody. The ratio of male to female positives was 1.75 to 1. The most common symptoms reported in the tTG positive population were abdominal gas (56%), bloating (33%), and diarrhea (22%). Forty–four percent of tTG positive persons reported having no subjective symptoms. The prevalence of concurrent disease states in the tTG positives were asthma (33%), depression (22%), and anemia, eczema, alopecia, each with (11%). The most prevalent symptoms in the entire tTG negative group were: abdominal gas 92 (50.5%), malaise 62 (34%), and bloating 56 (30.7%). The most common disease states of the entire tTG negative group were asthma 23 (13%), and anemia 16 (9%). Conclusions: Positive serology for the tTG antibody was more common in first– degree relatives of patients with CS than would be expected in a general population. Nonspecific gastrointestinal symptoms, while common in the tTG positive persons, were also common in subjects without CS. Practitioners need to be aware of the increased prevalence of CS in family members of those with CS, and testing should not be limited to only those with gastrointestinal symptoms.
240 HYPERBARIC OXYGEN THERAPY FOR PNEUMATOSIS CYSTOIDES INTESTINALIS Waqar A. Qureshi, M.D., FACG, Gregory Shannon, M.D., Fife Caroline, M.D. and Atilla Ertan, M.D., FACG*. Gastroenterology, Baylor College of Medicine and VAMC, Houston, TX and Hyperbaric Medicine, University of Texas, Houston, TX. Purpose: Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by the presence of multiple gas–filled cysts in the gastrointestinal tract. Many theories have been proposed to explain the pathogenesis of PCI. The mechanical theory postulates that intestinal gas dissects
Abstracts
S79
into the bowel wall through a breach in the intestinal mucosa. The pulmonary theory suggests that air released from ruptured alveoli dissects through the mediastinum, along the aorta and mesenteric arteries to the bowel. The bacterial theory proposes that gas–forming organisms, such as Clostridium perfringens, cause gaseous dissection within the bowel wall. The rationale for using hyperbaric oxygen is that breathing pure oxygen at enhanced atmospheric pressure causes resorption of gases such as nitrogen by increasing the driving force for gas diffusion. Methods: A 69 yr. old man presented with incapacitating abdominal pain, diarrhea and weight loss for over 2 years. About 2 yr. ago the patient underwent a laparotomy for acute abdominal pain and pneumoperitoneum, and was diagnosed with PCI. He failed to respond to supportive therapy including dietary changes, use of antidiarrheals and antacids. PMH was significant for hypertension, atrial fibrillation, Bell’s palsy, and diabetes. At the time of the present admission, in addition to chronic diarrhea the patient showed signs of wasting with marked weight loss and cachexia. The patient was treated with three sessions of hyperbaric oxygen therapy, each delivered at 2.4 times atmospheric pressure for 110 minutes in an oxygen chamber. A comprehensive Medline search identified fourteen cases of PCI managed by this approach but without standardized recommendations. Results: There was dramatic improvement in symptoms with complete resolution of the abdominal pain and distention by the second treatment. Radiological studies revealed resolution of the cysts at week two post therapy. At six months follow up, the patient was completely asymptomatic and his weight had returned to baseline. Conclusions: Hyperbaric oxygen appears to be an effective treatment for symptomatic patients with pneumatosis cystoides intestinalis. However, more studies are needed to define the ideal atmosphere level and duration of hyperbaric oxygen therapy required in symptomatic patients with pneumatosis cystoides intestinalis.
241 A NOVEL GAS CHROMATOGRAPHIC METHOD FOR DETECTION OF URINARY SUCRALOSE: APPLICATION TO THE ASSESSMENT OF INTESTINAL PERMEABILITY Ashkan Farhadi, M.D., Ali Keshavarzian, M.D.*, Earle W. Holmes, Ph.D., Jeremy Fields, Ph.D., Lei Zhang, M.D., PH.D. and Ali Banan, Ph.D. Department of Internal Medicine, Section of Gastroenterology and Nutrition, Rush Medical College, Rush University, Chicago, IL and Department of Pathology, Loyola University, Chicago, IL. Purpose: The most direct and accurate method to quantitatively assess intestinal barrier function is by measurement of intestinal permeability. To assess human intestinal permeability, we developed a highly–sensitive gas chromatography (GC) method for the measurement of urinary sucralose (S) along with three other sugar probes, including sucrose, lactulose (L) and mannitol (M). We also investigated the intestinal bacterial metabolism of these sugar probes to evaluate whether these probes are suitable for assessement of the whole gut permeability. Methods: To this end, 14 healthy controls were enrolled. 5– h and 19 – h urine samples were collected after ingestion of a water– based solution containing 7.5g L, 2.0 g M, 1 g S and 40 g sucrose. These sugar probes were then measured using a unique capillary column GC technique. Metabolism of sugar probes by intestinal bacteria was also evaluated by in vitro incubation of an iso– osmolar mixture of M, L and S with fecal bacteria at 37° C for 19 hours. Sugar concentration and pH of the mixture were monitored for 19 h. Results: All 4 sugars were detected in the urine samples without interference (see Table 1). The capillary column substantially enhanced the sensitivity of detection of sugar probes by 200 –2000 times as compared to a Packed Column GC method. It also lowered the coefficient of variation from 15% to 3.95%. The detection limit was 0.2 and 0.5 mg/L for S and L, respectively. While intestinal bacteria metabolized L by 51% and acidified the environment (pH 7.2 to 4.8) during incubation, they did not metabolize S or M.