Guidelines for the initial biopsy diagnosis of suspected chronic idiopathic inflammatory bowel disease. The British Society of Gastroenterology Initiative

Images

Transient radiological and colonoscopic features of inflammatory bowel disease in a patient with severe Salmonella gastroenteritis

Salmonella is the most commonly reported cause of food-borne outbreaks of gastroenteritis. We report a case of a severe and toxic form of enteritis caused by Salmonella enteritidis. Findings of colonoscopy, an upper G1 tract series, and small bowel follow-through were consistent with those of inflammatory bowel disease, but the enteritis was self-limited, and the patient recovered after supportive treatment only and has remained well.

Chronic health effects of microbial foodborne disease

The acute effects of foodborne disease are sometimes not the end of the illness. Several significant foodborne pathogens are capable of triggering chronic disease, and even permanent tissue or organ destruction, probably via immune mechanisms. Arthritis, septic and reactive, inflammatory bowel disease, haemolytic uraemic syndrome, Guillain-Barré syndrome, and possible several autoimmune disorders can be triggered by foodborne pathogens or their toxins. Research is needed to more fully understand the mechanisms by which the immune system is inappropriately activated by these common foodborne disease-causing agents.

Bacteria-specific T-cell clones are selective in their reactivity towards different enterobacteria or H. pylori and increased in inflammatory bowel disease

In the present study the authors investigated the T-cell response to different enterobacteria or Helicobacter pylori and tested the hypothesis that the frequency of bacteria-specific T cells is increased in the intestine of patients with active inflammatory bowel disease (IBD), i.e. Crohn's disease (CD) and ulcerative colitis (UC). The analysis of a large panel of T-cell clones (Tc) (n = 888) from peripheral blood, non-inflamed and inflamed intestine from IBD patients and control individuals shows that both peripheral blood and intestinal T-cell clones were selectively stimulated by either Salmonella typhimurium, Yersinia enterocolitica 03, Escherichia coli or Helicobacter pylori sonicates, that only < 3% of all bacteria-reactive Tc were crossreactive and that proliferation to bacterial sonicates was inhibited by anti-MHC class II antibody. In addition, bacteria-specific Tc from IBD patients were more frequently isolated from inflamed intestine than from peripheral blood (P = 0.0039) or non-inflamed intestine. These data, from a large number of T-cell clones, are the first systematic analysis describing the response of individual T cells towards different bacterial species (ssp.). They show that T cells with specificity for distinct antigens or superantigens that are characteristic for a defined bacteria ssp. are present in normal, and increased in inflamed, IBD-intestine. These bacteria-specific Tc may play a role in IBD pathogenesis.

Inflammatory large bowel disease in immunodeficient mice naturally infected with Helicobacter hepaticus

Large bowel disease detected clinically by rectal prolapse was studied in 64 immunodeficient mice (37 athymic NCr-nu/nu, 12 BALB/c AnNCr-nu/nu, 9 C57BL/6NCr-nu/nu, and 6 C.B17/Icr-scid/NCr) naturally infected with Helicobacter hepaticus. Rectal prolapse was found in approximately 5% of immunodeficient mice maintained in a research facility over a period of 3.5 years. All mice had various degrees of chronic proliferative typhlitis, colitis, and proctitis, usually without concomitant hepatitis. Some mice had severe proliferative proctitis with cystic hyperplasia. Histologic study of the large bowel of 48 athymic NCr-nu/nu mice without H. hepaticus infection and housed in another clean facility revealed only 12% of the mice with minimal-to-mild large bowel inflammation. Helicobacter hepaticus infection is associated with large bowel disease in immunodeficient mice but is not seen in H. hepaticus-infected immunocompetent mice. This new pathogenic bacterial infection should be considered as another potential cause or co-factor for rectal prolapse and large bowel disease in mice.

Effect of 4G-beta-D-galactosylsucrose (lactosucrose) on fecal microflora in patients with chronic inflammatory bowel disease

Metabolic interaction between the intestinal microflora and the host has been suggested to play a role in the pathogenesis of chronic inflammatory bowel disease. Elemental or low-fat, low-residual diets in patients with Crohn's disease or ulcerative colitis are reported to decrease anaerobic bacteria and to change the composition of the intestinal microflora. We examined the effect of an indigestible agent, 4G-beta-D-galactosylsucrose (lactosucrose), which is selectively utilized by intestinal Bifidobacterium, on the composition of the intestinal microflora. After the administration of lactosucrose to two patients with Crohn's disease and five patients with ulcerative colitis for 2 weeks, significant induction of the growth of Bifidobacterium was observed, and significant reduction in the population level of Bacteroidaceae was seen. Bowel movements improved in four patients. The intestinal environment, estimated by measuring fecal pH, fecal levels of short-chain fatty acids and putrid products, and the urinary secretion of indican, also improved in these patients. These results suggest that lactosucrose may be useful for patients with chronic inflammatory bowel disease.

Tolerance exists towards resident intestinal flora but is broken in active inflammatory bowel disease (IBD)

Hyporesponsiveness to a universe of bacterial and dietary antigens from the gut lumen is a hallmark of the intestinal immune system. Since hyperresponsiveness against these antigens might be associated with inflammation, we studied the immune response to the indigenous intestinal microflora in peripheral blood, inflamed and non-inflamed human intestine. Lamina propria monocuclear cells (LPMC) isolated from inflamed intestine but not peripheral blood mononuclear cells (PBMC) of IBD patients with active inflammatory disease strongly proliferated after co-culture with sonicates of bacteria from autologous intestine (BsA). Proliferation was inhibitable by anti-MHC class II MoAb, suggesting that it was driven by antigen. LPMC from adjacent non-inflamed intestinal areas of the same IBD patients and PBMC or LPMC isolated from non-inflamed intestine of controls and patients with IBD in remission, in contrast, did not proliferate. PBMC or LPMC which had been tolerant to bacteria from autologous intestine, however, strongly proliferated after co-culture with bacterial sonicates from heterologous intestine (BsH). This proliferation was associated with an expansion of CD8+ T cells, increased expression of activation markers on both CD4+ and CD8+ lymphocyte subsets, and production of IL-12, interferon-gamma (IFN-gamma), and IL-10 protein. These results show that tolerance selectively exists to intestinal flora from autologous but not heterologous intestine, and that tolerance is broken in intestinal inflammation. This may be an important mechanism for the perpetuation of chronic IBD.

[Isolation of nontuberculous mycobacteria during colonoscopy]

We conducted a survey on nontuberculous mycobacteria (NTM) isolated in association with colonscopy at two hospitals. NTM was isolated from the fluid-phase of colonic contents in 17.6% of the specimens obtained at hospital A and in 46.3% at hospital B. The rate of isolation from the preexamination suction fluid was 9.5% and 43.3% at hospital A and B, respectively. Tap water samples from both hospitals were examined and proved to be free from contamination with NTM. The mycobacterial species isolated at hospital A were M. chelonae subsp. abscessus, M. chelonae subsp. chelonae, M. fortuitum, and M. gordonae. M. chelonae subsp. abscessus was the only mycobacterial species isolated at hospital B. M. avium complex was not isolated at either hospital. By an additional procedure to cleans and decontaminate the endoscopes by suction with Maskin ethanol solution, the incidence of isolation of NTM from the fluid-phase of colonic contents was significantly reduced. None of the patients from whom NTM was isolated exhibited positive signs of colonic NTM infection by the endoscopic examination and non had any underlying diseases which might induce immune suppression. We suspect that most of the NTM isolates have originated from the contaminated endoscope. In conclusion, when a colonscopic examination is carried out in suspicion of NTM disease in intestine, it is essential to reassess the possibility of mycobacterial contamination of the colonscopes and implement appropriate steps for cleansing and sterilization of them.

Antibodies to Klebsiella pneumoniae, Escherichia coli and Proteus mirabilis in the sera of patients with axial and peripheral form of ankylosing spondylitis

IgM, IgG and IgA class serum antibodies against the whole Klebsiella pneumoniae, Escherichia coli and Proteus mirabilis bacteria, as well as against K. pneumoniae and E. coli lipopolysaccharides (LPSs) were studied earlier in two separate patient populations of 99 and 85 patients with ankylosing spondylitis (AS) and in 102 healthy blood donors by enzyme immunoassay. In this study the patients were divided into groups according to the presence or absence of peripheral arthritis. The patients with peripheral type AS had increased levels of IgM and IgA class antibodies against K. pneumoniae, whereas the patients with axial type AS had increased levels of IgG and IgA class antibodies to K. pneumoniae, as well as IgA class antibodies against E. coli and P. mirabilis bacteria. Sulphasalazine treatment decreased the IgM and IgA class antibodies in peripheral AS and IgA class antibodies in axial AS against K. pneumoniae LPS. The antibody levels were also decreased against E. coli and P. mirabilis bacteria in the sera of patients with axial AS. The immunological findings in patients with peripheral and axial form of AS were different from each other and thus may reflect different aetiopathogenetic mechanisms for these two types of AS.

Mycobacteria in the intestine of Japanese patients with inflammatory bowel disease

OBJECTIVES

It is still controversial whether or not a mycobacterial infection may be a cause of Crohn's disease. Mycobacterium paratuberculosis may be very difficult to detect using routine culture techniques. To clarify this, we detected mycobacterial DNA in patients with inflammatory bowel disease.

METHODS

IS900 sequences highly specific to M. paratuberculosis and the groEL gene encoding a conserved mycobacterial antigen were studied in colonic mucosa using polymerase chain reaction (PCR). PCR products were analyzed by Southern blot hybridization.

RESULTS

IS900 sequences were detected in all (100%) of 10 patients with Crohn's disease, in 11 (61.1%) of 18 patients with ulcerative colitis, and in 14 (87.5%) of 16 control patients with noninflammatory bowel disease. All IS900 positive samples had groEL PCR products.

CONCLUSIONS

Our results, on the basis of the prevalence, do not support the hypothesis that M. paratuberculosis is involved in the pathogenesis of Crohn's disease.

Spontaneous, heritable colitis in a new substrain of C3H/HeJ mice

BACKGROUND/AIMS

C3H/HeJ mice at the Jackson Laboratory have periodically been culled because of the occurrence of soft feces, perianal ulceration, and right-sided colitis. No pathogens have been isolated. The goal of the current study was to establish a substrain with a high incidence of this disease.

METHODS

Affected male and female C3H/HeJ mice were bred. The clinical, pathological, microbiological, and genetic features of 216 mice of the resulting pedigree were characterized.

RESULTS

A severely affected female crossed with a normal male resulted in a new substrain, denoted C3H/HeJBir, with a high incidence of right-sided colitis. Histologically, lesions occurred primarily in the cecum and proximal colon, characterized by acute and chronic inflammation, crypt abscesses, ulcerations, regenerative hyperplasia, and submucosal scarring. Such colitis peaked at 3-6 weeks; however, similar disease was found sporadically in animals more than 1 year of age. Small lesions at the anorectal junction were common throughout life. An extensive search for pathogens was negative. Genetic analysis of C3H/HeJBir mice suggested that the disease was inherited as a quantitative trait.

CONCLUSIONS

C3H/HeJBir mice develop a spontaneous, heritable form of idiopathic inflammatory bowel disease and will be a valuable resource for genetic and immunologic studies of this disease.

Inflammatory bowel disease. The case for an infectious etiology

The infectious hypothesis for IBD is certainly not new. The evidence for an infectious agent is tantalizing but not yet convincing. A failure to demonstrate a specific agent in the inflammatory process could mean that many different organisms are involved, or several organisms that, by themselves, do not cause disease interact. All candidate organisms proposed thus far are compatible with either hypothesis. Nevertheless, interaction between an agent(s) in a host modified by immunologic and genetic factors is still an attractive hypothesis for the cause of these illnesses.

A prospective study of first attacks of inflammatory bowel disease and non-relapsing colitis. Microbiologic findings

In 105 patients with a first attack of colitis, thorough microbiologic investigations of rectal biopsy, faecal, and serum samples were performed with the aims of identifying the colitis-causing agents and shedding light on factors that may precipitate or aggravate the onset of inflammatory bowel disease. Sixty-one patients were found to have inflammatory bowel disease. In 13 (21%) of these patients microbial findings were positive. Eight of the 61 patients fell ill during or immediately after antibiotic treatment, and 10 while travelling abroad. Forty-one of the 105 patients had non-relapsing colitis. In 32 (78%) of these the microbial findings were positive. Six of these 41 patients fell ill during or immediately after antibiotic treatment, and 14 while travelling abroad. Alteration of the intestinal microflora on travelling, gastrointestinal infection, or treatment with antibiotics seems to precipitate or aggravate the symptoms in latent inflammatory bowel disease. In such patients the mode of onset is often changed from insidious to more acute, which may cause difficulty in differentiation from non-relapsing colitis.

Intestinal mucosal inflammation associated with human immunodeficiency virus infection

The role of the human immunodeficiency virus type-1 (HIV) in producing intestinal disease was studied prospectively in 74 HIV-infected individuals with (43) or without (31) the acquired immunodeficiency syndrome (AIDS). Thirty-one subjects had enteric infections; all but one had AIDS. Alteration in bowel habits was the most common symptom and occurred independently of enteric infections. Abnormal histopathology was present in 69% of cases, and the finding was associated with altered bowel habits. An HIV-associated protein, p24, was detected in 71% of biopsies by ELISA assay. Tissue p24 contents varied with disease stage and were highest in HIV-infected individuals without AIDS (Walter Reed classes 3 and 4). Tissue p24 detection was associated with both altered bowel habits and histologic mucosal abnormalities. Tissue contents of the cytokines, tumor necrosis factor-alpha and interleukin-1 beta, were higher in HIV-infected individuals than in controls and their elevations were independent of enteric infection. We conclude that HIV reactivation in the intestinal mucosa may be associated with an inflammatory bowel syndrome in the absence of other enteric pathogens.

[Current insights on the pathogenesis of chronic inflammatory bowel diseases]

The pathogenesis and etiology of inflammatory bowel disease (IBD) is poorly understood. As a matter of fact, it is not even certain whether either one is a single entity with different forms of clinical manifestations, or whether each one represents a single clearly separable entity. Common features of both diseases are chronic persistence, recurrent exacerbation and remission, the production of autoantibodies, as well as the expression of aberrant HLA-class II molecules on the surface of epithelial cells on the site of inflammation gut. It is likely that these events involve a disturbed immunoregulatory function or autoimmune process. Since the beginning of investigation the cause of IBD, infectious agents (bacteria, virus, mycobacterium paratuberculosis and others) or bacterial products (endotoxin, peptidoglycans from the bacterial cell wall) have been considered as primary causes. Epidemiological studies showed a marked increase of the incidence rates of IBD in industrial countries leading to the hypothesis, that environmental factors could play a role in the pathogenesis of the disease. So far it is clear that the major identified risk factor for IBD is a genetic susceptibility confirmed by studies showing a positive family history.

Microbiologic assessment of tissue biopsy samples from ileal pouch patients

Tissue biopsy samples from patients with and without ileal pouches were examined by electron microscopic and microbiologic culture techniques to determine the numbers and types of microorganisms closely associated with or within the tissue biopsy samples. The disease status of each patient was determined by endoscopic and histopathologic methods. Of the 78 biopsy samples included in this study, 64 (82%) yielded obligately anaerobic and/or facultative bacteria when they were cultured. Fourteen of the 78 samples (17.9%) were negative by culture. Of the positive samples, 54 contained facultatively anaerobic bacterial species and 50 yielded obligately anaerobic species. The total counts for facultatively anaerobic bacteria for samples from patients with pouchitis were significantly greater than for samples from patients in control groups. In addition, the number of samples from patients with normal pouches that did not contain obligate anaerobes was significantly less than that from patients with pouchitis; 4 of 23 and 6 of 12 samples, respectively (P less than 0.043). For samples in which organisms were detected, there was agreement with electron microscopic detection of bacteria in 23 of 27 samples, for an overall sensitivity of electron microscopy compared with that of culture of 85%. The qualitative studies resulted in the characterization of 273 isolates comprising 77 different phenotypes. The specificity of these findings in patients with ileal pouchitis is discussed.

[Cytomegalovirus disease in the gastrointestinal tract]

Cytomegalovirus infections in immunocompromised patients may cause serious illness, particularly in patients with HIV-disease and in transplant recipients. There is an increasing number of reports of cytomegalovirus infections involving the alimentary tract, especially colitis. Diagnosis of cytomegalovirus disease is at present based on specific histological findings. Antibody findings can be difficult to interpret. The slow growth of cytomegalovirus in cultures makes this method less useful in the acute setting of diagnosis. It is important to recognize cytomegalovirus colitis as a differential diagnosis to idiopathic inflammatory bowel disease. In fulminant disease, colectomy should be considered in addition to antiviral treatment.

The assessment of faecal flora in patients with inflammatory bowel disease by a simplified bacteriological technique

A semi-quantitative bacteriological method was used to study faecal flora in 42 patients with Crohn's disease, 37 with ulcerative colitis and 21 healthy controls. Faecal homogenates were plated on primary isolation plates by a technique that allowed the growth of various microbial isolates to be assessed on a visual 1(+)-5+ score. This method was first calibrated against a standard quantitative bacteriological technique, which confirmed the reliability and reproducibility of the results obtained by the simpler method. Patients with clinically active Crohn's disease (22) had significantly higher total aerobe scores than patients with quiescent disease (20) (p less than or equal to 0.006) or ulcerative colitis (p less than or equal to 0.04) or normal controls (p less than or equal to 0.02). The scores of Escherichia coli were parallel to those of total aerobes. Lactobacillus and bifidobacteria scores were significantly reduced in patients with Crohn's disease compared to those with ulcerative colitis and controls. The anaerobic flora in both Crohn's disease and ulcerative colitis was indistinguishable from that of controls. Bacteroides vulgatus and B. fragilis were the predominant bacteroides in all groups. Patients with ulcerative colitis, regardless of disease activity, harboured faecal flora that did not differ from that of normal controls. The abnormal faecal flora in Crohn's disease did not correlate with established clinical and laboratory indicators of disease activity.

Clostridium difficile in inflammatory bowel disease relapse

Stools of 65 patients with exacerbation of symptoms of inflammatory bowel disease were examined for the presence of enteric pathogens and Clostridium difficile. Ten (16%) had C. difficile toxin. Symptoms in all patients cleared after therapy, with improvement correlating with elimination of toxin from the stool.

Clinical and histologic features differentiating non-relapsing colitis from first attacks of inflammatory bowel disease

This is a study of first attacks of colitis, evaluating prospectively the overall course with repeated histologic, clinical, laboratory, and initial microbiologic examinations. Forty-two attacks of colitis could after a follow-up period of 5.5 years be separated into relapsing and non-relapsing types. Relapse was chosen as a prerequisite for a final diagnosis of inflammatory bowel disease. In the non-relapsing group 72% of the patients harboured enteropathogenic bacteria. An insidious onset of diarrhoeal symptoms was highly discriminant of inflammatory bowel disease, whereas an acute onset mostly occurred in patients with non-relapsing colitis. Macroscopic differentiation at sigmoidoscopy was not possible. Distorted crypt architecture (92%) and/or basal plasmacytosis (77%) at initial biopsies strongly indicated inflammatory bowel disease but was also found transiently in patients with infectious colitis (19%). Thus, careful microbiologic and clinical investigation and repeated histologic examinations are necessary to distinguish infectious colitis from inflammatory bowel disease.

Bacterial immunofluorescence in the intestinal juice of patients with nonspecific chronic enteropathy

The bacterial immunofluorescence (BIF) in the intestinal juice was studied by the method of Virginia Thomas in a group of 26 patients with nonspecific chronic enteropathy (NCE). Our investigation revealed BIF in jejunal juice in 16 of 26 patients with NCE. The BIF test may be useful for the estimation of immune response to pathogenic germs at the level of the intestine.

[The effect of the acidic milk mixture "Nariné" on intestinal microflora in patients with functional and inflammatory bowel diseases]

A cultured milk mixture "Narine" (strain 317/402 lactobacilli and relevant metabolic products) given to 58 patients with various functional disorders and inflammation of the colon associated with dysbacteriosis resulted in a pronounced positive effect as related to intestinal microflora in 96.6% of the patients. In 75.8% of cases dysbacteriosis discontinued within 10 days.

Incidence of catheter-associated gram-negative bacteremia in children with short bowel syndrome

Children with catheter-associated bacteremia were evaluated for the type of bacteria recovered and the relationship of the bacteria to the predisposing disease. A previously unrecognized observation was that gram-negative isolates, namely, Escherichia coli and Klebsiella sp., were almost exclusively recovered (11 of 12 isolates [92%]) from children with short bowel syndrome (SBS) compared with those from children with other underlying diseases, such as inflammatory bowel disease, malignancies, and other disorders (P less than 0.001). Furthermore, children with SBS had a higher frequency of repeated infection (3.1 catheter-associated infections compared with 1.3 catheter-associated infections in children with other disorders during the same period). Only gram-positive bacteria were isolated from children with malignancies and other predisposing disorders. The very high frequency of catheter-associated gram-negative bacteremia in children with SBS compared with that in children with other bowel disorders, malignancies, and other predisposing diseases requires attention by the clinician in the management of patients in this group.

Antibodies against Campylobacter jejuni/coli in patients suffering from campylobacteriosis or inflammatory bowel disease

Sera from 74 patients from the Oslo area and 21 from Northern Norway with compylobacteriosis were analysed for antibodies against an antigen mixture comprising seven Campylobacter jejuni/coli strains including a PEN 0:6,7 isolate representing the most common serotype in Northern Norway. Seventy-seven per cent of the campylobacter patients from the Oslo area and 86% from Northern Norway had elevated antibody levels. Thirty-seven out of 57 (65%) seropositive patients from Oslo and 12 out of 18 (67%) from Northern Norway were positive in more than one immunoglobulin class. None of the patients, all from Northern Norway (N = 56), with inflammatory bowel disease i.e. Mb. Crohn or ulcerative colitis diagnosed for the first time, had elevated antibody levels in two immunoglobulin classes. Apparently campylobacteriosis is not associated with the precipitation of these diseases. Two sets of blood donor sera, from Oslo (N = 28) and Tromsø (N = 37) respectively, served as reference. The IgG antibody levels against C. jejuni/coli antigens in the blood donor group from Tromsø were higher than in the Oslo group.