Intestinal permeability in diabetic diarrhoea

Small intestinal permeability to mannitol and lactulose was studied in 12 patients aged 36-70 (mean 56) years with diabetic diarrhoea (DD). Ten uncomplicated diabetics aged 24-56 (mean 37) years and 25 normal subjects aged 22-60 (mean 37) years served as controls. Permeability was assessed by measuring urinary recovery of the test substances after oral ingestion. Mean lactulose excretion in patients with DD was significantly lower than in normal controls but was not significantly different from the uncomplicated diabetics. Mean lactulose excretion was not significantly different in the three groups. However, lactulose to mannitol excretion ratios (LMER) were significantly higher in patients with DD compared to the controls or the uncomplicated diabetics. LMER in seven patients with DD were outside the normal range. LMER in patients with DD did not correlate with blood urea, small intestinal transit time, faecal fat excretion, small intestinal bacterial overgrowth, duration of diabetes or duration of diarrhoea. Jejunal morphology was normal in all patients with DD. It was concluded that small intestinal permeability was abnormal in some patients with DD and that this might be a factor in the aetiology of the diarrhoea.

Upper gastrointestinal endoscopy in patients aged 80 years or more

A retrospective study of 208 upper gastrointestinal endoscopies (including 56 therapeutic procedures) performed over a 3-year period on 150 patients aged 80 years or more has shown that endoscopy is safe and well tolerated in this age group. Only 10% of first endoscopies were normal. If endoscopies performed for therapy or assessment of peptic ulcer healing are excluded, 79% of endoscopies were considered helpful in revealing the cause of the patients symptoms and/or aiding the patients' management. Endoscopy was particularly helpful in patients with gastrointestinal haemorrhage or dysphagia. Of 63 emergency endoscopies for acute upper gastrointestinal haemorrhage, a source of bleeding was found in 82%. Out-patient diagnostic endoscopy and even out-patient endoscopic oesophageal dilatation was safe in the more robust elderly patient. Patients aged 80 years or more made up 5% of all upper gastrointestinal endoscopies and 10% of all emergency endoscopies performed in our unit. The study emphasizes the important contribution of sophisticated investigative techniques to the care of the elderly.

Clostridium difficile toxin in chronic idiopathic colitis

Clostridium difficile toxin was isolated from the stools of three patients with chronic idiopathic colitis. Two patients were known to have chronic idiopathic colitis before Cl difficile toxin was isolated. The third patient was subsequently found to have ulcerative colitis after presentation with Cl difficile toxin in the stool. Two patients were on sulphasalazine at the time of diagnosis of Cl difficile infection and one had taken sulphasalazine two months previously. Only one patients had antibiotic exposure and that was at least three months before presentation. In each patient, treatment with vancomycin was accompanied by symptomatic improvement and disappearance of the toxin. The underlying colitis remained unaffected. In patients with inflammatory bowel disease in relapse, the presence of Cl difficile toxin should be sought as this may be a factor in the relapse. In any patient presenting with diarrhoea, the presence of Cl difficile toxin may obscure the presence of underlying inflammatory bowel disease.

The delayed diagnosis of coeliac disease

The prevalence of coeliac disease in New Zealand appears to be much lower than in the British Isles suggesting the possibility that coeliac disease is not being diagnosed in this country. This view point is supported by the two patients reported in this paper who had coeliac disease diagnosed after ten years and at least 36 years of symptoms respectively. The importance of diagnosing coeliac disease is stressed, particularly because of the greatly increased risk of developing lymphoma (from which one of the two patients died). The need to investigate all patients with chronic diarrhoea and other gastrointestinal symptoms is stressed.

Small intestinal permeability in normal Sudanese subjects: evidence of tropical enteropathy

Small intestinal permeability to mannitol and lactulose was studied in healthy English and apparently healthy Sudanese subjects to determine whether any differences were apparent. Permeability was assessed by measuring urinary recovery of the test substances after oral ingestion. The mean excretion of lactulose was significantly higher and the mean excretion of mannitol was significantly lower in the Sudanese than in the English subjects. Lactulose to mannitol excretion ratios were significantly higher in the Sudanese. These data demonstrate abnormal intestinal permeability in the Sudanese subjects and indicate the presence of an asymptomatic enteropathy.

Diarrhoea as a symptom

Diarrhoea is a common symptom in all communities and in both general and hospital practice. Diarrhoeal diseases, particularly of infectious aetiology, are a huge health problem world-wide, causing much morbidity and mortality, especially amongst children. Although the symptom is almost universally understood, the definition of diarrhoea is difficult because of the wide variation in the bowel habits of normal individuals. Diarrhoea is, perhaps, best described as a change in bowel habit from normal with an increase in stool volume and/or fluidity with or without an increase in stool frequency. The disorders causing diarrhoea are many and various, but most episodes of diarrhoea are mild and self-limiting. However, all cases of chronic diarrhoea and all severe cases of acute diarrhoea require investigation after the initial clinical assessment. Investigation must be logical and structured and can be divided into three stages: the initial work-up (sigmoidoscopy, stool examination, screening blood tests), anatomical and functional assessment of the gastrointestinal tract, and further investigation of the difficult case (osmotic or secretory diarrhoea?, hormone levels, tests for laxative abuse, perfusion studies, laparotomy, etc.) Most cases are diagnosed after clinical assessment or the initial work-up. In the remainder, there are usually clues to the diagnosis or to the area of the gastrointestinal tract which needs to be investigated. Only a small number of cases require extensive investigation including the third stage of work-up. Analysis of the symptom of diarrhoea requires all the attributes of the good physician: wide clinical experience, careful history and examination, diagnostic and therapeutic acumen, a sound understanding of normal and abnormal physiology, skill and experience in selecting the appropriate investigations and interpreting their results, meticulous attention to detail and finally, a caring and sympathetic attitude to the patient.

Small intestinal permeability as an indicator of jejunal mucosal recovery in patients with celiac sprue on a gluten-free diet

Lactulose/mannitol excretion ratios were measured in 13 patients with celiac disease at diagnosis and after 5-8 months on a gluten-free diet. Jejunal biopsies were assessed histologically at diagnosis and during treatment. The excretion ratios in untreated patients were significantly higher than in 25 normal controls (P less than 0.01). On the diet, the excretion ratios fell in every patient, but in only eight did the ratio return to normal. There was a good correlation between the ratio and jejunal histological grading. During treatment, the ratios significantly inversely correlated with jejunal villous height/mucosal thickness ratios (P less than 0.001). Therefore, excretion ratios provide a well-tolerated noninvasive means of assessing the jejunal mucosa in patients with celiac disease on a gluten-free diet.

Gastrocnemius myositis in a patient with inflammatory bowel disease

A young woman with long-standing inflammatory bowel disease presented with a tender left gastrocnemius myositis in association with an exacerbation of her disease. Muscle biopsy showed a chronic inflammatory cell infiltrate and atrophic muscle fibres, but no granulomata or vasculitis, and her symptoms responded to high-dose steroids. Twelve months later she underwent subtotal colectomy for troublesome symptoms and incidentally was discovered to have an adenocarcinoma of the sigmoid colon. Myositis without granulomata has not been reported previously in either Crohn's disease or ulcerative colitis.

Small intestinal permeability to mannitol, lactulose, and polyethylene glycol 400 in celiac disease

Mannitol (molecular weight 182), lactulose (342), and polyethylene glycol 400 (range 242-550) absorption was studied in 25 controls, 22 untreated celiacs, and 13 treated celiacs. Untreated celiacs absorbed less mannitol and more lactulose than controls. Absorption of higher as well as lower molecular-weight polyethylene glycols was reduced in untreated celiac disease. Absorption returned towards normal on treatment. Polyethylene glycol and lactulose absorption was enhanced by administering them in a hypertonic solution. Polyethylene glycol 400 but not lactulose or mannitol was lipid soluble in vitro. It was concluded that the mucosa in untreated celiac disease was more "leaky" than normal. Polyethylene glycol 400 absorption data suggested that its absorption may largely be determined by its lipid solubility and was decreased in celiac disease because of the reduced surface area of the small intestine. Polyethylene glycol 400 cannot be recommended as a suitable marker for permeability studies of the small intestine.

Small intestinal permeability to sugars in patients with atopic eczema

Absorption of lactulose and mannitol was measured in eleven patients with atopic eczema and lactulose/mannitol excretion ratios were calculated. Mean lactulose absorption was increased in the patients with exzema and their excretion ratios were higher than those of controls. There was no correlation between either eczema extent or severity and the excretion ratio. We conclude that small intestinal passive permeability is increased in some patients with atopic eczema.

Abnormal small intestinal permeability to sugars in patients with Crohn's disease of the terminal ileum and colon

The absorption of lactulose and mannitol in 20 patients with Crohn's disease limited to the ileum or colon was studied, and lactulose/mannitol excretion ratios were calculated. The results were compared to those from 16 normal controls and 6 patients with ulcerative colitis. The 13 patients with ileal Crohn's disease had significantly higher lactulose/mannitol excretion ratios than the controls (p less than 0.01) or ulcerative colitics (p less than 0.01). Similarly, the 7 patients with Crohn's disease limited to the colon had significantly higher excretion ratios than the controls (p less than 0.01) or ulcerative colitics (p less than 0.01). The results provide support for the concept that Crohn's disease may be more extensive than is apparent macroscopically.

Galactorrhoea, hyperprolactinaemia, and pituitary adenoma presenting during metoclopramide therapy

A 49-year-old woman presented with a one month history of headaches, loss of libido and galactorrhoea. She had been taking metoclopramide for the previous 3 months for reflux oesophagitis. She was found to have substantially elevated serum prolactin levels and a pituitary adenoma, which have not been previously described in a patient taking metoclopramide. The drug was stopped and the serum prolactin level fell progressively to normal with resolution of symptoms over 4 months. This suggested that contrary to our original impression that she had a prolactin-secreting pituitary adenoma which had been stimulated by metoclopramide, she had metoclopramide-induced hyperprolactinaemia and an incidental pituitary tumour.

Lymphoma risk in coeliac disease of later life

From 314 patients with coeliac disease, 20 patients were found to have developed a lymphoma. The incidence of lymphoma was much greater in the 6th, 7th and 8th decades of life than in the previous two decades. In 12 patients, the lymphoma was diagnosed within 4 years of the diagnosis of their coeliac disease and there were significantly more of these lymphomas appearing in coeliacs diagnosed between 51 and 80 years, who made up 23% of the series, than in those diagnosed between 21 and 50 years. We conclude that lymphoma is particularly a complication of older coeliacs and that coeliacs newly diagnosed at more than 50 years of age should be more closely followed up for they have a 1 in 10 chance of harbouring a lymphoma.

Serum lysozyme activity in coeliac disease: a possible aid to athe diagnosis of malignant change

Serum lysozyme activities were measured in 34 control subjects, 13 untreated adult coeliac patients, 21 adult coeliac patients on gluten-free diet, and eight coeliac patients with a histiocytic lymphoma. Serum lysozyme activities were raised in three untreated patients, three patients treated with a gluten-free diet, and in only two patients with coeliac disease and lymphoma. Serum lysozyme estimations cannot be recommended as an aid to the diagnosis of lymphoma in patients with coeliac disease.

GIP and insulin responses to oral glucose in coeliac patients before and after treatment

The responses of plasma gastric inhibitory polypeptide (GIP) and insulin to oral glucose were studied in five patients with untreated coeliac disease. These patients were restudied after one year on a gluten-free diet. In the untreated patients, the blood glucose, serum insulin, and GIP levels were significantly lower than in the controls. After gluten withdrawal there was an improvement towards normality in the responses of blood glucose, serum insulin, and GIP. The results show that untreated coeliac disease is associated with abnormalities of intestinal and pancreatic hormone secretion and that these abnormalities are improved by gluten withdrawal.

Hymenolepiasis: an unusual cause of diarrhoea in Western Europe

A young Indian man presented in England with a 6-month history of diarrhoea which started just before leaving India. He was found to have tropical enteropathy and H. nana infestation, but while the infestation and symptoms disappeared with antihelminthic treatment, the tropical enteropathy persisted. Hymenolepiasis is not well recognised as a cause of diarrhoea amongst Asians in Western Europe.

Effects of vasoactive intestinal peptide and pancreatic polypeptide in rabbit intestine

The effects of porcine vasoactive intestinal peptide (VIP) and bovine pancreatic polypeptide (PP) on jejunal, ileal, and colonic fluid transport were studied in the rabbit. VIP produced secretion in the small intestine (jejunum greater than ileum) but did not affect absorption in the colon. PP had no secretory effects in jejunum, ileum, or colon. The small intestinal secretion induced by VIP was not associated with raised cAMP concentrations in the mucosa; this suggests that the secretory effects of VIP in vivo are mediated by a mechanism other than stimulation of adenylate cyclase.

Gluten-sensitive diarrhea without evidence of celiac disease

Eight adult female patients suffering from abdominal pain and chronic diarrhea which was often incapacitating and frequently nocturnal, had dramatic relief on a gluten-free diet and return of symptoms after gluten challenge. Previous nonspecific measures and a milk-free diet were ineffective. Multiple jejunal biopsies showed minor, but significant changes in cellularity which returned to normal on the gluten-free diet. Apart from a slight increase in jejunal cellularity, no immunological abnormalities were found after gluten challenge. Steatorrhea or other biochemical defects, common in celiac disease, were not found. It was concluded that these patients had a gluten-sensitive diarrhea, but had no evidence of celiac disease.

Malabsorption and macroamylasemia. Response to gluten withdrawal

A 36 year old woman presented with malabsorption and macroamylasemia. The macroamylase was characterized and shown to be a complex of pancreatic amylase and immunoglobulin A(IgA). The patient had the clinical and histologic features of adult celiac disease, and responded to a gluten-free diet. The macroamylase complex disappeared from the serum after gluten withdrawal, a hitherto unreported finding in the syndrome of malabsorption and hyperamylasemia.

Gastrointestinal bleeding, angiodysplasia of the colon and acquired von Willebrand's disease

A 66-year-old man is reported who was found to have acquired von Willebrand's disease, which presented when the patient was 63 with iron deficiency anaemia and gastrointestinal bleeding. He subsequently bled from various sites in the gastrointestinal tract including an angiodysplasia of the right colon, which was successfully treated by right hemicolectomy. This is the second reported association between acquired von Willebrand's disease and angiodysplasia of the intestinal tract.

Celiac disease and malignancy

Fifty-five patients with celiac disease and coexistent malignant disease (27 lymphoma, 28 other malignancies) are described. The important clinical features at presentation of lymphoma were weight loss, abdominal pain, diarrhea, profound weakness and fever, associated with anemia, raised ESR, hypoalbuminemia and steatorrhea. There were no specific features to enable earlier diagnosis. Radiology was unhelpful and in no case were malignant cells seen in the jejunal biopsy. Four of the lymphomas were Hodgkin's disease, none of which involved the bowel; the remainder were reticulum cell sarcoma, 17 of which involved the bowel. Definitive diagnosis prior to death was made in only 18 patients, of whom 16 survived from 2 to 226 days (mean, 76 days). Of the remaining two patients, one is still alive, while the other died 26 years after the original diagnosis of Hodgkin's disease. The possibility of lymphoma should be considered in those who present with celiac disease in middle life and in those who deteriorate for no apparent reason after a period of stability on a gluten-free diet. The index of suspicion for lymphoma in celiac disease should be high and early laparotomy be considered in patients with unexplained deterioration. Twenty-eight patients with 29 carcinomas and 3 other tumors are also described. The presentations of these malignancies were no different from their presentations in non-celiac patients, and their development did not provoke a relapse of celiac disease. Considering the whole series of 55 patients, there was little evidence for the view that malignancy itself was the cause of the flat jejunal mucosal appearances seen in these patients.

Association of coeliac disease and inflammatory bowel disease

The association of coeliac disease and inflammatory bowel disease is rare, as only three individual cases have been reported. Four additional cases of the association are described. A review of the prevalence figures for the two disorders suggests that this is more than a chance association.

Coeliac disease presenting with a leuco-erythroblastic anaemia

A 49-year-old Irishman presented as an emergency with watery diarrhoea and a leuco-erythroblastic anaemia. Investigations showed that he had coeliac disease but no evidence of bone marrow infiltration. His leuco-erythroblastic picture disappeared on treatment with iron and folic acid.

Subcellular fractionation studies of the intestinal mucosa in congenital sucrase--isomaltase deficiency

1. Jejunal biopsy specimens from three children with congenital sucrase-isomaltase deficiency were assayed for disaccharidase activity and were subjected to analytical subcellular fractionation with enzymic microanalysis. 2. By use of the highly sensitive fluorigenic modification of the disaccharidase assay, brush-border sucrase and isomaltase activities were depressed but nevertheless detectable in each child. 3. Apart from the expected decrease in brush-border alpha-glucosidase activity, the other enterocyte marker-enzyme activities were normal. 4. There were no abnormalities in the enterocytes of any child on analytical subcellular fractionation or on electron microsocopy.

Response of the skin in dermatitis herpetiformis to a gluten free diet, with reference to jejunal morphology

Twenty-one patients with dermatitis herpetiformis have been on a gluten free diet regularly followed up for at least one year (mean four years). Eighteen patients had a 'flat' mucosal appearance (grade III), one patient had moderately severe mucosal abnormality (grade II), one patient had mild mucosal abnormality (grade I), and one patient had a normal mucosal appearance (grade O). On the diet, 10 patients had no skin rash and took no dapsone, seven patients controlled the skin rash on a lower dose of dapsone, and four noticed no improvement. There was no correlation between pre-diet jejunal morphology and response of the skin. A repeat jejunal biopsy, on the gluten free diet, was possible in 15 patients. While all those with skin improvement showed some improvement in jejunal morphology, there was no association between the degree of skin improvement and the degree of recovery of the jejunal mucosa.

Acid microclimate in coeliac and Crohn's disease: a model for folate malabsorption

The surface pH of human proximal jejunum was measured in biopsy samples and found to be more acid than the phosphate buffer in which they were incubated. The in vitro jejunal surface pH was 5.93 +/- 0.05 in control subjects and 6.19 +/- 0.09 in treated coeliac patients. A group of untreated coeliac patients with a surface pH of 6.56 +/- 0.14 had a significantly less acid surface pH compared to controls, as did a group of Crohn's patients with a surface pH of 6.21 +/- 0.04. These two groups with a significantly raised surface pH were subdivisible into 'high' and 'low'groups. Surface pH was found to remain low in the treated coeliac and control groups but became more acid over the incubation period reaching almost normal values in the Crohn's group and the untreated coelic initial surface pH. The raised surface pH in untreated coeliac disease and Crohn's disease would alter the amount of a weak acid available for non-ionic diffusion. Therefore the present results may help to explain the folate malabsorption known to occur in untreated coeliac disease and the frequently seen low serum folate levels in Crohn's disease.

Coeliac disease and immunological disorders

Out of 314 patients with coeliac disease, 63 had associated disorders of known or suspected immunological cause (excluding aphthous stomatitis and dermatitis herpetiformis). Autoimmune diseases appeared to occur more often in patients with coeliac disease than in the normal population, 52 such diseases being found in 45 patients. Of individual disorders, diabetes mellitus, thyroid diseases, and ulcerative colitis seemed to be more common than expected. Atopy (asthma and eczema) occurred in 7% of the patients. Most of these immunological disorders developed when the patients were on normal diet. A gluten-free diet and virtually normal jejunum did not prevent their development, and the diet had little ameliorating effect on their course apart from an occasional dramatic improvement in atopic patients.

Diabetes mellitus and coeliac disease: a clinical study

Fourteen adults in whom diabetes mellitus and coeliac disease coexist, are described. In no patient was coeliac disease diagnosed (biopsy proven) before the age of 28 years. Diabetes was recognized before coeliac disease in all except one. Diabetic control was very unstable and hypoglycaemia particularly troublesome before treatment with a gluten free diet. Following gluten restriction, insulin requirement increased in six patients, and diabetic control became more stable. Diarrhoea due to coeliac disease in a patient with coexisting diabetes, may be mistakenly diagnosed as 'diabetic diarrhoea'. However, certain clinical and laboratory features should arouse suspicion that the diarrhoea is not of diabetic origin. These included a history of gastrointestinal symptoms preceding the diagnosis of diabetes, the occurrence of repeated hypoglycaemia, absence of neuropathy, anaemia, low serum folate, low serum albumin and a malabsorption pattern on small bowel radiography. A definitive diagnosis of coeliac disease can be made only jejunal biopsy. The opportunity to diagnose coeliac disease in adult diabetics will usually fall to the diabetologist and wider use of jejunal biopsy in diabetics with chronic or recurrent diarrhoea is suggested.

IgA class reticulin antibodies in relatives of patients with coeliac disease

IgA class reticulin antibodies were not found in patients with Crohn's disease, ulcerative colitis, and hiatus hernia despite a significant incidence of IgG class reticulin antibodies. None of 56 normal healthy subjects was positive. In contrast, 13 (76%) of the sera from 17 patients with coeliac disease on normal diet were positive for IgA class antibodies as were 19 (20%) of 93 first degree relatives. Seventy-three relatives underwent jejunal biopsy. Grade III (flat) histology was found in 13 and, of these patients, 10 (77%) showed IgA class reticulin antibody in their serum. It is suggested that determination of IgA class reticulin antibodies was a useful test to determine which relative must be biopsied.

The genetic control of histocompatibility iso-antigens

This study provides evidence in mice of three strain combinations, that the classical law of transplantation that one gene ⇌ one antigen is applicable. It fails to confirm the suggestion that genic interaction may operate between the histocompatibility loci.