Epidemiology of inflammatory bowel disease in the county of Tübingen (West Germany)

The incidence and prevalence of Crohn's disease (CD) and ulcerative colitis (UC) were investigated retrospectively for 1970-1980 and prospectively for 1981-1984 in the predominantly rural county of Tübingen (FRG). Eight hundred and twenty-eight patients with CD and 376 patients with UC were detected. Point prevalence at the end of 1984 was 54.6 for CD and 24.8 for UC, respectively. The occurrence of UC was stable during the period of investigation. The annual incidence of CD rose during the end of the seventies and afterwards reached a plateau of about 4 new cases per 100,000 inhabitants per annum. The prevalence of IBD was markedly greater in the cities than in the rural areas of the county.

Postoperative recurrence of Crohn's disease in relation to radicality of operation and sulfasalazine prophylaxis: a multicenter trial

Recurrence rate is high after operation for Crohn's disease. A multicenter trial was performed to study the effect of radical or nonradical operation and of sulfasalazine prophylaxis versus placebo on postoperative recurrence rate in 232 patients with Crohn's disease. Sixteen medical and surgical centers participated in the study, 7 operating radically and 9 nonradically. The follow-up period lasted 3 years, the allocation to drug treatment was randomized and double blind. Recurrence was significantly less frequent and occurred later in patients who were operated nonradically. Patients on sulfasalazine prophylaxis had a better prognosis than on placebo. This effect was statistically significant in the first 2 years of treatment. Both strategies were additive: nonradical operation and sulfasalazine had the best prognosis, radical operation and placebo was worst. It is concluded that postoperative recurrence is best prevented by resecting nonradically and prescribing 3 g of sulfasalazine daily at least over 2 years.

Dissipative pattern formation in ternary non-linear reaction-electrodiffusion systems with concentration-dependent diffusivities

Conditions for the emergence of ionic dissipative structures after Turing instability of a spatially and temporaly homogeneous stationary concentration distribution are derived for electroneutral ternary ionic reaction systems with concentration-dependent diffusivities. The inhomogeneous solution branch first bifurcating while crossing a critical ratio of diffusivities is given as a series of eigenfunctions of the Laplace operator. The results are specified for a model reaction system and polynomial concentration dependence of diffusion. It is shown that the inclusion of concentration dependence controls the amplitudes of the spatial distribution.

[Changes in the ileal mucosa in Crohn disease. Endoscopic and histologic study]

In 383 patients, suffering from Crohn's disease, ileum was studied both endoscopically and histologically. In patients without surgical interventions (n = 207), endoscopic lesions were observed in 69%, histologic lesions in 74%. Most numerous endoscopic lesions were redness (51%), vulnerability (29%) and ulcer (27%), most frequent histologic lesions discontinuous infiltration (30%) and ulcer (30%). In patients, operated on, endoscopic and histologic lesions were found more often in the ileal region, near to anastomosis than in the more proximal ileum. Overall, the endoscopic and histologic appearance of the distal segment of the ileum widely corresponded to that of the terminal ileum in patients without surgery. Several endoscopic parameters were correlated to histologic variables, but overall the correlation was low (maximal correlation coefficient 0.34). Granulomas were present in 7.4% of the biopsies and 9.1% of the patients. The occurrence was significantly correlated to the endoscopic variables cobblestone appearance and ulcer as well as to the histologic variables density of infiltration, ulcer, and activity of inflammation. In conservatively treated patients, the incidence of mucosal vulnerability, and cobblestone appearance significantly declined in long standing disease, the incidence of stenosis increased. In patients operated on, aphthous lesions and ulcers increased in longstanding disease.

Morphologically different biopsy specimens of the human gastric mucosa. I. The use of enzymatic cell isolation for quantitative determination of parietal cells

Single biopsies of human gastric mucosa from controls and different groups of patients were used for enzymatic cell isolation by pronase and collagenase and subsequent count of parietal and nonparietal cells. This procedure was tested in regard to its validity and delivered the following cell numbers. Total gastric cells/mg wet weight gastric mucosa: normal gastric mucosa [controls (C), n = 95] 31,500 +/- (SEM) 1,490, chronic superficial gastritis (GI; n = 49) 36,300 +/- 2,770, chronic gastritis with beginning atrophy (GII; n = 36) 44,100 +/- 3,050 (p less than 0.025), chronic atrophic gastritis (GIII; n = 12) 40,100 +/- 5,760, duodenal ulcer (DU; n = 26) 29,340 +/- 2,280, gastric ulcer (GU; n = 23) 37,090 +/- 3,000, gastric resection according to Billroth I (BI; n = 7) 57,480 +/- 12,360 (p less than 0.005) and Billroth II (BII; n = 12) 52,560 +/- 6,730 (p less than 0.005). Parietal cells/mg wet weight gastric mucosa: 1,910 +/- 490 (C), 1,980 +/- 140 (GI), 1,700 +/- 200 (GII), 1,170 +/- 220 (GIII, p less than 0.025), 2,580 +/- 240 (DU, p less than 0.05), 1,690 +/- 150 (GU), 1,500 +/- 250 (BI), 1,360 +/- 320 (BII). Parietal cell concentration (density) did not differ in males and females and did not change with age. The method delivers relevant cell numbers, is suitable to detect qualitative differences and can be used for the interpretation of biochemical studies.

Colonoscopy in the investigation of drug absorption in healthy volunteers

In order to evaluate the absorptive capacity of the colonic mucosa, colonoscopy was used to investigate in six healthy volunteers the colonic absorption of the nonsteroidal anti-inflammatory drug diclofenac (Voltaren). Oral and colonic administration of 100 mg of diclofenac resulted in comparable peak plasma concentrations and areas under the plasma concentration time curves. The apparent relative availability of diclofenac from the colon compared to the oral form, which was assumed to be 100%, ranged from 54% to 109% with a mean of 78%. There was no difference in absorption between application of the drug in the cecum and in the splenic flexure. This new indication for colonoscopy proved to be simple, well tolerated, and well suited for phase I studies with new drugs or formulations.

Comparative radiological and morphological study of human pancreas. Pancreatitis like changes in postmortem ductograms and their morphological pattern. Possible implication for ERCP

A postmortem study by ductography and histology was performed on 69 human pancreata with no clinical or histological signs of chronic pancreatitis. The ductograms, supplemented by five postmortem ductograms of chronic pancreatitis, were independently evaluated by six clinicians, skilled in ERCP; the degree of alteration was estimated by simple rating, forced choice rating, and by determination of the grade of chronic pancreatitis, Histologically, the amount of intraductal epithelial proliferation, periductal, intralobular and perilobular fibrosis, intraductal protein plugs, and fat necrosis was determined by semiquantitative methods. The six ductographical evaluations significantly differed in the level of their data, but corresponded in the range of distribution. All evaluations were correct regarding judgement of ductograms from patients with chronic pancreatitis. Ductograms of patients without chronic pancreatitis, however, were also frequently classified as chronic pancreatitis; overall 81% (minimal 37%, moderate 33%, severe 11%). This high level of false positive diagnosis indicates the frequency of pancreatitis like lesions in the main duct and its side branches in patients without chronic pancreatitis. Ductal lesions were significantly correlated with perilobular fibrosis. This finding favours the assumption, that in the non-inflamed pancreas, perilobular fibrosis plays a key-role in the development of ductal alterations, as in chronic pancreatitis. Perilobular fibrosis may result from intralobular inflammation caused by age-dependent intraductal epithelial hyperplasia.

[Crohn disease: initial experiences with cyclosporin A in an adolescent girl]

The diagnosis of Crohn's disease with extensive involvement of small intestine and colon was first made in a 12 3/4-year-old girl, now 15 1/2 years old. Despite continued treatment with prednisolone and salazosulfapyridine, as well as azathioprine and metronidazole, no lasting remission was obtained. Widespread severe osteoporosis with vertebral fractures made it necessary to discontinue the prednisolone, despite endoscopically and biochemically confirmed signs of activity of the disease. Administration of cyclosporin A in this situation produced phases of improved clinical and biochemical parameters. Regular control of biochemical levels failed to reveal any drug-specific acute side-effects. Because of the increased incidence of malignant lymphoma under cyclosporin A this drug should be held in reserve in the treatment of Crohn's disease, until results from controlled studies have become available.

European Cooperative Crohn's Disease Study (ECCDS): colonoscopy

130 patients with Crohn's disease were colonoscopied in a multicenter trial. The obtained data were analyzed with respect to gathering information on the inflammation pattern, as well as on the importance and prognostic value of special lesions in Crohn's colitis. In 52 patients a second endoscopy was performed at the end of the 2-year study period. Ulcerations and aphthous lesions were the most common lesions, followed by pseudopolyps, cobblestone lesions and stenosis. In general, there was an increasing, distal gradient in the frequency of severe lesions. patients with Crohn's colitis alone had more signs of inflammation than patients with additional involvement of the small intestine. A segmental pattern was the most common form of inflammation. The group of patients (14%) with a continuous pattern did not deviate from the whole collective in clinical activity. In patients with previous resections, inflammation near the anastomosis was accompanied more often than not by stenosis. Patients with ulcerations had a rather short time since confirmation of the diagnosis. Cobblestone lesions and pseudopolyps correlated with short symptomatology. During the follow-up of the study, patients taking steroids or a combination with prednisolone and sulfasalazine seem to have better results than those under placebo or sulfasalazine alone, as regards the more severe symptoms.

Oxprenolol absorption in man after single bolus dosing into two segments of the colon compared with that after oral dosing

The systemic availability of oxprenolol after colonic and oral administration has been compared in a crossover study involving six healthy male volunteers. Drug administration into two regions of the colon (caecum and left flexure) was achieved by means of a colonoscopic technique. There were no obvious differences in plasma concentrations after drug administration to the caecum and left flexure, although in one subject it was necessary to repeat colonic administration because of unexpectedly high plasma drug levels on the first occasion. The possible reasons for this abnormal response are discussed. The mean systemic availability of oxprenolol was 82% after colonic compared with oral dosing, although marked differences were observed in individual plasma levels following drug administration by the two routes. The results of this study support the concept of extending the duration of oxprenolol release from a rate-controlled dosage form to permit once-daily administration with this short elimination half-life drug.

Endoscopic and bioptic study of the upper gastrointestinal tract in Crohn's disease patients

In the present study, virtually all of 225 patients suffering from Crohn's disease of the lower gastrointestinal tract (small and/or large bowel) were subjected to endoscopic examination of the upper gastrointestinal tract (esophagus, stomach, duodenum); while histologic examination of the upper gastrointestinal tract was performed in a portion of the patients (54 initial esophageal, 221 initial gastric and 210 initial duodenal examinations). Statistical evaluation of the findings from the upper gastrointestinal tract revealed that: Endoscopic lesions were observed in the esophagus of 15%, the stomach of 49%, and the duodenum of 34% of the 225 Crohn's disease patients. Of the 54 patients from which esophageal biopsies were taken, 31 (57%) revealed histopathologic alterations. Of the 221 patients from which gastric biopsies were obtained, 60% revealed histopathologic alterations; the rate was 53% in the 210 patients from which duodenal biopsies were taken. Calculated from the present data, noncaseating granulomas, i.e., Crohn's disease, were present only in the stomach of 29.4% of the patients, only in the duodenum in 3.4% of patients, and in both the stomach and duodenum in 4.9% of patients. Gastric granulomas were confined to the region of the stomach body and fundus in 3.4% of the patients from which gastric biopsies were obtained and to the antrum in 15.6% of the respective patients. Both gastric regions were involved in 8.3% of the respective patients. The incidence of gastric granulomas was significantly increased in young patients, patients with enterocolic manifestations of Crohn's disease, and those with brief duration of disease. Patient sex or previous drug therapy had no effect on the incidence of granulomas. The most frequent endoscopic findings in the stomach of patients with Crohn's disease were mucosal edema, mucosal redness, and acute or chronic erosions. Only chronic erosions were of significant predictive value for the presence of granulomas, i.e., diagnosis of Crohn's disease. The most frequent endoscopic lesion in the duodenum was mucosal redness, followed by mucosal edema and aphthous lesions. Ulcers, stenosis, and mucosal redness had significant predictive values for the presence of granulomas.

[Radical operation and recurrence prevention with azulfidine in Crohn disease: a prospective multicenter study--initial results]

The influence of radical versus more restricted operation and Azulfidine prophylaxis was studied in a controlled, partially randomized double blind multicenter trial (16 centres) in 177 patients over 3 years. Early relapse occurred more frequently in the radically operated group (49 vs. 31%) and less frequently under Azulfidine prophylaxis (34 vs. 46%). The radical operation had no advantage over the more restricted procedure and should be abandoned in Crohn's disease.

[Diagnostic value of unselected biopsies during gastroscopy]

In a prospective study 1414 unselected biopsies were obtained during 509 consecutive gastroscopies. Concordance between endoscopic and histological diagnosis was judged by means of the kappa coefficient. Best agreement was obtained with biopsies from the duodenal bulb, at 67.6% (kappa = 0.39). With biopsies from the body of the stomach agreement was only 35.7% (kappa = 0.12), from the antrum 28.8% (kappa = 0.10). Degree of agreement between endoscopic and histological result was independent of the instrument used, but was clearly dependent on the examining doctor and the number of examinations. The results suggest that clinically significant disease is often overlooked during endoscopy alone, unless simultaneously obtained unselected biopsies are examined at the same time. Thus, endoscopic examination alone missed Crohn's disease, chronic atrophic gastritis and various degrees of dysplasias. Unselected biopsy aids in objectifying the gastroscopic findings and in securing the diagnosis of various diffuse gastric mucosal changes.

Effects of semisynthetic diets on xenobiotic metabolizing enzyme activity and morphology of small intestinal mucosa in humans

We studied the effects of semisynthetic (elemental) diets on the function and morphology of the human small intestine. The enzymatic capacity of the intestinal mucosa to metabolize lipophilic xenobiotics was investigated using jejunal biopsy specimens from 15 normal subjects who were on an isocaloric, nutritionally balanced semisynthetic diet for 7 days and thereafter on a normal home diet. Each subject underwent biopsy twice: on day 7 of semisynthetic diet and again on home diet 2-6 wk later. The jejunal mucosal tissue was examined by histologic morphometry and stereomicroscopy. Moreover, 25-50 mg of the biopsy material was homogenized and the following enzyme activities were determined in 20,000 g supernatant: for cytochrome P450-dependent monooxygenase activity with 7-ethoxycoumarin O-deethylase (EOD) and with nicotinamide adenine dinucleotide phosphate (NADPH)-cytochrome c reductase and for conjugation activity with 1-naphthol glucuronyltransferase (NGT). The NGT and reductase activities were unchanged by the dietary alterations. However, the EOD activity was significantly depressed on semisynthetic diet and rose to control range on home diet (from 5.3 +/- 2.5 to 12.4 +/- 8.6 pmol/min X 10 mg wet wt). Male subjects had significantly higher EOD activities than female subjects on semisynthetic diet (6.6 +/- 2.3 vs. 3.2 +/- 0.9) as well as on home diet (16.3 +/- 9.0 vs. 6.4 +/- 3.0). Semisynthetic diet also reduced the jejunal villous height significantly when compared with home diet (408 +/- 49 vs. 373 +/- 44 micron). Therefore, on semisynthetic diet the toxicity of dietary xenobiotics that are inactivated by the intestinal mucosa may be increased.

The granuloma in Crohn's disease. A bioptical study

Serial sections of 1434 colonic and rectal biopsies of 347 patients with Crohn's disease were performed. The relationship between the incidence of granulomas and the inflammatory alterations of the mucosa and some clinical parameters was studied. The presence of granulomas depends on the severity of inflammatory alterations and not on the site of the biopsy. The number of granulomas per mm3 increases from caecum to rectum. The incidence of granulomas decreases with age, duration of illness and under a conservative therapy. If several biopsies, taken at the same or at different times, are studied, granulomas can be found in 40-50% of these patients.

European Cooperative Crohn's Disease Study (ECCDS): results of drug treatment

A multicenter double-blind study of the effectiveness of sulfasalazine and 6-methylprednisolone, alone and in combination, was conducted on 452 patients with Crohn's disease. One hundred sixty patients were previously untreated; 292 patients were previously treated. The Crohn's disease activity index (CDAI) was used to determine whether a patient had active (CDAI greater than or equal to 150, n = 215) or quiescent disease (CDAI less than 150, n = 237). Treatment of active disease consisted of high-dose 6-methylprednisolone, 6-methylprednisolone combined with 3 g of sulfasalazine, 3 g of sulfasalazine alone, or placebo, and lasted 6 wk. Patients in remission received maintenance doses of one of these drug regimens for periods of up to 2 yr. One hundred ninety-two patients completed the 2-yr study period. Results were evaluated using life-table analysis and outcome ranking. These methods showed 6-methylprednisolone to be the most effective drug in overall comparison of all patients (p less than 0.001); in previously treated patients (p less than 0.001); and in subgroups: active disease (p less than 0.001), only small bowel disease (p less than 0.05), and both small bowel and colon disease (p less than 0.05). Combination of 6-methylprednisolone and sulfasalazine was the most effective regimen in previously untreated patients (p less than 0.05) and when disease was localized in the colon (p less than 0.001). Sulfasalazine alone was least effective in overall comparison of all patients (p less than 0.05) and in all strata. Drug treatment was of no significant benefit to patients with quiescent disease. Continuous administration of low doses of 6-methylprednisolone, or the combination regimen, was beneficial in patients who responded initially to treatment of active disease. The addition of sulfasalazine, however, offered no advantage.