5-Aminosalicylic acid enemas in patients with active ulcerative colitis. Influence of acidity on the kinetic pattern

Enemas containing 1000 mg 5-ASA were administered to patients with active distal colitis in three separate studies: as a single dose in a neutral solution (pH 7.4); as a single dose in a slightly acidic, buffered suspension (pH 4.8); and as multiple doses once a day for 10 days with the acidic enema. 5-ASA was relatively rapidly absorbed from the neutral solution, resulting in plasma concentrations of 5-ASA sometimes two to three times higher than those found after peroral salazosulphapyridine (SASP) treatment. In contrast, absorption from the acidic enema was reduced and/or prolonged, giving plasma concentrations similar to those found during oral SASP treatment. After repeated doses of the acidic enema, plasma concentrations after an enema resembled those seen after the single dose. Urinary excretion was significantly lower, suggesting a reduced fraction of absorption at steady-state conditions. No side effects were observed, and no local irritation was reported. An acidic buffer suspension with 5-ASA seems to be safe for use as enema and deserves further clinical testing for treatment of distal ulcerative colitis.

Secretion rates of immunoglobulins, albumin, haptoglobin and complement factors C3 and C4 in the perfused jejunum and ileum of human Salmonella carriers

Secretion rates of immunoglobulins and other proteins were assessed by luminal perfusion of jejunum and distal ileum, and the jejunal histology was evaluated in eight Danish chronic Salmonella typhi and paratyphi carriers compared to nine healthy controls who previously had suffered from typhoid or paratyphoid fever not followed by a carrier state. The median secretion rates for each protein investigated in the distal ileum as well as in the jejunum revealed no significant differences between the two groups. The secretion rate of secretory IgA was raised in both groups compared to previously investigated normal persons. The histological examination revealed no signs of inflammation or presence of bacteria. It was concluded that no primary humoral immune defect was revealed in the carriers.

Type I allergy to normal cellular constituents in chronic inflammatory bowel disease? Results from basophil histamine release test compared with total IgE and antinuclear antibodies

The possibility of autoimmune type I reactions to cellular constituents was investigated in 22 patients with ulcerative colitis, 12 with Crohn's disease, and in 22 healthy volunteers. Nuclear components and colon mucosa fragments were tested as potential antigens by the basophil histamine release technique. One of 12 patients with ulcerative colitis responded to sonicated leukocyte nuclei and one of 12 patients with Crohn's disease responded to both nuclei and RNA. Increased serum levels of total IgE and antinuclear antibodies of IgE class were found in one and three of the 24 patients, respectively. Histamine release caused by colon mucosa fragments was not observed in a separate study consisting of 10 ulcerative colitis patients and 10 healthy volunteers. Autoimmune type I allergy to cellular constituents does not seem to be of significance for chronic inflammatory bowel disease and thus could not explain the involvement of tissue mast cells and eosinophils in this condition.

Treatment of Crohn's disease with peroral 5-aminosalicylic acid

Eighteen patients with active Crohn's disease entered an open trial with 5-aminosalicylic acid in a slow-release preparation. All had lesions of the small bowel. Ten of them also had Crohn's disease of the colon. 5-Aminosalicylic acid, 500 mg three times daily, was administered for 6 wk. Even with meticulous monitoring, no side effects of any kind were observed, particularly no cases of renal affection, which could have been expected from animal studies. The clinical course was estimated as improved in 13 patients (72%), unchanged in 2 patients (11%), and aggravated in 3 patients (17%); 2 of these 3 were withdrawn from the study and switched to alternative treatment. The Crohn's disease activity index decreased from a median of 226 points to 99 points. On the basis of these results, large-scale controlled therapeutic trails seem warranted in order to establish clinical evidence for the benefit of peroral treatment with 5-aminosalicylic acid in patients with Crohn's disease.

Clinical appearance at diagnosis of ulcerative colitis and Crohn's disease in a regional patient group

A regional patient group comprising 783 patients with ulcerative colitis (UC) and 185 patients with Crohn's disease (CD) diagnosed during the period 1960 to 1978 was analysed in accordance with clinical appearance at diagnosis. Of the UC patients, 16% showed total colonic involvement, 41% substantial colonic involvement, and 41% rectal affection only. The disease extent was positively correlated to the degree of activity but not to the age or sex of the patients. 70% of the patients were in moderately or very active stage of disease, 28% in slightly active stage, and 2% inactive at the time of diagnosis. 43% of the patients had experienced weight loss, 27% fever, and 53% abdominal pains in their initial attack of the disease. Immunological manifestations were present in 13%. Of the CD patients 31% had small-bowel localization only, 28% large bowel only, 36% ileocolonic affection, and 5% other combinations. Patients with ileal involvement were significantly younger than patients with colonic involvement. There was no sex difference in accordance with the localization of Crohn's disease. 71% of the patients were in moderately or very active stage of disease and 29% in low activity at diagnosis. The intestinal symptoms were independent of the sex and age of the patients, whereas abdominal pains were present significantly more frequently in younger age groups. In all, 76% of the patients experienced abdominal pains, 34% fever, and 54% weight loss. Immunological symptoms from joints, skin, or eyes were present in 12% of the patients.

5-aminosalicylic acid in a slow-release preparation: bioavailability, plasma level, and excretion in humans

The release pattern, bioavailability, and kinetics of a 5-aminosalicylic acid tablet with sustained release were studied in humans. Six ileostomy patients received a single dose (500 mg). Eight and 48 h later, respectively, 58% and 65% of the dose was recovered in the ileostomy effluents, either as 5-aminosalicylic acid still retained in the preparation, free 5-aminosalicylic acid or acetyl-5-aminosalicylic acid. Fourteen healthy volunteers took 1500 mg of 5-aminosalicylic acid per day for 6 days and a steady state plasma acetyl-5-aminosalicylic acid concentration was reached on day 5 (1.1-2.9 microgram/ml). 5-Aminosalicylic acid was not detected in the plasma. At steady state, 40% of the 24-h dose was recovered from feces, and 53% from the urine. The sustained-release preparation studied provides sufficient amounts of 5-aminosalicylic acid to all parts of the gut and its curative effect in ulcerative colitis and Crohn's disease should be examined in controlled trials.

Incidence and prevalence of ulcerative colitis and Crohn's disease in the County of Copenhagen, 1962 to 1978

The incidence of ulcerative colitis and of Crohn's disease in the County of Copenhagen was estimated during the years 1962 to 1978. A total of 909 patients were diagnosed in this area with approximately 500,000 inhabitants. The mean incidence of ulcerative colitis was 8.1 per 10(5) inhabitants. This incidence was constant during the period for women but rose significantly around 1970 for men. The rise in male incidence is due to a rise in the incidence late in life. The prevalence of ulcerative colitis as of December 31, 1978 was 117 per 10(5) inhabitants. The incidence of Crohn's disease was increasing during the period for both sexes with a mean value for the period 1970 to 1978 to 2.7 per 10(5) inhabitants. The prevalence of Crohn's disease as of December 31, 1978 was 34 per 10(5) inhabitants.

Leucocyte function in ulcerative colitis. Quantitative leucocyte mobilisation to skin windows and in vitro function of blood leucocytes

Leucocyte function was evaluated by the in vivo mobilisation to skin windows with chambers and by the chemotactic, phagocytic, and nitro blue tetrazolium reducing capacity of blood leucocytes from 20 patients with ulcerative colitis. The total number of leucocytes mobilised to the chambers after 12 hours did not differ from those in 21 healthy volunteers. After 24 and 48 hours reduced number of leucocytes were mobilised by patients with ulcerative colitis (p less than 0.01). Correspondingly, the leucocyte migration rates were normal initially but were reduced after 18 hours Mobilisation in vivo was positively correlated to the blood neutrophil count (Rho:0.5549 po less than 0.02) but unrelated to clinical activity. Blood leucocytes showed reduced random migration in vitro as well as chemotactic response to casein (p less than 0.01). Serum independent and dependent phagocytosis did not differ from healthy volunteers. Nitro blue tetrazolium reduction by resting leucocytes was increased (p less than 0.01) in ulcerative colitis compared with controls. Our findings suggest altered in vivo mobilisation and in vitro migration of leucocytes in ulcerative colitis with increased spontaneous nitro blue tetrazolium reduction reflecting increased generation of potentially tissue damaging agents. The findings probably reflect changes secondary to the disease but which may be important in maintaining the inflammatory process.

The chemotactic function of neutrophils in ulcerative colitis

Neutrophil chemotactic function was investigated in 30 patients with ulcerative colitis (UC) in an active (no. = 15) or an inactive (no. = 15) stage. Peripheral blood neutrophils from active cases had a significantly decreased stimulated migration in modified Boyden chambers. Simultaneously done investigations of neutrophil migration into skin window chambers showed normal results in both active and inactive cases of UC. Thus, the defective chemotaxis during in vitro conditions was not reflected in a quantifiable neutrophil dysfunction in experimental acute inflammation.

Leucocyte function in Crohn's disease. Studies on mobilisation using a quantitative skin window technique and on the function of circulating polymorphonuclear leucocytes in vitro

Leucocyte function was evaluated by mobilisation to skin windows with chambers and by the chemotactic, phagocytic, and nitro blue tetrazolium (NBT) reducing activity of circulating leucocytes in vitro in 20 patients with Crohn's disease, 21 healthy volunteers, and nine patients with sarcoidosis or tuberculosis. Leucocytes had been mobilised in significantly reduced numbers at 12, 24, 36, and 48 hours in Crohn's disease compared with healthy volunteers (P less than 0.01) and patients with sarcoidosis/tuberculosis (P less than 0.01). The leucocyte migration rate showed that mobilisation in Crohn's disease begins after a prolonged lag phase and is reduced compared with healthy volunteers (P less than 0.01) and patients with sarcoidosis/tuberculosis (P less than 0.02). The reduced mobilisation was not correlated with disease activity. In vitro random migration by leucocytes was slightly lower in Crohn's disease (P less than 0.05) than in healthy volunteers, but there was no difference after removal of the autologous plasma. Chemotactic response to casein did not differ between the groups studied. Serum independent and dependent phagocytosis did not differ from control groups. Serum independent phagocytosis was positively and significantly correlated to the disease activity (rho 0.4812, P less than 0.05). Resting leucocyte NBT reduction was increased in Crohn's disease and sarcoidosis/tuberculosis (P less than 0.01), but during phagocytosis a lower NBT reduction was found in Crohn's disease than in healthy volunteers (P less than 0.02). The inflammatory response in Crohn's disease, with reduced leucocyte accumulation, differs from patients with other granulomatous reactions and is independent of the disease activity. Our data suggest that the defect is not cellular. They support the hypothesis that a pathogenic factor in Crohn's disease may be foreign material that is normally eliminated remaining in the tissue and eliciting a chronic inflammatory response.

Ethical aspects of clinical decision-making

The aim of the present investigation was to describe and to classify significant ethical problems encountered by the members of the staff during the daily clinical work at a hospital medical department. A set of definitions was prepared for the purpose, including the definition of a 'significant ethical problem'. During a three month period 426 inpatients and 173 outpatients were admitted. Significant ethical problems were encountered during the management of 106 in-patients (25 per cent) and 9 out-patients (5 per cent). No significant difference was found between the frequency of ethical problems in female and male patients, but a positive correlation was noted between the number of problems and the patients' age. The problem types were classified according to a problem list. The results of this investigation suggest that greater attention must be paid to discussions about ethical problems among doctors and other categories of health personnel and that, among others, medical students ought to be taught the analysis of ethical problems.

Disodium cromoglycate in the treatment of ulcerative colitis and Crohn's disease

A controlled clinical study on disodium cromoglycate (DSCG) at a dose of 800 mg per day versus placebo was carried out in 141 patients with ulcerative colitis and 25 patients with Crohn's disease. Those of the ulcerative colitis patients who had been on sulphasalazine treatment continued that treatment during the trial (101 patients). Forty patients were intolerant of sulphasalazine. No patient received steroids during the last month before the study. Patients with Crohn's disease had their possible sulphasalazine treatment stopped before the trial. No beneficial effect of DSCG as compared with placebo was found, as the DSCG and the placebo group showed the same number of relapses in patients with a clinically inactive ulcerative colitis at the start of the trial and the same number of patients improving, deteriorating, and maintaining steady state in patients with clinically active ulcerative colitis at the start of the trial. There was no difference between relapse rate in DSCG and placebo groups in patients with Crohn's disease. No correlation between the eosinophil count in rectal mucosa and the outcome of the attack of ulcerative colitis could be demonstrated.

Social prognosis in patients with ulcerative colitis

One hundred and twenty-two randomly selected patients with ulcerative colitis (28 of whom had undergone colectomy) were interviewed to obtain data on the quality of their family, emotional, social, and professional lives. They were compared with an age- and sex-matched group of patients with acute conditions from the same area. The two groups were similar in marital status, the frequency of severe family or sexual problems, leisure activities, physical and earning capacity, the incidence of mental disorders before the interview, and intake of alcohol and psychopharmacological drugs. A higher proportion of the patients with colitis had had a higher education and belonged to higher socioeconomic groups than the controls, and this difference had been present at the time of diagnosis. These results show that patients with ulcerative colitis seem to adapt themselves well to their condition and suffer few social or professional disabilities.

Variations in plasma protein concentrations in individuals with ulcerative colitis: analytical and biological factors

Eight plasma proteins were determined in specimens taken every second day during a 14 day period from eleven patients with acute ulcerative colitis. The intra-individual variations in the concentrations of albumin, orosomucoid, haptoglobin, IgG, IgA, IgM and complement factors C3 and C4 were larger than expected in normal persons. A two-way analysis of variance was applied to the normalized protein values to estimate to what extent the observed variations could be explained by analytical errors and the influence of biological factors general to all proteins, such as changes in plasma volume and distribution between plasma and extravascular space. In half the non-operated patients the changes in all proteins could be explained by the above mentioned variations. The individual variations seen in the concentrations of haptoglobin, C4 and IgM occurred at random compared to the clinical state of the disease. Only the operated patients showed a more systematic sequence of protein changes.

The relapse-preventing effect of methyl-salazosulphapyridine compared to salazosulphapyridine during long-term treatment of ulcerative colitis. A double-blind controlled trial

In an attempt to improve the relapse-preventing effect of salazosulphapyridine (SASP) and to encircle the part of the molecule essential for therapeutic actin, methyl-SASP was compared to SASP in a controlled double-blind trial without cross-over. The patient group comprised 33 patients with ulcerative colitis who had been symptom-free for 1--6 months on continuous treatment with SASP (on an average 2 g daily). The daily doses were SASP 1 g X 3 and methyl-SASP 125 mg x 3. Thirty patients completed the trial, 14 on SASP and 16 on methyl-SASP. Applying clinical criteria, the relapse rate after 6 months was 0.14 in the SASP group and 0.69 in the methyl-SASP group. The difference is highly significant. The blood concentrations of SASP, methyl-SASP, sulphapyridine (SP), and methyl-sulphapyridine (methyl-SP) were measured after 3 and 6 months. The methyl-SASP concentration was on an average twice as high as that of SASP, and the methyl-SP on an average 1/10 of SP (the differences are significant). It is concluded that whereas SASP showed a relapse-preventing effect in ulcerative colitis in this study comparable to that previously reported, the effect of methyl-SASP was only comparable to that of placebo, and the active substance in SASP does not seem to be unsplit SASP.

The therapeutic effect of methyl-salazosulphapyridine versus salazosulphapyridine in active ulcerative colitis. A double-blind controlled trial

In an attempt to improve the ratio between therapeutic effect and side effects of salazosulphapyridine (SASP), methyl-salazosulphapyridine (methyl-SASP) was compared with SASP in a randomized controlled double-blind trial, without cross-over, in patients with active ulcerative colitis. The patient group comprised 53 patients. The daily doses were 1 g SASP x 3 and 125 mg methyl-SASP x 3. The methyl-SASP group comprised 26 patients, the SASP group 27 patients. The treatment period was 4 weeks. Applying clinical symptoms (bowel movements, registered by the patients on special charts), clinical condition (assessed by the patient), proctoscopic signs, and registration of side effects, it is concluded that methyl-SASP had an effect on ulcerative colitis indistinguishable from that of SASP. The rate of side effects was significantly less in the methyl-SASP group. The blood concentrations of SASP, methyl-SASP, sulphapyridine, and methyl-sulphapyridine were estimated at start during, and at the end of the trial. The methyl-SASP concentration was on an average twice as high as that of SASP, and the methyl-sulphapyridine on an average 1/13 of sulphapyridine, the differences being significant. It is concluded that methyl-SASP presents an improvement in the effect/side effect ratio when dealing with symptomatic ulcerative colitis. The discrepancy between the outcome of the present trial and the lack of effect in a controlled trial on the relapse-preventing effect of methyl-SASP is at present unexplained. A type II error in the present trial (or a type I error in the prophylactic one) is a possibility, or the patient-group selected for the present trial had a spontaneously benign course, cases demanding prednisone or colectomy having been excluded.

Circulating immune complexes in ulcerative colitis. I. Correlation to disease activity

Twenty-two patients with ulcerative colitis were studied for occurrence of circulating immune complexes (IC) by three independent methods, a complement consumption assay, a Clq-binding assay and a RF-binding assay. All patients had the disease in an active stage when the study was initiated. Positiveness in two or more test systems was considered to indicate the presence of IC in the serum sample examined. By this criterion, circulating complement-fixing IC were detected in eight out of the twenty-two patients (36%; 95% confidence limits: 17–60%). IC were detected most frequently in patients with long-standing disease.

A correlation between the occurrence of circulating IC and disease activity, in terms of visible blood in faeces and number of bowel movements per day, was demonstrated. Cytological examination of the rectal mucus indicated moderate to severe inflammation in all IC-positive patients. Six out of the eight IC-positive patients were subjected to short-term glucocorticosteroid treatment; only one of these patients exhibited circulating IC and high disease activity after treatment —this patient was colectomized. Salazosulphapyridine treatment showed no relation to IC occurrence. Four out of the twenty-two patients (18%; 95% confidence limits 5–40%) were positive for organ non-specific antinuclear factor (ANF), but the presence of ANF did not correlate with circulating IC. Neither was any significant correlation between antibody titres to E. coli O119:B14 antigen and IC occurrence demonstrable.

A prospective comparative study of clinical and pathological characteristics in Icelandic and Danish patients with gastric ulcer, duodenal ulcer, and X-ray negative dyspepsia. II. Histological results

The occurrence of gastritis in antral and body mucosa is compared in an Icelandic and a Danish group of patients with gastric ulcer, duodenal ulcer, and X-ray negative dyspepsia. In all 93 Icelandic and 88 Danish patients were examined. All signs of antral gastritis were more frequent in Icelandic than in Danish patients, but only the incidence of superficial inflammation and decreased mucus content in surface and crypt epithelium differed significantly. In body mucosa pseudopyloric metaplasia was more frequent in Iceland and occurred equally freqeuntly in all three diseases. A statistically significant correlation was found between macroscopic gastritis and occurrence of antral superficial inflammation and between smoking and superficial inflammation and decreased mucus content in the pyloric biopsy specimen. The presence of histological gastritis was not correlated to the intake of alcohol and salicylic acid, nor to the presence of pain at the time of investigation.

Leucocyte migration test with autologous colonic mucosa as antigen in patients with ulcerative colitis

The leucocyte migration agarose technique (LMAT) was applied in a study of the migration of peripheral leucocytes in 16 patients with ulcerative colitis using three different autologous types of tissue as antigen: rectal mucosa, skin and buccal mucosa. In all cases the migration indices were within normal limits, and they did not differ from a group of control patients suffering from peptic ulcer, irritable colon, or haemorrhoidal tumours. The present study does not support the theory of cellular hypersensitivity against colonic mucosa in patients with ulcerative colitis.

A prospective comparative study of clinical and histological characteristics in Icelandic and Danish patients with gastric ulcer, duodenal ulcer, and X-ray negative dyspepsia. I. Design and clinical features

Iceland (IS) and Denmark (DK) are ethnically, culturally, and economically closely related Nordic countries, but gastric cancer is much more frequent in Iceland, and other differences in the occurrence rates of gastric diseases are also suspected. Therefore a cooperative study was initiated comparing Icelandic and Danish patients with gastric ulcer (GU), duodenal ulcer (DU), and X-ray negative dyspepsia (XND) as regards clinical features, external factors of possible importance for gastritis and cancer, gastroscopic appearance, and histological gastric mucosal changes. The project lasted one year and comprised 93 Icelandic and 88 Danish patients. A large number of comparisons showed a high degree of similarity between Icelandic and Danish patients. Significant differences were found in tobacco consumption (DK greater than IS), duration of symptoms in XND (IS greater than DK), whereas the positon ratio of GU (IS less than DK) and acetylsalicylic acid consumption (DK greater than IS) showed non-significant trends. Significant difference was found between the occurrence of diffuse macroscopic changes of the gastric mucosa (IS greater than DK), which corresponds to the histological differences to be described in a subsequent article.

The leucocyte chemotactic function in patients with ulcerative colitis

The intermittent course of ulcerative colitis could hypothetically be be caused by fluctuations of the patients' natural systems of resistance. To evaluate this hypothesis the chemotactic function of leucocytes in ulcerative colitis patients has been investigated. The patient group comprised 59 patients, 24 men and 35 women. All activity stages were represented. The control group comprised 25 normal subjects, 10 men and 15 women. The chemotactic reaction was investigated in a double chamber with a cellulose-ester-micropore filter with a pore size of 3 mum as a diaphragm in which the migration takes place. The variable applied was the ratio between the number of cells 50 mum down in the filter and at the surface, calculated as a chemotactic Index. Casein was used as chemotactic agents. The corrected chemotactic was defined as the difference between stimulated and unstimulated Chemotactic Index. The chemotactic as well as the corrected chemotactic response of leucocytes from ulcerative colitis patients was significantly lower than in control subjects. The subgroup, active ulcerative colitis,showed the lowest corrected Chemotactic Index, whereas the unstimulated Control Index was significantly higher than in normal subjects. The results did not correlate with treatment. The investigation has shown that leucocytes in active ulcerative colitis cases have a high spontaneous mobility, whereas their chemotactic function after stimulation is significantly subnormal. Further investigation is needed to demonstrate whether this phenomenon plays a major role in the pathogenesis of ulcerative colitis.

Leucocyte migration test with autologous colonic mucosa as antigen in patients with ulcerative colitis

The leucocyte migration agarose technique (LMAT) was applied in a study of the migration of peripheral leucocytes in 16 patients with ulcerative colitis using three different autologous types of tissue as antigen: rectal mucosa, skin and buccal mucosa. In all cases the migration indices were within normal limits, and they did not differ from a group of control patients suffering from peptic ulcer, irritable colon or haemorrhoidal tumours. The present study does not support the theory of cellular hypersensitivity against colonic mucosa in patients with ulcerative colitis.

The small intestinal disaccharidase activity in ulcerative colitis

In 12 patients suffering from ulcerative colitis the small-intestinal disaccharidase activity has been determined during an acute exacerbation of the disease as well as after remission. The lactase activity was significantly lower during the acute stage. No case of transitoric lactose malabsorption was found.

The incidence of lactose malabsorption in ulcerative colitis

120 Danish patients with ulcerative colitis, admitted consecutively to a Department of Gastroenterology, were investigated for lactose malabsorption. The prevalence was 9.2 percent, which is not significantly higher than that in a mixed Danish gastroenterological material, There was no difference in distribution according to age and sex, and the incidence was not correlated to the severity of the ulcerative colitis. The possible reasons for the wide variation in the incidence of lactose malabsorption in materials of patients with ulcerative colitis are discussed, and it is concluded that the main cause must be that the materials with the highest incidence include patients of races and ethnic groups in which lactose malabsorption is a common finding.

The constipating effect of diphenoxylate (Retardinr) in ulcerative colitis. A double-blind controlled trial

A double-blind study of 20 patients with ulcerative colitis during treatment with diphenoxylate 5 mg three times daily and placebo is reported. There were two treatment periods of 14 days each, with cross-over technique and randomized sequence. Test variable for constipating effect was the mean number of defaecations per day. The criterion for inclusion of patients was the presence of 4 or more daily bowel movements; 2 patients did not complete the investigation. Significant difference (p less than 0.01) in constipating effect between diphenoxylase and placebo was demonstrated both during a period of 12 days and a period of 6 days (Tables II and III). The average number of bowel movements were reduced by 0.7 and 1.3 per day respectively. Side-effects during treatment with diphenoxylate were seen in 53% (Table III) with significant difference against placebo (p less than 0.05). On the basis of the small absolute reduction of defaecation frequency side-effects, it is concluded that diphenoxylate has no place in the routine treatment of ulcerative colitis.