[Extra-intestinal manifestations]

Since inflammation is an unlimited process, it is not surprising to find that inflammatory bowel diseases have extra-intestinal manifestations involving the digestive system itself (hepatic or, more rarely, pancreatic manifestations) or peripheral organs and tissues (osteoarticular, cutaneous and ophthalmological manifestations). Some of these manifestations may be concomitant with intestinal symptoms or they may precede or succeed them. One may also observe manifestations of infectious, mechanical or metabolic origin (biliary stones, urinary stones) or of nutritional origin, notably in Crohn's disease which may be iatrogenic. A better knowledge of these non-intestinal pathologies can lead to an earlier diagnosis of inflammatory bowel disease and therefore to a more rational treatment.

Tumor necrosis factor-alpha is not elevated in children with inflammatory bowel disease

Chronic undernutrition and high-dose daily corticosteroid therapy are well-accepted causes of growth failure in children with inflammatory bowel disease. Occasionally, children are seen with minimal gastrointestinal symptoms but in whom severe anorexia and profound growth impairment are evident. Recent observations that elevated serum levels of tumor necrosis factor-alpha (TNF) in cachexia associated with a number of disease states have suggested a similar possible role in inflammatory bowel disease. Accordingly, we determined TNF levels in 45 children and adolescents with inflammatory bowel disease (18 ulcerative colitis, 27 Crohn's disease) at varying times during their clinical course and compared them to values obtained from a group of 25 children with functional bowel disease. No differences were noted in serum TNF levels between the children with inflammatory bowel disease and the control population. Values were generally within the range of the lower limit of detection of the assay. In the children with inflammatory bowel disease, there was no significant correlation between TNF levels and disease activity or growth parameters. Our observations suggest that elevated TNF levels are not associated with inflammatory bowel disease in children.

Gastrointestinal disorders and rheumatic diseases

Pathologic changes in the gastrointestinal tract may be associated with clinical complaints in multiple organs. In some instances, the association between gastrointestinal pathology and extraintestinal disease is so strong that treatment of gastrointestinal disease cures the patient of the extraintestinal complaints. The references in Table 1 show that maintenance of the structural and immunologic barriers of the gastrointestinal tract are vital in determining the general health of the patient, and that the associations between the gut, arthritis, dermatitis, and autoimmune disease are much stronger than may appear at first glance.

Relationship of inflammatory bowel disease and primary sclerosing cholangitis

There is a strong association between PSC and IBD. PSC is the most common hepatobiliary lesion seen in association with IBD. Whether there are two subsets of PSC, one associated with IBD and one unassociated, is controversial. A lower male to female ratio in patients without IBD supports this view. The demonstration of the haplotype DRw52a in 100% of patients with PSC, irrespective of the absence of IBD, speaks against this view. Patients with isolated PSC tend to present with jaundice, pruritus, and fatigue more frequently than those with combined PSC and IBD. There may also be a difference in bile duct involvement between patients with and without IBD combined with PSC. Apart from usually being a total colitis, either Crohn's colitis or UC, the IBD associated with PSC cannot be distinguished from IBD without PSC with respect to symptoms and clinical course. Patients with combined IBD and PSC may have somewhat worse prognosis than those with isolated PSC. The majority of patients developing BDC have concomitant IBD, suggesting that patients without IBD represent a different subgroup of PSC and run a different clinical course. Most studies have, however, found no differences in epidemiology, pathogenetic factors, clinical findings related to the hepatobiliary disease and prognosis between those who present with PSC alone and those who present with combined PSC and IBD. A major problem when discussing the relationship between IBD and PSC is that the bowel is inadequately examined in many of the studies relating to this question.(ABSTRACT TRUNCATED AT 250 WORDS)

Psychiatric illness and irritable bowel syndrome: a comparison with inflammatory bowel disease

Structured psychiatric interviews and psychological self-report measures were administered to 28 patients with irritable bowel syndrome and 19 patients with inflammatory bowel disease. Significantly more of the patients with irritable bowel syndrome had lifetime diagnoses of major depression, somatization disorder, generalized anxiety disorder, panic disorder, and phobic disorder. They had significantly more medically unexplained somatic symptoms, and most had suffered from psychiatric disorders, particularly anxiety disorders, before the onset of their irritable bowel symptoms.

Treatment of severe acne with isotretinoin in patients with inflammatory bowel disease

Four patients with inflammatory bowel disease and severe cystic acne were treated with isotretinoin. Two patients had a successful course of treatment without any gastrointestinal side-effects. One patient had two episodes of profuse rectal bleeding that were probably related to pre-existing haemorrhoids. The fourth patient had a flare-up of his Crohn's disease after starting isotretinoin.

[Obstructive disorders of urine transport in the upper urinary tract--vascular and inflammatory causes]

Vascular and inflammatory causes of ureteral obstruction may be difficult in diagnosis and are recognized often too late. Symptoms, diagnostic approach and therapeutic measures are described in detail.

Endometrioma. An intra-abdominal troublemaker

A ten-year review of intestinal and abdominal wall endometriomas is reported. Seven cases of intestinal and two cases of abdominal wall endometriomas are presented. Symptoms were varied but a majority had some gynecologic complaint. In this select group of patients, preoperative investigations did not assist in establishing the diagnosis. All patients underwent surgery and coexisting inflammatory bowel disease was present in two patients. This review suggests that endometrioma of the intestine requires a high index of suspicion for diagnosis and that danazol does not appear to be effective treatment for these patients.

Acquired protein C and S deficiency, inflammatory bowel disease and cerebral arterial thrombosis

Thromboembolic complications may occur in inflammatory bowel disease. Recently, we had the opportunity to observe a case of a cerebral arterial thrombosis in a young patient with active ulcerative colitis. Investigation of blood coagulation revealed a temporary Protein C, Protein S and Factor II deficiency. To our knowledge, this is the first reported case of a temporary Protein C and S deficiency in a patient with thrombosis and inflammatory bowel disease.

Surgical aspects of sclerosing cholangitis. Results in 178 patients

Of 178 patients with sclerosing cholangitis treated since 1950, 88 patients had associated inflammatory bowel disease, 72 had no such history, and 18 had iatrogenic injury or stone disease. A total of 233 biliary operations were performed, with a 75% rate of temporary improvement after initial operation. Subsequent operations resulted in a lower success rate and a higher mortality rate. Radiologic findings included predominant extrahepatic, intrahepatic, and diffuse disease in 29%, 28%, and 43% of patients, respectively; no survival differences were noted. Seventy-five of one hundred three deaths (73%) were related to liver failure, bleeding, or sepsis. Of 14 patients undergoing portosystemic shunt, 13 died of surgical complications or related disease. Orthotopic liver transplantation was performed in 16 patients and resulted in eight deaths, mainly in patients who had previously undergone extensive surgical treatment. No survival differences were seen between the patients with inflammatory bowel disease, those without the condition, or those who had colectomy. Surgical treatment in patients with sclerosing cholangitis should be minimized. Orthotopic liver transplantation should be offered as the treatment of choice for patients with portal hypertension, refractory cholangitis, advanced cirrhosis, or progressive liver failure.

Superior vena caval obstruction in patients with gut failure receiving home parenteral nutrition

Clinical suspicion and venographic conformation were used to diagnose 15 cases of superior vena caval obstruction (SVCO) in 107 home parenteral nutrition (HPN) patients over 379 cumulative years of HPN (3.9 cases/100 patient-years). Patients with SVCO had been on HPN a mean of 51.5 months and had used 6.2 (range 1-50) central catheters, including short- and long-term, before SVCO was diagnosed. The frequency of inflammatory bowel disease (IBD) with SVCO was approximately the same as that in our general HPN population. Positive blood cultures were present immediately preceding the diagnosis of SVCO in 40% (six of 15) of cases. Atypical line placements were noted in two cases. The most common management strategies employed were conversion to enteral feedings in five patients and placement of a new catheter directly into the right atrium by thoracotomy in another five patients. Two of the five with right atrial catheters experienced a postpericardiotomy syndrome (fever, pericardial rub, and pulmonary infiltrates) that responded promptly to indomethacin. The most significant long-term sequela of SVCO was the need for a left jugular vein to right atrial appendage bypass in one patient with chronic venous congestion from her SVCO. Once the SVCO is confirmed, systemic heparinization provides immediate antithrombotic effect and minimizes the risk of pulmonary embolism. The use of streptokinase may result in rapid thrombolysis.

Cow's milk protein sensitivity during infancy in patients with inflammatory bowel disease

Seventy-eight patients with inflammatory bowel disease (35 with Crohn's disease and 43 with ulcerative colitis) and a control population of 36 children without organic disease were surveyed to determine the frequency of symptoms compatible with cow's milk-protein sensitivity during infancy. The incidence of a history compatible with cow's milk sensitivity was 8.5% (3/35) in patients with Crohn's disease and 2.8% (1/36) in controls. Patients with ulcerative colitis had a significantly greater prevalence of symptoms, compared with the other patient groups (20.9%, 9/43; p less than 0.03). In addition, patients with a history of cow's milk allergy, who subsequently developed ulcerative colitis, did so at an earlier age (6.68 +/- 2.05 yr vs. 10.62 +/- 0.74 yr: p less than 0.02) than those without a history of cow's milk sensitivity. Thus, there appears to be a potential relationship between early cow's milk sensitivity and the development of ulcerative colitis.

CT evaluation of enterovaginal and vesicovaginal fistulas

Computed tomography of 25 cases of enterovaginal (19 cases) or vesicovaginal fistula (6 cases) were reviewed. Underlying causes of fistulization included gynecological malignancy and radiation therapy (14 of 25), inflammatory diseases of bowel (8 of 25), and miscellaneous conditions (3 of 25). A CT finding of contrast within the vagina provided definitive confirmation of the suspected diagnosis of vaginal fistula in 60% of patients (15 of 25), a detection rate superior to conventional examinations in our series. Other CT findings suggestive of vaginal fistulas included detection of air (20 of 25) and/or fluid (5 of 25) within the vagina. Computed tomographic findings associated with vaginal fistulas such as radiation changes, contiguous pelvic mass, or adherent thickened bowel gave clues to the underlying etiology of the fistula and provided important information regarding the extent of disease prior to attempted surgical repair.

Major histocompatibility complex class II antigen (HLA-DR) expression by ileal epithelial cells in patients with seronegative spondylarthropathy

Major histocompatibility complex molecules act as non-specific receptors for antigenic proteins and present them to T-cells. Presented antigen together with class II molecules activates antigen specific T-helper cells and may trigger a cellular immune response. The expression of HLA-DR antigens by epithelial cells was examined with an indirect peroxidase technique in ileal biopsies from 38 patients with seronegative spondylarthropathy and features of acute or chronic gut inflammation on biopsy, 14 patients with chronic inflammatory bowel disease, 10 rheumatic and 10 non-rheumatic controls. In acute ileitis, there was more HLA-DR expression in villous and crypt epithelial cells than in non-inflamed controls (p less than 0.01). In chronic inflammation and in chronic inflammatory bowel disease, class II antigens were more expressed in villus (p less than 0.02) and crypt epithelium (p less than 0.01). Strong HLA-DR expression in crypt epithelial cells was connected with active inflammation (p less than 0.02). These findings suggest binding of unknown enterobacterial or nutritional luminal antigens to HLA-DR antigens normally present in enterocytes. The enterocytes act as antigen presenting cells causing a local increase of targets for activated T-cells and trigger the gut inflammation responsible for the clinical symptoms of the seronegative spondylarthropathy.

Pouchitis and extraintestinal manifestations of inflammatory bowel disease after ileal pouch-anal anastomosis

Although the etiology of pouchitis after ileal pouch-anal anastomosis (IPAA) is unknown, its manifestations resemble those of nonspecific inflammatory bowel disease, including, anecdotally, the apparent ability to evoke extraintestinal manifestations (EIM) of inflammatory bowel disease (IBD). Our aim was to determine in what manner pouchitis and EIMs were associated. The computerized records of 819 consecutive patients who underwent IPAA between January 1981 and December 1988 were reviewed. Eighty-five patients were excluded (because of incomplete follow-up, death, or permanent ileostomy). Follow-up of the remaining 734 patients was complete (mean, 41 months). The mean age was 32 years and the ratio of men to women was 1:1. Ileal pouch-anal anastomosis was performed for chronic ulcerative colitis in 91% of patients and for familial adenomatous polyposis in 9%. Pouchitis occurred in 31% of chronic ulcerative colitis patients and 6% of familial adenomatous polyposis patients (p less than 0.01). The mean time to first occurrence was 17 months. Pouchitis recurred in 61% of patients at risk. Patients with preoperative and postoperative EIMs had significantly higher rates of pouchitis than did patients without EIMs (39% preoperative EIMs versus 26% with no EIMs, p less than 0.001; 53% postoperative EIMs versus 25% with no EIMs, p less than 0.001). Of patients with pouchitis in whom EIMs resolved after IPAA but then recurred (n = 12), EIMs recurred when pouchitis occurred and abated when pouchitis was treated in seven patients. We concluded that pouchitis occurred frequently after IPAA and that patients with EIMs were at higher risk of developing pouchitis than were patients who never had EIMs. Furthermore some patients experienced a temporal relationship between flares of EIMs and pouchitis. These results imply that pouchitis may be a novel manifestation of inflammatory bowel disease persisting after operation.

Small bowel permeability to 51Cr-EDTA in children with recurrent abdominal pain

Small bowel permeability was investigated in 87 children with recurrent abdominal pain by measuring the 24-h urinary excretion of orally administered 51Cr-EDTA. The mean excretion was 3.64% +/- 1.49% per 24 h. The difference between the mean urinary excretion in children with recurrent abdominal pain and control children (2.51% +/- 0.70%), was significant (p less than 0.01, two sample t-test). The increased small bowel permeability in children with recurrent abdominal pain might indicate an intestinal etiology for the patients' complaints.

Diagnosis of abdominal pain. How to distinguish between pancreatic and extrapancreatic causes

Published reports have been reviewed and the results compared in an attempt to differentiate between pancreatic pain and abdominal pain from other causes, and between the pain of acute pancreatitis and that of chronic pancreatitis and pancreatic carcinoma. The role of pain as a diagnostic sign has been assessed, as have the patterns of pain in chronic pancreatitis.

A prospective study of viral and mycoplasma infections in chronic inflammatory bowel disease

Seventy-two children with chronic inflammatory bowel disease were investigated for infections with various viruses and Mycoplasma pneumoniae, Chlamydia psittaci, and Coxiella burnetii to determine whether these pathogens are associated with acute onset exacerbations. Altogether 54 infections were identified serologically, of which 23 (42.6%) were associated with exacerbations. This corresponded to 24.2% of the recorded exacerbations during the study period. The respiratory pathogens accounted for 59.3% of the infections and 43.8% of these were associated with gastrointestinal symptoms. This is consistent with the observation that up to 40% of the exacerbations were associated with symptoms of antecedent or concurrent infection, most commonly involving the respiratory tract. Rubella virus, Epstein-Barr virus, and adenovirus were associated with acute exacerbations in 5 children. Thus, common pathogens were frequently associated with exacerbations and account for a large proportion of the commonly reported symptoms of a concurrent infection. The possible causal relationship between these pathogens and exacerbation of inflammatory bowel disease is discussed. Reactivation of latent herpesviruses was identified in 4 children with active disease and indicates that the converse relationship may also occur.

Extraintestinal and systemic manifestations of inflammatory bowel disease

Extraintestinal and systemic manifestations occur commonly in patients with inflammatory bowel disease, specifically ulcerative colitis and Crohn's disease, and affect most all organ systems of the body. The occurrence of such widespread manifestations strongly suggests that these disorders are systemic in nature and may have a common mechanism. Extraintestinal manifestations may be incidental findings that cause no symptoms, but more commonly complicate the management of the underlying inflammatory bowel disease, being a source of considerable morbidity and mortality. Some extraintestinal manifestations not only correlate with a specific disease state but also with the location, extent, and degree of activity and disease. Most extraintestinal manifestations found in patients with inflammatory bowel disease involving the small intestine appear to correlate with some underlying pathophysiologic mechanism.

Does primary sclerosing cholangitis occurring in association with inflammatory bowel disease differ from that occurring in the absence of inflammatory bowel disease? A study of sixty-six subjects

Primary sclerosing cholangitis often occurs in association with inflammatory bowel disease, particularly ulcerative colitis but also Crohn's disease of the colon either with or without terminal ileal disease. Little data exist as to the effect of inflammatory bowel disease on the presenting symptoms, radiological features, response to liver transplantation, and potential risk of bile duct carcinoma in individuals with primary sclerosing cholangitis. In an effort to answer these questions, 66 patients with primary sclerosing cholangitis were studied. The definitive diagnosis of primary sclerosing cholangitis in each was accomplished using cholangiography, which in each case demonstrated characteristic beading, ectasia and stricturing of the intrahepatic and extrahepatic bile ducts. Inflammatory bowel disease was present in 47 (71.2%) patients. Thirty nine (59.1%) had ulcerative colitis; their mean age was 42.5 +/- 11.6 yr (mean +/- SD), and the male/female ratio was 2.9:1. In addition, eight patients (12.1%) had Crohn's colitis; their mean age was 40.5 +/- 6.5 yr, and the male/female ratio of this group was 1:1. Nineteen patients (28.8%) had primary sclerosing cholangitis without any inflammatory bowel disease; their mean age was 42.0 +/- 12.1 yr, and the male/female ratio in this group was 0.72:1. Seventy-two percent of the patients without inflammatory bowel disease had either jaundice, pruritus or fatigue at presentation compared with 41% of the patients with inflammatory bowel disease (p less than 0.05). In contrast, abnormal liver function tests were more common as the first manifestation of liver disease in the latter group (38% vs. 11%; p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Management of children and adolescents with inflammatory bowel disease

The management of children and adolescents with inflammatory bowel disease requires all the skills offered by the health care team. This article reviews the principles of therapy, the specifics of therapy, and the attitudes of the authors relating to long-term management of these patients. Specific recommendations relating to nutritional support for patients are also made. A pertinent updated bibliography is also given.

Follow-up study of ankylosing spondylitis over a period of 12 years (1977-1989)

A follow-up study was performed on 256 patients with ankylosing spondylitis. HLA-B27-negative Dutch patients very rarely had classical idiopathic ankylosing spondylitis. Most of these patients had psoriasis or inflammatory bowel disease or they were foreigners living in The Netherlands. Many of the B27-negative patients only have sacroiliitis. Psoriasis or inflammatory bowel disease among the HLA-B27-positive with a classical ankylosing spondylitis is rare.

Destructive lesions of small joints in seronegative spondylarthropathies: relation to gut inflammation

Destructive lesions of small joints were found in 40 out of 211 patients suffering from seronegative spondylarthropathies (SpA) on whom ileocolonoscopy with biopsies of the ileum and colon were performed. The destructive lesions of small joints, radiologically only distinguishable from rheumatoid arthritis lesions by the pauciarticular and asymmetrical involvement, the rare tendency to fusion and the rare occurrence of periosteal hypertrophy, were observed more frequently in patients presenting subclinical inflammatory gut lesions, predominantly of the chronic type, than in patients without gut inflammation.

Inflammatory bowel disease and irritable bowel syndrome

The irritable bowel syndrome accounts for 30 to 50 per cent of patients cared for by gastroenterology practices. Irritable bowel syndrome is more common than inflammatory bowel disease. Therefore, it should not be surprising that some patients with inflammatory bowel disease are initially told that they have irritable bowel syndrome before a diagnosis of inflammatory bowel disease is firmly established. This article contends that many people have both irritable bowel syndrome and inflammatory bowel disease.

Depression and anxiety in pediatric inflammatory bowel disease and cystic fibrosis

The lifetime and current prevalence of depression and anxiety disorders was determined in 41 children with Crohn's disease, 12 children with ulcerative colitis, and 52 children with cystic fibrosis, using the Kiddie-Schedule for Affective Disorders and Schizophrenia interview. The lifetime prevalence of depression was 29% in Crohn's disease, 21% in ulcerative colitis, and 11.5% in cystic fibrosis. The difference in the prevalence of depression between Crohn's disease and cystic fibrosis was significant (p less than 0.05). The lifetime and current prevalence of dysthymia was significantly greater in ulcerative colitis than Crohn's disease (p less than 0.01) or cystic fibrosis (p less than 0.01). The lifetime prevalence of atypical depression was significantly greater in Crohn's disease than cystic fibrosis (22% versus 5.8%, p less than 0.05) and was also greater in ulcerative colitis than cystic fibrosis (21% versus 5.8%, p = 0.1). There was no difference between the groups in the current prevalence of major depression or atypical depression, or in the lifetime or current prevalence of anxiety disorders.

Neurovascular and thromboembolic complications of inflammatory bowel disease in childhood

Vascular complications occurred in 3.3% (6 of 180) of children with chronic inflammatory bowel disease. Clinical disease activity was severe in four of six patients who presented with these symptoms. In contrast to adults, in whom deep-vein thrombotic complications predominate, the majority of children had involvement of the CNS including encephalopathy, arteritis, arterial occlusion, and thromboembolism. One patient died 3 1/2 years later from progressive intestinal and neurological deficits: morbidity included blindness, epilepsy, and developmental delay. Hematological parameters varied widely. Prevention is not always possible, but risk factors include: (a) family history of collagenosis (83% incidence), (b) severe inanition and immobility, (c) delayed hospitalization, and (d) clinical presentation with cutaneous vasculitis. Therapy must be individualized.

[Neutrophilic dermatosis in inflammatory intestinal disease]

The neutrophilic dermatosis are a group of cutaneous diseases that share similar clinical and histopathologic features. They frequently occur in association with other diseases, particularly idiopathic inflammatory bowel disease. We present herein three cases of neutrophilic dermatosis and inflammatory bowel disease. We emphasize the atypical cutaneous findings and we discuss their nosologic situation.

Angiodysplasia. Natural history and efficacy of therapeutic interventions

Angiodysplasia, a disease for which the optimal treatment is uncertain, is a frequent cause of lower intestinal bleeding among older patients. To study the natural history of angiodysplasia and compare the efficacy of medical therapy, endoscopic electrocoagulation, and surgery, the course of 101 patients evaluated from 1974 through 1983 at the Massachusetts General Hospital was reviewed. Angiodysplasia caused bleeding that ranged from occult blood in stools to massive hemorrhage and was also observed incidentally in nonbleeding patients. Patients were followed for up to 10 years (mean of 22 months). Rebleeding was defined as evidence of hemorrhage requiring hospital admission, transfusion, or surgery. Thirty-one patients were treated surgically, 19 patients were treated endoscopically, and 36 patients were treated medically. Using life table analysis we observed similar rebleeding rates among medically and endoscopically treated groups. The surgically treated group had a frequency of rebleeding less than half that of the other groups (P = 0.15). A multivariate regression analysis failed to identify any factors other than coagulopathy to explain the different incidence of rebleeding in the patients treated by endoscopic electrocoagulation and surgery.

Primary malignant lymphoma of the large intestine complicating chronic inflammatory bowel disease

Ten cases of malignant lymphoma of the colon and rectum complicating chronic inflammatory bowel disease are presented. Seven patients had chronic ulcerative colitis with a history varying from 6 to 20 years. There was extensive colitis in six of these patients and left-sided colitis in one. All seven lymphomas showed the pathological and immunohistological features of primary B-cell tumours of the gastrointestinal tract with a predominance of high-grade tumours. Three patients had Crohn's disease of the large intestine complicated by malignant lymphoma of the sigmoid colon or rectum. The history of Crohn's disease varied from 30 months to 20 years and in each case there was fissuring and fistulae. There was extensive anal involvement in two cases. Histologically the three lymphomas were heterogeneous: one was of 'granulomatous' T-cell type and the other two were markedly polymorphic and of equivocal phenotype. They were also characterized by numerous multinucleate tumour giant cells. Primary colorectal malignant lymphoma should be regarded as a rare, but significant, complication of ulcerative colitis. Immunosuppression may be an additional factor in the genesis of intestinal lymphoma in Crohn's disease. The prognosis appears to be dependent on factors already known to be of prognostic significance in primary gut lymphomas: a predominance of high-grade tumours suggests that the outlook is generally worse than that for idiopathic primary large intestinal lymphoma.

Atypical auricular pyoderma gangrenosum simulating fungal infection

We describe a patient with a highly unusual appearance of pyoderma gangrenosum. The pyoderma was located on the auricular region and preceded other manifestations of inflammatory bowel disease by 11 years. There was no correlation between the course of the pyoderma and the clinical activity of the associated bowel disease. Mycotic superinfections masked and delayed the diagnosis in our patient for several years. Only when typical pyoderma gangrenosum lesions developed on the legs at the site of trauma and responded dramatically to systemic corticosteroids was the correct diagnosis established. Pyoderma gangrenosum with secondary fungal infection was thus distinguished from deep ulcerated skin fungal infection simulating pyoderma.

Nutrition and inflammatory bowel disease

Nutritional support, whether enteral or parenteral, is an important part of the treatment of IBD. Inadequate oral intake, malabsorption, and increased gastrointestinal losses all contribute to malnutrition. Weight loss, cachexia, abnormal body composition, and multiple micronutrient deficiencies are common. Acute repletion of body weight and correction of specific nutrient deficiencies improve the patients' sense of well-being and decrease morbidity, especially in the perioperative period. If a short period of bowel rest (10 to 14 days) is part of the medical therapy of acute exacerbations of IBD, TPN should be administered to prevent further nutritional deficiencies. Chronic undernutrition, and growth failure in children, usually are best treated by intensive enteral supplementation. Prolonged bowel rest and TPN (4 to 6 weeks) have not been shown to improve outcome but may be appropriate in carefully selected patients. Long-term home TPN may be necessary for patients who have short gut syndrome. The mainstay of treatment for IBD is medical therapy including corticosteroids. Timely and appropriate surgery is equally important and should not be considered a last resort. Careful nutritional management is essential but is adjunctive rather than primary therapy.

Respiratory impairment in inflammatory bowel disease: does it vary with disease activity?

Serial assessments of respiratory function were made in 44 patients with inflammatory bowel disease. Pulmonary function tests were performed at the initial assessment and after three months to see if abnormality was associated with alteration in disease activity, drug therapy or with evidence of immunological disturbance. Fourteen patients (32%) had some abnormality of respiratory function when first investigated. Seven (16%) had a reduced gas transfer factor but these abnormalities were not related to disease activity, drug therapy or any immunological variable. Elevation of both functional residual capacity and residual volume was found in nine (20%) patients at the initial assessment. These abnormalities appeared to be associated with active inflammatory bowel disease and in four of these patients lung volumes returned to normal at 3 months when the bowel disease was in remission.

Pyoderma gangrenosum and related disorders

Pyoderma gangrenosum (PG) is an uncommon ulcerative cutaneous condition with distinctive clinical characteristics and a frequent association with systemic diseases. Most frequently among the associated disease list are: inflammatory bowel disease, arthritis, and a variety of hematologic disorders. There is no specific treatment of PG; however, the effective treatment of an accompanying systemic disease, local therapy, and/or the use of topical or systemic agents known to be useful in neutrophil disorders, have been beneficial in most patients.

Arthritis and the gut

The term "enteropathic arthritis" describes joint manifestations that occur in conjunction with gastrointestinal disease. Underlying causes include inflammatory bowel disease, reactive arthritis, iatrogenic disease. Whipple's disease, and other gastrointestinal diseases. A possible association between Reiter's syndrome and human immunodeficiency virus infection also has been reported. These arthritic syndromes can be treated symptomatically, but long-term therapy should be directed at the underlying cause. In most cases, prognosis for survival and joint function is good.

Vitamin status in patients with inflammatory bowel disease

The status of water- and fat-soluble vitamins was prospectively evaluated in 23 patients (13 men, 10 women, mean age 33 +/- 3 yr) admitted to the hospital with acute or subacute attacks of inflammatory bowel disease. Protein-energy status was also assessed by means of simultaneous measurement of triceps skinfold thickness, mid-arm muscle circumference, and serum albumin. Fifteen patients (group A) had extensive acute colitis (ulcerative or Crohn's colitis), and eight cases (group B) had small bowel or ileocecal Crohn's disease. Eighty-nine healthy subjects (36 men, 53 women, mean age 34 +/- 2 yr) acted as controls. In both groups of patients, the levels of biotin, folate, beta-carotene, and vitamins A, C, and B1 were significantly lower than in controls (p less than 0.01). Plasma levels of vitamin B12 were decreased only in group B (p less than 0.01), whereas riboflavin was lower in group A (p less than 0.01). The percentage of patients at risk of developing hypovitaminosis was 40% or higher for vitamin A, beta-carotene, folate, biotin, vitamin C, and thiamin in both groups of patients. Although some subjects had extremely low vitamin values, in no case were clinical symptoms of vitamin deficiency observed. Only a weak correlation was found between protein-energy nutritional parameters and vitamin values, probably due to the small size of the sample studied. The pathophysiological and clinical implications of the suboptimal vitamin status observed in acute inflammatory bowel disease are unknown. Further studies on long-term vitamin status and clinical outcome in these patients are necessary.

Gastrointestinal hemorrhage and the skin

Cutaneous manifestations are often associated with disorders in which gastrointestinal hemorrhage is a major feature. These manifestations include vascular abnormalities, connective tissue disorders, gastrointestinal polyposis, vasculitis and its variants, Kaposi's sarcoma, and inflammatory bowel disease. Because such skin lesions often develop prior to gastrointestinal hemorrhage, they may prove helpful in making a definitive diagnosis before gastrointestinal blood loss becomes a major clinical problem.

Prothrombotic abnormalities in inflammatory bowel disease

Inflammatory bowel disease (IBD) is known to be associated with a thrombotic tendency, which is often attributed to thrombocytosis, elevated fibrinogen, or decreased antithrombin III. We prospectively studied eight patients with IBD, seven of whom had little or no disease activity, to determine if they had any laboratory abnormality known to be associated with an increased risk of thrombosis. Abnormalities in fibrinolysis were noted in five patients: four with high plasminogen activator inhibitor levels and one with poor release of tissue plasminogen activator following venous occlusion. Circulating immune complexes were present in the sera of five patients. Fibrinogen was mildly elevated in one patient, and two patients had mild thrombocytosis. Decreased levels of antithrombin III, protein C, or protein S were not observed. There appears to be a high incidence of abnormalities in fibrinolysis in inactive IBD, which may contribute to the high frequency of thrombosis seen in IBD. The presence of circulating immune complexes may contribute to vascular injury and thrombosis.

Early cervical cancer coexistent with idiopathic inflammatory bowel disease

Early invasive carcinoma of the cervix may be treated by surgery or radiation therapy. Two patients with early cervical cancer are presented whose concomitant inflammatory bowel disease figured significantly in the selection of surgery as treatment. The use of radiotherapy in the face of inflammatory bowel disease, however, is not clearly addressed in the literature.