Abnormal mucus in cap polyposis

BACKGROUND

Cap polyposis is a rare disease characterised by mucoid and bloody diarrhoea, with polyps covered by a cap of mucoid and fibrinopurulent exudate. The pathogenesis is not known.

AIMS

To pour some light on cap polyposis pathogenesis, by examining the mucus of patients and analysing the expression of five mucin genes, MUC2, MUC3, MUC4, MUC5AC, and MUC5B.

PATIENT AND METHODS

The study was performed on biopsy specimens taken from a patient with recurrent cap polyposis. Histochemical examination, electron microscopy, and mRNA in situ hybridisation were used.

RESULTS

The mucus of cap polyposis differed in three respects from that of normal adult colon: abnormal ultrastructure of the mucus in the goblet cells, predominance of non-sulphated mucins, abnormal expression of the MUC4, MUC3, and MUC5AC genes.

CONCLUSIONS

Most of these abnormalities have been reported for other pathological situations, suggesting that the abnormalities observed in the mucus of this patient with cap polyposis are probably secondary phenomena rather than primary. However, the mucin abnormalities detected, which reflect deregulation of the expression of three apomucin genes, abnormal glycosylation, and abnormalities of the secretion process, are also probably involved in the clinical manifestations of cap polyposis.

Nitrate-reducing bacteria in diversion colitis: a clue to inflammation?

A pathogenic role of nitric oxide has been suggested in acute and chronic intestinal inflammation. We took the opportunity offered by studies in patients with excluded colon, which represents a model of chronic intestinal inflammation with no exogenous nitrite or nitrate supply, to evaluate the quantity and the quality of nitrate reducers in diversion colitis. Thirty patients (17 men, 13 women, mean age 45 years) having an excluded colon for various reasons were sampled by rectal swabs and compared to 30 healthy controls (11 men, 19 women, mean age 28 years). The percentage of nitrate-reducers among the total count of subcultured bacteria was 46 +/- 41% (mean +/- SD) in patients with diversion colitis as compared to 19 +/- 24% in healthy controls. This difference was significant (P < 0.05) despite great heterogeneity in individual values. In patients with diversion colitis, 75/254 (29.5%) different isolated bacterial strains were nitrate-reducers as compared to 61/294 (21%) (P < 0.05) in controls. Among the 75 nitrate-reducing strains isolated from patients with diversion colitis, 55 were aerobes. Pseudomonas species were only encountered in this population. The predominant group was enterobacteria with a high isolation rate of species belonging to the genera Proteus, Providencia, and Morganella. In healthy controls nitrate-reducing anaerobes were nearly as frequent as aerobes. The most frequent species was Eubacterium lentum, followed by Clostridium perfringens. It could be suggested that nitric oxide synthase might produce a bacterial substrate increasing the growth of bacteria with a high pathogenic potential, creating conditions for chronic inflammation and infection in patients with excluded colon.

Association between myelodysplastic syndromes and inflammatory bowel diseases. Report of seven new cases and review of the literature

We report seven patients with both myelodysplastic syndrome (MDS) and inflammatory bowel disease (IBD): Crohn's disease in six cases, ulcerative colitis in one case. We describe their characteristics, and those of 10 previously published similar cases are presented here. Median age at diagnosis of IBD (61 years) was high, as compared to the usual age at diagnosis of IBD. IBD was diagnosed first in nine cases, MDS first in one patient, and both diseases were diagnosed simultaneously in seven cases. Concerning IBD, there was a strong predominance of Crohn's disease (15/17 cases), with an unusually high frequency of colonic involvement (11/15 cases). MDS, in 12/17 cases, showed no excess of marrow blasts. Cytogenetic analysis was abnormal in five of the 13 evaluable cases. These observations suggest that the association between MDS and IBD may not be fortuitous in some cases, and that, in particular, patients with IBD and anemia of nonobvious origin should be evaluated for MDS. The pathogenesis of those associations, however, remains unclear.

Immunoglobulin G subclass distribution of anti-endothelial cell antibodies (AECA) in patients with ulcerative colitis or Crohn's disease

Anti-endothelial cell antibodies have been described in sera from patients with inflammatory bowel disease. The aim of this study was to determine, by ELISA, the IgG subclass distribution of anti-endothelial cell antibodies, in patients with ulcerative colitis (N = 28) or Crohn's disease (N = 82) as compared with blood donors (N = 95). Thirty-six percent of ulcerative colitis and 23% of Crohn's disease patients were positive for at least one of the IgG anti-endothelial cell subclasses. Interestingly, the pattern of IgG anti-endothelial cell subclass observed in the two inflammatory bowel diseases differs. In Crohn's disease, the IgG1 anti-endothelial cell antibody level was significantly increased (P < 0.05) while IgG2 and IgG4 anti-endothelial cell antibody levels were decreased (P < 0.0001 and P < 0.01, respectively) as compared to ulcerative colitis patients. The immunoglobulin G3 anti-endothelial cell antibody level was decreased in both ulcerative colitis and Crohn's disease patients as compared to healthy blood donors. No relationship was detected between disease activity of ulcerative colitis or Crohn's disease patients and anti-endothelial cell IgG subclasses. Finally, the disparity of IgG anti-endothelial cell subclass distribution in these two inflammatory bowel diseases suggests that the ability to activate effector mechanisms is not identical, and hence, deals with the concept of distinctive pathogenetic mechanisms in these two diseases.

Impact of surgery on quality of life in Crohn's disease

OBJECTIVE

Health-related quality of life (HRQOL) status is an important component in assessing the impact of disease and its treatments in patients with chronic disorders. We recently validated a HRQOL questionnaire in French patients with inflammatory bowel disease. The aim of this study was to evaluate prospectively the impact of surgery on HRQOL in patients operated on for Crohn's disease (CD).

METHODS

Twenty-six patients (14 women, 12 men; median age 28.5 yr) undergoing an elective ileocolonic resection for CD were studied. The HRQOL questionnaire comprised a general questionnaire of 36 items (Medical Outcomes Study-Short Form 36), to which was added a sleep module, and a specific questionnaire of 28 items (Rating Form of Inflammatory Bowel Disease Patient Concerns), to which were added three independent items because of their pertinence in the French population. HRQOL was assessed immediately preoperatively and 3 months postoperatively.

RESULTS

HRQOL was improved postoperatively compared with the immediate preoperative status in almost all scales. Patient concerns and worries decreased after surgery. However, ranking was unchanged for the five most intense concerns: having an ostomy bag, having surgery, energy level, uncertainty of the disease, and pain or suffering.

CONCLUSIONS

HRQOL is greatly improved after surgery for CD, and this reassuring message might be delivered to our patients. In addition, the questionnaire showed the ability to detect clinical changes over time. This attests to its potential use in research.

TAP gene transporter polymorphism in inflammatory bowel diseases

BACKGROUND

Many studies suggest the implication of genetic factors in inflammatory bowel diseases. Despite some associations with HLA genes, the lack of definite data may be due to ethnic variations, clinical heterogeneity, or the involvement of additional susceptibility genes beside or within the major histocompatibility complex (MHC), such as TAP genes. The aim of this study was to analyze in patients with ulcerative colitis (UC) or Crohn's disease (CD) the polymorphism of TAP genes that encode the proteins necessary for the transfer of antigenic peptides through the endoplasmic reticulum membrane.

METHODS

One hundred and one UC and 148 CD patients were compared with 173 unrelated healthy controls. Dimorphisms within the TAP1 and TAP2 alleles were analyzed by sequence-specific oligonucleotide typing.

RESULTS

No difference was found between patient groups and controls. However, when CD patients were classified on the basis of their responsiveness to steroid therapy, a significant decrease of TAP2 AA (*0101/*0101) genotype was found in CD patients who did not respond to steroid therapy (22.9% versus 43.7% in steroid responder group; Pc < 0.05; odds ratio = 2.6; 95% confidence limits (CL) = 1.2-5.9). These data appear independent of the distribution of HLA DRB1*01 or DRB1*03 alleles despite a significant linkage disequilibrium between these alleles and TAP2A.

CONCLUSIONS

This result suggests, despite the absence of arguments favoring a genetic susceptibility to CD, that the TAP2 gene or other genes located on chromosome 6 may be involved in the genetic heterogeneity of CD.

[Amyloidosis AL of the breast in an ileal carcinoid tumor]

An ileal tumor was detected in a patient with monoclonal plasmocytosis of the bone marrow (IgA Kappa). The pathological examination showed a carcinoid tumor with amyloid stroma. Immunotyping of the amyloidosis showed that it was stained with the antibody directed against light chain kappa, though the amyloidosis was located within a carcinoid tumor.

Distinct cytokine patterns in early and chronic ileal lesions of Crohn's disease

BACKGROUND & AIMS

Chronic intestinal lesions of patients with Crohn's disease (CD) are associated with a T helper (Th) 1-type cytokine profile, including high levels of interleukin 2 (IL-2) and interferon gamma (IFN-gamma). However, the mechanisms involved in the pathogenesis of the early mucosal lesions are poorly known. The aim of this study was to examine the pattern of Th1- and Th2-type (IL-4, IL-5, and IL-13) cytokines in the early ileal lesions occurring in patients with CD 3 months after ileal resection and ileocolonic anastomosis. Cytokines were also examined in the chronic ileal lesions to look for cytokine patterns related to disease progression.

METHODS

Ileal biopsy specimens were obtained from 17 patients with CD and 11 controls. Mucosal IL-2, IFN-gamma, IL-4, IL-5, and IL-13 messenger RNA (mRNA) was evaluated by competitive reverse-transcription polymerase chain reaction.

RESULTS

The early ileal lesions of patients with CD were associated with a significant increase of IL-4 mRNA and a decrease of IFN-gamma mRNA compared with the normal mucosa of patients with CD or controls. A Th1-type pattern was observed in the chronic ileal lesions.

CONCLUSIONS

Divergent cytokine patterns are observed during different clinical stages of CD. These observations need to be considered in the development of newer specific therapeutic agents to prevent CD recurrences.

Significance of interleukin-1beta and interleukin-1 receptor antagonist genetic polymorphism in inflammatory bowel diseases

OBJECTIVE

Genetic susceptibility to inflammatory bowel disease is well recognized. There is also increasing evidence for the activation of the mucosal immune system and the production of inflammatory cytokines, i.e., interleukin (IL)-1ra and IL-1beta in the inflammatory bowel disease. The aim of this study was to analyze the IL-1beta and IL-1ra gene polymorphism and linkage disequilibrium coefficient between the different alleles of these genes in patients with Crohn's disease (CD) or ulcerative colitis (UC), according to the severity of the disease.

METHODS

Two hundred twenty-eight inflammatory bowel disease patients (87 UC and 141 CD) were included in this study and compared with 113 unrelated controls. The IL-1beta and IL-1ra gene polymorphism was studied after specific amplification of variable regions by PCR. A penta-allelic polymorphism, corresponding to a VNTR region located in intron 2 of the IL-1ra gene, was analyzed, whereas bi-allelic RFLPs displayed by two restriction enzymes (TaqI and AvaI) at position -511 of the IL-1beta gene were analyzed.

RESULTS

There was no significant difference of genotype distribution between controls and CD or UC patients. However, surgically treated UC patients were characterized by a higher frequency of genotype IL-1ra 1-2 (39 vs 16%, pc < 0.01) compared with nonoperated UC patients. Moreover, nonoperated UC patients displayed a lower frequency of IL-1ra allele 2 than surgically treated UC patients (14 vs 34%, pc < 0.002) or controls (14 vs 30%, pc < 0.005). Furthermore, simultaneous analysis of the IL-1beta and IL-1ra genes that are located in the same region of chromosome 2 revealed that CD patients carrying the IL-1beta allele 2 were more often noncarriers of IL-1ra allele 2 (p < 0.005). Moreover, UC and CD patients were, characterized by a lower frequency of the association of IL-1ra allele 2 and IL-1beta allele 2 compared with controls (8.3 vs 20.3% and 10.6 vs 20.3%, p < 0.03).

CONCLUSIONS

IL-1ra and IL-1beta gene polymorphism analysis from a clinical standpoint might help in defining UC prognosis. However, functional studies at both the circulating and mucosal level with stratification on allele associations, especially IL-1ra allele 2-IL-1beta allele 2 subgroups must be realized before therapeutic implications.

Fecal beta-D-galactosidase production and Bifidobacteria are decreased in Crohn's disease

Digestive bacterial microflora play a major role in the pathogenesis of Crohn's disease (CD). Bacterial enzyme activities, especially beta-D-galactosidase, are decreased in fecal extracts from CD patients. We hypothesized that an alteration of the colonic flora might be responsible for this decrease. Indeed, we demonstrate that beta-D-galactosidase production in supernates of anaerobic cultures was significantly (P < 0.01) reduced in feces from patients with active Crohn's disease (N = 7), when compared to healthy controls (N = 8). Therefore using X-gal and selective media, we enumerated bacteria able to release beta-D-galactosidase in feces from patients with active (N = 16) or quiescent disease (N = 5) and healthy controls (N = 14). Bifidobacteria numbers were significantly reduced in patients (P < 0.01 for active; P < 0.02 for quiescent disease) whereas Bacteroides and Lactobacilli counts remained unchanged. beta-D-Galactosidase activity and Bifidobacteria counts were significantly correlated (P < 0.03). Bifidobacteria are regarded as beneficial for the host. The reduction in Bifidobacteria is responsible for decreased beta-D-galactosidase activity. Thus oral administration of prebiotics that promote their growth might have potential therapeutic interest.

[Chronic pancreatitis: an extraintestinal manifestation of hemorrhagic rectocolitis?]

We reported here a case of unexplained chronic pancreatitis diagnosed 4 years before the onset of ulcerative colitis. The diagnosis of chronic pancreatitis was confirmed by recurrent pancreatitis and irregularities of the main pancreatic duct on retrograde pancreatography. None of the classical etiologies for chronic pancreatitis was found. Chronic pancreatitis associated with ulcerative colitis has already been reported in 5 cases. Our case reinforces the hypothesis of a non fortuitous association between both diseases.

Colonic xanthelasma due to glyceride accumulation associated with an adenoma

The case is reported of a 66-year-old woman who presented with endoscopic and histological features of multiple lipid deposits in the mucosa of the sigmoid colon associated with an adenoma. Associated clinical features were abdominal pain and diarrhea. Colectomy led to the complete resolution of symptoms. Biochemical analysis disclosed the presence of glycerides in the mucosa. The pathogenesis of lipid deposits and the possible link with the formation of an adenoma is discussed.

Are HLA-DR or TAP genes genetic markers of severity in ulcerative colitis?

The pathogeny of ulcerative colitis (UC) is not yet elucidated, but some arguments suggest the implication of genetic factors. Among the candidate genes, those encoding for HLA class II genotypes have been extensively studied in UC; however, discordant data may be imputable to heterogeneity, characterized by immunological markers such as atypical ANCA (p-ANCA), or to inclusion of more or less intractable UC. The aim of our study is to evaluate the interest of HLA class II and TAP genetic markers to identify different clinical forms of UC, according to p-ANCA status. Unrelated patients with a history of UC (n = 91) and healthy control subjects with no personal or family history of inflammatory bowel diseases (IBD) (n = 200) were included. HLA-DRB1*03 was less frequent in UC patients than in healthy controls (8% vs 28%, PC < 0.03). No association was found with any TAP genotypes. Moreover, there was no association with the HLA-DR2 specificity, either in the entire group of UC patients (38% vs 28%) or in the p-ANCA-positive subgroup of patients (30%). The most consistent finding in the present study is that some genetic markers may characterize intractability in UC patients. HLA-DR2 was associated with poor prognosis, regardless of p-ANCA status. In HLA-DR2 and non-HLA-DR2 groups, colectomy was done in 55% and 27% of patients, respectively, (PC < 0.05). Furthermore, in non-HLA-DR2 patients, p-ANCA could be of interest to characterize those with more severe prognosis. Our results confirm the interest of genetic studies to define UC genetic susceptibility, taking into account intractability of the disease. They do not support the hypothesis that p-ANCA is a subclinical marker of genetic susceptibility to UC.

Intravenous cyclosporine in attacks of ulcerative colitis: short-term and long-term responses

The present study reports the results of intravenous cyclosporine in 32 patients with refractory and/or severe attacks of ulcerative colitis (UC). Twenty of 32 patients responded to intravenous cyclosporine; cyclosporine was clinically effective and improved colonic lesions. However, one colonic perforation and one postoperative death were observed in two patients with severe endoscopic colitis who had failed to reach clinical remission with high-dose corticosteroids and cyclosporine. Moreover, after a median follow-up of 190 days, only one-third of the patients avoided colectomy. No predictive factor of response to cyclosporine was identified. This study confirms that cyclosporine is effective in severe UC but suggests that its use could be associated with serious complications in patients with severe lesions who had failed to settle with corticosteroids and cyclosporine.

Chronic pancreatitis: a complication of sarcoidosis?

Gastrointestinal localizations of sarcoidosis are rare. A total of 14 cases of pancreatic involvement in sarcoidosis has been reported previously. We report here a case of late onset idiopathic chronic pancreatitis diagnosed at the same time as sarcoidosis with liver, colonic, renal, mediastinal and neurologic involvement in a 56-year-old man. This case further suggests a possible relationship between idiopathic chronic pancreatitis and multisystem diseases.

Treatment of severe Crohn's disease with anti-CD4 monoclonal antibody

BACKGROUND

Monoclonal CD4 antibodies have been proposed as a new immunosuppressant drug in the treatment of inflammatory bowel disease. We report our experience of treatment with a monoclonal anti-CD4 (B-F5) antibody in severe refractory Crohn's disease.

METHODS

Twelve patients with severe refractory Crohn's disease were treated in an open clinical trial. B-F5 was given intravenously at a dose of 0.5 mg. day/kg for 7 consecutive days (patients 1-8). For patients 9-12, B-F5 was given at a dose of 0.5 mg. day/kg on the first day (day 0) and of 1 mg.day/kg on days 1-6. Follow-up examinations were carried out at days 8, 15, 22 and 30. Endoscopic evaluation was performed on days 0 and 30 in eight of 12 patients.

RESULTS

Immediately after the first infusion, one patient had dyspnoea and tachycardia requiring cessation of the treatment. Among the 11 patients who received the complete course of treatment, two had prolonged clinical improvement and two had partial clinical improvement. Significant endoscopic improvement was observed in only one patient. No sustained depletion of CD4+ cells could be observed.

CONCLUSION

In this uncontrolled open trial, monoclonal anti-CD4 B-F5 antibody was not successful in severe Crohn's disease.

Clinical characteristics of Crohn's disease in 72 families

BACKGROUND & AIMS

Familial aggregation argues for genetic susceptibility to Crohn's disease. The aim of this study was to compare the age of onset and the clinical features of Crohn's disease between patients with familial disease and those with sporadic disease and investigate the concordance for disease location and type among relatives with Crohn's disease.

METHODS

Seventy-two families with 2 (n = 55), 3 (n = 8), 4 (n = 6), and 5 or more (n = 3) affected first-degree relatives were selected for the study. A population of 1377 patients with sporadic nonfamilial Crohn's disease was used for comparison.

RESULTS

Clinical data were obtained from 176 patients with familial Crohn's disease (79 men and 97 women). Median age at onset was younger in familial Crohn's disease than in sporadic cases: 22 vs. 26.5 years (P < 0.01). In familial cases, fewer patients had exclusively colonic involvement and more patients had both small bowel and colonic involvement. Among relatives of families with 2 affected members, 56% were concordant for disease location and 49% for disease type. These percentages reached 83% and 76%, respectively, within families with more than 2 affected members.

CONCLUSIONS

Patients with familial Crohn's disease are characterized by an early age at onset with more extensive disease and may represent a homogeneous clinical subgroup with a particularly strong genetic influence.

Association of HLA class II genes with susceptibility to Crohn's disease

BACKGROUND

Published studies on the association between HLA class II genes and inflammatory bowel disease are contradictory perhaps because of the limited size and ethnic heterogeneity of the populations studied.

AIM

To compare the frequencies of HLA class II genes in a large number of French patients with Crohn's disease and in an ethnically matched control group.

METHODS

344 patients (196 F, 148 M, mean age 23.6 years) with Crohn's disease were molecularly genotyped for the HLA-DQB1 and DRB1 alleles. The results were compared with those for an ethnically matched control population of 488 white adults.

RESULTS

There were two significant variations of alleles at the DQB1 locus: an increase in DQB1*0501 allele frequency (chi 2 = 10.6, corrected p value (pc) = 0.01, odds ratio (OR) = 1.61) and a decrease in DQB1*0602/0603 allele frequencies (chi 2 = 8.43, pc = 0.037, OR = 0.66). DRB1 analysis showed associations with three allelic variations: an increase in the frequencies of DRB1*01 (chi 2 = 12.86, pc = 0.003, OR = 1.75) and DRB1*07 alleles (chi 2 = 11.18, pc = 0.008, OR = 1.58) and a very significant decrease in that of the DRB1*03 allele (chi 2 = 19.7, pc = 9.10(-5), OR = 0.46).

CONCLUSION

The alleles DRB1*01 and DRB1*07 are associated with susceptibility to Crohn's disease. The strong negative association between the DRB1*03 allele and Crohn's disease suggests that the HLA-DRB1*03 allele mediates 'resistance' to Crohn's disease.

Methotrexate for the treatment of refractory Crohn's disease

BACKGROUND

Previous studies suggested that methotrexate has beneficial effects in patients with Crohn's disease. We report our experience with this agent in patients with chronic active Crohn's disease who previously failed to improve with conventional treatment, including azathioprine in most cases.

METHODS

Between June 1988 and June 1992, 39 patients with refractory Crohn's disease were treated with methotrexate. In patients with active disease, clinical remission was defined by a Harvey-Bradshaw index of less than 4. For patients also taking corticosteroids, the dates of remission and complete steroid withdrawal were recorded. For patients who achieved clinical remission, and those in clinical remission when methotrexate was started, the relapse rate on methotrexate therapy was noted.

RESULTS

In the 37 patients with active disease at methotrexate initiation, the probability of remission was 72% at 3 months. The probability of remission and steroid withdrawal was 42% at 12 months. In patients on clinical remission, the probability of relapse on methotrexate was 58% at 12 months. Twenty-two patients experienced side-effects, but these only warranted methotrexate discontinuation in four cases.

CONCLUSIONS

Methotrexate appears effective in most patients with refractory Crohn's disease and its short-term toxicity is acceptable, but the long-term benefit seems more limited.