Prevention and Treatment of Stricturing Crohn's Disease - Perspectives and Challenges

Introduction: Fibrostenosis is a hallmark of Crohn's disease (CD), remains a challenge in today's clinical management of inflammatory bowel disease patients and represents a key event in the disease course necessitating improved preventative strategies and a multidisciplinary approach to diagnosis and management. With the advent of anti-fibrotic therapies and well-defined clinical endpoints for stricturing CD, there is promise to impact the natural history of disease.Areas covered: This review summarizes current evidence in the natural history of stricturing Crohn's disease, discusses management approaches as well as future perspectives on intestinal fibrosis.Expert opinion: Currently, there are no specific therapies to prevent progression to fibrosis or to treat it after it becomes clinically apparent. In addition to the international effort by the Stenosis Therapy and Anti-Fibrotic Research (STAR) consortium to standardize definitions and propose endpoints in the management of stricturing CD, further research to improve our understanding of mechanisms of intestinal fibrosis will help pave the way for the development of future anti-fibrotic therapies.

Computed tomography enterography and magnetic resonance enterography: the future of small bowel imaging

In the last 5 years, computed tomography enterography (CTE) and to a lesser extent magnetic resonance enterography (MRE) have supplanted the routine small bowel series and enteroclysis in the evaluation of many small bowel diseases, especially Crohn's disease. Both CTE and MRE use similar methods of bowel lumen opacification and distension and both have distinct advantages and disadvantages. Both have been most extensively studied in patients with Crohn's disease. What is certain is that these cross-sectional examinations have largely replaced the historic fluoroscopic examinations in the evaluation of the small bowel.

Licorice-derived compounds inhibit linoleic acid (C:18:2 omega 6) desaturation in soybean chloroplasts

Although glycyrrhizic acid, a major constituent of licorice root, has important pharmacological effects in humans, the biological activity of glycyrrhizic acid and its aglycone glycyrrhetinic acid in plants is unknown. Here we report that these licorice-derived compounds and the analog carbenoxolone inhibit desaturation of linoleic acid (C18:2 omega 6) in soybean chloroplasts using monogalactosyldiacylglycerol and phosphatidylcholine substrates in an in vitro assay for desaturase activity. At 10 nM glycyrrhetinic acid, there is significant inhibition of desaturation of linoleic acid suggesting that licorice-derived compounds could prove useful in investigating biochemical pathways of linoleic acid desaturation in plant chloroplasts and plant desaturase regulation, which has application in modification of plant response to environmental stress, as well as optimization of oil seed composition.

Comparison of two barium suspensions for dedicated small-bowel series

OBJECTIVE

The in vivo radiographic features of two commercially available formulations of barium used as contrast media in dedicated small-bowel series were compared.

SUBJECTS AND METHODS

Fifty-six consecutive outpatients referred for a dedicated small-bowel series were randomly administered either E-Z-Paque or Entrobar. Representative survey radiographs from each examination were randomized and reviewed by six gastrointestinal radiologists from three institutions. Each observer assigned a numeric score (1 = poor, 2 = fair, 3 = good, and 4 = excellent) that rated the quality of the radiograph with respect to these characteristics: definition of fold pattern, translucency, distention, and integrity of the barium column. Statistical analysis was performed for each characteristic using Wilcoxon's two-sample rank sum test.

RESULTS

All six observers found a statistically significant difference between the two barium formulations for mean scores for definition of fold pattern and translucency. Mean scores for fold pattern were 3.3, 3.0, 3.2, 3.6, 3.3, and 3.4 for Entrobar and 2.1, 2.3, 2.4, 3.2, 2.6, and 2.7 for E-Z-Paque. Mean scores for translucency were 2.5, 2.7, 2.8, 3.1, 2.7, and 3.3 for Entrobar and 1.6, 1.7, 2.1, 2.3, 1.9, and 2.7 for E-Z-Paque. No statistically significant difference was found for mean score for distention or integrity of the barium column.

CONCLUSION

On radiographs, Entrobar was found to have superior characteristics for visualization of fold pattern and translucency but offered no advantages for distention or integrity of the barium column. Improved translucency and definition of fold pattern may translate into improved sensitivity and confidence in diagnosing small-bowel abnormality.

Evolution of permease diversity and energy-coupling mechanisms with special reference to the bacterial phosphotransferase system

Different classes of apparently unrelated permeases couple different forms of energy to solute transport. While the energy coupling mechanisms utilized by the different permease classes are clearly distinct, it is proposed, based on structural comparisons, that many of these permeases possess transmembrane, hydrophobic domains which are evolutionarily related. Carriers may have arisen from transmembrane pore-forming proteins, and the protein constituents or domains which are specifically responsible for energy coupling may have had distinct origins. Thus, complex permeases may possess mosaic structures. This suggestion is substantiated by recent findings regarding the evolutionary origins of the bacterial phosphoenolpyruvate-dependent phosphotransferase system (PTS). Mechanistic implications of this proposal are presented.

Computed tomography of a traumatic, diaphragmatic, Richter's hernia: findings mimicking an abscess

We present a case of a Richter's hernia through a traumatic, diaphragmatic defect presenting with the appearance of an abscess on computed tomography. We underscore the importance of this hernia variant, the need for its recognition, and stress caution in percutaneous aspiration of a lesion where a hernia might exist.

CT of fundoplication

To determine the CT findings postfundoplication, we retrospectively compared CT in 22 postfundoplication patients with CT in 22 patients with unrepaired hiatal hernias and gastroesophageal (GE) junction abnormalities and 24 patients with gastric or esophageal carcinoma involving the GE junction. Seventeen of the 22 postfundoplication patients had undergone a Nissen procedure. Of the 22 patients, 11 had esophageal dilatation, 14 had GE junction masses, 4 had esophageal wall thickening, 7 had surgical clips, and none had hepatic metastases or upper abdominal lymphadenopathy. Statistically, on CT, postfundoplication patients are more likely to have a GE junction mass (p = 0.023) and least likely to have wall thickening (p = 0.021). Nonetheless, because the findings occur frequently in each group, they are not diagnostic in the individual patient. However, 11 of 12 post-Nissen masses had the unique finding of an oval or linear central fat density within the mass. This finding was absent in the other postfundoplication masses and in those patients with repaired hiatal hernia or tumor. We conclude that pseudomasses occur on CT postfundoplication and can be indistinguishable from hiatal hernias and GE junction neoplasms unless a central fat density is present.

Deletion of 12 carboxyl-terminal residues from pig 3alpha/beta,20beta-hydroxysteroid dehydrogenase affects steroid metabolism

Pig 3alpha/beta,20beta-hydroxysteroid dehydrogenase (3alpha/beta,20beta-HSD) is 80-85% identical to human, rat, and mouse carbonyl reductases. However, pig 3alpha/beta,20beta-HSD contains an extra 12 amino acids at its COOH-terminus that these other mammalian carbonyl reductases lack. We constructed a pig 3alpha/beta,20beta-HSD mutant, G278opal, which lacks these amino acids and found that compared to wild-type 3alpha/beta,20beta-HSD, G278opal has a 10-fold lower catalytic efficiency for testosterone and progesterone. G278opal also has lower 3alpha- and 20beta-reductase and increased 3beta-reductase activity compared to wild-type 3alpha/beta,20beta-HSD. Binding of NADPH to G278opal was similar to that of wild-type 3alpha/beta,20beta-HSD. The recently determined three-dimensional structure of 3alpha/beta,20beta-HSD, without a steroid substrate, shows the 12 COOH-terminal amino acids in a random configuration. Our data indicate that the 12 COOH-terminal amino acids have a role in steroid metabolism suggesting that binding of steroid to wild-type 3alpha/beta,20beta-HSD induces a conformational change in which the 12 COOH-terminal amino acids interact with the steroid substrate.

Amino acid sequence homology between the C3 chain of rat prostatic steroid binding protein and human alpha 2-macroglobulin

Using a computer program designed to detect evolutionary relationships between proteins, I find that exon 2 of the C3 chain of rat prostatic steroid binding protein has amino acid sequence homology with residues 1058-1119 of the protease inhibitor alpha 2-macroglobulin. This finding suggests interesting approaches for studying the functions of these proteins.

Clinical issues facing pouch patients: an introduction to a special issue on the ileal pouch

For over 40 years, restorative proctocolectomy has been used in patients with ulcerative colitis or familial adenomatous polyposis undergoing proctocolectomy. Radiologists are now encountering an increasing number of patients with an ileal pouch and therefore need to understand the clinical issues and concerns in these patients. This review is the introduction of a special issue on the ileal pouch and was written with both surgeon and gastroenterology input. The intent is to assist the radiologist in understanding the clinical questions posed by both the patients and their physicians. Subsequent sessions will address specific imaging modalities and techniques, how the gastroenterologists and surgeons address issues with these patients, and a final session summarizing the sessions and speculating on future investigations and approaches.

Recognizing and managing acute diverticulitis for the internist

Colonic diverticulitis can present as mild abdominal discomfort or as life-threatening septic shock and can also mimic many inflammatory conditions. Most patients with acute diverticulitis can be managed with antibiotics and supportive care. Surgery is reserved for those with repeat attacks, disease unresponsive to medical therapy, certain complications, and the possibility of colon cancer that cannot otherwise be excluded.

An NADPH-dependent reductase in neonatal pig testes that metabolizes androgens and xenobiotics

We have isolated an NADPH-dependent reductase from neonatal pig testes that metabolizes androgens and a variety of xenobiotics. This enzyme is distinct from 3alpha/beta,20beta-hydroxysteroid dehydrogenase or its homologue, carbonyl reductase, as judged by its immunological and molecular properties and its much narrower specificity for steroids. This reductase and 3alpha/beta,20beta-hydroxysteroid dehydrogenase may be part of a mechanism for regulating androgen levels the neonatal pig testes. Interestingly, we could not find multiple isoforms of 3alpha/beta,20beta-hydroxysteroid dehydrogenase/carbonyl reductase in pig testes unlike human and rat testes and other organs in which multiple isoforms are expressed.

Gastroenterology and pancreatic adenocarcinoma: what the radiologist needs to know

In this article, we review the information that radiologists need to know regarding the endoscopic approach to the diagnosis and management of pancreatic cancer. This includes a review of the indications, techniques, and complications of endoscopic ultrasound. We also review information regarding endoscopic retrograde cholangiopancreatography, including the various biliary drainage techniques and the use of endoscopic palliation for patients with pancreatic cancer.