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Abstract
The majority of patients with Crohn's disease require resectional surgery in the course of their disease. Most of them will suffer symptomatic recurrence in the years after their operation, leading to new complications and sometimes repeated surgery. Clinical risk factors for early and evolutive recurrence have not been well identified. Smoking, perforating behaviour of the disease and ileal or ileocolonic location seem to predispose to early and aggressive recurrence. No clear prophylactic drug regime has been identified. Sulfasalazine and 5-ASA are only mildly protective and meta-analysis of all studies does not show superiority over placebo. Glucocorticosteroids are not efficacious. Nitroimidazole antibiotics, metronidazole and ornidazole prevent early endoscopic recurrence and postpone symptomatic relapse but are not well tolerated. Immunosuppression with azathioprine or 6-MP is attractive but hard data concerning their efficacy are still lacking. No data are available on the use of biologicals for the prevention of post-operative Crohn's disease. We need well designed and well powered multicentre trials to investigate the efficacy of different drugs for recurrence prophylaxis.
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Affiliation(s)
- Paul Rutgeerts
- University Hospital, Department of Internal Medicine, 3000 Leuven, Belgium
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52
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Gisbert JP, Gomollón F, Maté J, Figueroa JM, Alós R, Pajares JM. [Treatment of stenosis due to Crohn's disease]. GASTROENTEROLOGIA Y HEPATOLOGIA 2002; 25:560-9. [PMID: 12435308 DOI: 10.1016/s0210-5705(02)70313-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- J P Gisbert
- Servicio de Aparato Digestivo. Hospital Universitario de la Princesa. Madrid. Spain.
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53
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Mahadevan U, Loftus EV, Tremaine WJ, Pemberton JH, Harmsen WS, Schleck CD, Zinsmeister AR, Sandborn WJ. Azathioprine or 6-mercaptopurine before colectomy for ulcerative colitis is not associated with increased postoperative complications. Inflamm Bowel Dis 2002; 8:311-6. [PMID: 12479645 DOI: 10.1097/00054725-200209000-00001] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
AIM To determine whether the use of azathioprine/6-mercaptopurine before colectomy is associated with an increased rate of postoperative complications. METHODS All patients who underwent colectomy with ileal pouch-anal anastomosis for ulcerative colitis between 1997 and 1999 were identified. Medical records were abstracted for demographics, extent and duration of disease, dose and duration of corticosteroids and azathioprine/6-mercaptopurine, albumin, and Truelove/Witts score. Early (30-day) and late (6-month) complications were identified. Noncorticosteroid immunosuppressive use was coded as none, azathioprine/6-mercaptopurine within 1 week of surgery, or therapy with other immunosuppressive agents within 1 month of surgery. A logistic regression analysis assessed the association between these variables and complications. RESULTS Early complications occurred in 49 of 151 (32%) patients not treated with immunosuppressive agents, 12 of 46 (26%) azathioprine/6-mercaptopurine-treated patients, and 4 of 12 (33%) patients treated with other immunosuppressive agents (p = 0.71). Late complications occurred in 72 of 148 (49%), 20 of 46 (43%), and 8 of 12 (67%) patients in these same groups, respectively. Intravenous or oral steroids at doses of 40 mg/d or greater (p < 0.01) and severe or fulminant disease (p = 0.0094) were associated with greater early complication rates. CONCLUSION Early complications after restorative proctocolectomy for ulcerative colitis are associated with high dose steroids and severe disease but not use of azathioprine/6-mercaptopurine.
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Affiliation(s)
- Uma Mahadevan
- Division of Gastroenterology, University of California, San Francisco, USA
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54
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Mamula P, Telega GW, Markowitz JE, Brown KA, Russo PA, Piccoli DA, Baldassano RN. Inflammatory bowel disease in children 5 years of age and younger. Am J Gastroenterol 2002; 97:2005-10. [PMID: 12190168 DOI: 10.1111/j.1572-0241.2002.05915.x] [Citation(s) in RCA: 158] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Clinicians are becoming increasingly aware that inflammatory bowel disease (IBD) can affect all age groups, although it has not been well described in infants and young children. Our aim was to evaluate early onset IBD in patients 5 yr of age and younger. METHODS Medical records of patients diagnosed with early onset IBD at The Children's Hospital of Philadelphia between 1977 and 2000 were reviewed. Patients were divided into three categories: those with Crohn's disease (CD), those with ulcerative colitis (UC), and those with indeterminant colitis (IC). RESULTS A total of 82 patients fulfilled the criteria. In 12 patients (15%), the IBD diagnosis was changed during the course of illness. At the end of the follow-up period, linear growth failure was present in 10 of 35 (29%) children with CD, one of 30 (3%) with UC, and three of 17 (18%) with IC. Failure to thrive was a frequent presenting symptom in children with CD (44%) and IC (39%), whereas in all four patients with UC and failure to thrive the diagnosis was subsequently changed to CD or IC. A high proportion of patients with CD had large bowel (89%), and perianal (34%) disease. None of the tested patients were positive for anti-Saccharomyces cerevisiae antibody (ASCA), and 10 tested positive for perinuclear antineutrophil cytoplasmic antibody (three of five patients with CD, five of seven with UC, and two of three with IC). CONCLUSIONS Failure to thrive, at the time of presentation, is indicative of a final diagnosis of CD or IC, not UC. Linear growth failure is a common finding in patients with early onset CD. A high proportion of patients with CD have failure to thrive, colonic, and perianal disease. The IBD serology panel is of limited clinical relevance in providing definitive diagnostic information in this pediatric population.
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Affiliation(s)
- Petar Mamula
- Division of Gastroenterology and Nutrition, The Children's Hospital of Philadelphia, Pennsylvania 19104, USA
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55
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MacLean AR, O'Connor B, Parkes R, Cohen Z, McLeod RS. Reconstructive surgery for failed ileal pouch-anal anastomosis: a viable surgical option with acceptable results. Dis Colon Rectum 2002; 45:880-6. [PMID: 12130874 DOI: 10.1007/s10350-004-6321-y] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Salvage procedures for failed ileal pouch-anal anastomoses frequently require total reconstruction with a combined abdominal and perineal approach. The aim of this study was to determine the indications for surgery and the outcomes in this group of patients. METHODS All patients who underwent combined abdominal and perineal ileal pouch-anal anastomosis reconstruction at the Mount Sinai Hospital between 1982 and 2000 were reviewed. Data were collected prospectively in the inflammatory bowel disease database. RESULTS Sixty-three reconstructive procedures were performed in 57 patients, with a mean age of 33.9 (+/-10.4) years at the time of reconstruction. There were 14 males. The mean follow-up was 69.1 months. The initial indication for ileal pouch-anal anastomosis was ulcerative colitis in 98 percent. The primary indication for reconstruction was pouch-vaginal fistula in 21 patients, long outlet in 14, pelvic sepsis in 14, ileoanal anastomotic stricture in 5, pouch-perineal fistula in 2, and chronic pouchitis in 1. The mean operative time was four hours (+/-1.1), the average blood loss was 500 mL (+/-400), and the average length of stay was 10.3 days (+/-4.6). All patients had a diverting ileostomy. Forty-two (73.6 percent) of the patients have a functioning pouch. Seven (12.3 percent) patients have had their pouch excised. The ileostomy has not yet been closed in 8 (14 percent) patients; 3 of these patients are awaiting closure, whereas the remaining 5 have a permanently defunctioning ileostomy. Eighty-nine percent have ten or fewer bowel movements per day. No patients are incontinent of stool during the day, whereas two patients are incontinent at night. Seventeen percent complain of frequent urgency. Despite this, more than 80 percent rate their physical and psychological health as good to excellent. CONCLUSION Reconstructive pouch surgery has a high success rate in experienced hands. The functional results in those whose pouch is in use are good.
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Affiliation(s)
- Anthony R MacLean
- Inflammatory Bowel Disease Research Unit, Department of Surgery, Department of Health, Health Policy, Management, and Evaluation, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
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56
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57
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Abstract
Patients with ileal pouches and ostomies present with management issues that are challenging to the clinician. Endoscopy plays a significant role in diagnosing and guiding therapy in such patients. Unfortunately, there are very few prospective studies that evaluates endoscopy in these situations. Nevertheless, it is clear that endoscopy remains a powerful tool that is important for diagnosis and therapy of complications unique to these surgical procedures. It seems prudent to advocate endoscopic cancer surveillance for patients with pouches and ostomies; however, it remains to be seen whether these efforts will ultimately have an impact on long-term patient morbidity and mortality.
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Affiliation(s)
- Peter Ghali
- Division of Gastroenterology and Hepatology, McGill University Health Center, Royal Victoria Hospital Site, Division of Gastroenterology, Ross 2.28, 687 Pine Avenue, Montreal, Quebec, Canada H3A
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58
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Abstract
Crohn's disease is not medically (and is rarely surgically) curable. Patients do, however, live a normal life span. The goal of therapy is to optimize the quality of life, minimize disease activity and disease-related complications, and avoid therapeutic toxicity.
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Affiliation(s)
- Janet Harrison
- Department of Medicine and Clinical Pharmacology, Section of Gastroenterology and Nutrition, Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
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59
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Abstract
Crohn's disease is a chronic inflammatory bowel disease of unknown aetiology which affects around 35,000 people in the UK (population 56.8 million). The potential for onset in early adult life, disease chronicity and a need for hospitalisation and surgery mean that the disease can be associated with substantial healthcare costs. Cost-of-illness studies focusing on direct medical costs have identified that over half the average costs associated with the disease relate to hospital costs. Estimates of the contribution of drug costs to the total direct economic burden have varied between 4.6 and 25%. Figures for average annual direct costs per patient in the US have been put at between US dollars 6561 (1990 values) and US dollars 12,417 (1994 values), whereas European studies have given much lower cost estimates (US dollars 655, 1994 values). However, all studies have highlighted that much of the total cost of illness relates to extensive interventions required by a small proportion of severely affected individuals. Indirect costs associated with reduced productivity in Crohn's disease can be high, with long periods of absenteeism and early disability. However, most patients (90%) remain in the workforce and life expectancy is relatively normal. A variety of drugs are employed for the treatment of Crohn's disease, both in an attempt to induce clinical remission in active disease and to maintain remission once this has been achieved. Comparative data on cost effectiveness is lacking, though crude estimates based on randomised trials suggest that the frequently prescribed aminosalicylates, which have only modest efficacy, are a relatively costly drug option. The costs associated with adverse drug effects, particularly for corticosteroids, have not been formally quantified. Despite high costs, new drug therapies for more severe disease, such as anti-tumour necrosis factor (TNF-alpha) antibodies, may prove a cost-effective option if the need for hospitalisation is reduced. In a modelling exercise, a US group estimated that if a theoretical new drug was introduced which was capable of reducing non-drug costs (including hospitalisation) by a fifth despite doubling the overall drugs bill, there would still be a reduction in the overall costs of Crohn's disease by 13%. Although surgical therapy is costly, there may be prolonged post-surgical remission following resection of localised disease and early surgery may represent a cost-effective option for selected patients. Without formal cost-effectiveness analyses, or (better still) clinical trials incorporating cost data, decisions about the relative efficiency of treatment alternatives for Crohn's disease remain subjective and more research is clearly required in this area.
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Affiliation(s)
- Keith Bodger
- Department of Medicine, Clinical Sciences Centre, University Hospital Aintree, Liverpool, UK.
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60
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Shebani KO, Stucchi AF, Fruin B, McClung JP, Gee D, Beer ER, LaMorte WW, Becker JM. Pouchitis in a rat model of ileal J pouch-anal anastomosis. Inflamm Bowel Dis 2002; 8:23-34. [PMID: 11837935 DOI: 10.1097/00054725-200201000-00004] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Endorectal ileal pouch-anal anastomosis (IPAA) has become the operation of choice for patients with chronic ulcerative colitis. Although this procedure improves the quality of life, pouchitis remains a significant postoperative complication. Because our understanding of the pathophysiology of pouchitis may, in part, be due to the lack of small animal model, our aim was to develop a model of IPAA in a rat that mimics its clinical counterpart. Colectomy, proctectomy, construction of an ileal J pouch, and ileal pouch-rectal anastomosis as a model of IPAA was performed in Sprague-Dawley and Lewis rats. Radiographic contrast studies were performed to quantitate intestinal transit. The presence of activated neutrophils was quantified by measuring mucosal myeloperoxidase (MPO) activity. Oxidative stress was quantitated by measuring urinary 8-isoprostane (8-IP) levels. Anaerobic and aerobic bacterial counts were determined on Brucella and tryptic soy agar plates, respectively. Dextran sulfate sodium (DSS) was used to exacerbate ileal J pouch inflammation. Mortality was low, and animals gained weight normally after recovery. Stasis was documented radiographically. MPO levels were elevated (p < 0.05) in the ileal J pouch 30 and 60 days after IPAA, indicating an inflammation that was associated with stasis and bacterial overgrowth. 8-IP levels were elevated by 80% compared with controls. Oral administration of 5% DSS to IPAA rats with further elevated MPO and 8-IP levels in concert with a pouchitis-like syndrome that included the physical, gross, and histologic characteristics of clinical pouchitis. An understanding of the pathophysiology of pouchitis is essential to the future development of new therapeutic modalities. This model is applicable to investigating several key etiologic mechanisms purportedly related to pouchitis.
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Affiliation(s)
- Khaled O Shebani
- Department of Surgery, Boston University School of Medicine, Massachusetts 02118, USA
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61
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Abstract
Inflammatory bowel disease (IBD) is a chronic condition that often presents in adolescence. The characteristic manifestations, exacerbations, and treatment of the disease affect the adolescent's physical, physiological, and psychological development. Body image, self-esteem, and dependence/independence issues may lead to noncompliance, further complicating the disease process and its management. This article will review IBD and present treatment options and interventions in the care of the adolescent with IBD.
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Affiliation(s)
- N Rayhorn
- Phoenix Children's Hospital, Gastroenterology, 909 E. Brill Street, Phoenix, AZ 85006, USA.
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62
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Abstract
Fibrosis is a serious complication of Crohn disease for which there is no effective therapy. It is unclear why fibrosis, particularly fibrosis of the mucosal layer, develops in Crohn disease and not in ulcerative colitis. Smooth muscle cells, subepithelial myofibroblasts, and fibroblasts have traditionally been considered mediators of fibrosis, but new information points to a role of interstitial cells of Cajal and mast cells. Recent evidence about the role of each of these cell types in fibrosis in Crohn disease or other inflammatory bowel diseases is described. Hypothetical models to describe how altered function of these cells could underlie fibrosis of the mucosa or submucosal layers are presented. Fibrosis is not well characterized in any animal model of inflammatory bowel disease. The merits of several animal models for defining the mechanisms of inflammation-induced intestinal fibrosis are reviewed.
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Affiliation(s)
- P K Lund
- Department of Cell and Molecular Physiology and Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7545, USA.
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63
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Alexakis C, Guettoufi A, Mestries P, Strup C, Mathé D, Barbaud C, Barritault D, Caruelle JP, Kern P. Heparan mimetic regulates collagen expression and TGF-beta1 distribution in gamma-irradiated human intestinal smooth muscle cells. FASEB J 2001; 15:1546-54. [PMID: 11427486 DOI: 10.1096/fj.00-0756com] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Radiation-induced intestinal fibrosis is characterized by collagen accumulation, a process in which TGF-beta1 plays a key role. We analyzed the effects of gamma radiation on collagen expression and TGF-beta1 distribution in human intestinal smooth muscle cells (HISM). We investigated the activity of a carboxymethylated and sulfated dextran (RG-1503), exhibiting antifibrotic properties and promoting in vivo intestinal tissue repair, on irradiated HISM. After (60)Co irradiation (10 Gy), HISM were labeled with [(3)H] proline (+/-RG-1503). Radiolabeled collagen I, III, and V were quantified by SDS-PAGE. TGF-beta1 was quantified by ELISA in culture medium, pericellular and intracellular compartments. Irradiation induced a specific 2.85-fold increase in collagen III production by HISM. Collagen V decreased by 80% 72 h after irradiation. Pericellular TGF-beta1 was increased (up to twofold) in irradiated HISM. RG-1503 added before or after irradiation reversed both mRNA and protein levels of collagen III and V to control values. RG-1503 decreased the amount of TGF-beta1 in the cell layer below the control values. Irradiation of HISM induced the development of a fibrotic phenotype in terms of collagen production and TGF-beta1 distribution. The antifibrotic RG-1503 restored HISM physiological characteristics and may represent a promising therapeutic approach for radiation-induced intestinal fibrosis.
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Affiliation(s)
- C Alexakis
- CRRET/CNRS UPRESA 7053, Faculté des Sciences de Créteil, Université PARIS-12, France
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64
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Cima RR, Pemberton JH. Surgical Management of Inflammatory Bowel Disease. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2001; 4:215-225. [PMID: 11469979 DOI: 10.1007/s11938-001-0034-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Surgery continues to be a central component in the treatment of patients with inflammatory bowel disease (IBD). The most important aspect of caring for patients with IBD is a close and ongoing interaction between the surgeon and gastroenterologist both before and after surgery. Surgery in patients with chronic ulcerative colitis (CUC) is curative. In the appropriate patient, we recommend proctocolectomy with ileal pouch anal anastomosis (IPAA). In contrast, patients with Crohn's disease cannot be cured with surgery. Instead, surgery is used in conjunction with maximal medical therapy to treat symptoms of the disease and improve the patient's quality of life. Surgical interventions should be limited in scope. Small bowel disease should be treated with either limited resection or strictureplasty, if possible, to conserve bowel length. For limited involvement of the colon, segmental resection yields good results. Minimal surgical intervention, drainage of abscesses, placing draining setons, and aggressive medical therapy is recommended as treatment of perianal Crohn's disease.
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Affiliation(s)
- Robert R. Cima
- Division of Colon and Rectal Surgery, The Mayo Clinic, 200 First Street, SW, Rochester, MN, 55905, USA
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65
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Chang P, Schwartz RW. Crohn's disease: current concepts in diagnosis and treatment. CURRENT SURGERY 2001; 58:288-292. [PMID: 11397489 DOI: 10.1016/s0149-7944(01)00423-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- P Chang
- Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky, USA
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66
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Chu UB, Mastrangelo MJ, Park A. Laparoscopic management of Crohn's disease. CURRENT SURGERY 2001; 58:293-298. [PMID: 11397490 DOI: 10.1016/s0149-7944(01)00422-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- U B. Chu
- Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky, USA
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67
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Williams KL, Fuller CR, Dieleman LA, DaCosta CM, Haldeman KM, Sartor RB, Lund PK. Enhanced survival and mucosal repair after dextran sodium sulfate-induced colitis in transgenic mice that overexpress growth hormone. Gastroenterology 2001; 120:925-37. [PMID: 11231946 DOI: 10.1053/gast.2001.22470] [Citation(s) in RCA: 185] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND & AIMS Growth hormone (GH) is used as therapy for inflammatory bowel disease (IBD), but the specific effects on intestine are unknown. Transgenic mice overexpressing GH (MT1-bGH-TG) were used to test whether increased plasma GH levels alter inflammation or crypt damage during dextran sodium sulfate (DSS)-induced colitis. METHODS MT1-bGH-TG and wild-type (WT) littermates were given 3% DSS for 5 days followed by up to 10 days of recovery. Colitis and epithelial cell proliferation were evaluated histologically. Plasma insulin-like growth factor (IGF)-I and colonic IGF-I, interleukin (IL)-1beta, and intestinal trefoil factor (ITF) messenger RNAs (mRNAs) were measured. RESULTS DSS induced similar disease onset in MT1-bGH-TG and WT. More MT1-bGH-TG survived than WT. By recovery day 7, MT1-bGH-TG had less inflammation and crypt damage, elevated plasma IGF-I, and increased colonic ITF expression relative to WT. Colonic IL-1beta was elevated in DSS-treated MT1-bGH-TG and WT, but IL-1beta mRNA abundance correlated with disease only in WT. MT1-bGH-TG showed earlier increases in epithelial cell proliferation than WT during recovery but only WT showed atypical repair. CONCLUSIONS GH does not alter susceptibility to acute DSS-induced colitis but enhances survival, remission of inflammation, and mucosal repair during recovery. GH therapy may be beneficial during active IBD by improving mucosal repair.
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Affiliation(s)
- K L Williams
- Department of Cell and Molecular Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7545, USA.
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Affiliation(s)
- S B Hanauer
- University of Chicago Pritzker School of Medicine, Illinois 60637, USA
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69
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Pucilowska JB, Williams KL, Lund PK. Fibrogenesis. IV. Fibrosis and inflammatory bowel disease: cellular mediators and animal models. Am J Physiol Gastrointest Liver Physiol 2000; 279:G653-9. [PMID: 11005750 DOI: 10.1152/ajpgi.2000.279.4.g653] [Citation(s) in RCA: 118] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The cellular mediators of intestinal fibrosis and the relationship between fibrosis and normal repair are not understood. Identification of the types of intestinal mesenchymal cells that produce collagen during normal healing and fibrosis is vital for elucidating the answers to these questions. Acute injury may cause normal mesenchymal cells to convert to a fibrogenic phenotype that is not maintained during normal healing but may lead to fibrosis when inappropriately sustained. Proliferation of normal or fibrogenic mesenchymal cells may lead to muscularis overgrowth associated with fibrosis. The presence of increased numbers of vimentin-positive cells within fibrotic, hypertrophied muscularis in Crohn's disease suggests that changes in mesenchymal cell phenotype and number may indeed be associated with fibrosis. Fibrosis is induced in rats by peptidoglycan polysaccharides or trinitrobenzene sulfonic acid-ethanol administration, but inducing fibrosis in mice has been technically challenging. The development of current mouse models of colitis, such as dextran sodium sulfate or trinitrobenzene sulfonic acid-ethanol administration, into models of fibrosis will allow us to use genetic manipulation to study molecular mediators of fibrosis.
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Affiliation(s)
- J B Pucilowska
- Department of Cell and Molecular Physiology and Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7545, USA
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70
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Abstract
Optimal management of patients with IBD requires a multidisciplinary approach involving primary care physicians, gastroenterologists, surgeons, radiologists, and nutritionists. The rapidly evolving medical armamentarium promises better quality of life for patients afflicted with these complex, chronic diseases. It is expected that future development of biologic agents will add to the therapeutic options, although it may complicate treatment algorithms. Surgical advancements, particularly in ileoanal anastomosis and bowel preservation by strictureplasty, have improved outcome dramatically. The focus on development of new therapies and refinement of older ones demands a constant attention to the latest peer-reviewed literature and that the clinician keep abreast of the various advancements that have been summarized here.
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Affiliation(s)
- B R Stotland
- Department of Medicine, Boston Medical Center, Boston University Medical School, Massachusetts, USA
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71
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Abstract
Fulminant ulcerative colitis necessitates immediate hospitalization. Supportive therapy such as aggressive rehydration, restriction of oral intake, and consideration of parenteral nutrition should be initiated. High-dose intravenous steroids should be started in almost all cases. Antibiotics and cyclosporine should be considered, especially in disease refractory to steroid therapy. Indications for surgery should always be kept in mind, and early involvement of the surgical team is always encouraged. Avoidance of life-threatening complications such as toxic megacolon, hemorrhage, and perforation is the goal of any treatment for fulminant ulcerative colitis.
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72
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Shebani KO, Stucchi AF, McClung JP, Beer ER, LaMorte WW, Becker JM. Role of stasis and oxidative stress in ileal pouch inflammation. J Surg Res 2000; 90:67-75. [PMID: 10781377 DOI: 10.1006/jsre.2000.5842] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Although ileal pouch-anal anastomosis has become the operation of choice for patients with chronic ulcerative colitis and familial adenomatous polyposis coli, ileal pouch inflammation or pouchitis remains a significant postoperative complication. Numerous factors such as fecal stasis have been implicated in the etiology of pouchitis; however, pouchitis remains poorly understood due to the lack of a small animal model. One of the primary goals of this study was to surgically create a reservoir or U-pouch in the ileum of a rat in which stasis would occur in a manner that was unimpeded by other complicating factors such as a colectomy. This model would allow investigation of the hypothesis that intestinal stasis leads to biochemical changes that predispose the ileal pouch to inflammation and oxidative stress. MATERIALS AND METHODS A U-pouch was surgically created in the terminal ileum of Lewis rats just proximal to the ileocecal valve without a colectomy. Stasis was assessed by serial barium radiographs over 48 h. Thirty days after surgery, mucosa was obtained from the ileal U-pouches and nonoperated ileum to assess inflammation and neutrophil infiltration histologically and by measuring myeloperoxidase activity. Oxidative stress was assessed by measuring 8-isoprostane levels in urine. Once the model was validated and it was established that stasis and inflammation occurred in the pouch, either vitamin E or allopurinol was administered for 30 days after which myeloperoxidase and 8-isoprostane levels were again measured. RESULTS In our experimental model, ileal stasis resulted in increases in both mucosal myeloperoxidase activity and urinary 8-isoprostane levels, suggesting that oxidative stress was associated with stasis. Thirty-day treatment with vitamin E or allopurinol reduced ileal myeloperoxidase activity and urinary 8-isoprostane levels. CONCLUSION These studies demonstrated that stasis in the ileum occurred and was associated with neutrophil infiltration and oxidative stress. Antioxidant treatment reduced the inflammatory response suggesting a role for antioxidant therapy in the treatment of pouchitis.
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Affiliation(s)
- K O Shebani
- Department of Surgery, Boston University School of Medicine, Boston, MA 02118, USA
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