Inflammatory bowel disease: a survey of the epidemiology in Asia

Anti-inflammatory effects of orally administered glucosamine oligomer in an experimental model of inflammatory bowel disease

Anti-inflammatory effects of oral administration of the glucosamine oligomers (chito-oligosaccharides: COS) were evaluated in an experimental model of inflammatory bowel disease (IBD). Oral administration of COS improved shortening of colon length and tissue injury (as assessed by histology) in mice. Oral administration of COS inhibited inflammation in the colonic mucosa by suppression of myeloperoxidase activation in inflammatory cells, as well as activation of nuclear factor-kappa B, cyclooxygenase-2, and inducible nitric oxide synthase. Oral administration of COS also reduced serum levels of pro-inflammatory cytokines (tumor necrosis factor-α and interleukin-6). Moreover, it prolonged survival time in mice. These data suggest that COS have anti-inflammatory effects in an experimental model of IBD, and could be new functional foods for IBD patients.

Molecular imaging of inflammatory bowel disease

Inflammatory bowel disease (IBD) is a kind of chronic non-specific intestinal inflammatory disease of unknown etiology. Traditional imaging is difficult for early detection of mucosal lesions and is not conducive to early treatment. Colonoscopy is a kind of invasive procedure, and its clinical use is therefore limited. Molecular imaging provides a new approach for early diagnosis of IBD. In this paper, we review recent advances in molecular imaging of IBD.

Differentiation of Crohn's disease from intestinal tuberculosis by clinical and CT enterographic models

BACKGROUND

Crohn's disease (CD) and intestinal tuberculosis (ITB) have similar clinical, radiological, and endoscopic features. The objective of our study was to investigate the values of clinical features and computed tomographic (CT) enterographic manifestations in the differential diagnosis between CD and ITB.

METHODS

Clinical features and CT enterographic manifestations in a cohort of 141 patients with CD and 47 patients with ITB were reviewed retrospectively. Parameters were screened by logistic regression analysis. Furthermore, the diagnostic efficacy of screened parameters was analyzed by regression equation (mathematical model) and receiver operating characteristic curve.

RESULTS

The clinical features indicative of CD were hematochezia and perianal disease; features indicative of ITB include positive purified protein derivative skin test, occurrence of ascites, pulmonary tuberculosis, and night sweats. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of regression mathematical model established by clinical features were 94.3, 80.4, 91.0, 93.7, and 82.6%, respectively. CT enterographic manifestations indicative of CD were the involvement of the left colon, asymmetric pattern of involvement and abscess, comb sign; manifestations indicative ITB were the distribution of the lymph nodes along the right colic artery, contracture of ileocecal valve, fixed patulous ileocecal valve and lymph nodes with central necrosis The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of regression mathematical model established by CT enterographic parameters were 96.5, 93.6, 95.7, 97.8, and 89.8%, respectively.

CONCLUSIONS

The accuracy of CT enterographic model suggests the possibility of using CT enterography as an alternative to endoscopy in the differentiation between CD and ITB.

Exogenous pigment in Peyer patches of children suspected of having IBD

OBJECTIVES

The base of human Peyer patches of the terminal ileum has been noted to contain black granular pigment deposits, composed of titanium dioxide and aluminosilicate, which are food additives typically present in a Western diet, and pharmaceuticals. In the present study, we investigated the distribution of exogenous pigment throughout the gastrointestinal tract of children suspected of having inflammatory bowel disease (IBD), the correlation between their age and the presence and amount of pigment in Peyer patches, and its relation to pediatric IBD.

METHODS

Biopsies (upper and lower gastrointestinal tract) from children suspected of having IBD who underwent endoscopy, were reassessed by a blinded, expert pathologist. The amount of pigment in biopsies was scored using a semiquantitative scale (range 0 to +++).

RESULTS

A total of 151 children were included: 62 with Crohn disease (CD), 26 with ulcerative colitis, and 63 with non-IBD. In 63 children (42%), deposits of black pigment were found only in biopsies from the terminal ileum, located in Peyer patches. A significant correlation was found between increasing age and the amount of pigment (P = 0.004). Pigment deposits were found significantly less in the patients with CD compared with those in patients with ulcerative colitis and those with non-IBD (26% vs 62% and 49%, P = 0.002).

CONCLUSIONS

These results provide support for the hypothesis that the amount of pigment, only present in Peyer patches in the terminal ileum, becomes denser with increasing age. Absence of pigment in Peyer patches in a higher number of patients with CD suggests that microparticles may have become involved in the inflammatory process, possibly because of disrupted autophagy.

Gastrointestinal, liver and biliary tract pathology: a histopathological and epidemiological perspective from Pakistan with a review of the literature

AIM

To present an epidemiological and histological perspective of diseases of the gastrointestinal tract (including liver and biliary tract) at the Section of Histopathology, Department of Pathology, AKUH, Karachi, Pakistan.

MATERIALS AND METHODS

All consecutive endoscopic biopsies and resections between October 1 and December 31, 2012 were included.

RESULTS

A total of 2,323 cases were included. Carcinoma was overwhelmingly the commonest diagnosis on esophageal biopsies (69.1%); chronic helicobacter gastritis (45.6%) followed by adenocarcinoma (23.5%) were the commonest diagnoses on gastric biopsies; adenocarcinoma (27.3%) followed by ulcerative colitis (13.1%) were the commonest diagnoses on colonic biopsies; acute appendicitis (59.1%) was the commonest diagnosis on appendicectomy specimens; chronic viral hepatitis (44.8%) followed by hepatocellular carcinoma (23.4%) were the commonest diagnoses on liver biopsies; chronic cholecystitis was the commonest diagnosis (over 89%) on cholecystectomy specimens.

CONCLUSIONS

Squamous cell carcinoma comprised 88.8% of esophageal cancers. About 67% were in the lower third and 56.5% were moderately differentiated; mean ages 49.8 years for females and 55.8 years for males; 66% cases were from South West Pakistan. Over 67% patients with gastric adenocarcinoma were males; mean ages 59 and 44 years in males and females respectively, about 74% gastric carcinomas were poorly differentiated; and 62.2% were located in the antropyloric region. About 63% patients with colorectal adenocarcinoma were males; mean ages 46.1 and 50.5 years for males and females respectively; tumor grade was moderately differentiated in 54%; over 80% were located in the left colon. In 21.2% appendicectomies, no acute inflammation was found. Acute appendicitis was most common in young people. Hepatitis C (66.3%) was more common than hepatitis B (33.7%); about 78% cases of hepatocellular carcinoma occurred in males; females comprised 76.7% patients with chronic cholecystitis; and 77.8% patients with gall bladder carcinoma. All resection specimens showed advanced cancers. Most cancers occurred after the age of 50 years.

Review article: the association of diet with onset and relapse in patients with inflammatory bowel disease

BACKGROUND

The role of diet in inflammatory bowel disease (IBD) is supported by migration studies and increasing incidences in line with Westernisation.

AIM

To give a complete overview of studies associating habitual diet with the onset or relapses in ulcerative colitis (UC) or Crohn's disease (CD).

METHODS

A structured search in Pubmed, the Cochrane Library and EMBASE was performed using defined key words, including only full text papers in English language.

RESULTS

Forty-one studies were identified, investigating onset (n = 35), relapses (n = 5) or both (n = 1). Several studies reported high intake of sugar or sugar-containing foods (n = 7 UC, n = 12 CD), and low intake of fruits and/or vegetables (n = 5 UC, n = 10 CD) to be associated with an increased onset risk. However, these findings could not be confirmed by similar or higher numbers of other studies. A possible protective role was found for grain-derived products in CD onset, but results were inconsistent for dietary fibre in UC and CD and grain-derived products in UC. No definite conclusions could be drawn for unsaturated fatty acids (UFA), protein and energy intake due to limited and/or inconsistent results. Six studies reported on diet and relapse risk, of which only two (n = 1 UC, n = 1 CD) had a prospective follow-up.

CONCLUSIONS

The current evidence is not sufficient to draw firm conclusions on the role of specific food components or nutrients in the aetiology of IBD. Furthermore, large prospective studies into the role of habitual diet as a trigger of relapses are needed, to identify new therapeutic or preventive targets.

Inflammatory bowel disease: an expanding global health problem

This review provides a summary of the global epidemiology of inflammatory bowel diseases (IBD). It is now clear that IBD is increasing worldwide and has become a global emergence disease. IBD, which includes Crohn’s disease (CD) and ulcerative colitis (UC), has been considered a problem in industrial-urbanized societies and attributed largely to a Westernized lifestyle and other associated environmental factors. Its incidence and prevalence in developing countries is steadily rising and has been attributed to the rapid modernization and Westernization of the population. There is a need to reconcile the most appropriate treatment for these patient populations from the perspectives of both disease presentation and cost. In the West, biological agents are the fastest-growing segment of the prescription drug market. These agents cost thousands of dollars per patient per year. The healthcare systems, and certainly the patients, in developing countries will struggle to afford such expensive treatments. The need for biological therapy will inevitably increase dramatically, and the pharmaceutical industry, healthcare providers, patient advocate groups, governments and non-governmental organizations should come to a consensus on how to handle this problem. The evidence that IBD is now affecting a much younger population presents an additional concern. Meta-analyses conducted in patients acquiring IBD at a young age also reveals a trend for their increased risk of developing colorectal cancer (CRC), since the cumulative incidence rates of CRC in IBD-patients diagnosed in childhood are higher than those observed in adults. In addition, IBD-associated CRC has a worse prognosis than sporadic CRC, even when the stage at diagnosis is taken into account. This is consistent with additional evidence that IBD negatively impacts CRC survival. A continuing increase in IBD incidence worldwide associated with childhood-onset of IBD coupled with the diseases’ longevity and an increase in oncologic transformation suggest a rising disease burden, morbidity, and healthcare costs. IBD and its associated neoplastic transformation appear inevitable, which may significantly impact pediatric gastroenterology and adult CRC care. Due to an infrastructure gap in terms of access to care between developed vs. developing nations and the uneven representation of IBD across socioeconomic strata, a plan is needed in the developing world regarding how to address this emerging problem.

Clinical profile and predictors of disease behavior and surgery in Indian patients with Crohn's disease

BACKGROUND

Recent years have seen the emergence of Crohn's disease (CD) in India and the predictors of disease behavior and surgery in these patients are not known.

METHODS

The demographic and clinical profiles of patients diagnosed to have CD from January 1995 to December 2008 were analyzed retrospectively and associations with disease behavior and surgery were determined using multivariate analysis.

RESULTS

Two hundred and twenty-three patients (age 35 ± 14.7 years, males 57.9 %) were included. Extraintestinal manifestations were noted in 27.4 % patients. There was a median delay of 24 months to diagnosis; 66 (29.6 %) patients received antitubercular therapy prior to diagnosis. The most common site of involvement was ileocolonic (40.4 %), and the most common disease behavior was nonstricturing and nonpenetrating (57.8 %). The disease was moderate to severe in 79 %. Around 40 % patients had a relapsing course of illness. Seventy-three patients (32.7 %) had at least one surgical intervention. Independent associations with aggressive disease behavior included the presence of small bowel disease and longer duration of illness. Predictors of surgical intervention were male sex, small bowel disease, perianal disease, and aggressive disease behavior.

CONCLUSION

Diagnosis of CD is still delayed in India. Longer duration of illness predicted aggressive disease behavior. Surgery was performed more often in males with aggressive disease involving the small bowel and perianal area.

A genome-wide association study identifies 2 susceptibility Loci for Crohn's disease in a Japanese population

BACKGROUND & AIMS

Crohn's disease is an inflammatory bowel disease induced by multiple genetic and environmental factors. Genome-wide association studies have identified genetic factors that affect the risk for Crohn's disease in European populations, but information from other ethnic groups is scarce. We therefore investigated genetic factors associated with Crohn's disease in the Japanese population.

METHODS

We performed a genome-wide association study with 372 individuals with Crohn's disease (cases) and 3389 controls, all from the Japanese population. To confirm identified associations, we performed a replication study with an independent panel of 1151 Crohn's disease cases and 15,800 controls. We also performed an association analysis using genome-wide genotype imputation in the discovery cohort.

RESULTS

We confirmed associations of Crohn's disease with variants in MHC (rs7765379, P = 2.11 × 10(-59)), TNFSF15 (rs6478106, P = 3.87 × 10(-45)), and STAT3 (rs9891119, P = 2.24 × 10(-14)). We identified 2 new susceptibility loci: on chromosome 4p14 (rs1487630, P = 2.40 × 10(-11); odds ratio, 1.33), and in the SLC25A15-ELF1-WBP4 region on 13q14 (rs7329174 in ELF1, P = 5.12 × 10(-9); odds ratio, 1.27).

CONCLUSIONS

In a genome-wide association study, we identified 2 new susceptibility loci for Crohn's disease in a Japanese population. These findings could increase our understanding of the pathogenesis of Crohn's disease.

Epidemiology and Disease Burden of Ulcerative Colitis in Taiwan: A Nationwide Population-Based Study

OBJECTIVES

A rising trend of incidence and prevalence of ulcerative colitis (UC) had been noticed in Asian countries. We conducted this study to investigate the epidemiology and medical burden of UC in Taiwan.

METHODS

In this 10-year retrospective database study, we identified cases of patients with UC during 1998 to 2008 from the Taiwan National Health Insurance Research Database. Patients who had a catastrophic illness certificate were included in epidemiology and medical burden calculation.

RESULTS

There were 1522 cases identified in our study period. The incidence increased twofold from 0.37 per 100,000 in 1998 to 0.78 per 100,000 in 2008. The incidence and prevalence had an increasing trend in our population. The cases onset age was 45.0 years on average. In our survey, most of the top 20 coexisting diseases were gastrointestinally relevant diseases, anemia (9.99%), and hypertension (7.69%). There were more than 70% patients using mesalamine, and the medical expenditure on mesalamine occupied the highest position in patients with UC. The average medical expenditure of patients with UC had a decreasing trend after 2001.

CONCLUSIONS

This study had the largest sample and the longest study period for the epidemiology and medical burden estimation of UC in Taiwan. The incidence rates and medicine use of patients with UC had a definite rising trend across the years in Taiwan. Patients with anemia or choric diseases were observed in our population. More surveillance of UC-related diseases and health care costs need to be conducted in the future.

Emerging inflammatory bowel disease in saudi outpatients: a report of 693 cases

BACKGROUND/AIM

Inflammatory bowel disease (IBD) is a chronic disease of unknown etiology and considered traditionally as a disease of the western world. Recently, rising trends have been observed in countries previously known to have a low prevalence and incidence. The aim of this study is to collect epidemiological data on IBD outpatients and to add data from the Kingdom of Saudi Arabia (KSA) to the available IBD literature.

PATIENTS AND METHODS

The medical records of 693 Saudi patients with IBD over a period of 17 years, between 1993 and 2009, were reviewed. The demographic and clinical data and methods of diagnosis were retrieved.

RESULTS

The total number of patients in this cohort was 693. It constituted 238 (34.3%) ulcerative colitis (UC) and 455 (65.7%) Crohn's disease (CD) patients. UC was steady throughout the years, whereas only 1.2 CD patients were diagnosed per year in the first 11 years, and 73.7 per year in the last six years. The median age of UC patients was 34 years, ranging from 10 to 80 years with a peak between 21 and 40 years and in CD it was 27 years, ranging from 11 to 73 years with a peak between 11 and 30 years. There was a male preponderance of 1.5:1 and 2:1, respectively. The rest of the data is discussed in this study.

CONCLUSION

IBD is no longer a rare disease in KSA. UC is in a steady state, whereas CD is increasing significantly and far outnumbering UC.

The experience of fatigue in people with inflammatory bowel disease: an exploratory study

AIMS

To explore fatigue, the impact it has on daily life and the strategies used to ameliorate the symptom, as described by people with inflammatory bowel disease.

BACKGROUND

Fatigue is the most troublesome symptom during remission of inflammatory bowel disease. Fatigue affects people's daily functioning, impacting on quality of life. There is limited understanding of the nature of and the ways fatigue in inflammatory bowel disease is experienced and managed in everyday adult life.

DESIGN

An epistemological interpretive approach to understand participants' self-reported experiences of disease-related fatigue.

METHODS

A convenience sample of 46 participants was recruited from the Crohn's and Colitis UK member database. Five focus group interviews (November 2008-February 2009) were conducted, audio-recorded, transcribed, and analysed using an inductive thematic framework.

FINDINGS

Five themes were identified: the experience of fatigue, causes of fatigue, managing fatigue, consequences of fatigue, and seeking support. Fatigue had a debilitating effect on the social and emotional well-being of participants and limited their employment opportunities. People used a range of strategies to cope and reported that fatigue-related issues seemed to be poorly understood by clinicians and were not addressed in medical consultations.

CONCLUSION

Fatigue was an inextricable part of daily life for some people with inflammatory bowel disease. Specialist nurses and medical colleagues need to address the personal, social, and economic consequences of fatigue, whilst further nursing research would improve understanding of the impact of fatigue and help develop appropriate intervention strategies for people with inflammatory bowel disease.

Survey of inflammatory bowel diseases in India

INTRODUCTION

Inflammatory bowel disease (IBD), both ulcerative colitis (UC) and Crohn's disease (CD), once thought to be uncommon, is now seen commonly in India. The Indian Society of Gastroenterology (ISG) Task Force on IBD decided to collate data on the clinical spectrum of IBD currently prevailing in India.

METHODS

An open call to members of ISG was given through publication of a proforma questionnaire in the Indian Journal of Gastroenterology and the web portal of ISG. The proforma contained questions related with demographic features, family history, risk factors, clinical manifestations and characteristics, course of disease, and pattern of treatment of IBD.

RESULTS

Of 1,255 filled questionnaires received, 96 were rejected and 1,159 (92.3 %) were analyzed. This comprised data on 745 (64.3 %) patients with UC, 409 (35.3 %) with CD, and 5 with indeterminate colitis. The median duration of illness was longer in patients with CD (48 months) compared to those with UC (24 months) (p = 0.002). More than one half of patients (UC 51.6 %, CD 56.9 %) had one or more extraintestinal symptoms. A definite family history of IBD was present in 2.9 % (UC 2.3 % and CD 4.6 %; p = 0.12). The extent of disease in UC was pancolitis 42.8 %, left-sided colitis 38.8 %, and proctitis alone in 18.3 %. The extent of disease involvement in CD was both small and large intestine in 39.6 %, colon alone in 31.4 % and small intestine alone in 28.9 %. Stricturing and fistulizing disease were noted in 18.8 % and 4.4 % of patients with CD respectively. Chronic continuous and intermittent disease course were present in 35.5 % and 47.2 % of UC patients respectively, and in 23.1 % and 68.8 % of CD patients. Four percent of patients with UC had undergone colectomy, while 15.2 % of patients with CD underwent surgical intervention.

CONCLUSIONS

The present survey provides a reasonable picture of the demographic features and clinical manifestations of Indian patients with IBD, their risk factors, course of disease, and the treatment given to them.

A cheese-containing diet modulates immune responses and alleviates dextran sodium sulfate-induced colitis in mice

Diet has a significant effect on immune and inflammatory responses. To date, no studies have described how consumption of a diet containing a relatively high amount of cheese affects immune responses and the inflammatory status of the body. We examined these responses in normal mice and mice with dextran sodium sulfate (DSS)-induced colitis associated with increased inflammatory responses, using a diet containing approximately 44% of a whole cheese powder and a diet containing casein, lard, and corn oil as the control. In normal mice, consumption of the cheese-containing diet induced regulatory T cells (T(reg)), which regulate immune and inflammatory responses, and suppressed the production of IL-17, IL-4, and IL-10 in Peyer's patch cells from the intestine. The T(reg) population and cytokine production were not altered in spleen cells. In mice with DSS-induced colitis, consumption of the cheese-containing diet alleviated the symptoms of colitis, as evidenced by prevention of body weight loss and colon length shortening, and inhibition of an increase in the disease activity index, which includes diarrhea and fecal bleeding. This relief of clinical symptoms was also associated with decreased production of proinflammatory cytokines (IL-17 and IL-6) and increased production of the antiinflammatory cytokine transforming growth factor-β1 in Peyer's patch cells. The T(reg) population was reduced by consumption of the cheese-containing diet in Peyer's patch cells and spleen cells, which might reflect the alleviated symptoms of colitis. Consumption of the cheese-containing diet compared with the control diet enhanced antiinflammatory and immune regulatory responses in normal mice and in a DSS-colitis mouse model.

Progress in the diagnosis of ileocecal lesions

The ileocecal area includes the ileocecal valve, terminal ileum, cecum, appendix, and top ascending colon. Since this area may be affected by pathologic conditions that are either common throughout the gastrointestinal system or exclusive to this area, a great variety of intestinal diseases may arise in this region, making the diagnosis of ileocecal lesions difficult. In clinic, the diagnosis of ileocecal lesions depends on the combination of disease history, clinical features, imaging and endoscopic findings. The development of advanced imaging and endoscopy technology has greatly increased the detection rate of ileocecal lesions. In this review, we discuss the use of imaging and endoscopic examinations for evaluation of ileocecal area to help ensure accurate diagnosis and appropriate treatment.

Effects of family history on inflammatory bowel disease characteristics in Japanese patients

BACKGROUND

Although the prevalence of inflammatory bowel disease (IBD) is reported to have reached a plateau in Western countries, it is increasing in Asia. The etiology of IBD is still under investigation. We performed an epidemiological study to clarify the characteristics of IBD in Japan, focusing on patients' family history.

METHODS

We obtained clinical data on ulcerative colitis (UC) (46,114 cases) and Crohn's disease (CD) (11,305 cases) in 2007 from an electronic database maintained under the Japanese Ministry of Health, Labour and Welfare's nationwide registry system, and analyzed the differences in disease characteristics between patients with IBD who had a family history of the disease and those who did not.

RESULTS

A total of 2.7% of the patients with UC and 2.6% of those with CD had a family history. The present age and age at disease onset were lower among the patients with UC who had a family history than among those without (present age: p < 0.001; age at disease onset: p < 0.001; Mann-Whitney U-test), but no similar trend was observed in the patients with CD. Disease severity was worse among both the UC and CD patients with a family history. The clinical course of patients with UC was not affected by family history. Levels of independence in daily life were associated with family history among CD patients, whereas age was associated with levels of independence in daily life among UC patients.

CONCLUSION

Disease characteristics of IBD vary in some aspects according to the presence or absence of a family history.

An update of the role of nutritional therapy in the management of Crohn's disease

Crohn's disease is an increasingly global health concern. Currently without a cure, it significantly alters the quality of life of Crohn's disease sufferers and places a heavy financial burden on the community. Recent reports show that the rising prevalence of Crohn's disease is no longer confined to Western countries, with considerable increases seen particularly in Asia. Nutritional problems are often associated with Crohn's disease, most notably in the paediatric population, with underweight and stunting commonly seen at presentation. In addition, linear growth retardation and pubertal delay can also manifest in these younger patients. Therefore, exclusive enteral nutrition has been used as a therapeutic option to treat Crohn's disease, in part to address the nutritional complications of the disease. Exclusive enteral nutrition can improve nutrition as well as induce remission at a rate equivalent to corticosteroids. It is safe particularly with long-term use and can induce mucosal healing, considered the gold standard for therapy, at a rate superior to corticosteroids. Exclusive enteral nutrition has thus become the preferred therapeutic option in many centres for the treatment of paediatric Crohn's disease. This review discusses the role of exclusive enteral nutrition as a therapeutic option for the treatment of Crohn's disease, as well as the latest findings into its mechanisms of action.

Proteome profiling of spinal cord and dorsal root ganglia in rats with trinitrobenzene sulfonic acid-induced colitis

AIM: To investigate proteomic changes in spinal cord and dorsal root ganglia (DRG) of rats with trinitrobenzene sulfonic acid (TNBS)-induced colitis.

METHODS: The colonic myeloperoxidase (MPO) activity and tumor necrosis factor-α (TNF-α) level were determined. A two-dimensional electrophoresis (2-DE)-based proteomic technique was used to profile the global protein expression changes in the DRG and spinal cord of the rats with acute colitis induced by intra-colonic injection of TNBS.

RESULTS: TNBS group showed significantly elevated colonic MPO activity and increased TNF-α level. The proteins derived from lumbosacral enlargement of the spinal cord and DRG were resolved by 2-DE; and 26 and 19 proteins that displayed significantly different expression levels in the DRG and spinal cord were identified respectively. Altered proteins were found to be involved in a number of biological functions, such as inflammation/immunity, cell signaling, redox regulation, sulfate transport and cellular metabolism. The overexpression of the protein similar to potassium channel tetramerisation domain containing protein 12 (Kctd 12) and low expression of proteasome subunit α type-1 (psma) were validated by Western blotting analysis.

CONCLUSION: TNBS-induced colitis has a profound impact on protein profiling in the nervous system. This result helps understand the neurological pathogenesis of inflammatory bowel disease.

Efficacy and safety of Fufangkushen colon-coated capsule in the treatment of ulcerative colitis compared with mesalazine: a double-blinded and randomized study

ETHNOPHARMACOLOGICAL RELEVANCE

Fufangkushen colon-coated capsule (FCC) was a newly developed herbal drug for treating ulcerative colitis (UC) patients with traditional Chinese medicine (TCM) pattern of damp-heat accumulating in the interior.

OBJECTIVE

To explore the efficacy and safety of FCC in the treatment of active UC compared with Huidi (HD, mesalazine enteric-coated tablets) were evaluated in a double-blinded and randomized clinical trial.

MATERIALS AND METHODS

In the double-blind, double-dummy, multicenter, randomized and controlled study, 320 active UC patients with TCM pattern of damp-heat accumulating in the interior were assigned to two groups: 240 treated with FCC plus HD placebo treatment, 80 with HD plus FCC placebo. The drugs and their corresponding placebos were administrated at advised dosage for 8 weeks. The primary endpoint was a positive clinical response at week 8, and Mayo scoring system was employed for assessment of UC activity.

RESULTS

At the 8th week, 72.50% of patients in FCC group (170 of 234) and 65.00% of patients in HD group (52 of 80) had achieved a clinical response. There was no statistically significance between the 2 groups (P>0.05). The proportions of patients who had a clinical remission was similar in 2 groups (41.50% in FCC group, 41.25% in HD group, P>0.05), mucosal healing rate at week 8 in the two groups were also without significant difference (55.13% in FCC group, 55.00% in HD group, P>0.05). Mayo scores at week 8 showed no statistically difference in the two groups. No significant differences were observed between the safety profiles of the 2 groups (P>0.05). No severe AEs were reported in either group. The latent class analysis indicated that FCC was superior applicable for the left hemicolon involved patients than HD.

CONCLUSIONS

Compared with HD, a mesalamine enteric-coated tablet, FCC is similarly effective and safe in the treatment of active UC with TCM pattern of damp-heat accumulation interior pattern. In addition, FCC indicates superior effect in the treatment of UC with inflamed area of the left hemicolon than HD.

Cost-utility analysis of biologic treatments for moderate-to-severe Crohn's disease

STUDY OBJECTIVE

To compare the cost versus utility of four guideline-recommended biologic treatments-infliximab, adalimumab, certolizumab pegol, and natalizumab-for the treatment of Crohn's disease from a United States payer perspective.

DESIGN

Cost-utility decision analytic model using a Monte Carlo simulation of 10,000 cases.

DATA SOURCE

Published primary and tertiary literature.

PATIENTS

Patients with moderate-to-severe Crohn's disease, as categorized by the Crohn's Disease Activity Index, that failed to respond to standard therapy and who were treatment naive to biologics.

MEASUREMENTS AND MAIN RESULTS

The decision analytic model base case was a 35-year-old patient weighing 70 kg with moderate-to-severe Crohn's disease. Therapeutic efficacy data were obtained from published clinical trials. Online prescription drug, hospitalization data, and Current Procedural Terminology codes were used to estimate cost. Utility measures were estimated using published data obtained from patients with Crohn's disease. The time end point used for the model was 54 weeks. The analysis demonstrated considerable overlap in quality-adjusted life years gained with the four agents (i.e., mean values across four treatments 0.79-0.80). Although infliximab had the lowest median cost, there was overlap in the 95% confidence intervals (CIs) compared with the other three biologic products: mean (95% CI) cost for infliximab $22,663 ($19,105-26,433), adalimumab $27,515 ($23,796-31,584), certolizumab pegol $29,062 ($24,952-33,882), and natalizumab $31,166 ($25,915-37,195). However, the cost-effectiveness acceptability curve demonstrated that infliximab had the most scenarios (95.2%) when it was the most cost-effective biologic therapy using a willingness-to-pay threshold of $100,000/quality-adjusted life years gained.

CONCLUSION

Patients with moderate-to-severe Crohn's disease that failed to respond to standard treatment should preferentially receive infliximab as their initial biologic treatment, since this agent had the highest probability of being the most cost-effective therapy compared with the other biologic treatment options.

Attenuation of colonic inflammation by partial replacement of dietary linoleic acid with α-linolenic acid in a rat model of inflammatory bowel disease

Increasing prevalence of inflammatory bowel disease may be due to imbalance in the intake of n-6 and n-3 PUFA in the diet. This study investigates the impact of varying ratios of dietary linoleic acid (LA, 18 : 2n-6) to α-linolenic acid (ALA, 18 : 3n-3) on the inflammatory response in dextran sulphate sodium (DSS)-induced colitis. Weanling male Sprague-Dawley rats were divided into five groups: a non-colitic group with a LA:ALA ratio of 215 (CON-215), and colitic groups with LA:ALA ratios of 215 (DSS-215), 50 (DSS-50), 10 (DSS-10) and 2 (DSS-2). Blends of groundnut, palmolein and linseed oils were used to provide varying LA:ALA ratios. All the rats were fed the respective experimental isoenergetic diets containing 10 % fat for 90 d and DSS was administered during the last 11 d. Colonic inflammation was evaluated by clinical, biochemical and histological parameters. The results showed attenuation of colitis in the DSS-2 group as evidenced by significant reductions in disease activity index, mucosal myeloperoxidase activity (P < 0·05), alkaline phosphatase activity (P < 0·01) and increase in colon length (P < 0·01) compared to the groups fed with higher ratios (DSS-215). This was accompanied by significant reductions in mucosal proinflammatory cytokines TNF-α (P < 0·01) and IL-1β (P < 0·01) and improvement in the histological score. Further, ALA supplementation increased long-chain (LC) n-3 PUFA and decreased LC n-6 PUFA in colon structural lipids. These data suggest that substitution of one-third of LA with ALA (LA:ALA ratio 2) mitigates experimental colitis by down-regulating proinflammatory mediators.

A neutraceutical by design: the clinical application of curcumin in colonic inflammation and cancer

Unquestionably, the natural food additive curcumin, derived from the colorful spice turmeric used in many Asian cuisines, possesses a diverse array of biological activities. These range from its anti-inflammatory, antineoplastic, and metabolic modifying properties to surprising roles in disorders ranging from Alzheimer's disease to cystic fibrosis. Its effects on growth factor receptors, signaling molecules, and transcription factors, together with its epigenetic effects are widely considered to be extraordinary. These pleiotropic attributes, coupled with its safety even when used orally at well over 10 g/day, are unparalleled amongst pharmacological agents. However, there is one drawback; apart from the luminal gastrointestinal tract where its pharmacology predicts that reasonable drug levels can be attained, its broader use is hampered by its poor solubility and hence near undetectable plasma levels. Medicinal chemistry and nanotechnology have resulted in the generation of compounds where the modified drug or its delivery system has improved matters such that this shortcoming has been addressed to some extent, with the surprising finding that it remains safe to use. It is predicted that either the parental compound or its derivatives may eventually find a place in the therapeutic management protocols of several conditions.

Food intolerance and inflammatory bowel disease

AIM: To explore the relationship between food intolerance and inflammatory bowel disease (IBD).

METHODS: One hundred and forty-three patients with IBD, including 97 patients with ulcerative colitis and 46 patients with Crohn's disease were included in the study. Forty-seven healthy subjects served as normal controls. Serum levels of specific IgG antibodies to 14 food allergens were semi-quantitatively measured by ELISA.

RESULTS: The positive rates of food-specific IgG antibodies were 75.52% (108/143) in patients with IBD, 78.35% (76/97) in patients with UC and 69.57% (32/46) in patients with CD, all of which were significantly higher than that in the control group (17.02%) (all P < 0.05). There were no significant differences in the positive rates of food-specific IgG antibodies between patients with IBD, UC, or CD (all P > 0.05). Of 14 kinds of food tested, the percentage of IBD patients developing food intolerance ranged from 1.39% (beef, mushroom) to 45.46% (egg). Egg was most likely to be intolerable, followed by shrimp, crab, corn, milk, rice, and codfish.

CONCLUSION: Food intolerance may be one of the causes of IBD. Testing the levels of food-specific IgG antibodies can provide reference for clinical diagnosis and treatment of IBD.

Risk of inflammatory bowel disease in first- and second-generation immigrants in Sweden: a nationwide follow-up study

BACKGROUND

The objective was to analyze whether there is an association between country of birth in first-generation immigrants and first hospitalization for an inflammatory bowel disease, and to study whether any such association remains in second-generation immigrants.

METHODS

In this follow-up study a nationwide research database at Lund University was used to identify all primary hospital diagnoses of Crohn's disease (CD) and ulcerative colitis (UC) in all first- and second-generation immigrants in Sweden between January 1, 1964, and December 31, 2007. Standardized incidence ratios (SIRs) with regard to age, gender, time period, geographical region, and socioeconomic status were estimated in first- and second-generation immigrants.

RESULTS

No increased but some decreased risks for CD and UC were found among first-generation immigrants. These decreased risks partly remained in the second generation. Moreover, second-generation immigrants of Danish, Eastern European, and Iraqi origin had higher risks of CD than the reference group. Second-generation immigrants of Finnish and Iranian origin had higher risks of UC.

CONCLUSIONS

Decreased risks of CD and UC found in some first-generation immigrant groups partly persisted in the second generation. For some immigrant groups, increased risks of CD or UC emerged in the second generation.

Upregulated mRNA expression of major histocompatibility complex class I chain-related gene A in colon and activated natural killer cells of Chinese patients with ulcerative colitis

OBJECTIVE

To explore the expression of major histocompatibility complex class I chain-related gene A (MICA) and its ligand in colonic mucosa and the role of MICA-natural killer (NK) group 2D (NKG2D) interaction in activating NK cells in ulcerative colitis (UC) patients.

METHODS

Intestinal mucosal biopsies were obtained from patients with UC and the controls. The expression of major histocompatibility complex class I-related gene (MIC) genes was determined by a reverse transcription polymerase chain reaction (RT-PCR) and the imaging of MICA expressed on colonic mucosa was measured by confocal microscopy resonance scanning. NKG2D and intracellular interferon (IFN)-γ expressions on NK cells were assayed by flow cytometry.

RESULTS

The relative amount of MICA mRNA in the colonic mucosa of UC patients was significantly higher than in that of the controls (3.5408 ± 2.6658 vs 1.0477 ± 0.7201, P = 0.001), as were the major histocompatibility complex class I chain-related gene B (MICB) (8.9879 ± 3.2893 vs 4.6293 ± 1.2616, P < 0.001) and NKG2D mRNA expression (2.4395 ± 0.8147 vs 1.1624 ± 0.3954, P < 0.001). Confocal microscopy resonance scanning had shown that MICA was localized predominantly on the basolateral membranes of the epithelium. Further flow cytometry confirmed that the percentage of IFN-γ producer NK cells that expressed NKG2D in peripheral blood lymphocytes was higher in UC patients than in the healthy controls (45.36% ± 12.47% vs 27.45% ± 9.30%, P < 0.001).

CONCLUSION

MICA, MICB and NKG2D were upregulated in the colonic mucosa of UC and were associated with activating NK cells with promoted NKG2D and IFN-γ production.

Predictors of clinical and endoscopic findings in differentiating Crohn's disease from intestinal tuberculosis

BACKGROUND

There are many similarities and overlaps in clinical manifestations and ileocolonoscopic features between Crohn's disease (CD) and intestinal tuberculosis (ITB). Differentiation between CD and ITB is of great importance.

AIM

To investigate the values of clinical and endoscopic findings in differential diagnosis between CD and ITB.

METHODS

Clinical and endoscopic features of a cohort of 130 cases of CD and 122 cases of ITB from June 2003 to February 2009 were retrospectively reviewed following predetermined criteria. Parameters were screened by logistic regression analysis. Furthermore, the diagnostic efficacy of screened parameters was analyzed by regression equation (mathematical model) and receiver operating characteristic curve (ROC curve).

RESULTS

The clinical features helpful in differentiating CD from ITB are hematochezia, intestinal surgery, perianal diseases, pulmonary tuberculosis, ascites, and positive of PPD skin test; the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of regression mathematical model established by clinical features were 90.3, 76.8, 83.8, 80.7, and 88.0%, respectively. The endoscopic features helpful in differentiating CD from ITB were rectum involved lesions, longitudinal ulcer, cobblestone appearance, fixed-open ileocecal valve, transverse ulcer, and rodent ulcer; the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of regression mathematical model established by endoscopic features were 82.9, 82.0, 82.5, 82.9, and 82.0%, respectively.

CONCLUSIONS

It was proposed that a diagnostic algorithm based on available clinical and endoscopic regression equation could improve the current sensitivity, specificity, and accuracy in differentiating between CD from ITB.

Effect of cytotoxic T lymphocyte-associated molecule 4 1661 gene polymorphism on its expression and transcription in ulcerative colitis

OBJECTIVE

Our aim was to investigate the expression of cytotoxic T lymphocyte-associated molecule 4 (CTLA-4) in ulcerative colitis (UC) and to evaluate the effect of CTLA-4 gene -1661A/G polymorphism on CTLA-4 expression and transcription.

METHODS

A total of 20 UC patients and 22 healthy controls matched by age and sex were enrolled at Zhongnan Hospital of Wuhan University in central China. The CTLA-4 -1661A/G polymorphism was genotyped by the polymerase chain reaction-restriction fragment length polymorphism method. A Western blot analysis was performed to determine the full length CTLA-4 (flCTLA-4) protein expression in the peripheral blood of the UC patients. Serum-soluble CTLA-4 (sCTLA-4) levels were measured by enzyme-linked immunosorbent assay. CTLA-4-1661G mutant promoter transcription function was analyzed by site-directed PCR-based mutagenesis.

RESULTS

CTLA-4 protein expression on CD4(+) T cells in UC patients was lower than that in the healthy controls (P < 0.001) while serum sCTLA-4 in the UC patients was significantly higher than that in the healthy controls (P < 0.001). No correlation was found between flCTLA-4 and sCTLA-4 expression levels and the -1661 A/G polymorphism of the CTLA-4 gene. Meanwhile, CTLA-4 -1661 allele A had no significant impact on the promoter activity compared with allele G (P > 0.05).

CONCLUSION

CTLA-4 expressions were aberrant in UC patients compared with the healthy controls. CTLA-4 -1661A/G polymorphism had no significant impact on CTLA-4 expression and transcription in the peripheral CD4 T cells of UC patients.

Alteration of the murine gut microbiota during infection with the parasitic helminth Heligmosomoides polygyrus

BACKGROUND

In a murine model of inflammatory bowel disease (IBD), treatment of colitis in IL-10 gene-deficient mice with the parasitic helminth Heligmosomoides polygyrus ameliorates colonic inflammation. The cellular and molecular mechanisms driving this therapeutic host response are being studied vigorously. One proposed mechanism is that H. polygyrus infection favors the outgrowth or suppression of certain bacteria, which in turn help modulate host immunity.

METHODS

To quantify the effect of H. polygyrus infection on the composition of the gastrointestinal (GI) tract microbiota, we conducted two independent microbial ecology analyses of C57BL/6 mice. We obtained and analyzed 3,353 bacterial 16S rRNA encoding gene sequences from the ileum and cecum of infected and uninfected mice as well as incective H. polygyrus larvae at the outset of the second experiment and adult worms taken directly from the mouse duodenum at the end of the second experiment.

RESULTS

We found that a significant shift in the abundance and relative distribution of bacterial species in the ileum of mice is associated with H. polygyrus infection. Members of the bacterial family Lactobacillaceae significantly increased in abundance in the ileum of infected mice reproducibly in two independent experiments despite having different microbiotas present at the outset of each experiment.

CONCLUSIONS

These data support the concept that helminth infection shifts the composition of intestinal bacteria. The clinical consequences of these shifts in intestinal flora are yet to be explored.

A family report of Crohn's disease in three children immigrating from Albania to Greece and review of the literature

Cases of immigrant families affected by IBD have rarely been reported and seem to be of exceptional interest towards a better understanding of disease aetiopathogenesis. The first case of Crohn's disease in a family of immigrants from Albania to Greece with three offspring is described herein. A family with three children, one 22 year-old male and two 18-year-old twin females immigrated from southern Albania to northwest Greece ten years ago. The whole family lived in the same house and had no previous history of bowel or other chronic diseases. Two years ago the boy complained of diarrhoea, perianal pain and loss of weight. Subsequent investigation revealed ileal and perianal Crohn's disease. One year after Crohn's disease was diagnosed in the boy, one of the twins was diagnosed with ileal Crohn's disease. Six months afterwards, the second twin underwent emergency appendectomy due to acute appendicitis; four months later she was diagnosed with ileal Crohn's disease. Genetically predisposed individuals seem to be vulnerable to a continuous pressure of a still unknown environmental factor(s). In addition, lifestyle modification seems to represent a predisposing factor toward inflammatory bowel disease in immigrants.

Inflammatory bowel disease: Established and evolving considerations on its etiopathogenesis and therapy

Modern studies of inflammatory bowel disease (IBD) pathogenesis have been pursued for about four decades, a period of time where the pace of progress has been steadily increasing. This progress has occurred in parallel with and is largely due to developments in multiple basic scientific disciplines that range from population and social studies, genetics, microbiology, immunology, biochemistry, cellular and molecular biology, and DNA engineering. From this cumulative and constantly expanding knowledge base the fundamental pillars of IBD pathogenesis appear to have been identified and consolidated during the last couple of decades. Presently there is a general consensus among basic IBD investigators that both Crohn's disease (CD) and ulcerative colitis (UC) are the result of the combined effects of four basic components: global changes in the environment, the input of multiple genetic variations, alterations in the intestinal microbiota, and aberrations of innate and adaptive immune responses. There is also agreement on the conclusion that none of these four components can by itself trigger or maintain intestinal inflammation. A combination of various factors, and most likely of all four factors, is probably needed to bring about CD or UC in individual patients, but each patient or set of patients seems to have a different combination of alterations leading to the disease. This would imply that different causes and diverse mechanisms underlie IBD, and this could also explain why every patient displays his or her own clinical manifestations and a personalized response to therapy, and requires tailored approaches with different medications. While we are becoming increasingly aware of the importance of this individual variability, we have only a superficial notion of the reasons why this occurs, as hinted by the uniqueness of the genetic background and of the gut flora in each person. So, we are apparently facing the paradox of having to deal with the tremendous complexity of the mechanisms responsible for chronic intestinal inflammation in the setting of each patient's individuality in the response to this biological complexity. This obviously poses considerable challenges to reaching a full understanding of IBD pathogenesis, but being aware of the difficulties is the first step in finding answers to them.

Role of PPAR-gamma in inflammation. Prospects for therapeutic intervention by food components

Peroxisome proliferator activated receptor gamma (PPARγ) is a ligand-dependent transcription factor and a member of the nuclear receptor superfamily. Acting as sensors of hormones, vitamins, endogenous metabolites and xenobiotic compounds, the nuclear receptors control the expression of a very large number of genes. PPARγ has been known for some time to regulate adipocyte differentiation, fatty acid storage and glucose metabolism, and is a target of anti-diabetic drugs. More recently, PPARγ has been recognized as playing a fundamentally important role in the immune response through its ability to inhibit the expression of inflammatory cytokines and to direct the differentiation of immune cells towards anti-inflammatory phenotypes. A feature of PPARγ is the structural diversity of its ligands, which encompass endogenous metabolites, dietary compounds and synthetic drugs. The high and increasing incidence of inflammatory and allergic disease, coupled with encouraging results from recent clinical trials, suggest that natural PPARγ agonists found in foods may be beneficial to human health by acting as anti-inflammatory molecules. PPARγ is therefore not only a target of the pharmaceutical industry, but also of great potential interest to the food industry, since it is activated by several natural dietary constituents. The prospects for dietary intervention in inflammatory disease have improved somewhat over the last few years, and are reviewed here.

Neuro-endocrine-immune network and inflammatory bowel disease

Inflammatory bowel disease (IBD) is a group of chronic inflammatory gastrointestinal diseases of unknown etiology, including mainly ulcerative colitis (UC) and Crohn's disease (CD). Numerous studies have indicated that there is considerable relationship between the pathogenesis of IBD and the neuro-endocrine-immune network. This article will describe the essential role of the neuro-immune-endocrine network in the development of IBD in terms of the hypothalamus-autonomic nervous system (HANS) axis, hypothalamic-pituitary-adrenal (HPA) axis and immunity.

Inflammatory bowel disease in the Asia-Pacific area: a comparison with developed countries and regional differences

The Asia-Pacific region has been marked as an area with a low incidence of inflammatory bowel disease (IBD), although confusion always existed as to whether this low incidence was a result of low diagnostic awareness, a high incidence of infective diarrhoea and its diagnostic overlap or a true low incidence. As epidemiological studies from this region are being made available it is clear that the incidence and prevalence rates of IBD in Asia-Pacific region are low compared with Europe and North America. They are however, increasing rapidly. There are substantial variations in the incidence and prevalence rates of IBD in various ethnic groups in Asia. The highest incidence rates are recorded from India, Japan and the Middle East and there exists a genetic predisposition of South Asians (Indians, Pakistanis and Bangladeshis) to ulcerative colitis (UC). It appears that certain racial groups are more prone than others to develop IBD. For instance, Indians in South-East Asia have higher rates than Chinese and Malays. While there is a host genetic predisposition, environmental factor(s) may be responsible for this difference. The clinical phenotypes and complication rates of Asian IBD resemble those of the Caucasian population in general, but some heterogeneity is observed in different regions of Asia. There is no evidence of a north-south or an east-west divide in the Asia-Pacific region. The available studies suggest an increasing incidence of UC in the Asia-Pacific region and hence it is an appropriate time to launch well-designed epidemiological studies so that etiopathogenetic factors can be identified. There is a male predominance in Crohn's disease in the Asian population. The NOD2/CARD15 gene is not associated with CD in the Japanese, Korean, Chinese and Indian population.

Geographical variation of Crohn's disease residual incidence in the Province of Quebec, Canada

Background

Crohn's disease (CD) is clinically expressed as a chronic affection of the gastrointestinal tract currently known to have a multifactorial etiology involving a complex pathophysiological host response modulated by genetic susceptibilities, demographic determinants and environmental factors. With more than 20 cases per 100,000 person-years, the province of Quebec, Canada is among regions of the world with highest reported occurrence of CD in relation to other places where comparable estimates are available. This ecological study was designed to provide a medium-scale spatial exploration of CD incidence after accounting for the influence of known population and regional determinants. Health records of consulting patients in southern Quebec were compiled from 1995 to 2000 and used to estimate age and sex standardized rates per health area (n = 156). Various statistical models taking into account the regional effect of Jewish ethnicity, aboriginal ancestry, material deprivation, prescription for oral contraceptives, reportable enteric infection incidence, smoking as well as latitude and longitude locations were fitted.

Results

The final regression model presented a coefficient of determination of 22.8% and there was evidence of an eastern trend in the residual incidence (p = 0.018). Overall, the smoothed residual incidence presented a heterogeneous spatial pattern with evidence of patches (multiple health areas) of high, low and contrasting values. Health areas with most extreme incidence residuals where also distributed over the whole province including one area in the metropolitan area of Montreal and others in surrounding areas.

Conclusions

These findings suggest that known populational and regional factors derived through census information only explain a limited fraction of the geographical variation of CD incidence and lead to speculate that the effects of these factors may be incompletely captured (imperfect construction of proxy variables) or that other important factors remain unmeasured. In this view, markers of genetic profiles of homogeneous sub-populations, and other factors linked to agroenvironmental microbial exposure should be further investigated. Once accounting for known factors, it would also be worth comparing adjacent geographical areas demonstrating abrupt changes in residual incidence rates to further explore effect linked to regional factors from those resulting from various reporting systems.

Prevalence of inflammatory bowel disease in two districts of Sri Lanka: a hospital based survey

Background

Inflammatory bowel disease (IBD) is being increasingly diagnosed in Asia. However there are few epidemiological data from the region.

Methods

To determine prevalence and clinical characteristics of IBD, a hospital-based survey was performed in the Colombo and Gampaha districts (combined population 4.5 million) in Sri Lanka. Patients with established ulcerative colitis (UC) and Crohn's disease (CD), who were permanent residents of these adjoining districts, were recruited from hospital registries and out-patient clinics. Clinical information was obtained from medical records and patient interviews.

Results

There were 295 cases of IBD (UC = 240, CD = 55), of which 34 (UC = 30, CD = 4) were newly diagnosed during the study year. The prevalence rate for UC was 5.3/100,000 (95% CI 5.0-5.6/100,000), and CD was 1.2/100,000 (95% CI 1.0-1.4/100,000). The incidence rates were 0.69/100,000 (95% CI 0.44-0.94/100,000) for UC and 0.09/100,000 (95% CI 0.002-0.18/100,000) for CD. Female:male ratios were 1.5 for UC and 1.0 for CD. Mean age at diagnosis was (males and females) 36.6 and 38.1y for UC and 33.4 and 36.2y for CD. Among UC patients, 51.1% had proctitis and at presentation 58.4% had mild disease. 80% of CD patients had only large bowel involvement. Few patients had undergone surgery.

Conclusions

The prevalence of IBD in this population was low compared to Western populations, but similar to some in Asia. There was a female preponderance for UC. UC was mainly mild, distal or left-sided, while CD mainly involved the large bowel.

The Asia-Pacific consensus on ulcerative colitis

Inflammatory bowel disease (IBD) is increasing in many parts of the Asia-Pacific region. There is a need to improve the awareness of IBD and develop diagnostic and management recommendations relevant to the region. This evidence-based consensus focuses on the definition, epidemiology and management of ulcerative colitis (UC) in Asia. A multi-disciplinary group developed the consensus statements, reviewed the relevant literature, and voted on them anonymously using the Delphi method. The finalized statements were reviewed to determine the level of consensus, evidence quality and strength of recommendation. Infectious colitis must be excluded prior to diagnosing UC. Typical histology and macroscopic extent of the disease seen in the West is found in the Asia-Pacific region. Ulcerative colitis is increasing in many parts of Asia with gender distribution and age of diagnosis similar to the West. Extra-intestinal manifestations including primary sclerosing cholangitis are rarer than in the West. Clinical stratification of disease severity guides management. In Japan, leukocytapheresis is a treatment option. Access to biologic agents remains limited due to high cost and concern over opportunistic infections. The high endemic rates of hepatitis B virus infection require stringent screening before initiating immune-suppressive agents. Vaccination and prophylactic therapies should be initiated on a case-by-case basis and in accordance with local practice. Colorectal cancer complicates chronic colitis. A recent increase in UC is reported in the Asia-Pacific region. These consensus statements aim to improve the recognition of UC and assist clinicians in its management with particular relevance to the region.

Screening of clinical and endoscopic parameters for differentiating Crohn's disease from intestinal tuberculosis by logistic regression analysis

AIM: To evaluate the value of clinical and endoscopic parameters for differential diagnosis of Crohn's disease (CD) from intestinal tuberculosis (ITB).

METHODS: The clinical and colonoscopic data from 130 CD patients and 122 ITB patients, who were treated from June 2003 to February 2009, were analyzed retrospectively. The parameters for differentiating CD from ITB were screened by logistic regression analysis. The diagnostic efficacy of the screened parameters was analyzed using the regression equation and receiver operating characteristic (ROC) curve.

RESULTS: The clinical parameters helpful in differentiating CD from ITB include bloody stools, history of intestinal surgery, perianal diseases, history of pulmonary tuberculosis, ascites and positive PPD skin test. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of regression mathematical model established using these clinical parameters are 90.3%, 76.8%, 83.8%, 80.7% and 88.0%, respectively. The endoscopic parameters helpful in differentiating CD from ITB include retcum involvement, longitudinal ulcer, cobblestoning, stuck open ileocecal valve, ring ulcer and rodent ulcer. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of regression mathematical model established using these endoscopic parameters are 82.9%, 82.0%, 82.5%, 82.9% and 82.0%, respectively.

CONCLUSION: The parameters screened may aid in distinguishing CD from ITB. The regression mathematical model established using clinical and endoscopic parameters can help improve the sensitivity and accuracy of differential diagnosis between CD and ITB.

Comparison of the pathologic characteristics of biopsy and operative specimens between Crohn's disease and intestinal tuberculosis: an analysis of 148 cases

AIM: To explore the distinctive diagnostic features of biopsy and operative specimens between Crohn's disease and intestinal tuberculosis.

METHODS: A retrospective study was performed to analyze the pathological features of 110 biopsy specimens (55 from patients with Crohn's disease, and 55 from patients with intestinal tuberculosis) and 38 operative specimens (29 from patients with Crohn's disease, and 9 from patients with intestinal tuberculosis). The value of these pathological features in differential diagnosis of the two diseases was analyzed.

RESULTS: Pathologic parameters of biopsy specimens helpful in differentiating Crohn's disease from intestinal tuberculosis included broadened submucosa, fissure-like ulcer, and granuloma (37.5% vs 14.0%, 10.9% vs 0%, and 10.9% vs 43.6%, respectively; all P < 0.05). Pathologic parameters of operative specimens helpful in differentiating Crohn's disease from intestinal tuberculosis included broadened submucosa, fissure-like ulcer, broadened muscularis propria, cobblestone appearance, and granuloma (51.7% vs 11.1%, 34.5% vs 0%, 62.1% vs 11.1%, 37.9% vs 0%, and 20.7% vs 77.8%, respectively; all P < 0.05).

CONCLUSION: The pathological features of biopsy specimens have limited value in differential diagnosis of Crohn's disease and intestinal tuberculosis. The pathological features of operative specimens have appreciable value in differentiating Crohn's disease from intestinal tuberculosis. It is essential to combine clinical, endoscopic and imageologic parameters to differentially diagnose the two diseases.

Neurologic presentations of gastrointestinal disease

In recent years, there has been increasing recognition of the presence of gastrointestinal (GI) dysfunction in the setting of neurologic diseases. Parkinson's disease is a particularly well-known example, but GI dysfunction also may occur in multiple sclerosis, stroke, and in various myopathic and peripheral neuropathic processes. There is much less awareness, however, that primary GI diseases may also display neurologic dysfunction as part of their clinical picture. This article focuses on some of those disease processes. Illnesses primarily targeting the GI tract are addressed and examples of primary esophageal, gastric, and intestinal disease processes are described.

Curcumin as a therapeutic agent: the evidence from in vitro, animal and human studies

Curcumin is the active ingredient of turmeric. It is widely used as a kitchen spice and food colorant throughout India, Asia and the Western world. Curcumin is a major constituent of curry powder, to which it imparts its characteristic yellow colour. For over 4000 years, curcumin has been used in traditional Asian and African medicine to treat a wide variety of ailments. There is a strong current public interest in naturally occurring plant-based remedies and dietary factors related to health and disease. Curcumin is non-toxic to human subjects at high doses. It is a complex molecule with multiple biological targets and different cellular effects. Recently, its molecular mechanisms of action have been extensively investigated. It has anti-inflammatory, antioxidant and anti-cancer properties. Under some circumstances its effects can be contradictory, with uncertain implications for human treatment. While more studies are warranted to further understand these contradictions, curcumin holds promise as a disease-modifying and chemopreventive agent. We review the evidence for the therapeutic potential of curcumin from in vitro studies, animal models and human clinical trials.

The geoepidemiology of autoimmune intestinal diseases

Inflammatory bowel diseases (IBD) are chronic diseases of the intestinal tract which principally are composed of ulcerative colitis (UC) and Crohn's disease (CD). The prevalence and incidence of both forms of IBD have historically been higher in developed countries with decreasing North-South gradient. However, more recent evidence demonstrate changing demographics as countries become more developed and immigration increases from underdeveloped countries to developed countries. Typically these changes are marked by an increase in ulcerative colitis followed by an increase in CD. Thus, most if not all human populations appear to be susceptible to IBD under certain environmental influences. Several hypothesis have been advanced to explain these changing demographics including alterations in the bowel microflora, but direct experimental evidence is lacking in most cases. Celiac disease or gluten-sensitive enteropathy is a related inflammatory condition which is induced in susceptible individuals when exposed to gluten-containing foods. Similarly, the prevalence of celiac disease is increasing as the consumption of gluten-containing foods is increasing worldwide.

Curcumin suppresses p38 mitogen-activated protein kinase activation, reduces IL-1beta and matrix metalloproteinase-3 and enhances IL-10 in the mucosa of children and adults with inflammatory bowel disease

Inflammatory bowel disease (IBD) is a major source of morbidity in children and adults. Its incidence is rising, particularly in young people. IBD carries a lifelong risk of cancer, which is proportional to disease duration. Drug and surgical treatments rarely offer cure and often carry a high side effect burden. Dietary therapy is highly effective in Crohn's disease. For these reasons, there is much interest in developing novel dietary treatments in IBD. Curcumin, a component of the spice turmeric, and an anti-inflammatory and anti-cancer agent, shows preclinical and clinical potential in IBD. Its mechanisms of action are unknown. Our aim was to assess the effect of curcumin on key disease mediators p38 mitogen-activated protein kinase (MAPK), IL-1beta, IL-10 and matrix metalloproteinase-3 (MMP-3) in the gut of children and adults with IBD. Colonic mucosal biopsies and colonic myofibroblasts (CMF) from children and adults with active IBD were cultured ex vivo with curcumin. p38 MAPK, NF-kappaB and MMP-3 were measured by immunoblotting. IL-1beta and IL-10 were measured by ELISA. We show reduced p38 MAPK activation in curcumin-treated mucosal biopsies, enhanced IL-10 and reduced IL-1beta. We demonstrate dose-dependent suppression of MMP-3 in CMF with curcumin. We conclude that curcumin, a naturally occurring food substance with no known human toxicity, holds promise as a novel therapy in IBD.

Role of PPAR-gamma in inflammation. Prospects for therapeutic intervention by food components

Peroxisome proliferator activated receptor gamma (PPARgamma) is a ligand-dependent transcription factor and a member of the nuclear receptor superfamily. Acting as sensors of hormones, vitamins, endogenous metabolites and xenobiotic compounds, the nuclear receptors control the expression of a very large number of genes. PPARgamma has been known for some time to regulate adipocyte differentiation, fatty acid storage and glucose metabolism, and is a target of anti-diabetic drugs. More recently, PPARgamma has been recognized as playing a fundamentally important role in the immune response through its ability to inhibit the expression of inflammatory cytokines and to direct the differentiation of immune cells towards anti-inflammatory phenotypes. A feature of PPARgamma is the structural diversity of its ligands, which encompass endogenous metabolites, dietary compounds and synthetic drugs. The high and increasing incidence of inflammatory and allergic disease, coupled with encouraging results from recent clinical trials, suggest that natural PPARgamma agonists found in foods may be beneficial to human health by acting as anti-inflammatory molecules. PPARgamma is therefore not only a target of the pharmaceutical industry, but also of great potential interest to the food industry, since it is activated by several natural dietary constituents. The prospects for dietary intervention in inflammatory disease have improved somewhat over the last few years, and are reviewed here.