Cortisone in ulcerative colitis; final report on a therapeutic trial

Toxic megacolon: ultimate fate of patients after successful medical management

The clinical course and ultimate outcome in 38 patients with toxic megacolon who were successfully treated nonoperatively has been reviewed. Thirty-two patients had ulcerative colitis and 6 had Crohn's disease. Follow-up was complete and ranged from 3 to 22 years (average 13 years). Eleven of 38 patients (29 percent) eventually suffered second episode of fulminant acute colitis or recurrent toxic megacolon. Ultimately, a total of 18 patients (47 percent) underwent colon resection, which was performed on an emergency or urgent basis in 15 patients. A modified Visick classification was employed to assess the long-term results of medical therapy in the entire group, in patients showing improvement within 48 or 72 hours, in patients 30 years or younger, in patients whose initial presentation of inflammatory bowel disease was toxic megacolon, and in patients with ulcerative colitis as opposed to Crohn's disease. The results were equally poor for all subgroups, and they have strengthened our opinion that medical management of toxic megacolon should be regarded almost exclusively as preparation for imminent surgery.

Comparative pharmacokinetics of sulphasalazine and sulphapyridine after rectal and oral administration to patients with ulcerative colitis

Rectal administration of sulphasalazine to patients with ulcerative colitis has recently been shown to have similar therapeutic activity but fewer side effects than oral treatment. The present study is a comparison of the pharmacokinetics of sulphasalazine (SASP) and its metabolite sulphapyridine (SP) after rectal and oral administration of SASP to 6 patients with ulcerative colitis. The areas under the concentration-time curves (AUC) and the maximum concentrations (Cmax) of SASP and SP were significantly lower after rectal than oral administration of SASP (p less than 0.05). These findings support the view that the lower frequency of side effects after rectal administration of SASP may result from the lower plasma levels of SASP and SP.

Assessment of disease activity in inflammatory bowel disease: a new approach using 111In granulocyte scanning

111In leucocyte scanning yields images of diseased bowel in patients with inflammatory bowel disease. The technique has recently been improved by being made more specific for acute inflammation by the isolation and labelling of a pure granulocyte preparation. The value of 111In granulocyte scanning in monitoring response to steroid treatment was assessed in 22 patients with Crohn's disease or ulcerative colitis. After steroid treatment there was agreement between the change in the scan grade and the change in clinical disease activity in 18 of the 22 patients. Overall there was a significant correlation between the change in the scan grade and clinical improvement (r = 0.775, p less than 0.001). This study suggests that 111In granulocyte scanning can provide a rapid assessment of disease activity in inflammatory bowel disease.

Functional differences of anti-T-cell antibody in patients with systemic lupus erythematosus and ulcerative colitis

The loss of suppressor T-cell function results in an abundant production of autoantibodies in systemic lupus erythematosus (SLE). As a cause of this suppressor T-cell defect, anti-T-cell antibody seems to be of prime importance. On the other hand, anti-T-cell antibodies can be detected in various other autoimmune diseases, but their functional characteristics have not been determined. In the present study, the functional characteristics of anti-T-cell antibody from a selected subgroup of patients with ulcerative colitis (UC) were compared with those from patients with SLE. Anti-T-cell antibody from the patients with SLE reacted with a T8 subset, resulting in a suppressor defect, whereas anti-T-cell antibody from the UC patients reacted primarily with a T4 subset. Functionally, SLE- T cells failed to proliferate in response to concanavalin A, whereas UC- T cells from UC patients failed to proliferate in response to phytohaemagglutinin. In the Ig synthesis system, both SLE- and UC- T cells increased Ig production of B cells. Since UC+ T cells did not contribute to the generation of Con-A-inducible suppressor activity, we believe that serum from the selected subgroup of patients with UC reacted with the inducer T-cell subset.

Splanchnic exchange of glucose, amino acids and free fatty acids in patients with chronic inflammatory bowel disease

In order to study arterial concentrations and splanchnic exchange of substrates and hormones in patients with chronic inflammatory bowel disease three patients with Crohn's disease and four with ulcerative colitis were studied using the hepatic venous catheter technique. Systemic turnover and regional exchange of free fatty acid were evaluated using intravenous infusion of 14C-labelled oleic acid. All measurements were made in the postabsorptive, overnight fasted state. Arterial glucose concentrations were 10% lower in the patients but net splanchnic glucose output was similar in patients and controls. Glucose precursor uptake (lactate, pyruvate, and glycerol), however, was increased two to five fold in the patients. Arterial amino acid concentrations were generally reduced but net splanchnic amino acid uptake was the same in patients and controls. Arterial concentrations of free fatty acid and oleic acid as well as systemic and fractional turnover were similar in patients and controls. The patients' splanchnic uptake of oleic acid was increased more than three fold in comparison with controls. Splanchnic release of oleic acid was also augmented in the patients. Both arterial concentrations and splanchnic production of ketone bodies were raised in the patients. The proportion of splanchnic free fatty acid uptake which could be accounted for by ketone body production was significantly greater in the patients (37 +/- 4%) than the controls (20 +/- 5%, p less than 0.025). Estimated hepatic blood flow was 55% greater (p less than 0.01) in the patients as compared with the controls (1930 +/- 150 vs 1240 +/- 70 ml/min), while splanchnic oxygen uptake was similar in the two groups. From these findings it is concluded that patients with chronic inflammatory bowel disease show (1) markedly increased hepatic blood flow, reflecting an inflammatory hyperaemia in the splanchnic region, (2) a normal net splanchnic glucose output, (3) accelerated hepatic gluconeogenesis as well as ketogenesis, probably as a consequence of the altered hormonal milieau, and (4) low concentrations of most amino acids possibly because of protein malabsorption. These findings underscore the importance of adequate protein and carbohydrate administration to this patient group.

No evidence for a prethrombotic state in stable chronic inflammatory bowel disease

Ulcerative colitis and Crohn's disease are associated with a high risk of thromboembolic complications. The questions whether reported risk factors such as low antithrombin III concentrations, thrombocytosis and spontaneous platelet aggregation are merely related to the activity of the inflammatory process remains to be answered. Therefore we investigated 40 patients with an established colitis or Crohn's disease, without signs of active inflammation (normal history, normal ESR and leucocyte count). Of these patients only one patient revealed thrombocytosis, six patients spontaneous platelet aggregation. All patients had normal beta-thromboglobulin and platelet factor 4 plasma levels. No other prethrombotic abnormalities were encountered. There was normal factor VIII C (increased in three patients), normal VIII C/VIII R Ag ratio (1.2), antithrombin III, normal plasminogen and normal alpha 2-antiplasmin. Normal fibrinopeptide A and B beta (15-42) plasma levels (n = 15) in these patients excluded in vivo thrombin or plasmin generation. We conclude that stable chronic inflammatory bowel disease is in general not associated with prethrombotic coagulation abnormalities.

Assessment of disease activity in ulcerative colitis using indium-111-labelled leukocyte faecal excretion

A new method of assessing disease activity in ulcerative colitis has been developed utilizing indium-111-labelled granulocytes. Faecal 111In excretion after intravenous administration of labelled granulocytes ranged from 1.1% to 45% of the injected dose in patients with ulcerative colitis, showing significant differences between mild, moderate, and severely active groups. There was a significant correlation between faecal 111In excretion and a clinical index based on the Crohn's disease activity index (r = 0.79, p less than 0.001) and the erythrocyte sedimentation rate (r = 0.73, p less than 0.001). Quantitative faecal 111In-labelled granulocyte excretion is an objective and specific method of assessing disease activity in ulcerative colitis.

In vitro model for the assessment of luminal factors on rectal mucosa

An organ culture method for the maintenance of rectal biopsies over a period of 24 hours is described. Good preservation of histological architecture and continued crypt cell proliferation were shown over the culture period. The colonic enzyme alkaline phosphatase was found to rise over the period of culture. This rise was dependent upon continued protein synthesis by the cell. Changes in alkaline phosphatase activity during culture in biopsies from patients with ulcerative colitis and Crohn's disease are reported. This organ culture system and the measurement of alkaline phosphatase activity during culture provides a new approach to the assessment of luminal antigens as possible effectors of colonic epithelial cell damage.

Drug therapy of inflammatory bowel disease

Although the etiology of inflammatory bowel disease is unknown and specific therapy is unavailable, enough information on existing empiric agents is available to allow rational therapy. These agents include sulfasalazine, steroids, immunosuppressive drugs, metronidazole and cholestyramine. Sulfasalazine is a two-part molecule that depends on bacterial cleavage in the colon to deliver locally acting 5-aminosalicylate, whose mechanism of action may relate to inhibition of prostaglandin synthesis. The other half of the molecule, sulfapyridine, is responsible for most of the side effects of the drug. While the efficacy of sulfasalazine in the treatment and prevention of attacks of ulcerative colitis is well established, its use in Crohn's disease appears to be limited to patients with active colitis and ileo-colitis. Sulfasalazine is of major benefit in preventing relapses in patients with ulcerative colitis in remission. New formulations of 5-aminosalicylate may allow delivery of the apparently active moiety to the small bowel and colon without concomitant sulfapyridine toxicity. Corticosteroids are highly effective in acute attacks of ulcerative colitis and Crohn's ileitis and ileo-colitis; the mechanism of antiinflammatory action remains speculative. However, maintenance therapy with steroids is ineffective in preventing relapses or recurrent attacks of either ulcerative colitis or Crohn's disease. Steroid enemas allow topical administration to patients with distal colitis and proctitis with few systemic side effects. In children with growth failure associated with active Crohn's disease, amelioration by steroid therapy may actually restore normal growth. Immunosuppressive agents such as azathioprine and 6-mercaptopurine are of little value in active Crohn's disease when administered alone; however, in combination with other agents they may help diminish steroid dose, close fistulae and prevent relapse. Their mode of action likely depends on long-term cytostatic effects on immune effector cells. Concern for leukopenia and the development of late malignancy has limited their use to patients not responding to other therapies. Metronidazole, an antimicrobial agent that is effective against anaerobes, has recently been shown useful in Crohn's disease involving the colon and perianal area. Its mechanism of action is uncertain, but may be related to its antibacterial actions on anaerobes. Cholestyramine can be successfully used to control bile salt-induced diarrhea in Crohn's patients with terminal ileal resections. Effective drug therapy of inflammatory bowel disease is only part of a total program of management including reassurance, frequent explanation, well-timed use of surgery, and an understanding physician.

Human chorionic gonadotropin and alpha chain of glycoprotein hormones in patients with inflammatory bowel disease

In twenty patients with Crohn's disease and ten patients with ulcerative colitis serum levels of human chorionic gonadotropin and the common alpha-subunit of glycoprotein hormones were determined by radioimmunoassay. In contrast to published data, all serum samples except one revealed levels within the normal range of 148 controls (human chorionic gonadotropin levels up to 3.9 IU/l, alpha-subunit up to 3.8 micrograms/l). Neither the serum levels of human chorionic gonadotropin nor of the alpha-subunit differed significantly between patients with Crohn's disease (median/maximum: 0.9/4.4 IU/l; 0.7/3.6 micrograms/l) and ulcerative colitis (1.0/3.4 IU/l; 0.8/2.2 micrograms/l). Furthermore, the serum levels studied in patients with active (0.9/3.0 IU/l; 0.7/3.5 micrograms/l) and inactive (0.9/4.4 IU/l; 0.8/3.6 micrograms/l) Crohn's disease and in patients with active (1.1/3.4 IU/l; 0.9/2.2 micrograms/l) and inactive (0.9/2.9 IU/l; 0.8/1.3 micrograms/l) ulcerative colitis were not significantly different. There was no relationship of the duration of the disease or a bowel resection to the serum levels of human chorionic gonadotropin or the alpha-subunit. It is concluded that both parameters are not useful as markers in patients with Crohn's disease or ulcerative colitis. The normal serum levels found in patients with inflammatory bowel diseases indicate human chorionic gonadotropin as a highly specific marker for malignant diseases.

Effect of inflammatory bowel disease on absorption and disposition of prednisolone

The pharmacokinetics and bioavailability of prednisolone after doses of oral prednisone and intravenous prednisolone were determined in seven patients receiving corticosteroids for treatment of inflammatory bowel disease in active disease and remission. Prednisone absorption and conversion to the active form of prednisolone was complete in both disease phases. Pharmacokinetic parameters for total and free (unbound) prednisolone did not differ significantly between disease phases. Differences in protein binding were observed between active disease and remission with the fractional binding of prednisolone to plasma proteins decreased in active disease. This may be accounted for by decreased plasma albumin concentrations in active disease. Alpha 1-acid glycoprotein concentrations were significantly higher in active disease but did not contribute to the overall binding of prednisolone.

T lymphocyte subsets in inflammatory bowel disease: peripheral blood

Peripheral blood T lymphocytes and T lymphocyte subsets have been quantified in 28 patients with ulcerative colitis and 26 with Crohn's disease by an indirect immunofluorescence technique using monoclonal antibodies: OKT3, which detects all peripheral blood T lymphocytes; OKT4 (T cells of helper phenotype); and OKT8 (T cells of supressor-cytotoxic phenotype). Eighteen normal subjects and 16 patients with a variety of non-inflammatory gastrointestinal disorders were studied as controls. No significant differences were found between patient and control groups in the proportions of circulating T lymphocytes or their subsets. When compared with normal subjects, absolute numbers of T lymphocytes were reduced in patients with active ulcerative colitis or Crohn's disease (p less than 0.05). OKT4+ T cell numbers were reduced in ulcerative colitis, whether active (p less than 0.02) or inactive (p less than 0.05) and in active Crohn's disease (p less than 0.05) Numbers of OKT8+ T cells were reduced in active Crohn's disease (p less than 0.01). There were no differences in T lymphocyte numbers between the patient groups and the disease control subjects. The OKT4+:OKT8+ ratio in patients with inflammatory bowel disease did not differ from that in controls. No relation was found between any of the parameters studied and disease activity, site, or extent of disease, or treatment with sulphasalazine or corticosteroids. The presence of Ia-like, HLA-DR antigens on T cells was detected using a double marker immunofluorescence technique. In control subjects up to 7% of OKT3+ cells were HLA-DR+. In only three patients was the proportion of HLA-DR+ cells greater than in controls. These results indicate that the pathogenesis of ulcerative colitis or Crohn's disease does not depend upon an alteration in the proportion of circulating T lymphocytes nor upon an imbalance of T lymphocyte subsets as defined by monoclonal antibodies. The reduction in T lymphocyte numbers may result from mucosal infiltration. The findings also suggest that circulating T lymphocytes are not activated.

Occurrence of Clostridium difficile toxin in inflammatory bowel disease

The occurrence of Clostridium difficile toxin in faeces has been studied in 53 inpatients with inflammatory bowel disease (IBD) at 57 admissions. Before faecal sampling of the patients had had sulphasalazine therapy--17 for more than 1 year--and 16 patients had taken antibiotics on 20 occasions within the last year. The toxin was found in 3 out of 57 samples (5%). In all cases it could be detected only in undiluted stool filtrate. None of the patients was treated for the C. difficile infection; remission was achieved in two of the patients, whereas the third patient with severe ulcerative colitis was referred to colectomy. Our results suggest that neither IBD as such nor long-term sulphasalazine therapy predisposes to occurrence of C. difficile toxin. Antibiotic therapy in these patients does not imply a higher risk of toxin occurrence than in other patients. In our region there is no need for routine screening for this in symptomatic patients with IBD.

Motility of neutrophils and monocytes in Crohn's disease and ulcerative colitis

Random motility and chemotaxis of peripheral blood neutrophils and monocytes from patients with Crohn's disease and ulcerative colitis have been measured using a modified Boyden Chamber filter assay. Increased random motility and chemotaxis of monocytes were found in patients with active ulcerative colitis. Monocyte motility was normal in Crohn's disease and no abnormality of neutrophil motility or chemotaxis was found in either disease. Drug therapy with prednisolone or sulphasalazine received in vivo was found to have no effect on the motility of the washed neutrophils and monocytes in vitro. This work adds to the evidence that monocytes are activated in ulcerative colitis but does not support the hypothesis that Crohn's disease is due to an inherent defect in phagocyte motility.

Sacroiliac joint uptake ratios in inflammatory bowel disease: relationship to back pain and to activity of bowel disease

Sacroiliac uptake ratios based on 99Tcm methylene diphosphonate images were calculated in 14 patients with ankylosing spondylitis, 23 patients with non-specific backache, 33 patients with inflammatory bowel disease (ulcerative colitis 19, Crohn's disease 14) and 33 control subjects. Twenty-eight of the control subjects were patients referred from a breast cancer clinic. In the control subjects, and in 20 patients with inflammatory bowel disease who did not have back pain, sacroiliac ratios decreased significantly with increasing age (p less than 0.001 and p less than 0.01 respectively). Sacroiliac uptake ratios were significantly higher in ankylosing spondylitis than in patients with non-specific backache. Seven of the 14 patients with ankylosing spondylitis had higher sacroiliac ratios than any recorded in the control subjects. Eleven patients with inflammatory bowel disease had abnormally high sacroiliac uptake ratios; ten of these patients had back pain. Increased sacroiliac joint uptake in such patients may reflect early sacroiliitis. No relationship was detected between sacroiliac uptake and the activity of the bowel disease. Sacroiliac uptake ratios were significantly higher in the inflammatory bowel disease patients suffering from back pain than in age and sex matched patients with (a) inflammatory bowel disease but no back pain or (b) non-specific backache.

Retrograde colonic spread of sulphasalazine enemas

In five patients with inflammatory bowel disease and in two healthy control subjects retrograde spread and colonic distribution of rectally introduced sulphasalazine (SASP) enema were investigated. The SASP enema was labeled with 99mTc and imaged by a gamma camera. In all patients the SASP enema reached the inflamed portion of the colon. From 73% to 84% of the total SASP enema were fairly homogeneously distributed beyond the patients' rectum. The results suggest that patients with inflammatory bowel disease may benefit from SASP enemas even if the total colon is involved.

Serum levels of C-reactive protein in Crohn's disease and ulcerative colitis

Prospective measurements were made of serum C-reactive protein levels and erythrocyte sedimentation rate in sixty-four patients with Crohn's disease and fifty with ulcerative colitis. The results were related to clinical assessment of disease activity. C-reactive protein levels were raised in both groups but were significantly higher in Crohn's disease than ulcerative colitis for all categories of disease severity: with mild disease the median and range of C-reactive protein concentration were 4, 0-65 mg/l in Crohn's disease v. 0, 0-15 mg/l in ulcerative colitis, P less than 0.01; in moderate disease the values were 15, 1-100 mg/l v. 3, 0-29 mg/l respectively, P less than 0.05 and in cases of severe disease, 85, 15-183 mg/l v. 12, 2-33 mg/l respectively, P less than 0.001. Erythrocyte sedimentation rate was also higher in Crohn's disease but did not closely reflect disease activity in individual patients. C-reactive protein levels corresponded closely with clinical and pathological indices of relapse, remission and response to therapy in patients with Crohn's disease. The precise assay of serum C-reactive protein provides an objective criterion of inflammatory activity, which may be useful in the assessment, management and study of Crohn's disease.

Inhibition of leucocyte motility and prevention of immune-complex experimental colitis by hydroxychloroquine

The inhibitory effects of hydroxychloroquine on leucocyte motility have been compared with those of prednisolone. It has been shown to have similar potency to prednisolone as an inhibitor of human neutrophil and monocyte motility. Hydroxychloroquine has then been compared with placebo in the prevention of an immune-complex experimental colitis in rabbits. Rectal biopsies were taken from rabbits 24 hours after initiation of colitis, coded, and graded histologically. The summated gradings for acute inflammation and goblet cell depletion had worsened more in the control rabbits (mean grade +6.7) than in the treated rabbits (mean grade +1.8) P less than 0.05. There was no difference in the mononuclear cell infiltrate between the two groups. Hydroxychloroquine, which is a potent inhibitor of leucocyte motility, effectively prevents the acute inflammatory infiltrate in this experimental colitis model and therefore merits trial in human ulcerative colitis.

Splenic phagocytic function in patients with inflammatory bowel disease

Splenic phagocytic function has been assessed in patients with inflammatory bowel disease. No Howell-Jolly bodies were found on blood film examination. Slow clearance times of heat damaged red cells were found in 13 of 16 patients with ulcerative colitis compared with 4 of 17 patients with Crohn's disease (P less than 0.01). For ulcerative colitis prolonged clearance times were strongly related to the length of history (r = 0.90; P less than 0.01). The prolongation of half-clearance times correlated poorly with splenic size suggesting a functional impairment of the reticuloendothelial system.

Zinc nutrition in Crohn's disease

A prospective evaluation of zinc status was made in 63 randomly selected patients with Crohn's disease. In the patients, mean serum and 24-hr urinary zinc values--105 microgram/dl and 383 microgram/day, respectively--were not different from controls. However, 46% of these patients had less than normal serum zinc and 36% had low urinary zinc excretions. Simultaneous reductions in both serum and urinary zinc were detected in 19% of patients. A direct correlation (P = 0.01) was found between serum levels of zinc and the concentration of albumin, the major zinc-binding protein, in outpatients but not in hospitalized patients or patients with Crohn's disease as a whole. Intake of zinc was surprisingly good--a mean intake of 13.4 +/- 1.4 mg/day. A significant (P = 0.006) association was found between urinary zinc and the Crohn's disease activity index but not between serum zinc concentration and this index. No association was found between zinc measurements and the presence or absence of fistulas, use of prednisone or sulfasalazine (Azulfidine), large bowel resections, and length of small bowel resected.

Spontaneous suppressor cell function in inflammatory bowel disease

We investigated suppressor cell activity in the peripheral blood of 39 patients with inflammatory bowel disease (30 Crohn's disease and 9 ulcerative colitis) by the short-lived suppressor cell assay. There was a significant decrease in the suppressor cell activity in patients with inflammatory bowel disease (IBD), compared to 26 healthy subjects studied simultaneously. Five other patients with acute bacterial infections had normal suppressor activity. A group of 14 IBD patients was also investigated for concanavalin A-induced suppressor cell activity and decreased suppressor function was confirmed. A significant positive correlation was found between the two assays. A defect in suppressor cell activity may permit the expression or maintenance of immunologically mediated damage to the gut in IBD.

Assessment of appropriate laboratory measurements to supplement the Crohn's disease activity index

The ability of 11 laboratory parameters to reflect the degree of activity of Crohn's disease, using a clinical index as reference point was compared by means of multiple stepwise regression analysis. Activity was best defined in decreasing order by orosomucoid, sedimentation rate, C reactive protein, alpha-1-antitrypsin, albumin, haematocrit, IgM, circulating immune complexes, serum iron, IgG, and IgA. The haematocrit, the only laboratory measurement in the Crohn's disease activity index developed by the National Cooperative Study Group in the USA, is less discriminant than acute phase reactants. Only three parameters-namely, orosomucoid, sedimentation rate, and C reactive protein-have a significant weight and should be complementary to a simple clinical index.

Cytomegalovirus: detection in human colonic and circulating mononuclear cells in association with gastrointestinal disease

The specificity and strength of the reported association between cytomegalovirus (CMV) and colonic adenocarcinoma were tested by analysis of a consecutive series of surgically resected colons for: CMV-DNA by a DNA-DNA reassociation kinetics (hybridization) procedure; latent virus by co-cultivation of fresh tissue with indicator fibroblasts; and CMV viral antigens by immunofluorescence. Ten of 13 cancer patients whose colonic tissue was able to be examined by all techniques showed evidence of active or prior CMV infection. Four cancer specimens were CMV-DNA (hybridization)- positive; an additional specimen from a cancerous colon was culture-positive. In six instances, CMV DNA was detected in mucosal cells adjacent to colon adenocarcinoma. In tissue from one of three patients with ulcera tive colitis and two of seven patients with other non-neoplastic colonic disease, CMV DNA was also detected. No fresh colonic tissues were demonstrated to have CMV surface or nuclear antigens when examined by immunofluorescence. Culture of peripheral lymphocytes was positive for CMV in three of 14 cancer patients. A CMV specific defect in humoral immunity could not be documented in that most cancer patients, as well as cancer-free patients, exhibited circulating specific antibody to CMV and had a normal capacity for CMV-specific antibody-dependent cellular cytotoxicity. We conclude that CMV, probably in a latent form, is readily detectable in colonic cells of man, including those derived from malignant, pre-malignant and non-malignant tissues. Neither preferential replication in damaged tissue nor carriage of CMV by peripheral lymphocytes homing to gut appear to explain the presence of CMV in colon cells.

Toxic megacolon in ulcerative colitis: a continuing challenge

The incidence, predisposing factors, management and outcome of toxic megacolon (TM) has been reviewed in 65 cases of severe ulcerative colitis (UC) and compared in 2 successive 6-year periods before and after January, 1973. Nineteen episodes of TM occurred in 18 patients. Despite a conscious aim towards earlier surgery in recent years this was not achieved, and despite more intensive medical therapy the incidence of TM was unchanged. Emergency operative mortality in UC fell from 36% to 21% but the mortality of TM remained at 30%. The chief cause of death was colonic perforation. Mortality was associated with increased age, longer pre-operative hospital stay and lower levels of serum albumin. These findings reemphasize the need for earlier surgery if TM is to be prevented, but such a policy must result in some unnecessary emergency colectomies.

Effect of prednisolone on prostaglandin synthesis by rectal mucosa in ulcerative colitis: investigation by laminar flow bioassay and radioimmunoassay

The effect of two concentrations of prednisolone on synthesis of prostaglandin E2 (PGE2) by 40 rectal biopsies in organ culture was investigated using both laminar flow bioassay and radioimmunoassay (RIA). Prednisolone (concentration 8.33 x 10(-7)M) reduced mean synthesis of PGE2 to 36.4% of control values (measured by bioassay) or 26.2% of control values (measured by RIA). With prednisolone (concentration 5.66 X 10(-4) M) synthesis of PGE2 was 7.7% of control values (RIA). The two concentrations are similar respectively to those achieved in plasma after oral prednisolone and delivered topically by prednisolone enemata. Inhibition of PG synthesis may thus explain prednisolone's anti-inflammatory action in the treatment of ulcerative colitis.

Studies of prostaglandins and sulphasalazine in ulcerative colitis

Specific evidence is presented of the release of prostaglandins from the colon in active ulcerative colitis. An increase in the levels of bioassayed prostaglandin-like activity in the stools and colo-rectal venous plasma from patients with active ulcerative colitis is described. Radioimmunoassay confirms the presence of prostaglandin E and prostaglandin F in the stools in colitis. Increased urinary levels of prostaglandin F metabolite occur in patients with active colitis and return to normal as the disease becomes quiescent. Sulphasalazine and its faecal metabolite, 5-aminosalicylic acid, were shown by an indirect method (reduction of the tone of the isolated rat fundus strip) to inhibit prostaglandin biosynthesis in vitro. In contrast, sulphasalazine was without effect on the urinary excretion of prostaglandin F metabolite in 7 healthy subjects. In 2 patients with colitis withdrawal of sulphasalazine was associated with increasing levels of stool prostaglandin-like activity and urinary prostaglandin F metabolite excretion. Indomethacin, given to 3 patients with chronically active ulcerative colitis, unresponsive to standard medical treatment, was associated with a decreased urinary excretion of prostaglandin F metabolite but was without clinical benefit. The possible mode of action of sulphasalazine as a prostaglandin inhibitor in colitis is discussed along with the potential use of other prostaglandin inhibitors.

Complement inhibitors and immunoconglutinins in ulcerative colitis and Crohn's disease

The serum concentrations of the complement inactivators C1INH, C3bINA and beta 1H have been determined in patients with ulcerative colitis and Crohn's disease and their correlation with C3 and properdin factor B examined. The incidence of immunoconglutinins (1K) in these patients was investigated. Raised serum concentrations of C1INH and C3bINA have been found in patients with active disease, but no significant alteration was found in serum concentration of beta 1H. An increasing incidence of positive 1K titres was found with increased length of disease history. These results suggest continuing complement activation in these diseases.

Monocytes in inflammatory bowel disease: phagocytosis and intracellular killing

The ability of peripheral blood monocytes from patients with ulcerative colitis and Crohn's disease to phagocytose and kill a standard strain of Staphyloccus aureus has been studied. Using lysostaphin, a rapidly acting muralytic enzyme, phagocytosis could be accurately differentiated from intracellular killing. When compared with normal healthy individuals and patients with gastrointestinal diseases not thought to be immunologically mediated, monocytes from patients with inflammatory bowel disease showed a statistically significant increase in the number of bacteria phagocytosed in 2 hours. There was no difference, however, between patients with Crohn's disease and those with ulcerative colitis. For all groups studied, more than 95% of ingested organisms were killed, and there was no difference between groups. These results suggest that peripheral blood monocytes in patients with Crohn's disease and ulcerative colitis are activated. It is unlikely that the granulomata of Crohn's disease result from a defect in the microbicidal function of the monocyte/macrophage system.

Monocytes in inflammatory bowel disease: absolute monocyte counts

Using a cytochemical staining technique, peripheral blood monocytes have been precisely identified and enumerated in patients with inflammatory bowel disease and compared with healthy and disease control subjects. For ulcerative colitis there was a significant monocytosis, which was closely correlated with the total white cell count and with the activity of the disease. For patients with Crohn's disease, the peripheral blood monocyte count was also raised compared with that of the control groups, but the difference did not reach statistical significance. There was no correlation between the monocyte count in patients with Crohn's disease and the total white cell count or the disease activity. Some of the mechanisms that may influence the production and distribution of peripheral blood monocytes are discussed.

Alteration in T lymphocyte subpopulations in inflammatory bowel disease

Peripheral blood mononuclear cells from thirty-one patients with inflammatory bowel disease (ulcerative colitis and Crohn's disease) were analysed for the proportions and absolute numbers of total T cells, and for the T cell subpopulations carrying Fc receptors for either IgM (Tmu cells) or IgG (T gamma cells). Twenty-six control subjects were studied simultaneously. Total T cell numbers were normal in patients with inflammatory bowel disease but there was a marked reduction in the proportion and absolute numbers of Tmu cells in patients, whether their disease was active or in remission. T gamma cells were normal. Simultaneous assessment of lymphocyte response to mitogens in vitro was performed in a group of patients. Responses to phytohaemagglutinin, concanavalin A and pokeweed mitogen were decreased and a positive correlation was found between the number of circulating Tmu cells and the responses to mitogens in vitro. These studies demonstrate that despite the presence of normal numbers of total T cells in inflammatory bowel disease, there is a marked imbalance in T cell subpopulations that correlates with mitogen responsiveness. This imbalance provides a possible cellular basis for the defect in cell-mediated immunity seen in these patients.

Superior sagittal sinus thrombosis 10 years after surgery for ulcerative colitis

Cerebral vein thrombosis is a known complication of active ulcerative colitis. It is generally believed that panproctocolectomy ameliorates the thromboembolic and other systemic complications of ulcerative colitis. We report an unusual patient, 10 years post-panproctocolectomy for ulcerative colitis, who developed a cerebral sinus thrombosis. Physicians should be aware of the possibility of thromboembolic complications of ulcerative colitis long after definitive surgery has been performed.

Inflammatory bowel disease: study of cell mediated cytotoxicity for isolated human colonic epithelial cells

A better understanding of the mechanism(s) of cell mediated toxicity for colon cells in vitro may help clarify the pathogenesis of inflammatory bowel disease (IBD). We have examined both the cytotoxicity of IBD peripheral blood mononuclear cells and the kinetics of induction of such toxicity by soluble plasma factors. Peripheral blood mononuclear cells from IBD patients were found to be cytotoxic for the colon cells. With the use of Chang cells, this cytotoxicity was shown not to be due to an increase in spontaneous cell mediated cytotoxicity. Colon cell toxicity in vitro did not correlate with site of disease or severity, but decreased toxicity appeared to be associated with in vivo steroid administration. Plasma from some IBD patients was capable of inducing normal peripheral blood mononuclear cells to be toxic to colon cells. This ability was not affected by steroid therapy. The induction capacity of IBD plasma was not associated with the presence of circulating immune complexes, as measured by Raji RIA, suggesting that large complement fixing complexes are not the inducing and directing factors. Unlike findings in other systems, induction could be demonstrated after a one hour preincubation of mononuclear cells with IBD plasma. The kinetics of induction are consistent with the hypothesis that either cytophilic antibody or small circulating immune complexes arm K cells for specific colon cell lysis.

Inflammatory bowel disease associated circulating immune complexes

Circulating immune complexes have been detected in patients with inflammatory bowel disease (IBD). To determine if these complexes are related specificially to IBD or more generally to loss of intestinal mucosal integrity, we compared circulating immune complex levels in the sera of 86 IBD patients, nine pseudomembranous and nine bacterial colitis patients, and 42 healthy controls. Immune complexes were measured by a Raji cell radioimmunoassay. Raji detectable circulating immune complex levels were significantly higher in the IBD group than in the healthy controls (P<0.001). Circulating immune complex levels in the pseudomembranous-bacterial colitis group and the healthy controls were essentially identical. While nearly 20% of the IBD patients (16 of 86) had abnormally high levels, none of the patients with the other forms of intestinal inflammation (0 of 18) had abnormal levels. These data suggest that the circulating immune complexes present in inflammatory bowel disease patients are related to the IBD process rather than to non-specific mucosal cell (barrier) damage. Patients with intestinal inflammation and normal peripheral immune complex levels also had normal mesenteric vein levels. These data suggest that lack of formation, rather than more efficient hepatic reticuloendothelial clearance, was primarily responsible for the absence of detectable complexes in Raji negative individuals. Circulating immune complex levels did not correlate with type, location, severity, or extraintestinal manifestations of inflammatory bowel disease. The absence of Raji detectable circulating immune complexes in the majority of patients, even in those with extraintestinal manifestations, raises serious doubts about the pathogenic significance of such complexes. Nevertheless, as the circulating immune complexes appear to be disease related, they may be used to isolate and identify disease specific antigen(s) of possible aetiological importance.

Angiographic evaluation of vascular changes in ulcerative colitis

Selective superior and inferior mesenteric angiography was carried out in 25 patients with ulcerative colitis. Vascular changes in angiography were compared with the clinical features of the patients. There was no correlation between vascular changes in angiography and the duration of illness or the extent of involvement. The vascular changes of large vessels, such as increased diameter of the inferior mesenteric artery, had better correlation with the severity or the activity of illness. However, we found that in some cases microcirculatory changes of small vessels of the intestinal wall, such as the findings of capillary brush or loss of normal tapering of vasa recta, still remain in remission of this disease. We assume that this microcirculatory disturbance plays an important role in the pathophysiology of ulcerative colitis.

Studies on monocytes in inflammatory bowel disease: factors influencing monocyte lysosomal enzyme activity

The effect of endotoxin and immune complexes on monocyte lysosomal enzyme activity has been studied in patients with Crohn's disease and ulcerative colitis. Immune complexes made at equivalence or in antigen excess caused a rapid fall in intracellular activity of the enzyme N'acetyl-beta-D-glucosaminidase which was significantly greater than that seen when cells were incubated with medium alone. Endotoxin had no effect on intracellular enzyme activity but there was a significant elevation of activity in the supernatants. Cells from patients with inflammatory bowel disease were no different to cells from healthy control subjects in their response to either endotoxin or immune complexes.

Precancerous lesions in the mucosa in ulcerative colitis. A radiographic, endoscopic, and histopathologic study

A series of 150 patients with ulcerative colitis, 100 of which had had the disease more than 10 years, underwent colonoscopy on at least one occasion. 4700 biopsies of the mucosa of the gut were taken and examined histopathologically. 148 of the colonoscopies were performed within 12 months of the radiographic examination of the colon. Precancerous lesions were detected in 12 patients and moderate to severe reactive inflammatory changes in 39. One of the 12 patients with precancerous lesions was found to have a carcinoma in the same region at surgery 18 months later. No further cases of carcinoma in the series have been observed at follow-up surgery. Radiography and endoscopy demonstrated a higher rate of certain features of inflammation in the parts of colon with precancerous lesions, but no particular feature could be taken to indicate the presence of such lesions. All patients with precancerous lesions had on some occasion been radiologically and/or endoscopically judged to have total colitis, compared with 75% in the whole series. Analysis of clinical data in patients with and without precancerous lesions revealed no significant difference between the groups.

Toxic megacolon complicating Crohn's colitis

Toxic megacolon complicating ulcerative colitis has been a well-recognized entity since its original description in 1950. The presence of toxic megacolon frequently has precluded a diagnosis of Crohn's colitis. Recent literature, however, has demonstrated that the incidence of toxic megacolon associated with Crohn's colitis (4.4-6.3%) may be higher than that in ulcerative colitis (1-2.5%). Differentiation between these two catastrophic forms of colitis is important in respect to prognosis and long-term results. Medical management of toxic megacolon may be initially successful in either type of colitis. Surgical intervention is indicated if the patient's condition does not improve within 48-72 hours. A subtotal colectomy with an ileostomy and mucous fistula is probably the treatment of choice for most of these extremely ill patients. The influence of the type of colitis on the results of subsequent management of the rectal stump remains unresolved.

Clq metabolism in ulcerative colitis and Crohn's disease

The metabolism of pure radioiodine labelled Clq has been observed in five patients with ulcerative colitis, five patients with Crohn's disease, and in five control subjects. Both the fractional catabolic rate and the synthesis rate of Clq were increased in the five patients with Crohn's disease and in four of the five patients with ulcerative colitis. The fifth patient was in remission and had a normal synthesis rate. These results support the hypothesis that complement activation plays a role in the pathogenesis of these disease states and that the increased complement activation is primarily via the classical pathway.

A clinical scoring system for chronic inflammatory bowel disease in children

A clinical scoring system for the assessment of children with chronic inflammatory bowel disease has been devised. A close correlation is demonstrated between severity of disease and the level of serum albumin. The clinical score is simple to perform, sensitive to changes in clinical status, reproducible by different observers, and specifically designed to evaluate inflammatory bowel disease in children and adolescents. The clinical score is a useful adjunct in the management of children with chronic inflammatory bowel disease and can be used in prospective studies of various therapeutic modalities.

Significance of serum complement levels in patients with gastrointestinal disease

Levels of the serum complement components, C3 and C4, in patients with Crohn's disease, ulcerative colitis, and miscellaneous gastrointestinal disorders were compared with those of normal blood donors. Significant increases of both components were found in all three patient groups, the highest being in patients with Crohn's disease. Generally, levels of C3 and C4 were lower in patients with inactive rather than active Crohn's disease and ulcerative colitis. These results provide some evidence in support of an immunological basis for inflammatory bowel disease. However, in view of the frequent elevation of C3 and C4 in other gastrointestinal diseases, it is equally possible that the complement components are behaving as acute phase proteins.

Intestinal gas in ulcerative colitis

Intestinal gas was measured planimetrically on plain abdominal films from 25 healthy subjects and 47 patients with active ulcerative colitis (mild, moderate, severe and toxic megacolon). Compared with controls, significant colonic distention was found in toxic megacolon. Gas in the small bowel was significantly increased in toxic megacolon and in severe colitis but was within the normal range in the mild and moderate forms. Two groups of patients with severe colitis were identified, showing either normal or increased gas content in the small bowel. Two of seven patients in the latter group developed toxic megacolon in spite of intensive medical treatment. Intestinal gas values showed a linear correlation with arterial blood pH, ESR and body temperature. No correlation was found between intestinal gas and other features of severity. It is suggested that an abnormal collection of gas in the small bowel loops associated with metabolic alkalosis corresponds to an early stage of a toxic complication ("impending megacolon").

Idiopathic ulcerative colitis in Istanbul: clinical review of 204 cases

A clinical review of 204 cases of idiopathic ulcerative colitis (IUC) seen in an insurance hospital in Istanbul during a period of nine years is presented. The criteria of diagnosis were based on history and results of rectosigmoidoscopic, biopsy, and barium-enema examinations. In the majority of cases (74 per cent), the disease manifested in the mild form, despite a history of one to five years' duration at the time of diagnosis. These patients usually had single attacks, with recovery in reponse to treatment. The mortality rate for the whole series was 3.9 per cent. Death occurred in eight cases of patients who had the severe form of the disease involving the entire colon, with fulminating courses. One additional death was due to an accident. Treatment consisted of a high-protein, low residue diet, vitamins, rest, sulfa drugs and steroids. Azathioprine, in addition, was used in fulminating cases. Surgery supplemented medical therapy in 19 cases. Indications for surgical treatment were resistance to medical management, cancer, and polyposis. Only two patients (1.0 per cent) were found to have cancer during the follow-up period. These two were operated upon. Idiopathic ulcerative colitis is not a rare entity; with awareness and use of appropriate diagnosis facilities, more cases are being discovered.

Inhibition of antibody-dependent cellular cytotoxicity by artificial immune complexes and pathological sera

Detection of immune complexes by inhibition of antibody-dependent cellular cytotoxicity (ADCC) is based on the principle that soluble complexes can compete with target cell-bound antibody for receptors (FcR) on cytotoxic lymphocytes. The objective of this study was to define a cytotoxicity system for the determination of soluble immune complexes in the sera of patients with inflammatory bowel disease (IBD). For this purpose, the conditions under which soluble complexes of rat serum albumin (RSA) and rabbit anti-RSA inhibited human K-cell mediated lysis of sensitized Chang cells were examined, on the assumption that the behaviour in the system of circulating immune complexes putatively present in inflammatory bowel disease, is similar to that of artificial immune complexes. Inhibition of ADCC by a standard amount of artificial complex in different normal human sera was relatively uniform provided that the final concentration of the latter did not exceed 10% of the culture medium. In the absence of extraneous complexes, the effect of both normal and IBD sera on ADCC varied widely. Differential inhibition of ADCC by sera from patients with IBD and normal subjects was thus expressed as a function of ADCC in a standard batch of foetal bovine serum (FBS). Under these conditions differences between pathological (n = 51) and normal (n = 52) sera were highly significant (P less than 0.001), which could not be explained by the presence in the patients' sera of HL-A antibodies reactive with the effector cells, nor by a deficit in nutritional support of ADCC. The absence of a correlation between inhibition of ADCC and total serum IgG or IgM inferred that inhibition was attributable to immune complexes in the IBD sera. The limitations of this assay for assessment of the incidence of immune complexes in pathological sera are discussed.