Cortisone in ulcerative colitis; final report on a therapeutic trial

Further experience in the treatment of severe attacks of ulcerative colitis

One hundred courses of an intensive intravenous regimen have been used in 87 patients with severe attacks of ulcerative colitis during the past 5 years, 11 of the patients having been treated more than once during separate admissions to hospital. 60% of the attacks responded swiftly to the regimen, and the patients were symptom-free at the end of the 5-day course. In 15% there was improvement but the patients were not entirely symptom-free. In 25% failure to respond resulted in emergency colectomy, the usual operation being proctocolectomy as a single-stage procedure. There were no deaths directly due to ulcerative colitis or to surgical treatment in these patients during the period of the study, the mean period of follow-up being 25 months; but 4 elderly patients died from unrelated causes. These favourable results are better than most published figures. The advantages of the intensive medical regimen are that: (i) many patients quickly go into clinical remission, which is frequently sustained; and (ii) failure to improve can be regarded as a clear-cut indication for emergency surgery.

Decreased suppressor cell activity in inflammatory bowel disease

Studies were performed on eleven patients with inflammatory bowel disease to determine if there was an alteration in concanavalin A (Con A) induced suppressor cell activity. Similar investigations were also performed on twenty-one control subjects and five patients with other inflammatory conditions. Supressor cells were generated by pre-incubation of peripheral blood mononuclear cells with a mitogenic concentration of Con A, followed by treatment with mitomycin C and alpha-methyl mannoside. Under these conditions, cells obtained from normal individuals are then capable of suppressing the Con A-stimulated blast transformation responses of fresh allogeneic lymphocytes in new cultures. We found that in twenty out of twenty-one control subjects, and all five patients with other inflammatory disorders, Con A-stimulated suppressor cell activity was demonstrable. Four patients with inflammatory bowel disease, whose disease was mildly active or was in clinical remission, had elicitable suppressor cell activity which fell within the normal range. In contrast, suppressor cell activity was markedly diminished or absent in seven patients with severe and active inflammatory bowel disease. These studies suggest that an alternation in Con A-stimulated suppressor cells exists in patients with active inflammatory bowel disease, which may contribute, in part, to the persistent inflammation in the gastrointestinal tract.

Serum lysozyme, serum proteins, and immunoglobulin determinations in nonspecific inflammatory bowel disease

The serum levels of lysozyme, serum electrophoresis, and serum immunoglobulins were determined prospectively in 101 patients with ulcerative colitis, ulcerative proctitis, Crohn's disease, or nonclassifiable nonspecific inflammatory bowel disease. Although the mean serum lysozyme concentration of patients with Crohn's disease (10.5 +/- 6.8 microgram/ml) and ulcerative colitis (9.6 +/- 4.1 microgram/ml) performed by a standardized lysoplate method was significantly greater than normal controls (6.0 +/- 1.5 microgram/ml), the results did not correlate with the diagnosis nor with the degree of disease activity. Individually separated protein fractions and serum immunoglobulins also did not correlate with the serum lysozyme levels. This study indicates that measurement of the level of serum lysozyme in individual patients is not helpful in determining the cause or degree of activity of nonspecific inflammatory bowel disease.

The humoral immune system in inflammatory bowel disease. II. Immunologlobulin levels

As there have been reports of differences in mean levels of serum immunoglobulins between patients with ulcerative colitis and Crohn's disease, serum IgG, IgA, and IgM were estimated in 158 patients with inflammatory bowel disease and the results correlated with the clinical features of the patients. Although a higher mean IgG level in ulcerative colitis compared to Crohn's disease was confirmed, no difference was found when the comparison was limited to patients with colonic Crohn's disease. Patients with either disease had higher mean IgM levels than controls, and the IgM levels were higher on treatment with corticosteroids and showed a tendency to rise in remission. IgG and IgM levels were also higher in both diseases if extraintestinal manifestations were present. It is concluded that if clinical features, particularly disease site, are taken into account, the overall immunoglobulin responses in these two diseases show no differences.

A survey of protein nutrition in patients with inflammatory bowel disease--a rational basis for nutritional therapy

The incidence of protein malnutrition was studied in 74 unselected patients with inflammatory bowel disease who were in the following categories: ileostomy (16), remission (15), elective surgery (12), acute attack (12), urgent surgery (10) and post-surgical complications (9). Compared with a control group, the patients in the urgent surgery group had low values for plasma albumin transferrin, pre-albumin and haemoglobin and these values were even lower in the patients who developed a major complication after surgery. There was no evidence of protein malnutrition in the ileostomy patients or in those in whom the disease was in remission. Nutritional therapy is strongly indicated in patients who are admitted to hospital with a severe attack of colitis and in whom urgent surgery is probable.

Muramidase (lysozyme) in Crohn's disease and in ulcerative colitis

Estimation of lysozyme (LZM) activity in the serum was suggested as a valuable test to distinguish between Crohn's disease and ulcerative colitis. Subsequently several reports either supported or denied the original observation. Selection of patients and methodological differences were suggested as an explanation for the controversy. We estimated serum LZM in a large group of patients using the lysoplate method and human LZM as a standard. The conditions of the assay were strictly standardized. In 90 patients with Crohn's disease the LZM level was 8.3 +/- 2.1 (SD) microgram/ml, in 57 patients with ulcerative colitis was 7.4 +/- 2.0 (SD) microgram/ml, and in 40 healthy individuals it was 7.0 +/- 1.2 (SD) microgram/ml. Although the difference between the mean LZM levels in Crohn's disease and in ulcerative colitis was statistically significant, there was a definite overlapping of values between these two diseases. No significant correlation of LZM level to the duration or extent of the disease, activity, or treatment was found in Crohn's disease. In ulcerative colitis the LZM level was often a little higher in severe disease, especially when the whole colon was involved.

Humoral immune system in inflammatory bowel disease: I. Complement levels

Serum levels of complement components Clq, C4, C3, and Properdin factor B, from the classical and alternative pathways of complement activation, have been estimated in patients with ulcerative colitis and Crohn's disease. C3, factor B, and to some extent C4 concentrations all increased when the disease was active. In remission the levels of these components did not differ from hospital control patients. There was no evidence for the preferential consumption of the proteins of either pathway of activation, even in those patients with evidence of circulating immune complexes.

Immune complexes in ulcerative colitis and Crohn's disease

Sera from 156 patients with ulcerative colitis and Crohn's disease were tested for the presence of immune complexes, by the detection of anti-complementary activity and 125I-labelled Clq precipitation. Using aggregated IgG, a comparison between the two tests indicated that the anti-complementary test was most sensitive to aggregates of 11S in size, while the 125I-labelled Clq test detected aggregates over 20S in size. Excess anti-complementary activity was common in patients with active bowel disease, and in those with extra-intestinal manifestations, particularly acute arthritis, ankylosing spondylitis and liver disease. Large complexes were only common in patients with liver disease. Immune complexes in the gut mucosa may play a role in the pathogenesis of these diseases, and the deposition of circulatory immune complexes may explain at least some of the extra-intestinal manifestations.

C3 metabolism in ulcerative colitis and Crohn's disease

The metabolism of the third component of complement (C3) has been investigated in four patients with ulcerative colitis, three patients with Crohn's disease and seven control subjects, using radioiodinated C3 prepared from fresh human plasma. Both the fractional catabolic rate and synthesis rate of C3 were increased in the patients with inflammatory bowel disease, although the serum-C3 levels were normal or raised. The results suggest that complement activation may play a role in the pathogenesis of mucosal inflammation in these diseases.

Treatment of toxic megacolon. A comparative review of 29 patients

A review of 29 patients with toxic megacolon complicating ulcerative colitis was undertaken to (1) compare the results of medical and surgical treatment; (2) determine the optimal timing for surgical intervention, and (3) identify possible precipitating factors. Twenty-one patients were treated medically with nasogastric suction, steroids, parental fluids, blood transfusions, and antimicrobial agents. Of the 21 patients, 11 (53%) showed improvement by subjective and objective criteria and 10 (47%) failed to respond. Sixteen patients were treated surgically. This group was subdivided into 8 patients who failed to respond to medical treatment and 8 treated surgically. Total proctocolectomy with ileostomy was performed in 8 and subtotal colectomy and ileoproctostomy in 8, with subsequent proctectomy and ileostomy in 6 patient. Six of 8 patients (75%) treated primarily surgically improved, and 2 (25%) died. Seven of 8 patients (87.5%) treated surgically after failure of medical trial showed definite postoperative improvement, and 1 (12.5%) failed. Those who were operated on within the first 48-72 hr after the diagnosis of toxic megacolon was made responded uniformly well. Anticholinergics, opiates,, barium enema, and colonoscopy were identified as possible precipitating factors in 70% of cases. The results of this tudy in this patient population indicate that early surgical therapy in toxic megacolon is associated with better results than medical therapy (P less than 0.025). Although intensive, optimal medical therapy plays a significant role in the management of toxic megacolon, failure to induce rapid improvement within 48-72 hr constitutes an indication for definitive surgical treatment.

Zinc in ulcerative colitis: a therapeutic trial and report on plasma levels

A double-blind controlled trial of oral zinc sulphate as adjuvant treatment in idiopathic ulcerative colitis or proctitis in relapse is reported. Fifty-one patients were treated, and the clinical and sigmoidoscopic improvement in the zinc treated patients was similar to that in patients receiving placebo. No difference was found between plasma zinc levels in a further 46 patients with idiopathic ulcerative colitis or proctitis and those obtained in a group of healthy controls.

Blood pH: a test for assessment of severity in proctocolitis

Acid base balance was studied in 58 patients with active idiopathic proctocolitis; the condition of 10 of them was complicated by toxic megacolon. Arterial blood pH increased progressively with increased severity of the colitis and as the lesions became more widespread. Statistically significant differences were observed in pH values between the mild/moderate and severe forms and between the severe and complicated forms ('toxic megacolon'). A linear correlation was found between pH and the amount of intestinal gas, pulse rate, and plasma albumin.

Serum lysozyme levels in Crohn's disease and ulcerative colitis

Serum lysozyme levels were determined in healthy volunteers, patients with Crohn's disease, and patients with ulcerative colitis. The mean concentration in Crohn's disease was significantly greater than in the other groups. In patients with Crohn's disease, as well as in patients with ulcerative colitis, the lysozyme levels correlated with the severity of the disease process and with the extent of the lesions: the more severe the disease and the more extensive the involvement, the higher the lysozyme levels. However, the lysozyme values of the different groups overlapped considerably. Our results indicate that lysozyme determinations have only limited discriminative value for the diagnosis of Crohn's disease and for determining the severity and the extent of the disease process in the individual patient.

Na+-K+-activated adenosine triphosphatase and intestinal electrolyte transport. Effect of adrenal steroids

Sodium-potassium-activated adenosine triphosphatase (Na-K-ATPase) is associated with electrolyte transport in many tissues. To help delineate its role in intestinal transport, changes in rat intestinal electrolyte and water transport induced by injecting methylprednisolone acetate 3 mg/100 g or deoxycorticosterone acetate (DOCA) 0.5 mg/100 g per day for 3 days were correlated with changes in Na-K-ATPase activity. Methylprednisolone increased sodium and water absorption, potassium secretion, transmural potential difference, and Na-K-ATPase activity in the jejunum, ileum, and colon. Examination of isolated epithelial cells demonstrated that the jejunal and ileal increase in Na-K-ATPase occurred in both the villus tip and crypermeability, Mg-ATPase, and adenylate cyclase activities were unchanged by methylprednisolone. DOCA increased sodium and water absorption, potassium secretion, transmural potential difference, and Na-K-ATPase activity in the colon alone. Colonic Mg-ATPase and adenylate cyclase activities were unaffected. Jejunal and ileal enzyme activity, electrolyte transport, and permeability were unchanged by DOCA. Methylprednisolone and DOCA were not additive in their effect on colonic Na-K-ATPase activity. Methylprednisolone and DOCA increased electrolyte and water transport and Na-K-ATPase activity concomitantly in specific segments of small intestine and colon. These data are consistent with an important role for Na-K-ATPase in intestinal electrolyte and water transport.

Assessment of severity in colitis: a preliminary study

Clinical features, alone and in combinations of up to five, noted early in patients during 181 admissions to one hospital for treatment of acute colitis over five years, have been correlated with the success or failure of drug treatment as judged by death during medical treatment or the need for urgent surgical treatment. Many of the 56 clinical features studied were of no value in predicting the outcome of the attack. The four features of greatest predictive value were the maximum daily body temperature, the maximum daily pulse rate, the bowel frequency and plasma albumin. The simplest and most discriminating prediction at the end of the first 24 hours in hospital was obtained by combining observations on maximum body temperature and the number of stools passed. Serial observations of temperature or pulse rate over the first four days in hospital gave more prognostic information than observations confined to the first day. The predictive value of certain other features, such as x-ray appearances, is described. A simple classification of severity in acute colitis is proposed from these results as a basis for prospective testing in other hospitals.

Carcinoembryonic antigen in patients suffering from ulcerative proctocolitis

Carcinoembryonic antigen (CEA) has been measured by radioimmunoassay in samples obtained from all patients suffering from ulcerative proctocolitis and seen within a four-month period. The characteristics of this group of patients have been compared with reported epidemiological studies in this disease, and have been found to have a similar sex ratio and age of onset, but a more limited disease. Among 59 patients, 11 were found to have elevated circulating CEA values. One of the 11 had a colonic carcinoma and another was pregnant. Excluding these two patients, an overall prevalence of elevated CEA levels of 17.5% was found. The prevelance in ulcerative proctitis was 7.1%, and in colitis was 19.9%. The patients in whom elelvated plasma CEA values were found were compared with the remaining patients in relation to factors known to be associated with an increased propensity for the development of colorectal carcinoma complicating ulcerative colitis. There was no difference in mean age of the patients at disease onset, nor was there any difference in disease duration, extent, and control. A significant correlation was found between elevated plasma CEA levels and the severity of the initial attack. One patient with premalignant changes in the rectal mucosa had consistently normal concentrations of plasma CEA. There was no significant correlation between elevated plasma CEA values and disease activity. The mean age of the two groups of patients was similar. No carcinoma has manifested in any patient during follow-up periods of at least 18 months.

Serum lysozyme in Crohn's disease and ulcerative colitis

Serum lysozyme (muramidase) concentrations were determined in patients with different types of inflammatory bowel disease and in normal subjects. The mean (plus or minus S.E.M.) lysozyme concentration for each group was as follows: controls, 8.8 plus or minus 0.3, ulcerative colitis, 9.3 plus or minus 0.6, Crohn's disease, 26.3 plus or minus 1.4. a and bacterial and nonbacterial enteritis, 8.9 plus or minus 0.7 mug per milliliter. Thus, mean enzyme levels were significantly greater in Crohn's disease than in ulcerative colitis (p smaller than 0.001), bacterial and nonbacterial enteritis (p smaller than 0.001) and healthy volunteers (p smaller than 0.001). The elevation of serum lysozyme in Crohn's disease may be related to tissue macrophages because no correlation was found between either the serum lysozyme concentration and the white-cell counts or the absolute numbers of circulating granulocytes or monocytes. Our findings suggest that serum lysozyme may be useful in the differential diagnosis of Crohn's disease from other types of bowel inflammation.

Some aspects of medical management of gastrointestinal disease. Part II

Antacids are among the most frequently used drugs, yet common prescribing habits suggest that there is little familiarity with effective dosage schedules, side effects, or the differences between various antacid preparations. These factors, which are important in the choice of a specific antacid preparation, are discussed in an attempt to provide a rational basis for therapy.Corticosteroids, salicylazosulfapyridine (Salazopyrin) and diphenoxylate hydrochloride-atropine (Lomotil) are often used in treatment of inflammatory bowel disease. Recently described regimens for treating acute exacerbations and maintaining remission in patients with ulcerative colitis are reviewed, and attention is drawn to possible adverse effects of Lomotil in the treatment of colonic disease.

Azathioprine in ulcerative colitis: final report on controlled therapeutic trial

Eighty patients, all of whom were suffering from a frank clinical attack of ulcerative colitis, were admitted to the trial. The attack was treated with a standard course of corticosteroids and the patients were immediately placed on treatment with either azathioprine in a dose of 2.5 mg/kg body weight or dummy tablets. The trial tablets were continued for one year while the patients were maintained under regular clinical, sigmoidoscopic, histological, haematological, and biochemical surveillance. If a patient relapsed during such maintenance treatment he or she was treated with a further course of corticosteroids without interrupting maintenance treatment.In the treatment of an actual attack of ulcerative colitis the results in the attacks which brought the 80 patients into the trial show that no benefit came from the addition of azathioprine to a standard course of corticosteroid therapy.Patients admitted in their first attack of ulcerative colitis showed no benefit from the one-year maintenance treatment with azathioprine, the benefits of which were confined to patients admitted in a relapse of established disease. Even in these the difference between the treated group and the control group failed to reach statistical significance, but the difference was big enough to suggest that there is a prima facie case for regarding azathioprine as of some benefit in this group of patients.

Short-term course and prognosis of Crohn's disease

An analysis is presented of the course and outcome of the initial referred attack in a group of 332 patients with Crohn's disease treated at the General Infirmary at Leeds from 1939 to 1968 inclusive. A further 50 cases were excluded on the basis of insufficient diagnostic evidence: usually such patients had acute terminal ileitis. Only 5% of patients achieved full remission on conservative management, and most eventually came to surgery. The overall fatality rate was some 3.3% and this was affected chiefly by the severity of attack and the age of the patient. The severity of attack was classified as mild, moderate, or severe according to a system which took into account factors such as bowel habit, rectal bleeding, abdominal pain, pulse rate, temperature, haemoglobin, and weight. In attacks graded as ;mild', no deaths occurred; in those graded ;severe' the fatality rate was 8.8%. Similarly, whilst no patient under 20 years of age died, the fatality rate in the over 60s was some 14.8%. Further comparison between the present group of 332 patients and an earlier series of 204 patients suffering from ulcerative colitis (Watts, de Dombal, Watkinson, and Goligher, 1966a) shows considerable differences in the course and prognosis of the two diseases. In particular 70% of patients with ulcerative colitis achieved remission on conservative management alone whereas only 5% of Crohn's disease patients did so. These differences, and in particular the poor response to conservative therapy, are discussed, together with their implications for management.

Acute toxic dilatation of the colon in Crohn's colitis

Twelve new cases of acute toxic dilatation of the colon in Crohn's colitis treated by total colectomy and ileorectal anastomosis are reported, and criteria for making the diagnosis are given.The complication has occurred in 6% of patients diagnosed as having Crohn's disease of the colon treated at the Gordon Hospital since 1948. The patients have been predominantly young adult females, with a short preoperative history of disease. The sigmoidoscopic appearance of the rectum preoperatively has been no indication of the likelihood of recurrent disease at the anastomosis. Only four patients still have successfully functioning ileorectal anastomoses and four patients have died from the effects of the disease.

Long-term prognosis of children with ulcerative colitis

The subsequent course of ulcerative colitis in 25 children admitted to hospital during the period 1931 to 1971 is reviewed. The period of observation averaged 24 years, ranging from 1 to 41 years. 19 patients showed extracolonic manifestations. 4 patients had a single attack of colitis, and in 19 the disease was of the chronic intermittent type. There was one case each of the acute fulminating and chronic continuous types. Three of 8 patients who had colectomy died postoperatively. One further patient died later of carcinoma of the rectal stump. At follow-up 5 patients (20%) had died and the remaining 20 (80%) were in remission. Although the case for surgery in the treatment of acute fulminating or resistant ulcerative colitis may be clear, that for prophylactic panproctocolectomy while the disease is in remission requires further study.

Azathioprine in ulcerative colitis: an interim report on a controlled therapeutic trial

This interim report on a controlled therapeutic trial of azathioprine in ulcerative colitis deals with the first 40 patients to complete a one-year period of maintenance treatment with azathioprine or with dummy tablets. The patients all suffered from classical ulcerative colitis and were in an actual attack of the disease at the time of admission. The attack was treated with a standard corticosteroid regimen and the patients were assigned at random to maintenance treatment with real or dummy azathioprine tablets, using a stratified design. The treatment and control groups were closely similar at the beginning of the trial.The effect of treatment has been assessed on the basis of the number of relapses of the disease occurring during the one-year trial period, supplemented by an assessment of the sigmoidoscopic picture and of the histological findings on serial rectal biopsy. In the patients receiving azathioprine the disease ran a more favourable course than in the control group. After the attack had been treated 11 of the 20 patients on azathioprine were symptom-free throughout the rest of the one-year trial period compared with only 5 out of 20 in the control group. The only three patients classed as failures were all in the control group. These differences just fail to reach conventional levels of statistical significance.Azathioprine is not dramatically successful but may still be a useful addition to the medical treatment of ulcerative colitis, particularly if conventional medical treatment is ineffective and there are reasons for wishing to avoid radical surgery. In the dose used azathioprine was virtually free from undesirable side effects.

Reliability of physical signs in patients with severe attacks of ulcerative colitis

A series of observer variation studies in a small group of patients suffering from severe acute ulcerative colitis is reported. Seventy-two separate assessments of the patients' physical signs and clinical progress were made by three independent observers.The results of this investigation suggest that there is difficulty in eliciting general physical signs such as anaemia or dehydration in these patients. By contrast, local abdominal signs such as tenderness and distension were relatively reliably elicited. The results also suggest that there are considerable problems in evaluating these clinical signs in terms of the patient's immediate subsequent progress.

Gastric ulcer and the anti-arthritic drugs

Sixteen cases are described of gastric ulcer in patients receiving anti-arthritic drugs. Half of the ulcers were in the antrum or on the greater curve. Ten patients were under treatment with indomethacin and/or prednisone, seven of them receiving both drugs.

The ulcers healed readily when the drugs were withdrawn, and in the case of prednisone a continued daily dose of 10 mg or less did not prevent healing.

All the patients with haemorrhage were taking aspirin, with or without other drugs.

The literature is reviewed, and it is suggested that the increased incidence of peptic ulcer in patients receiving anti-arthritic drugs is confined to gastric ulcer. There is suggestive evidence of an increased susceptibility to antral ulcer in severe rheumatoid disease, which may largely account for the ‘steroid ulcer’.

Indomethacin is potentially ulcerogenic, and its combined use with steroids may be inadvisable. Apart from its tendency to produce haemorrhagic erosions, the role of aspirin in the aetiology of chronic ulcer remains doubtful. No serious ill-effects have been reported in the use of ibuprofen or Distalgesic in ulcer subjects.

Trends in mortality from ulcerative colitis in England and Wales

Mortality rates for ulcerative colitis in England and Wales over the years 1946 to 1967 showed trends which varied with age. Between the ages of 15 and 34 rates fell with only minor irregularities. At ages 35 to 64, rates were constant from 1946 to 1957 and then began to decline. At ages 65 and above, rates rose during most of the period but with a recent tendency to stabilize. These trends are discussed in relation to possible effects of the introduction of steroids and other therapies.

Surgical treatment of severe attacks of ulcerative colitis, with special reference to the advantages of early operation

The management and outcome of 258 severe attacks of ulcerative colitis from 1952 to 1969 has been reviewed. If remission did not occur during an initial course of intensive medical treatment, including administration of corticosteroids, operation (generally ileostomy with proctocolectomy or subtotal colectomy) was performed. This took place some 12 to 17 days after admission as a rule during the years 1952-63, but usually within five to seven days from 1964 to 1969.Roughly half the attacks underwent spontaneous remission during the two periods, but the medical mortality was 4.8% in the former and 0.7% in the latter, the operative mortality 20.0 and 7.0%, and the overall mortality 11.3 and 4.5% respectively. The lowering of the mortality was particularly striking in severe first attacks and in severe attacks in patients over 60 years of age.Perforation of the colon was found in 21 cases, or nearly 20% of 112 patients coming to operation during attacks, being commoner in the first period (32.5%) than in the second (11.1%). The immediate mortality of all such operations was 11.6%; in cases with perforation it was 28.6%.Acute colonic dilatation was observed in 28 cases. All but one were treated by emergency colectomy, at which the colon was noted to be perforated in 11. The mortality of these operations was 18.5%.Follow-up of the 140 patients who survived without coming to operation during their attacks shows that 52 (37.1%) subsequently underwent surgical treatment either during further attacks or electively.Though all 258 attacks were thought at the time to be due to ordinary ulcerative colitis, subsequent pathological examination of operative specimens derived from 98 patients who came to urgent or subsequent operation during the 1964-9 period revealed that the lesion in the large bowel was Crohn's disease in 17 instances.

Absorption and secretion of water and electrolytes by the intact human colon in diffuse untreated proctocolitis

The net transport and unidirectional fluxes of water, sodium, and potassium were studied in four subjects with diffuse untreated proctocolitis, by perfusing the colon with isotopically-labelled solution instilled through a tube introduced by mouth. The results were compared to those obtained in 13 healthy subjects. In proctocolitis the colonic absorption of sodium and water was impaired and the secretion of potassium increased. The movement of electrolytes across the colonic mucosa into the lumen was increased and the movement in the opposite direction reduced. The close correlation between water and sodium absorption in healthy subjects was maintained in those with proctocolitis. These alterations in the colonic handling of water and electrolytes diminish the reserve capacity of the colon and may explain the diarrhoea of proctocolitis.

The management of ulcerative colitis

A plea for a combined medicosurgical treatment of ulcerative colitis has been made. While considerable advances in therapy have improved the results of medical treatment in the last 20 years increasing knowledge of the natural history and prognosis of ulcerative colitis has shown that proctocolectomy has been increasingly required in severe colitic attacks, in elderly subjects and in patients with total colonic involvement.