From symptom to diagnosis: clinical distinctions among various forms of intestinal inflammation

Investigating intestinal inflammation in DSS-induced model of IBD

Inflammatory bowel disease (IBD) encompasses a range of intestinal pathologies, the most common of which are ulcerative colitis (UC) and Crohn's Disease (CD). Both UC and CD, when present in the colon, generate a similar symptom profile which can include diarrhea, rectal bleeding, abdominal pain, and weight loss.(1) Although the pathogenesis of IBD remains unknown, it is described as a multifactorial disease that involves both genetic and environmental components.(2) There are numerous and variable animal models of colonic inflammation that resemble several features of IBD. Animal models of colitis range from those arising spontaneously in susceptible strains of certain species to those requiring administration of specific concentrations of colitis-inducing chemicals, such as dextran sulphate sodium (DSS). Chemical-induced models of gut inflammation are the most commonly used and best described models of IBD. Administration of DSS in drinking water produces acute or chronic colitis depending on the administration protocol.(3) Animals given DSS exhibit weight loss and signs of loose stool or diarrhea, sometimes with evidence of rectal bleeding.(4,5) Here, we describe the methods by which colitis development and the resulting inflammatory response can be characterized following administration of DSS. These methods include histological analysis of hematoxylin/eosin stained colon sections, measurement of pro-inflammatory cytokines, and determination of myeloperoxidase (MPO) activity, which can be used as a surrogate marker of inflammation.(6) The extent of the inflammatory response in disease state can be assessed by the presence of clinical symptoms or by alteration in histology in mucosal tissue. Colonic histological damage is assessed by using a scoring system that considers loss of crypt architecture, inflammatory cell infiltration, muscle thickening, goblet cell depletion, and crypt abscess.(7) Quantitatively, levels of pro-inflammatory cytokines with acute inflammatory properties, such as interleukin (IL)-1β, IL-6 and tumour necrosis factor (TNF)-α,can be determined using conventional ELISA methods. In addition, MPO activity can be measured using a colorimetric assay and used as an index of inflammation.(8) In experimental colitis, disease severity is often correlated with an increase in MPO activity and higher levels of pro-inflammatory cytokines. Colitis severity and inflammation-associated damage can be assessed by examining stool consistency and bleeding, in addition to assessing the histopathological state of the intestine using hematoxylin/eosin stained colonic tissue sections. Colonic tissue fragments can be used to determine MPO activity and cytokine production. Taken together, these measures can be used to evaluate the intestinal inflammatory response in animal models of experimental colitis.

Clinical and Pathological Manifestations with Differential Diagnosis in Behçet's Disease

Behçet's disease is a multisystemic inflammatory disease of unknown etiology which usually occurs as a trait of symptoms: aphthous stomatitis, genital ulcerations, and ocular disease. At the beginning of the disease the diagnosis is uncertain because of various clinical manifestations and a long period up to the full clinical picture manifestation. Since neither the laboratory data nor the histopathological signs are truly pathognomonic in Behçet's disease, the differential diagnosis depends on a careful evaluation of the medical history and meticulous physical examination to detect concomitant systemic manifestations. Sometimes, some laboratory test may help establish the diagnosis. Subspecialty referral to ophthalmology, rheumatology, neurology, and gastroenterology should be considered when indicated.

Associations between variants in the ABCB1 (MDR1) gene and corticosteroid dependence in children with Crohn's disease

BACKGROUND

Corticosteroids (CS) effectively induce remission in patients with moderate to severe Crohn's disease (CD). However, CS dependence in children is a significant clinical problem associated with numerous side effects. Identification of molecular markers of CS dependence is of paramount importance. The ABCB1 gene codes for P-glycoprotein, a transporter involved in the metabolism of CS. We examined whether DNA variation in the ABCB1 gene was associated with CS dependency in children with CD.

METHODS

A retrospective study was carried out in two Canadian tertiary pediatric gastroenterology centers. Clinical information was abstracted from medical charts of CD patients (N = 260) diagnosed with CD prior to age 18 and administered a first course of CS during the 1 year since diagnosis. Patients were classified as CS-dependent if they relapsed during drug tapering or after the end of therapy. DNA was extracted from blood or saliva. Thirteen tagging single nucleotide polymorphisms (tag-SNPs) and a synonymous variation (C3435T) in the ABCB1 gene were genotyped. Allelic, genotype, and haplotype associations were examined using logistic regression and Haploview.

RESULTS

Tag-SNP rs2032583 was statistically significantly associated with CS dependency. The rare C allele of this SNP (odds ratio [OR] = 0.56, 95% confidence interval [CI]: 0.34-0.95, P = 0.029) and heterozygous genotype TC (OR = 0.52, 95% CI: 0.28-0.95, P = 0.035) conferred protection from CS dependency. A three-marker haplotype was significantly associated with CS dependence (multiple comparison corrected P-value = 0.004).

CONCLUSIONS

Our results suggest that the ABCB1 gene may be associated with CS dependence in pediatric CD patients.

TH1 and TH17 interactions in untreated inflamed mucosa of inflammatory bowel disease, and their potential to mediate the inflammation

BACKGROUND

Crohn's disease (CD) and ulcerative colitis (UC) have been associated with a T helper1 (TH1) and a TH2 cytokine profile, respectively. Recently, a TH17 lineage has been introduced, but their role in the inflammation of CD and UC is not fully understood.

AIM

To characterize the cytokines directing the TH17 cells and their interactions with TH1 cells in the mucosa of untreated patients with CD and UC.

METHOD

Seventy-nine patients with untreated UC, 32 patients with untreated CD and 23 controls with no signs of colon disease were included in the study. Clinical indices for ulcerative colitis (UCDAI) and Crohn's disease (CDAI) were assessed. Biopsies for measurements of interleukin (IL)-17A, IL-23, IL-6, transforming growth factor-beta (TGF-β), interferon-gamma (IFN-γ), mRNA levels as well as immunohistochemical (IHC) analyses were performed.

RESULTS

The gene expression for all cytokines in UC and for all cytokines except for TGF-β in CD were significantly increased compared with the controls. The immunohistochemical analysis showed significantly increased number of IL-17A positive cells in lamina propria and epithelium of both UC and CD compared to controls. The levels of IL-17A and IL-23 mRNA were significantly higher in UC than in CD while the levels of IL-6 were significantly higher in CD compared with UC. The levels of IL-17A, IL-6 and IL-23 mRNA were associated with the disease activity score in both UC and CD. IFN-γ was associated with the disease activity in UC, but did not reach significant level in CD.

CONCLUSION

Increased levels of IL-17A and IL-23 were found in both UC and CD compared to controls. Association to the grade of inflammation and clinical activity was also observed. IL-17A and IL-23 were significantly higher in UC than in CD. TH1 and TH17 cytokines seem to act synergistically in inflammatory bowel disease (IBD) with no apparent polarization between UC and CD.

Antimicrobial peptide response to blood translocation of bacterial DNA in Crohn's disease is affected by NOD2/CARD15 genotype

BACKGROUND

Blood translocation of bacterial-DNA has been described in patients with Crohn's disease (CD). The host's immune cell types cooperate to respond against bacterial insults. Some antimicrobial peptides are inducible after culture with bacterial products and a linkage has been established between them and NOD2/CARD15. The aim was to test whether defensins and cathelicidin (LL-37) expression and NOD2/CARD15 mutations in blood neutrophils are related to molecular bacterial translocation events in CD patients.

METHODS

Fifty consecutively admitted CD patients and 15 healthy controls were included. Clinical and analytical characteristics of patients were considered. NOD2/CARD15 genotyping, presence of bacterial-DNA, defensin and cathelicidin gene, and protein levels in neutrophils and serum cytokine levels were studied.

RESULTS

Twenty patients (40%) presented bacterial-DNA in blood. Eleven were active and 9 were in remission. Bacterial-DNA was not present in controls. NOD2/CARD15 mutations were identified in 25 patients (50%), 15 of which were in remission. Sixty percent of bacterial-DNA(+) and 43% of bacterial-DNA(-) patients showed a NOD2/CARD15 mutation. β-Defensin 2 and LL-37 mRNA and protein levels were upregulated in bacterial-DNA(+) patients. β-Defensin 2 and LL-37 expression correlated with bacterial-DNA concentration only in patients with a wildtype NOD2/CARD15 genotype. Cultured neutrophils of bacterial-DNA(-) patients confirmed the muramyl dipeptide-independent association between DEFB2 and LL-37 with bacterial-DNA concentration in wildtype NOD2/CARD15 patients. Cytokine levels were increased in bacterial-DNA(+) patients and correlated with bacterial-DNA concentration. NOD2/CARD15 genotype did not influence this correlation.

CONCLUSIONS

β-Defensin 2, LL-37, and proinflammatory cytokines are increased in CD patients with bacterial-DNA in a concentration-dependent manner. NOD2/CARD15 plays a key role in the regulation of this response.

Safety of biologics in inflammatory bowel disease

Various biologic agents have been evaluated in patients with inflammatory bowel disease (eg, Crohn's disease ) and ulcerative colitis (UC). At present, only one, infliximab (humanized monoclonal anti-tumor necrosis factor-alpha antibody), is approved by the US Food and Drug Administration for induction and maintenance treatment in patients with active moderate to severe and/or fistulizing CD who are refractory to conventional therapy. Two recent trials, Active Ulcerative Colitis Trial (ACT) 1 and ACT 2, observed high efficacy of infliximab in inducting and maintaining clinical remission, mucosal healing, and corticosteroid-sparing effects in patients with moderate to severe UC. A plethora of randomized, double-blind, controlled and open-label, uncontrolled studies on large and small numbers of patients has assessed efficacy and safety of various biologic agents of potential use in treatment of inflammatory bowel disease. With respect to safety of biologic agents used for treatment, the most accurate data are available only in the case of infliximab. This is due to the fact that infliximab was evaluated in many more trials than any other biologic agent. Moreover, postmarketing experience also provides very valuable information about any side effects occurring during treatment with this agent.

Immediate and long-term outcomes of corticosteroid therapy in pediatric Crohn's disease patients

BACKGROUND

Although a mainstay of treatment of moderate to severe Crohn's disease (CD), corticosteroids use presents significant challenges because of large interindividual variability in response. Corticosteroid-dependence is of particular concern in children, where high rates have been reported. We examined the burden of corticosteroid-resistance and dependence in a well-characterized cohort of pediatric CD patients and investigated potential predictors of response.

METHODS

Children diagnosed with CD (<18 years), were recruited from two Canadian pediatric gastroenterology clinics. Immediate and long-term responses to corticosteroid therapy were retrospectively ascertained. Response rates (resistance and dependence) were estimated and potential predictors assessed using logistic regression analysis.

RESULTS

Of the 645 CD patients, 364 (56.2%) received corticosteroids. The frequency of corticosteroid-resistance was (8.0%) (95% confidence interval [CI]: 5.0%-11%) and 40.9% (95% CI: 39.0%-46.0%) became dependent. In univariate analysis female gender (odds ratio [OR] = 2.49, 95% CI: 1.1-5.5, P = 0.025), disease severity (OR = 2.43, 95% CI: 1.10-5.38, P = 0.029), and complicated disease (OR = 2.75, 95% CI: 1.18-6.41, P = 0.019) were associated with resistance. In multivariate analysis lower age at diagnosis (OR = 1.34,95% CI: 1.03-3.01, P = 0.040), coexisting upper digestive tract involvement (OR = 1.35, 95% CI: 1.06-3.07, P = 0.031), and concomitant immunomodulator use (OR = 0.35, 95% CI: 0.16-0.75, P = 0.007) were significantly associated with steroid dependency.

CONCLUSIONS

Our results demonstrate that steroid dependency is a frequent complication in children with CD. Children with an earlier age at diagnosis and coexisting upper digestive tract involvement could be potentially targeted for steroid-sparing therapy.

Inflammatory bowel disease: a systematic review on the value of diagnostic testing in primary care

AIM

The clinical presentation of inflammatory bowel disease in primary care represents a diagnostic challenge as its symptoms are heterogeneous and common. To assist the primary care physician, we have summarized the available evidence on diagnostic tests in patients with abdominal symptoms.

METHOD

We searched PubMed and Embase and screened references. Studies were selected if the design was a primary diagnostic study. Patients were adults attending with nonacute abdominal symptoms. Tests included clinical assessment, blood or faecal tests or abdominal ultrasonography. Quality assessment using a modified version of the QUADAS tool and data extraction was performed by two reviewers independently. Diagnostic two-by-two tables and pooled estimates of sensitivity and specificity are given. We refrained from pooling when there was considerable clinical or statistical heterogeneity.

RESULTS

A total of 24 studies were included. While the diagnostic performance of the individual symptoms was highly variable (range sensitivity 0.0-0.96, specificity 0.09-1.0), the performance of symptom-based classification systems was both more consistent and better (sensitivity 0.65-1.0, specificity 0.17-0.82). Among faecal and blood tests, calprotectin was studied most frequently and showed the best results (sensitivity 0.61-1.0, specificity 0.71-1.0). Statistical pooling for ultrasonography resulted in a sensitivity of 0.73 (0.65-0.80) and a specificity of 0.95 (0.91-0.97).

CONCLUSION

Although calprotectin and ultrasonography showed consistent and promising findings, none of the studies was performed in primary care. To assist primary care physicians in diagnostic decision making, we urgently need high quality studies performed in primary care.

Macrophages from IBD patients exhibit defective tumour necrosis factor-α secretion but otherwise normal or augmented pro-inflammatory responses to infection

Defects in macrophage function have been implicated in the establishment of Crohn's disease (CD). However, the response of macrophages from CD patients to live bacteria, particularly Mycobacterium avium subsp. paratuberculosis (MAP), has not been addressed. Considering MAP has long been associated to CD, our objective was to assess whether macrophages from CD patients showed impaired inflammatory response to infection by MAP comparing to M. avium subsp. avium (MA) and other live intestinal commensal bacteria. Human peripheral blood monocyte-derived macrophages were obtained from CD patients, ulcerative colitis (UC) patients and controls. Following in vitro infection with MAP, MA, Escherichia coli or Enterococcus faecalis, cytokine levels and cell surface receptor expression were evaluated at different time points. Macrophages from CD patients showed impaired TNF-α secretion in response to bacterial challenge, but augmented IL-23 secretion and preserved IL-12 secretion and CD-40 expression. In addition, CD macrophages showed low IL-10 secretion. Macrophages from IBD patients showed increased expression of TLR-2 and -4, unaffected by infection. Differences in cytokine secretion observed after bacterial challenge were not MAP-specific, as other bacteria (E. coli and MA) showed similar effects. Macrophages from UC patients showed a less compromised TNF-α synthesis in response to mycobacterial infection than CD macrophages, with increased constitutive IL-12 secretion, and preserved IL-10 secretion. The increased IL-23 levels in response to infection and decreased IL-10 production observed in macrophages from CD patients may contribute to the inflammatory exacerbation observed in those patients.

Short-and Long-Term Clinical Outcomes of Infliximab in Fulminant Ulcerative Colitis

The aim was to characterize short- and long-term clinical outcomes of infliximab in fulminant ulcerative colitis. Patients with severe ulcerative colitis meeting the criteria of fulminant colitis after 3 days of glucocorticosteroid treatment were randomized to control or additional induction therapy of infliximab followed by an on demand/maintenance therapy of infliximab. Twenty six patients with fulminant colitis were equally randomized. At Day 7, ten patients in the control group and none in the infliximab group were in the need of colectomy (). Due to superior effect of infliximab, patients in the control group were of ethical reasons transformed to infliximab treatment instead of performing colectomy. The probability to avoid colectomy was 0.66 with a median observation time of 52 months and a maximal of 91 months. The addition of azathioprine reduced the risk of late colectomy. We conclude that infliximab is effective in preventing early and late colectomy in fulminant colitis.

Genes involved in the metabolism of poly-unsaturated fatty-acids (PUFA) and risk for Crohn's disease in children & young adults

Background and Objectives

Epidemiological evidence for the role of polyunsaturated fatty-acids (PUFA) in Crohn's disease (CD) is unclear, although the key metabolite leucotriene B4 (LTB₄) is closely linked to the inflammatory process. We hypothesized that inherited variation in key PUFA metabolic enzymes may modify susceptibility for CD.

Methods and Principal Results

A case-control design was implemented at three pediatric gastroenterology clinics in Canada. Children ≤20 yrs diagnosed with CD and controls were recruited. 19 single nucleotide polymorphisms (SNPs) across the ALOX5 (4) CYP4F3 (5) and CYP4F2 (10) genes, were genotyped. Associations between SNPs/haplotypes and CD were examined. A total of 431 cases and 507 controls were studied. The mean (±SD) age of the cases was 12.4 (±3.3) years. Most cases were male (56.4%), had ileo-colonic disease (L3±L4, 52.7%) and inflammatory behavior (B1±p, 87%) at diagnosis. One genotyped CYP4F3 SNP (rs2683037) not in Hardy-Weinberg Equilibrium was excluded. No associations with the remaining 4 CYP4F3 SNPs with CD were evident. However haplotype analysis revealed associations with a two-marker haplotype (TG) (rs3794987 & rs1290617) (p = 0.02; permuted p = 0.08). CYP4F2 SNPs, rs3093158 (OR (recessive) = 0.56, 95% CI = 0.35–0.89; p = 0.01), rs2074902 (OR (trend) = 1.26, 95% CI = 1.00–1.60; p = 0.05), and rs2108622 (OR (recessive) = 1.6, 95% CI = 1.00–2.57; p = 0.05) were significantly associated whereas rs1272 (OR (recessive) = 0.58, 95% CI = 0.30–1.13; p = 0.10) showed suggestions for associations with CD. A haplotype comprising these 4 SNPs was significantly associated (p = 0.007, permuted p = 0.02) with CD. Associations with SNP rs3780901 in the ALOX5 gene were borderline non-significant (OR (dominant) = 1.29, 95% CI = 0.99–1.67; p = 0.056). A haplotype comprising the 4 ALOX5 SNPs (TCAA, p = 0.036) was associated with CD, but did not withstand corrections for multiple comparisons (permuted p = 0.14).

Conclusions

Inherited variation in enzymes involved in the synthesis/metabolism of LTB₄ may be associated with CD. These findings implicate PUFA metabolism as a important pathway in the CD pathogenesis.

Diagnosis and assessment of Crohn's disease: the present and the future

Diagnosis of Crohn's disease (CD) is often challenging and requires the utmost precision and perseverance in defining location, extent, severity and type of disease (inflammatory vs stricturing/penetrating), as well as in excluding septic complications and extraintestinal manifestations. Endoscopy and histology remain, as of today, the best tests for initial diagnosis of CD. Increasingly important roles are played by imaging techniques (small bowel MRI, computed tomographic enterography and intestinal ultrasound) and noninvasive markers of disease such as fecal calprotectin and specific autoantibodies. Here, we will review the main tools presently available to make the initial diagnosis of intestinal and perianal CD, to evaluate the response to treatment and to diagnose disease recurrence after surgery. Finally, we will discuss some of the future diagnostic challenges in CD.

Inflammatory bowel disease-associated interleukin-33 is preferentially expressed in ulceration-associated myofibroblasts

Interleukin-33 (IL-33) is a novel member of the interleukin-1 family that induces mucosal pathology in vivo and may drive fibrosis development and angiogenesis. To address its potential role in inflammatory bowel disease, we explored its tissue expression in biopsy specimens from untreated ulcerative colitis patients, observing a 2.6-fold up-regulation of IL-33 mRNA levels, compared to controls. Immunohistochemical analyses of surgical specimens showed that a prominent source of IL-33 in ulcerative colitis lesions were ulceration-associated myofibroblasts that co-expressed the fibroblast marker heat shock protein 47, platelet-derived growth factor receptor (PDGFR)β, and, in part, the myofibroblast marker α-smooth muscle actin (SMA). In contrast, IL-33-positive myofibroblasts were almost absent near the deep fissures seen in Crohn's disease. A screen of known and putative activators of IL-33 in cultured fibroblasts revealed that the Toll-like receptor-3 agonist poly (I:C) was among the strongest inducers of IL-33 and that it synergized with transforming growth factor-β, a combination also known to boost myofibroblast differentiation. Experimental wound healing in rat skin revealed that the de novo induction of IL-33 in pericytes and the possible activation of scattered, tissue-resident IL-33(+)PDGFRβ(+)αSMA(-) fibroblast-like cells were early events that preceded the later appearance of IL-33(+)PDGFRβ(+)αSMA(+) cells. In conclusion, our data point to a novel role for IL-33 in mucosal healing and wound repair and to an interesting difference between ulcerative colitis and Crohn's disease.

Serologic markers: impact on early diagnosis and disease stratification in inflammatory bowel disease

Inflammatory bowel disease (IBD) is difficult to diagnose, and differentiating between ulcerative colitis (UC) and Crohn's disease (CD) can be challenging. Overlapping symptoms of UC and CD often delay diagnosis, despite availability of endoscopic, radiologic, and histologic tools. This delay in diagnosis is quite common in clinical practice, which may also delay initiation of appropriate treatment. Abnormal immune responses found in IBD have led to the use of serum biomarkers (eg, anti-Saccharomyces cerevisiae antibody [ASCA], perinuclear antineutrophil cytoplasmic antibody [pANCA], antibodies to flagellin [anti-CBir1]) to improve diagnostic confidence in IBD. These biomarkers are beginning to be used to stratify patients with UC and CD according to disease phenotype and risk of complications. Associations between quantity and quality of immune reactivity and severe disease phenotypes are increasingly evident. This suggests that serologic panels of multiple IBD biomarkers can be used to identify the relative risk of progression to complicated disease behaviors, and that this information may ultimately impact therapeutic decisions. This review discusses the diagnostic process and challenges in IBD, with emphasis on the role that serologic markers may play in addressing these challenges.

New insights into the immunological effects of food bioactive peptides in animal models of intestinal inflammation

Bioactive peptides have proven to be active in several conditions, including inflammatory bowel disease (IBD). This is a chronic and relapsing condition of unknown aetiology that comprises chiefly ulcerative colitis and Crohn's disease. Although there are treatments for IBD, they have frequent side effects and they are not always effective; therefore there is a need for new therapies that could alleviate this condition. Two bioactive peptides present in milk (transforming growth factor-beta (TGF-beta) and casein macropeptide, also named glycomacropeptide) have been shown to have intestinal anti-inflammatory activities. In fact, TGF-beta is currently added to formulas intended for patients with IBD, and several studies indicate that these formulas could induce clinical remission. In this paper, evidence supporting the anti-inflammatory effect of TGF-beta and bovine glycomacropeptide, as well as their mechanisms of action, is reviewed, focusing on the evidence obtained in animal models.

Proteomic analysis of biopsied human colonic mucosa

BACKGROUND AND OBJECTIVES

: Pediatric gastroenterologists have a unique opportunity to study the proteins in the gastrointestinal tract. To assess the power of proteomic studies we compared 2 methods for analysis of proteins in normal human colonic mucosa: 2-dimensional gel electrophoresis (2DE) and 2-dimensional liquid chromatography (2DLC) in conjunction with mass spectrometry. We used Ingenuity Pathway Analysis to examine these proteins regarding function, location, and relation to disease.

RESULTS

: 2DLC identified 550 proteins, whereas 2DE identified 107 proteins, 18 of which were not observed with 2DLC. The function associated with the largest number of proteins for both methods was cancer (236 proteins with 2DLC, 61 proteins with 2DE). The largest group of proteins was from the cytoplasm (49.3% from 2DE and 49.1% from 2DLC). Two hundred seventy of the total 568 proteins were related to 26 different categories of human disease and 200 of these 270 were described in large intestine, 227 were described in blood, and 149 were described in serum or plasma.

CONCLUSIONS

: These methods are complementary, although many more proteins were identified with 2DLC. This suggests that 2DLC should have greater utility in examining changes in the proteome of the colonic mucosa during disease than 2DE. However, some proteins found were unique to 2DE, and thus the methods chosen for a given analysis must be matched with the proteins to be studied. When pediatric gastroenterologists use proteomic methods, there is a new opportunity to increase our understanding of the gastrointestinal tract in health and disease.

Inflammatory bowel diseases, celiac disease, and bone

The article summarizes the current knowledge on the pathogenesis, clinical aspects and treatment of bone problems in the major inflammatory bowel diseases (Crohn's disease and ulcerative colitis) and celiac disease. It presents the physiological relationship between intestine and bone as well as the alterations determined by disease-disrupted intestinal integrity. Two hypotheses about the pathogenetic mechanisms of bone metabolism derangements and bone loss are discussed: the classical one, that indicates calcium malabsorption as the main culprit, and the new one, that emphasizes the role of inflammation. The article summarizes the available epidemiological data about osteopenia/osteoporosis and fragility fractures in these chronic intestinal diseases and presents the state-of-the-art treatment options.

Higher levels of CCL20 expression on peripheral blood mononuclear cells of chinese patients with inflammatory bowel disease

This study aimed at characterizing the levels of CCL20 mRNA transcripts in peripheral mononuclear blood cells (PMBC) of 56 Chinese patients with inflammatory bowel disease (IBD), 30 other intestinal diseases and 30 healthy controls by quantitative real time polymerase chain reaction. The levels of CCL20 mRNA transcripts in PBMC of patients with IBD were significantly higher than that of patients with non-IBD intestinal diseases and healthy controls (p < 0.01) and the CCL20 expression in active IBD patients was significantly higher than that in remission patients (p < 0.01). Importantly, the levels of CCL20 expression in PBMC were significantly correlated with the degrees of disease severity, the levels of erythrocyte sedimentation rate and C-reaction protein, but not hemoglobin, in patients with IBD (p < 0.01). Furthermore, the levels of CCL20 expression in active IBD patients after treatment with salazosulphapyridine or prednisone were significantly reduced, as compared with before treatment (p < 0.01). Therefore, analysis of CCL20 expression in PBMC may be used as a surrogate measure for evaluation of IBD activity, disease progression and therapeutic efficacy in Chinese IBD patients.

Absence of Mycobacterium avium ss paratuberculosis-specific IS900 sequence in intestinal biopsy tissues of Indian patients with Crohn's disease

BACKGROUND AND OBJECTIVE

The role of Mycobacterium avium ss paratuberculosis (MAP) in the etiopathology of Crohn's disease (CD) remains controversial, because of conflicting reports demonstrating the presence of MAP-specific insertion sequence from intestinal biopsy tissues of patients clinically diagnosed for the disease. The present study was carried out to investigate the presence of MAP DNA in the intestinal tissues of CD patients to ascertain the relevance of MAP in Indian patients with CD.

METHODS

Patients diagnosed as CD at our institute were recruited. Healthy individuals without inflammatory bowel disease served as controls. Mucosal biopsy specimens were collected from ileum and colon in duplicates and subjected to histopathological examination and polymerase chain reaction (PCR) amplification. Total DNA (81 CD patients, 85 healthy individuals) and total RNA (12 CD patients, 12 healthy individuals) isolated from tissue specimens was used for amplification of MAP-specific IS900 by nested PCR.

RESULTS

MAP-specific IS900 DNA and RNA could not be detected by nested PCR in the intestinal tissues of any patient with CD.

CONCLUSION

Our results do not support the etiological role of MAP in the pathogenesis of CD in Indian patients.

Protein profiles of peripheral blood mononuclear cells are useful for differential diagnosis of ulcerative colitis and Crohn's disease

BACKGROUND

Effective biomarkers for discrimination between ulcerative colitis (UC) and Crohn's disease (CD) have not been established yet. In this study, we analyzed protein profiles of peripheral blood mononuclear cells (PBMCs) of the patients to find such a biomarker.

METHODS

Peripheral blood mononuclear cell proteins from 17 UC patients, 13 CD patients, and 17 healthy controls were separated by two-dimensional gel electrophoresis. The intensities of individual protein spots were subjected to discriminant analysis of UC and CD using the SIMCA-P+program.

RESULTS

We found that 547 protein spots were commonly detected among the UC, CD, and healthy groups. Orthogonal partial least squares-discriminant analysis using 276 protein spots clearly discriminated the UC patients from the CD patients (R (2) 0.994; Q (2) 0.462). A similar analysis using a further selected 58 protein spots showed higher performance for discrimination of the diseases (R (2) 0.948; Q (2) 0.566). Eleven out of the 58 protein spots were successfully identified; these were functionally related to inflammation, oxidation/reduction, the cytoskeleton, endocytotic trafficking, and transcription. In addition, the PBMC protein profiles were useful for the prediction of disease activity in the UC and the CD patients, and they were also useful for predicting disease severity and responses to treatments in the UC patients.

CONCLUSIONS

PBMC protein profiles are useful for the discrimination of UC from CD. The profiles could be a potent biomarker for the differential diagnosis of these diseases. Further investigation of the proteins which contributed to the discrimination could promote elucidation of the pathophysiology of UC and CD.

Nutritional follow-up of patients with ulcerative colitis during periods of intestinal inflammatory activity and remission

CONTEXT: Ulcerative colitis is an inflammatory bowel disease involving superficial inflammation of the mucosa of the colon, rectum, and anus, sometimes including the terminal ileum. When in clinical activity, the disease is characterized by various daily evacuations containing blood, mucus and/or pus alternating periods of remission. OBJECTIVE: To compare nutritional parameters (dietary, biochemical and anthropometric) among patients with ulcerative colitis followed up on an outpatient basis over a period of 1 year and during periods of intestinal inflammatory activity and remission. METHODS: Sixty-five patients were studied over a period of 1 year and divided into two groups: group 1 with inflammatory disease activity (n = 24), and group 2 without disease activity (n = 41). Anthropometric measures, biochemical parameters, quantitative food intake, and qualitative food frequency were analyzed. RESULTS: A significant reduction in body mass index and weight and in the intake of energy, proteins, lipids, calcium, iron and phosphorus was observed in the group with inflammatory activity (group 1) when compared to the period of clinical remission. The most affected food groups were cereals, legumes, oils, and fats. In contrast, in group 2 significant differences in triceps and sub scapular skin fold thickness, total protein, hemoglobin and hematocrit were observed between the first and final visit. Calcium and vitamin B6 intake, as well as the consumption of legumes, meat and eggs, and sugar and sweets, was significantly higher than on the first visit. CONCLUSION: Patients with ulcerative colitis followed up on an outpatient basis tend to be well nourished. However, the nutritional aspects studied tend to worsen during the period of inflammatory disease activity.

Inflammatory bowel disease in Korea: epidemiological, genomic, clinical, and therapeutic characteristics

Inflammatory bowel disease (IBD) describes chronic inflammatory disease of the intestines and has a variable course; Crohn's disease and ulcerative colitis comprise the two main forms of the condition. Although IBD occurs worldwide, its epidemiologic and clinical characteristics vary depending upon the geographic location and the ethnicity of the population. Identifying the characteristic features of IBD in populations living in different geographical locations and with different ethnicities may provide significant clues about its etiology and pathophysiology, which in turn may be helpful in the development of more appropriate treatment strategies for IBD for these different populations. Therefore, it is important for each country and region to evaluate critically the epidemiology, genomics, and clinical characteristics of IBD among its own population. We have performed a critical review of the recent data in Korea, and describe herein the current epidemiologic and genotypic status, as well as the clinical manifestations and therapeutic responses of IBD that are unique to Korean patients.

Inflammatory bowel disease

Inflammatory bowel diseases (IBDs) encompass ulcerative colitis, Crohn's disease, and indeterminate colitis, all of which are characterized by remission and exacerbation of gastrointestinal symptoms, and a variety of extraintestinal manifestations including those affecting the oral cavity. Although not particularly a cause for mortality, inflammatory bowel diseases are associated with significant morbidity and impact on the quality of life. This article reviews clinical presentation, diagnostic criteria, and therapeutic modalities for the 2 main types of inflammatory bowel disease and discusses manifestations of these conditions in the oral cavity. The role of the oral health care provider in timely recognition and referral for medical work-up as well as management of oral complaints is also emphasized.

Evolving inflammatory bowel disease treatment paradigms: top-down versus step-up

Crohn disease (CD) and ulcerative colitis (UC) comprise a group of inflammatory disorders of the gastrointestinal tract that can vary in severity of disease, anatomic extent of inflammation, presence and nature of extraintestinal manifestations, and response to therapeutic approaches. There have been attempts to classify CD based on the location and behavior of disease. Advances in understanding of genetic susceptibility to inflammatory bowel disease (IBD) suggest that CD and UC may represent a continuum of overlapping disorders. This has led to an attempt to classify IBD on clinical, molecular, and serologic grounds. Differences in clinical, genetic, and immunologic profiles may require more targeted, refined treatment approaches to help clinicians make decisions regarding recently introduced biologic agents. This article provides an overview of the current approaches to therapy for CD and UC and focuses on the evidence supporting the rationale for changing paradigms in the management of IBD, including mucosal healing as an end point and earlier use of immunosuppressive and biologic agents, particularly in CD (so-called top-down therapy).

Evolving inflammatory bowel disease treatment paradigms: top-down versus step-up

Crohn disease (CD) and ulcerative colitis (UC) comprise a group of inflammatory disorders of the gastrointestinal tract that can vary in severity of disease, anatomic extent of inflammation, presence and nature of extraintestinal manifestations, and response to therapeutic approaches. There have been attempts to classify CD based on the location and behavior of disease. Advances in understanding of genetic susceptibility to inflammatory bowel disease (IBD) suggest that CD and UC may represent a continuum of overlapping disorders. This has led to an attempt to classify IBD on clinical, molecular, and serologic grounds. Differences in clinical, genetic, and immunologic profiles may require more targeted, refined treatment approaches to help clinicians make decisions regarding recently introduced biologic agents. This article provides an overview of the current approaches to therapy for CD and UC and focuses on the evidence supporting the rationale for changing paradigms in the management of IBD, including mucosal healing as an end point and earlier use of immunosuppressive and biologic agents, particularly in CD (so-called top-down therapy).

Optimized protocol for diagnosis of acute ileitis

BACKGROUND & AIMS

Suspected acute ileitis (AI) is a poorly defined clinical condition with multiple causes; its diagnostic protocol has not been standardized properly. We performed a prospective evaluation of the incidence and causes of AI to create a standard protocol for diagnosis.

METHODS

The definition of AI included abdominal pain, diarrhea, fever, and at least 1 confirmatory imaging method (abdominal computed tomography scan or ultrasound) showing pathologic changes in the terminal ileum that indicated ileal inflammation. We studied all patients with a presumptive diagnosis of AI seen in the Emergency Room at the Ramón y Cajal Hospital in Madrid, from March 2005 to May 2007, according to a pre-established protocol. Sixty-six patients with primary AI were followed up for at least 6 months.

RESULTS

An infectious cause was found in 33.3% of cases; the most frequently detected microorganism was Yersinia spp. A gynecologic condition was identified in 9.1% of cases initially diagnosed as AI, representing 13.95% of the cases among female patients. Crohn's disease was identified in 12.1% of patients. The diagnostic protocol led to negative results in 33.4% of the patients; 6.1% of patients did not complete the study. The initial diagnosis did not change among any of the patients during the follow-up period.

CONCLUSIONS

This protocol led to a definitive diagnosis of AI in more than 60% of potential cases. The most common cause was acute infection. About 10% of cases were of gynecologic origin and about 12% of patients presented with Crohn's disease.

Infliximab therapy decreases the levels of TNF-alpha and IFN-gamma mRNA in colonic mucosa of ulcerative colitis

OBJECTIVE

The mechanisms of action of infliximab (IFX) in the treatment of ulcerative colitis (UC) are poorly understood. The aim of the study was to investigate the changes in tissue expression of tumor necrosis factor-alpha (TNF-alpha) and other cytokines in UC patients receiving IFX treatment.

MATERIAL AND METHODS

The levels of TNF-alpha, interleukin (IL)-10, IL-4, and interferon-gamma (IFN-gamma) mRNA in colonic biopsies from 32 UC patients during IFX treatment were measured by real-time polymerase chain reaction (PCR) and compared with those of 19 controls. Immunohistochemistry was performed to characterize the changes of inflammatory cells during treatment.

RESULTS

IFX reduced the expression of TNF-alpha and IFN-gamma mRNA, but not that of IL-10 and IL-4 mRNA. Reductions in TNF-alpha mRNA were correlated to clinical and endoscopic improvements, and normalization of TNF-alpha mRNA was obtained in patients with healed mucosa. The numbers of T lymphocytes and macrophages were significantly decreased in patients with healed mucosa after IFX treatment, although compared to normal controls, there were still increased levels of TNF-alpha-positive cells after treatment.

CONCLUSIONS

IFX induced down-regulation of the mucosal TNF-alpha and IFN-gamma mRNA expression in UC patients. The numbers of T lymphocytes and macrophages were significantly decreased in patients with endoscopically healed mucosa after IFX treatment.

Associations between ABCB1/MDR1 gene polymorphisms and Crohn's disease: a gene-wide study in a pediatric population

BACKGROUND

Functional studies support the involvement of the MDR1 gene in the pathways leading to Crohn's disease (CD). Two common single nucleotide polymorphisms (SNPs), C3435T and G2677T/A, thought to alter the function of the corresponding P-glycoprotein, have shown inconsistent associations with CD. We investigated whether DNA variants in the MDR1 gene were associated with susceptibility for CD and specific phenotypes in children.

METHODS

A case-control study was conducted at 3 gastroenterology clinics across Canada. Children with CD and population- or hospital-based controls were included. CD cases were classified using the Montreal Classification. Thirteen tag-SNPs and the C3435T variant in the MDR1 gene were genotyped. Single-SNP allelic, genotype as well as gene-wide haplotype associations with CD and its phenotypes at diagnosis were assessed.

RESULTS

A total of 270 CD cases and 336 controls were studied. Most cases were male (56.3%), had disease location L3+/-L4 (58.1%), and an inflammatory phenotype B1+/-p (88.5%). Allelic association analysis revealed that SNP rs17327442 was significantly associated with overall susceptibility to CD (odds ratio [OR] = 0.72, 95% confidence interval [CI] = 0.50-0.99, P = 0.04) but this association did not withstand corrections for multiple testing (q-value = 0.56). Genotype-phenotype analysis indicated that 2 SNPs (rs10248420, P = 0.007, q-value = 0.07; rs2032583, P = 0.01, q-value = 0.07) were significantly associated with colonic disease. Five SNPs, rs1128503 (P = 0.02), rs1202184 (P = 0.008), rs1202186 (P = 0.02), rs2091766 (P = 0.03), and rs2235046 (P = 0.03) were nominally associated with noninflammatory CD. Specific haplotypes comprising of the tag-SNPs were significantly associated with either colonic or noninflammatory CD.

CONCLUSIONS

Our comprehensive gene-wide analysis suggests that the MDR1 gene may be associated with clinical phenotypes of CD in children.

Interleukin 10 (IL-10) gene variants and susceptibility for paediatric onset Crohn's disease

BACKGROUND

A recent genome-wide association study in adult patients with ulcerative colitis (UC) has implicated the interleukin 10 (IL-10) gene as an important candidate gene. Moreover, a UC-associated single nucleotide polymorphism (SNP) rs3024405 was also significantly associated with adult Crohn's disease (CD).

AIMS

To examine whether IL-10-CD associations extended to paediatric-onset CD.

METHODS

We implemented the case-control design at three paediatric gastroenterology clinics in Canada. CD patients (<or=20 years) were recruited along with healthy controls. DNA samples were genotyped for tag-single nucleotide polymorphisms (tag-SNPs) in the IL-10 gene. Allelic, genotype and haplotype associations with CD were studied.

RESULTS

A total of 270 patients and 336 controls were studied. The mean age (+/-s.d.) at diagnosis was 12.1 (+/-3.5). There were a slightly higher proportion of male patients (56.3%). Of the five IL-10 tag-SNPs, rs2222202 (C/T) (P = 0.03) and rs1800871 (C/T) (P = 0.05) showed significant allelic associations with CD. Specific IL-10 SNPs were associated with CD disease location and/or disease behaviour.

CONCLUSIONS

Our gene-wide analysis replicates recent findings of associations between IL-10 and adult CD, and suggests that these associations extend to paediatric-onset CD as well.

Cytokine association with bacterial DNA in serum of patients with inflammatory bowel disease

BACKGROUND

The pathogenesis of inflammatory bowel disease (IBD) involves the interaction between genetic susceptibility, mucosal immunity, and intestinal bacteria. Bacterial translocation is a common event in these patients and plays an important role in the perpetuation of chronic intestinal inflammation. Blood microbiological cultures, however, are frequently negative. The aim was to evaluate the presence of bacterial DNA (bactDNA) and the associated cytokine response in patients with IBD.

METHODS

Fifteen healthy donors, 29 patients with ulcerative colitis (UC), and 33 patients with Crohn's disease (CD) were studied. The presence of bactDNA was pursued by PCR followed by nucleotide sequencing analysis. Microbiological cultures were carried out among all controls and patients. Cytokine serum levels were measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

BactDNA was detected in 14 out of 33 patients with CD (42.4%) and in 15 out of 29 patients with UC (51.7%). BactDNA translocation was present in 7 out of 21 (33%) and in 10 out of 15 (34%) patients with CD and UC in remission, respectively. None of healthy controls showed bactDNA in serum. A statistically significant increase in all Th1-derived cytokines in CD but not in UC patients with the presence of bactDNA was observed in comparison with patients without bactDNA and controls.

CONCLUSIONS

BactDNA is present in IBD patients, irrespective of their disease activity. This fact is associated with a marked Th1-driven immune reaction in CD patients, even in those in remission. Whether bactDNA is inducing or is favored by an increased inflammatory scenario in these patients remains under discussion.

Pathogenesis of and unifying hypothesis for idiopathic pouchitis

Ileal pouch-anal anastomosis is the procedure of choice in the surgical management of refractory ulcerative colitis. Pouchitis affects up to 60% of patients following ileal pouch-anal anastomosis for ulcerative colitis. It overlaps significantly with ulcerative colitis such that improvements in our understanding of one will impact considerably on the other. The symptoms are distressing and impinge significantly on patients' quality of life. Despite 30 years of scientific and clinical investigation, the pathogenesis of pouchitis is unknown; however, recent advances in molecular and cell biology make a synergistic hypothesis possible. This hypothesis links interaction between epithelial metaplasia, changes in luminal bacteria (in particular sulfate-reducing bacteria), and altered mucosal immunity. Specifically, colonic metaplasia supports colonization by sulfate-reducing bacteria that produce hydrogen sulfide. This causes mucosal depletion and subsequent inflammation. Although in most cases antibiotics lead to bacterial clearance and symptom resolution, immunogenetic subpopulations can develop a chronic refractory variant of pouchitis. The aims of this paper are to discuss proposed pathogenic mechanisms and to describe a novel mechanism that combines many hypotheses and explains several aspects of pouchitis. The implications for the management of both pouchitis and ulcerative colitis are discussed.

Autophagy gene ATG16L1 but not IRGM is associated with Crohn's disease in Canadian children

BACKGROUND

Recent genome-wide studies have implicated the autophagy genes ATG16L1 and IRGM in the pathogenesis of Crohn's disease (CD). We investigated whether these genes were associated with CD in Canadian children.

METHODS

A case-control study was carried out at 2 pediatric gastroenterology clinics in Canada. Confirmed cases of CD <20 years diagnosed using standard criteria were classified according to the Montreal Classification scheme. Single nucleotide polymorphisms (SNPs) rs2241880 (ATG16L1) and rs10065172 (IRGM) along with CARD15 SNPs, SNP8, SNP12, and SNP13 were genotyped.

RESULTS

A total of 289 CD cases and 290 controls were studied. The mean age (+/-SD) of the cases was 12.1 (+/-3.5) years of age. Most cases were male (55.4%), had disease location L3 +/- L4 (56.7%), and an inflammatory phenotype B1 +/- p (87.2%) at diagnosis. rs2241880 (ATG16L1) was strongly associated with CD (allelic P = 1.24 x 10(-6)). Children with GG genotype had a more than 3-fold elevated risk for disease as compared to the wildtype AA homozygotes (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.93-4.94; P = 1.8 x 10(-6)). Association with SNP rs2241880 was specific for ileal disease (with or without colonic involvement) (case-based allelic P = 0.02; P-value versus controls = 9.5 x 10(-8)). The frequency of IRGM SNP rs10065172 was higher in cases but differences with controls were not statistically significant. No interactions between CARD15 and either ATG16L1 or IRGM were evident.

CONCLUSIONS

We have confirmed associations between CD and ATG16L1 in a pediatric cohort of Canadian children. Associations with IRGM need to be further evaluated in larger studies.

Clinical Immunology Review Series: an approach to the patient with recurrent orogenital ulceration, including Behçet's syndrome

Patients presenting with recurrent orogenital ulcers may have complex aphthosis, Behçet's disease, secondary complex aphthosis (e.g. Reiter's syndrome, Crohn's disease, cyclical neutropenia) or non-aphthous disease (including bullous disorders, erythema multiforme, erosive lichen planus). Behçet's syndrome is a multi-system vasculitis of unknown aetiology for which there is no diagnostic test. Diagnosis is based on agreed clinical criteria that require recurrent oral ulcers and two of the following: recurrent genital ulcers, ocular inflammation, defined skin lesions and pathergy. The condition can present with a variety of symptoms, hence a high index of suspicion is necessary. The most common presentation is with recurrent mouth ulcers, often with genital ulcers; however, it may take some years before diagnostic criteria are met. All patients with idiopathic orogenital ulcers should be kept under review, with periodic focused assessment to detect evolution into Behçet's disease. There is often a delay of several years between patients fulfilling diagnostic criteria and a diagnosis being made, which may contribute to the morbidity of this condition. Despite considerable research effort, the aetiology and pathogenesis of this condition remains enigmatic.

Intestinal bacteria and inflammatory bowel disease

Crohn's disease (CD) and ulcerative colitis (UC) are the two principal forms of inflammatory bowel disease (IBD). Animal studies show that bacteria are involved in the etiology of IBD, and much is now known about the inflammatory processes associated with CD and UC, as well as the underlying genetic, environmental, and lifestyle issues that can affect an individual's predisposition to these diseases. However, while a number of candidate microorganisms have been put forward as causative factors in IBD, the primary etiologic agents are unknown. This review discusses the potential role of luminal and mucosal microbial communities in the etiology of IBD, and outlines studies that have been made using a variety of biotherapeutic therapies, involving the use of antibiotics, probiotics, prebiotics, and synbiotics.

Management of Crohn's disease in adults

Guidelines for clinical practice are intended to suggest preferable approaches to particular medical problems as established by interpretation and collation of scientifically valid research, derived from extensive review of published literature. When data that will withstand objective scrutiny are not available, a recommendation may be made based on a consensus of experts. Guidelines are intended to apply to the clinical situation for all physicians without regard to specialty. Guidelines are intended to be flexible, not necessarily indicating the only acceptable approach, and should be distinguished from standards of care that are inflexible and rarely violated. Given the wide range of choices in any health-care problem, the physician should select the course best suited to the individual patient and the clinical situation presented. These guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee. Expert opinion is solicited from the outset for the document. The quality of evidence upon which a specific recommendation is based is as follows: Grade A: Homogeneous evidence from multiple well-designed randomized (therapeutic) or cohort (descriptive) controlled trials, each involving a number of participants to be of sufficient statistical power. Grade B: Evidence from at least one large well-designed clinical trial with or without randomization, from cohort or case-control analytic studies, or well-designed meta-analysis. Grade C: Evidence based on clinical experience, descriptive studies, or reports of expert committees. The Committee reviews guidelines in depth, with participation from experienced clinicians and others in related fields. The final recommendations are based on the data available at the time of the production of the document and may be updated with pertinent scientific developments at a later time.

Clinical characteristics of inflammatory bowel disease in Turkey: a multicenter epidemiologic survey

AIM

To investigate the epidemiologic and clinical characteristics of inflammatory bowel disease (IBD) patients in a large multicenter, countrywide, hospital-based study in Turkey.

MATERIALS AND METHODS

Twelve centers uniformly distributed throughout Turkey reported through a questionnaire the new IBD cases between 2001 and 2003. The incidence of ulcerative colitis (UC) and Crohn's disease (CD) has been reported per 100,000 people. Epidemiologic features and clinical characteristics of both diseases were analyzed.

RESULTS

During the study period, 661 patients of UC and 216 patients of CD were identified. The incidence in the referral population was 4.4/100,000 and 2.2/100,000 for UC and CD, respectively. The age of the patients showed the characteristic biphasic distribution with 2 peaks between 20 and 30 and 50 and 70 years. A male predominance was observed in both diseases. A history of smoking was detected in 15.5% of UC patients and 49.3% of patients with CD. Family history was positive in 4.4% in UC and 8.3% in CD patients. Concomitant amebiasis was observed in 17.3% of patients with UC and 1.3% of patients with CD. A history of appendectomy was reported in 15% of patients with CD and only 3% of patients with UC. Both extraintestinal and local complications were more frequent in CD patients, whereas arthritis was most common in both diseases.

CONCLUSIONS

IBDs are frequently encountered in Turkey. IBD incidence is lower than North and West Europe but close to Middle East in our country. The majority of IBD cases are diagnosed in young people (20 to 40 y) with predominance in males. The rate of both intestinal and extraintestinal complications in our population was low when compared with the data reported in the literature. IBD and especially UC, can coexist with amebiasis or become manifest with amebic infestation. The presence of concomitant ameba may create confusion and cause dilemmas in the diagnosis and treatment of UC.

Incidence and prevalence rates of inflammatory bowel diseases, in midwestern of São Paulo State, Brazil

CONTEXT

The incidence and populational prevalence of inflammatory bowel diseases, hitherto unknown in Brazil, were estimated for a region in the Midwest of São Paulo State, Brazil.

METHODS

Using a sequential registry of 115 adult patients (>15 years old) with inflammatory bowel diseases - exclusively residing in the studied region with 533,508 inhabitants (2005) and attended at the reference hospital during a 20 year interval (1986-2005) - were estimated, in four consecutives periods of 5 years each, the incidences according to gender, type of the disease and the prevalence of these diseases, and its inner-relations evaluated by the Poisson regression model.

RESULTS

The inflammatory bowel diseases in the studied region predominated among young, white race and people living in urban area, and the incidence on the female population rose during this period. The incidence of ulcerative colitis were higher than Crohn's disease and non-classified colitis, and showed a progressive increase in the first three periods with a decrease in the last one (2001-2005), where the observed rates of ulcerative colitis, Crohn's disease and non-classified colitis were 4.48, 3.50 and 1.75 cases/100,000 inhabitants, with prevalence of 22.61, 14.81, 5.65, 2.14 cases/100,000 inhabitants for total inflammatory bowel diseases.

CONCLUSION

The inflammatory bowel diseases incidence in the studied area was as low as in other countries of Latin America and smaller than that found in countries of South Europe. The crescent prevalence justifies the policies to adequate medical cares for inflammatory bowel diseases patients in this area.

Prebiotics, synbiotics and inflammatory bowel disease

The normal colonic microflora is intimately involved in the aetiology of inflammatory bowel diseases (IBD) such as ulcerative colitis (UC) and Crohn's disease (CD). These conditions are often refractile to conventional treatments involving the employment of anti-inflammatory and immunosuppressant drugs, and this has led to a search for alternative therapies based on the use of probiotics, prebiotics and synbiotics. The majority of investigations in this area have been done with probiotics, and while there is increasing interest in the abilities of prebiotics and synbiotics to control the symptoms of IBD, very few randomised controlled trials have been reported. Although the results have been variable, human and animal studies have demonstrated that in many circumstances, these functional foods can alter the composition of the colonic microbiota, reduce inflammatory processes in the gut mucosa, and have the potential to induce disease remission. More work is needed to understand the effects of prebiotics and synbiotics on microbial communities in the gut, and their interactions with the host's immune system.

Accumulation, activation, and survival of neutrophils in ulcerative colitis: regulation by locally produced factors in the colon and impact of steroid treatment

BACKGROUND AND AIMS

Neutrophil granulocytes infiltrate the intestinal mucosa in active ulcerative colitis (UC), and may contribute to tissue damage and inflammation. The aim of this investigation was to study the importance of locally produced factors and the impact of steroid treatment on neutrophil functions in UC.

PATIENTS AND METHODS

Intestinal perfusion fluids from 11 patients with active distal UC before and after seven and 28 days of treatment with prednisolone and from seven control patients were used in the study. Neutrophil migration towards perfusion fluid was measured in a microchemotaxis chamber. The effect of perfusion fluids on neutrophil activation was assessed as the surface expression of CD66b by flow cytometry. Neutrophil survival was evaluated by staining with propidium iodide, annexin V, and fluorescein di-acetate. We also assessed the viability of freshly isolated tissue neutrophils from rectal biopsy samples.

RESULTS

Perfusion fluids from untreated patients caused increased migration, activation, and survival of neutrophils. Perfusion fluids collected after treatment had no effect on neutrophil migration, but some of the activation and anti-apoptotic effects remained after 7 days. Anti-granulocyte-macrophage colony-stimulating factor (GM-CSF) inhibited the anti-apoptotic effect of perfusion fluids. Rectal tissue neutrophils from patients with active proctitis had increased viability compared to patients with inactive proctitis and control subjects.

CONCLUSIONS

These data show that mediators in the colon of patients with active UC stimulate the migration, activation, and survival of neutrophils. The activities were partly neutralized by topical steroid treatment. We also identified GM-CSF as an anti-apoptotic factor for neutrophils in inflamed colon.

Different regulation of eosinophil activity in Crohn's disease compared with ulcerative colitis

The aim of this investigation was to study the involvement of eosinophil and neutrophil granulocytes in different stages of Crohn's disease (CD) and ulcerative colitis (UC). Biopsy samples were taken from the right flexure of the colon and from the rectum in patients with active (n=12) and inactive colonic CD (n=7), patients with active (n=33) and inactive UC (n=24), and from control subjects (n=11). Cell suspensions from biopsies and blood were analyzed by flow cytometry with regards to activation markers and viability. Immunohistochemistry was used to evaluate cell number and degranulation. Blood eosinophils were cultured with Th1 and Th2 cytokines, and the expression of activity markers was assessed by flow cytometry. Eosinophil number, viability, and activity were increased during active CD and UC compared with controls. The activity, assessed as CD44 expression, tended to diminish during inactive CD but was increased further in quiescent UC. Neutrophil number and activity were increased only during inflammation in both diseases. Culture of blood eosinophils with IL-5 and IL-13 caused increased CD44 expression, whereas IL-5 and IFN-gamma induced elevated CD69 expression. We observed different patterns of eosinophil activation in CD and UC, with the highest CD44 expression during quiescent UC. Our in vitro experiments with recombinant cytokines suggest that the diverse mechanisms of eosinophil activation in CD and UC are a result of different cytokine milieus (Th1 vs. Th2). In contrast, neutrophil activation reflects the disease activity in CD and UC, irrespective of Th cell skewing.

Investigation of associations between the pregnane-X receptor gene (NR1I2) and Crohn's disease in Canadian children using a gene-wide haplotype-based approach

BACKGROUND

The pregnane-X-receptor (PXR) is involved in the metabolism and detoxification of numerous xenobiotics and is critical for maintaining intestinal integrity. The NR1I2 gene encoding PXR may confer susceptibility for Crohn's disease (CD) but evidence for associations is conflicting. We investigated whether the NR1I2 gene was associated with susceptibility for pediatric CD.

METHODS

A case-control and family-based (case-parent) study was carried out at 3 inflammatory bowel disease (IBD) clinics across Canada. Confirmed cases of CD <20 years were diagnosed using standard criteria. For determination of gene associations parents of the cases and unrelated controls were evaluated. Clinical phenotypes were established based on the Montreal Classification scheme. Eight tag-SNPs (tag-single nucleotide polymorphisms) across the gene were genotyped for allelic or genotypic associations.

RESULTS

A total of 270 CD cases, 336 controls, and 395 parents were studied. The mean age (+/-SD) of the cases was 12.1 (+/-3.5) years of age. Most cases were male (56.3%), had disease location L3+/-L4 (58.1%), and an inflammatory phenotype B1+/-p (88.4%) at diagnosis. For 7 SNPs single SNP analysis using case-control or case-parent data did not reveal associations with development of CD and none of the SNPs were significantly associated with disease location or disease behavior at diagnosis. One SNP rs2461823 (P = 0.05) was nominally associated with CD. No overall haplotype association (omnibus P-value = 0.61) or associations with individual haplotypes was evident.

CONCLUSIONS

Our gene-wide analysis in a pediatric cohort using both the case-control and case-parent designs suggests that the NR1I2 gene is not associated with CD in Canadian children.

The multidisciplinary team for management of inflammatory bowel diseases

Crohn's disease (CD) and ulcerative colitis (UC) are inflammatory bowel diseases (IBD) characterized by a relapsing clinical pattern that typically affect people during their adult and economically productive lives. Affected patients require clinical follow-up because of periodic disease flare-up and of the risk of long-term complications. Extensive diagnostic procedures, medical and surgical treatments are often needed over a lifetime. The challenge posed by management of IBD is better faced by a multidisciplinary team that includes health care providers with complementary diagnostic or therapeutic skills. The team is expected to provide the best practice to manage IBD by defining a realistic "diagnostic and therapeutic pathway" for the patients to follow based on locally available professional, structural and technological resources. This approach appears to improve quality of care for IBD patients and to be cost-effective.

Multigene analysis can discriminate between ulcerative colitis, Crohn's disease, and irritable bowel syndrome

BACKGROUND & AIMS

Inflammatory bowel diseases (IBDs) and the irritable bowel syndrome (IBS) are heterogeneous disorders of the gastrointestinal tract and can profoundly affect the quality of life. Because many of the symptoms of IBD are similar to those of IBS, the former may be misdiagnosed. In addition, the 2 major forms of IBD, ulcerative colitis (UC) and Crohn's disease (CD), have overlapping nonspecific, pathologic features leading to difficulties in assessing colonic inflammation and hence the term IBD unclassified has been proposed. The aim of this study was to identify and assess the utility of a certain set of marker genes that could help to distinguish IBS from IBD, and further to discriminate between UC and CD.

METHODS

Subtractive suppression hybridization was used to identify IBD-specific genes in colonic mucosal biopsy specimens. In quantitative polymerase chain reaction experiments, the differential expressions of identified genes then were analyzed using a classification algorithm and the possible clinical value of these marker genes was evaluated in a total of 301 patients in 3 stepwise studies.

RESULTS

Seven marker genes were identified as differentially expressed in IBD, making it possible to discriminate between patients suffering from UC, CD, or IBS with area under the receiver-operating characteristic curves ranging from 0.915 to 0.999 (P < .0001) using the clinical diagnosis as gold standard.

CONCLUSIONS

Expression profiling of relevant marker genes in colonic biopsy specimens from patients with IBD/IBS-like symptoms may enable swift and reliable determination of diagnosis, ultimately improving disease management.

Monomeric Calgranulins Measured by SELDI-TOF Mass Spectrometry and Calprotectin Measured by ELISA as Biomarkers in Arthritis

Background: SELDI-TOF mass spectrometry (MS) is a high-throughput proteomic approach with potential for identifying novel forms of serum biomarkers of arthritis.

Methods: We used SELDI-TOF MS to analyze serum samples from patients with various forms of inflammatory arthritis. Several protein profiles were collected on different Bio-Rad Laboratories ProteinChip arrays (CM10 and IMAC-Cu2+) and were evaluated statistically to select potential biomarkers.

Results: SELDI-TOF MS analyses identified several calgranulin proteins [S100A8 (calgranulin A), S100A9 (calgranulin B), S100A9*, and S100A12 (calgranulin C)], serum amyloid A (SAA), SAA des-Arg (SAA-R), and SAA des-Arg/des-Ser (SAA-RS) as biomarkers and confirmed the results with other techniques, such as western blotting, immunoprecipitation, and nano-LC-MS/MS. The S100 proteins were all able to significantly differentiate samples from patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and ankylosing spondylitis (AS) from those of patients with inflammatory bowel diseases used as an inflammatory control (IC) group, whereas the SAA, SAA-R, and SAA-RS proteins were not, with the exception of AS. The 4 S100 proteins were coproduced in all of the pathologies and were significantly correlated with the plasma calprotectin concentration; however, these S100 proteins were correlated with the SAA peak intensities only in the RA and IC patient groups. In RA, these S100 proteins (except for S100A12) were significantly correlated with the serum concentrations of C-reactive protein, matrix metalloproteinase 3, and anti–cyclic citrullinated peptide and with the Disease Activity Score (DAS28).

Conclusions: The SELDI-TOF MS technology is a powerful approach for analyzing the status of monomeric, truncated, or posttranslationally modified forms of arthritis biomarkers, such as the S100A8, S100A9, S100A12, and SAA proteins. The fact that the SELDI-TOF MS data were correlated with results obtained with the classic calprotectin ELISA test supports the reliability of this new proteomic technique.

Identification of bacteria from blood in febrile patients with ulcerative colitis by terminal restriction fragment length polymorphism profile analysis of 16S rRNA gene

OBJECTIVE

Recently, highly sensitive molecular-biological approaches using the 16S rRNA gene sequence have been carried out for the detection of bacteria. The aim of this study was to detect bacteremia in febrile patients with ulcerative colitis (UC) using a new molecular approach.

MATERIAL AND METHODS

Fifteen febrile patients with relapsing UC were enrolled, and 15 healthy volunteers participated as normal controls. Blood samples were analyzed for bacteremia using nested polymerase chain reaction (PCR) with universal primers (27F, 529F, 1492R). We investigated the bacterial DNA by means of terminal restriction fragment length polymorphism (T-RFLP) with five restriction enzymes (Alu I, Hha I, Hae III, Msp I, and Rsa I). A terminal restriction fragment (TRF) profile database was created with the predicted profiles of 63 common bacteria isolated from blood cultures, using computer simulation based on sequence information. TRF lengths were analyzed using the TRF profile database and a T-RFLP profiler.

RESULTS

The bacterial gene was detected in 9 out of 15 UC patients (60%) and 8 of out 15 controls (53%). The numbers of Hae III- and Rsa I-digested T-RFs and the average number of five restriction enzyme-digested T-RFs were significantly higher in UC patients than in controls (p=0.0189, 0.0151, 0.0092, respectively). In UC patients, the most prevalent species included the 7 common species in controls and 10 other species.

CONCLUSIONS

In febrile UC patients with relapse, bacteremia undetected by culture was found at high frequency by the PCR method. Therefore, antibiotic treatment for UC can be approved on the basis of the finding of bacteremia in this study.

Distress among inflammatory bowel disease patients at high risk for colorectal cancer: a preliminary investigation of the effects of family history of cancer, disease duration, and perceived social support

Patients with inflammatory bowel disease (IBD) are one of only three groups at high risk for colorectal cancer (CRC), a leading cause of cancer-related mortality. Yet, no research has examined psychological effects of their high-risk status. The present study offered an initial investigation of three potential predictors of patient distress: disease duration, family history of cancer, and perceived social support. Longer disease duration and stronger family history of cancer are associated with elevated CRC risk in this already high-risk population. Perceived support was conceptualized as a resource that could decrease vulnerability to distress or buffer adverse psychological effects of disease duration and family history. Men and women (n = 223) with IBD participating in a colon disease family registry completed measures for this cross-sectional study. Family history of CRC and non-colorectal cancers among first-degree relatives (FDRs) and more distant relatives (DRs) was examined separately. Hierarchical multiple regression analyses revealed that having greater perceived support predicted lower generalized distress (p<0.001). Having an FDR history of CRC predicted higher CRC-specific distress (p = 0.02). Having a DR history of CRC also predicted higher CRC-specific distress, but only among patients diagnosed more recently (p = 0.03). Clinical implications of these findings are discussed along with future research directions.

Bovine glycomacropeptide ameliorates experimental rat ileitis by mechanisms involving downregulation of interleukin 17

BACKGROUND AND PURPOSE

Bovine glycomacropeptide (BGMP) is an inexpensive, non-toxic milk peptide with anti-inflammatory effects in rat experimental colitis but its mechanism of action is unclear. It is also unknown whether BGMP can ameliorate inflammation in proximal regions of the intestine. Our aim was therefore two-fold: first, to determine the anti-inflammatory activity of BGMP in the ileum; second, to characterise its mechanism of action.

EXPERIMENTAL APPROACH

We used a model of ileitis induced by trinitrobenzenesulphonic acid in rats. Rats were treated orally with BGMP and its efficacy compared with that of oral 5-aminosalicylic acid or vehicle, starting 2 days before ileitis induction.

KEY RESULTS

BGMP pretreatment (500 mg kg(-1) day(-1)) resulted in marked reduction of inflammatory injury, as assessed by lower extension of necrosis and damage score, myeloperoxidase, alkaline phosphatase, inducible nitric oxide synthase, interleukin 1beta, tumour necrosis factor and interleukin 17. These effects were generally comparable to those of 5-aminosalicylic acid (200 mg kg(-1) day(-1)). Neither compound affected the production of interferon gamma, tumour necrosis factor and interleukin 2 by mesenteric lymph node cells isolated from animals with ileitis. The expression of Foxp3 was increased in ileitis and not reduced significantly by BGMP or aminosalicylate treatment.

CONCLUSIONS AND IMPLICATIONS

These results demonstrate that BGMP has anti-inflammatory activity in the ileum with similar efficacy to 5-aminosalicylic acid. The mechanism of action may involve Th17 and regulatory T cells and perhaps macrophages but probably not Th1 lymphocytes. Patients with Crohn's ileitis may benefit from treatment with BGMP.

Association between genetic variants in the IL-23R gene and early-onset Crohn's disease: results from a case-control and family-based study among Canadian children

BACKGROUND AND OBJECTIVES

Interleukin (IL)-23 is a key regulator of inflammation and influences the activities of T-helper 17 (Th-17) lymphocytes. Recent reports indicate that variants in the gene coding for its receptor (IL-23R) are strongly associated with Crohn's disease (CD). We investigated whether DNA variants in the IL-23R gene determine susceptibility for CD in Canadian children.

DESIGN AND METHODS

A case-control and case-parent trio design was implemented at three pediatric centers across Canada. Cases of CD (</=20 yr) along with their parents and controls were recruited. DNA samples were collected and genotyped for 10 single nucleotide polymorphisms (SNPs) in the IL-23R gene and three common SNPs in the CARD15 gene. Transmission disequilibrium-based tests were applied to the case-parent data and logistic regression models to the case-control data to study the association between the SNPs and CD.

RESULTS

A total of 259 CD cases, 139 controls, and 232 families (167 trios and 65 dyads) were studied. The mean age at diagnosis was 13.3 yr (range 2.6-20 yr). The majority of the patients were Caucasian. Case-control analysis revealed significant associations with three SNPs (rs1004819, rs7517847, and rs11209026 [R381Q]) and borderline nonsignificant associations with three other SNPs (rs10489629, rs10889697, and rs11465804) in the IL-23R gene. Having any CARD15 variant was associated with a significant risk for CD (P < 0.0001). Analyses of case-parent data confirmed the findings from the case-control analysis including significant associations with the R381Q SNP (P= 0.002). The common variant in this SNP conferred risk for CD. These associations were largely independent of the CARD15 gene.

CONCLUSIONS

Our findings confirm recently reported genome-wide associations between the IL-23R gene and CD. They suggest that the gene is also associated with pediatric-onset CD among Canadian children.

Dietary patterns and risk for Crohn's disease in children

BACKGROUND

Some dietary foods are considered protective (vegetables and fruits), whereas others (fatty foods) are thought to enhance the risk for Crohn's disease (CD). The evidence, however, is inconsistent.

METHODS

We postulated that specific dietary patterns may influence the risk for CD. A case-control study was carried out. Newly diagnosed CD cases with population and/or hospital-based controls < or =20 years were selected from 3 tertiary hospitals across Canada. Pre-disease diet was assessed using a validated food frequency questionnaire (FFQ) administered within 1 month of diagnosis. Factor analyses and unconditional logistic regression (adjusted) was used to determine gender-specific dietary patterns and assess associated risks for CD. Odds ratios (ORs) and corresponding 95% confidence intervals (95% CIs) were estimated.

RESULTS

A total of 149 cases and 251 controls were included. The mean age (range) of the cases was 13.3 (2.6-20 years). There were more boys (61.1%). Four dietary patterns each were observed among both boys and girls. Pattern 1 in girls, characterized by meats, fatty foods, and desserts, was positively associated with CD (OR 4.7, 95% CI 1.6-14.2). Pattern 2, common to both boys and girls, was characterized by vegetables, fruits, olive oil, fish, grains, and nuts and was inversely associated with CD in both genders (girls: OR 0.3, 95% CI 0.1-0.9; boys: OR 0.2, 95% CI 0.1-0.5).

CONCLUSIONS

Our results suggest that specific dietary patterns could be associated with higher or lower risks for CD in children. Larger prospective studies are required to confirm these findings.