Clinical activity assessment in inflammatory bowel disease

Magnetic resonance enterography predicts the prognosis of Crohn's disease

Background/Aims

Magnetic resonance enterography (MRE) has emerged as an important tool in the diagnosis and follow-up of Crohn's disease (CD). The aim of this study was to evaluate whether MRE findings could predict the prognosis of CD.

Methods

In this retrospective study, a total of 173 patients with clinical remission of CD (n=61) or active CD (n=112) were identified. The outcomes of clinical relapse, admission, surgery, and need for other medications according to the MRE findings were evaluated.

Results

The presence of active inflammation on MRE was observed in 93 (83%) patients with clinically active CD and in 44 (72.1%) patients with clinical remission of CD, without a statistically significant difference (P=0.091). In multivariate analysis, active inflammation on MRE increased the risk for clinical relapse (hazard ratio [HR], 6.985; 95% confidence interval [CI], 1.024–47.649) in patients with clinical remission of CD. In patients with clinically active CD, active inflammation on MRE increased the risk for CD-related hospitalization (HR, 2.970; 95% CI, 1.006–8.772).

Conclusions

The presence of active inflammation on MRE was significantly associated with poor prognosis both in patients with clinical remission of CD and in those with active CD.

Magnetic resonance enterography in Crohn's disease: new simple proposal to assess disease activity

PURPOSE

The aim is to determine the accuracy of magnetic resonance enterography (MRE) in evaluating Crohn's disease (CD) activity.

MATERIALS AND METHODS

Seventy-seven patients with CD underwent MRE. The primary analysis was to determine associations between MRE findings, Harvey-Bradshaw Index, and C-reactive protein (CRP), then we have created a new MRE score that it was also correlated with clinical and laboratory data.

RESULTS

MRE score for CD significantly correlates with CRP (P=.003). Significant associations were found between degree of contrast enhancement and CRP (P=.002) and between comb sign and CRP (P=.001).

CONCLUSIONS

These results make MRE an important instrument for evaluation of CD activity.

Immunosuppressive effects via human intestinal dendritic cells of probiotic bacteria and steroids in the treatment of acute ulcerative colitis

BACKGROUND

In ulcerative colitis (UC) gut bacteria drive inflammation. Bacterial recognition and T-cell responses are shaped by intestinal dendritic cells (DCs); therapeutic effects of probiotic bacteria may relate to modulation of intestinal DC. The probiotic mixture, VSL#3, increases interleukin (IL)-10 and downregulates IL-12p40 production by DC in vitro. We evaluated in vivo effects of oral VSL#3 and steroids on colonic DC in patients with acute UC.

METHODS

Rectal biopsies were obtained from patients with active UC before and after treatment with VSL#3, corticosteroids, or placebo, and from healthy controls. Myeloid colonic DC were studied from freshly isolated lamina propria cells using multicolor flow cytometry. Surface expression of activation markers, CD40, CD86, pattern recognition receptors, Toll-like receptor (TLR)-2 and TLR-4 were assessed. Changed function was measured from ongoing intracellular IL-10, IL-12p40, IL-6, and IL-13 production.

RESULTS

Acute UC colonic myeloid DC were producing more IL-10 and IL-12p40 than control DC (P = 0.01). In VSL#3-treated patients DC TLR-2 expression decreased (P < 0.05), IL-10 production increased and IL-12p40 production decreased (P < 0.005); 10/14 patients on VSL#3 showed a clinical response. Corticosteroids also resulted in increased IL-10 and reduced IL-12p40 production by DC. Conversely, in patients on placebo, TLR-2 expression and intensity of staining for IL-12p40 and IL-6 increased (all P < 0.05); 5/14 patients on placebo showed a clinical response (P = NS).

CONCLUSIONS

Despite small numbers of human colonic DC available, we showed that treatment of UC patients with probiotic VSL#3 and corticosteroids induced "favorable" intestinal DC function in vivo, increasing regulatory cytokines and lowering proinflammatory cytokines and TLR expression. These effects may contribute to therapeutic benefit.

Scoring systems in inflammatory bowel disease

Inflammatory bowel disease (IBD) is a chronic, relapsing condition affecting the GI tract that can affect individuals of any age and results in lifelong treatment, frequently including the need for surgery. Historically, the lack of a single effective and sensitive test for IBD has posed a great challenge in assessing disease severity, effectiveness of medication and predicting outcomes for this complex condition. Several IBD scoring and classification systems have been developed over many years to classify and characterize IBD patients, with the goal of helping to better define the disease status and effectiveness of therapy. Recent genetic investigations have revealed the complexity of IBD at the pathophysiologic level, revealing numerous genetic mutations associated with the disease. Thus, these clinically based IBD classification systems can provide the basis for the eventual correlation between the underlying genotype with clinical expression of disease and lead to better characterization of disease subtypes and, hopefully, customized treatment regimens.

A novel population of human CD56+ human leucocyte antigen D-related (HLA-DR+) colonic lamina propria cells is associated with inflammation in ulcerative colitis

Ulcerative colitis (UC) involves inappropriate mucosal immune responses to intestinal microbiota. Gut dendritic cells (DC) are central immunoregulators of the response to commensal bacteria, and the subset of CD11c(+) cells within the human leucocyte antigen D-related (HLA-DR(+)) lineage (lin)(-/dim) population are activated in inflammatory bowel disease. We hypothesized that CD11c(-) cells within this population may also be involved in intestinal inflammation. HLA-DR(+) lin(-/dim) cells were identified in freshly isolated lamina propria mononuclear cells by multi-colour flow cytometry in 54 UC patients and 22 controls. Proportion and number of CD11c(+) and CD11c(-) cells, and surface expression of activation markers CD40, CD86, Toll-like receptor (TLR)-2, TLR-4, and CD56(+)[natural killer (NK) marker], were determined. Cytokine production was assessed by intracellular staining. Lamina propria colonic CD11c(-) HLA-DR(+) lin(-/dim) cells were increased significantly in inflamed and 'non-inflamed' UC tissue, compared with control tissue. CD11c(+) HLA-DR(+) lin(-/dim) cells were unchanged. Fewer CD11c(-) cells expressed activation markers and produced intracellular cytokines than their CD11c(+) counterparts, and they were weakly stimulatory in mixed leucocyte reactions. Few CD11c(-) cells expressed blood plasmacytoid DC markers, but a major subset expressed high levels of CD56. CD11c(-) cells decreased after inflammation resolved. Intestinal inflammation in UC is associated with the presence of cells that share phenotypic features of both DC and NK cells. This novel population of human colonic CD56(+) HLA-DR(+) cells may play a role in immune regulation or tissue repair. Their increase in quiescent UC may be a marker of subclinical inflammation.

Magnetic resonance imaging of the small bowel in children with idiopathic inflammatory bowel disease: evaluation of disease activity

BACKGROUND

Examinations using ionizing radiation are frequently used in the evaluation of disease activity in children affected by idiopathic inflammatory bowel disease (IBD).

OBJECTIVE

To develop an MR imaging protocol without the need for fluoroscopic insertion of an enteral tube and to assess the disease activity in children with IBD.

MATERIALS AND METHODS

Included in the study were 37 children (22 girls and 15 boys; age range 7-15 years, mean 11.67 years) with IBD who underwent MR imaging of the small bowel. Of these 37 children, 32 had Crohn disease and 5 had indeterminate colitis. A water solution containing herbal fibres was administered orally or through a nasogastric tube. Patients were imaged on a 1.5-T MR scanner with T1-weighted and Tau2-weighted sequences followed by a dynamic study using 3-D T1-W images after intravenous administration of gadolinium.

RESULTS

The percentage enhancement of the bowel wall was significantly increased in patients with abnormal C-reactive protein (CRP) values compared to patients with CRP values in the normal range (P<0.001). A relatively weak but significant correlation between percentage enhancement of the bowel wall and CRP values was noted during all phases of enhancement.

CONCLUSION

This MR imaging protocol is a safe and well-tolerated method for evaluating disease activity and extraintestinal manifestations of IBD in children.

Mural inflammation in Crohn disease: location-matched histologic validation of MR imaging features

PURPOSE

To validate proposed magnetic resonance (MR) imaging features of Crohn disease activity against a histopathologic reference.

MATERIALS AND METHODS

Ethical permission was given by the University College London hospital ethics committee, and informed written consent was obtained from all participants. Preoperative MR imaging was performed in 18 consecutive patients with Crohn disease undergoing elective small-bowel resection. The Harvey-Bradshaw index, the C-reactive protein level, and disease chronicity were recorded. The resected bowel was retrospectively identified at preoperative MR imaging, and wall thickness, mural and lymph node/cerebrospinal fluid (CSF) signal intensity ratios on T2-weighted fat-saturated images, gadolinium-based contrast material uptake, enhancement pattern, and mesenteric signal intensity on T2-weighted fat-saturated images were recorded. Precise histologic matching was achieved by imaging the ex vivo surgical specimens. Histopathologic grading of acute inflammation with the acute inflammatory score (AIS) (on the basis of mucosal ulceration, edema, and quantity and depth of neutrophilic infiltration) and the degree of fibrostenosis was performed at each site, and results were compared with MR imaging features. Data were analyzed by using linear regression with robust standard errors of the estimate.

RESULTS

AIS was positively correlated with mural thickness and mural/CSF signal intensity ratio on T2-weighted fat-saturated images (P < .001 and P = .003, respectively) but not with mural enhancement at 30 and 70 seconds (P = .50 and P = .73, respectively). AIS was higher with layered mural enhancement (P < .001), a pattern also commonly associated with coexisting fibrostenosis (75%). Mural/CSF signal intensity ratio on T2-weighted fat-saturated images was higher in histologically edematous bowel than in nonedematous bowel (P = .04). There was no correlation between any lymph node characteristic and AIS.

CONCLUSION

Increasing mural thickness, high mural signal intensity on T2-weighted fat-saturated images, and a layered pattern of enhancement reflect histologic features of acute small-bowel inflammation in Crohn disease.

Magnetic resonance imaging of the small bowel in children with idiopathic inflammatory bowel disease: evaluation of disease activity

BACKGROUND

Examinations using ionizing radiation are frequently used in the evaluation of disease activity in children affected by idiopathic inflammatory bowel disease (IBD).

OBJECTIVE

To develop an MR imaging protocol without the need for fluoroscopic insertion of an enteral tube and to assess the disease activity in children with IBD.

MATERIALS AND METHODS

Included in the study were 37 children (22 girls and 15 boys; age range 7-15 years, mean 11.67 years) with IBD who underwent MR imaging of the small bowel. Of these 37 children, 32 had Crohn disease and 5 had indeterminate colitis. A water solution containing herbal fibres was administered orally or through a nasogastric tube. Patients were imaged on a 1.5-T MR scanner with T1-weighted and Tau2-weighted sequences followed by a dynamic study using 3-D T1-W images after intravenous administration of gadolinium.

RESULTS

The percentage enhancement of the bowel wall was significantly increased in patients with abnormal C-reactive protein (CRP) values compared to patients with CRP values in the normal range (P<0.001). A relatively weak but significant correlation between percentage enhancement of the bowel wall and CRP values was noted during all phases of enhancement.

CONCLUSION

This MR imaging protocol is a safe and well-tolerated method for evaluating disease activity and extraintestinal manifestations of IBD in children.

Assessment of Crohn's disease activity in the small bowel with MR-enteroclysis: clinico-radiological correlations

BACKGROUND

The aim of our study was to evaluate the accuracy of magnetic resonance imaging (MRI) in evaluating Crohn's disease (CD) activity compared to clinical/laboratory data.

METHODS

Ninety-three consecutive patients with CD were prospectively studied by MR imaging, before and after Gadolinium chelates administration, with use of a biphasic endoluminal contrast agent. MR image analysis included: number of lesions, presence/absence of bowel stenosis, upstream bowel dilation, wall thickness, presence of enhancement, enhancement pattern, presence/absence of comb sign, lymph nodes, and perianal fistulas/abscesses. Clinical evaluation was performed by means of Harvey & Bradshaw Index. Acute-phase reactants were considered standard of reference to monitor biological activity (BA). MR imaging findings were compared with clinical and laboratory data.

RESULTS

MR image analysis detected: In 96 exams multiple lesions in 16, 1 in 50; no lesions in 30; stenosis in 52; dilatation in 28; wall thickening in 59; significant enhancement in 57; layered pattern in 50; comb sign in 37; enlarged lymph nodes in 16; fibro-fatty proliferation in 40; fistulas in 9.

CONCLUSIONS

MRI is able to depict morphological changes and is helpful in assessing Crohn's inflammatory disease.

MRI scoring system including dynamic motility evaluation in assessing the activity of Crohn's disease of the terminal ileum

RATIONALE AND OBJECTIVES

We sought to investigate the value of a MRI scoring system including dynamic motility evaluation in the assessment of small bowel Crohn's disease activity.

MATERIALS AND METHODS

From March 2005 to December 2006, 52 patients with suspected Crohn's disease onset or relapse underwent MRI on a 1.5-T magnet. Bowel distention was achieved orally assuming a mean of 1.6 L of a polyethyleneglycol (PEG) preparation. Per-patient assessment of disease activity was based on a scoring system including evaluation of morphology and motility of the small bowel and perivisceral structures (true-FISP, cine-true-FISP, and HASTE T2W sequences) and dynamic assessment of parietal contrast enhancement (FLASH T1W sequence). Patients were included in three categories, using endoscopic biopsy as the standard reference: no activity/quiescent disease, mild activity, or moderate-to-severe activity. Patients without terminal ileum involvement were excluded from data analysis.

RESULTS

MRI allowed a detailed and panoramic evaluation of the small bowel in all subjects examined. MRI properly assessed 14 of 16 (87.5%) cases of no activity/quiescent disease, 12 of 14 (85.7%) cases of mild activity, and 15 of 15 (100%) cases of severe activity. Overall, activity score led to a per-patient misdiagnosis of disease activity in a nonsignificant proportion of subjects (4 of 45; 8.8%) (P > .05), determining two false-positive and two false-negative results of mild disease activity. Sensitivity, specificity, PPV, NPV, and overall accuracy in assessing disease activity were 93.1%, 87.5%, 93.1%, 87.5%, and 91.1%, respectively.

CONCLUSION

Accurate assessment of Crohn's disease activity is achieved by using an activity score providing an overall interpretation of MRI findings.

MR imaging in patients with Crohn disease: value of T2- versus T1-weighted gadolinium-enhanced MR sequences with use of an oral superparamagnetic contrast agent

PURPOSE

To prospectively compare oral contrast-enhanced T2-weighted half-Fourier rapid acquisition with relaxation enhancement (RARE) magnetic resonance (MR) imaging with T1-weighted gadolinium-enhanced fast low-angle shot (FLASH) MR and standard examinations in the evaluation of Crohn disease.

MATERIALS AND METHODS

Institutional review board approval and informed consent were obtained. Fifty-nine patients with Crohn disease underwent MR imaging after oral administration of a superparamagnetic contrast agent; RARE plain and fat-suppressed sequences and FLASH sequences were performed before and after intravenous injection of gadolinium chelate. References were endoscopic, small-bowel barium, computed tomographic, ultrasonographic, and clinical-biochemical scoring of disease activity. Two radiologists analyzed MR images for presence and extent of Crohn disease lesions, presence of strictures or other complications, and degree of local inflammation. MR findings were correlated with endoscopic, radiologic, and clinical data (kappa statistic and Spearman rank correlation test).

RESULTS

T2-weighted MR was 95% accurate, 98% sensitive, and 78% specific for detection of ileal lesions. Agreement between T1- and T2-weighted images ranged from 0.77 for ileal lesions to 1.00 for colic lesions. T2-weighted MR enabled detection of 26 of 29 severe strictures, 17 of 24 enteroenteric fistulas, and all adhesions and abscesses; T1-weighted MR enabled detection of 20 of 29 severe strictures, 16 of 24 enteroenteric fistulas, and all adhesions and abscesses. Complications leading to surgery were found in 12 (20%) patients; these were assessed correctly with either T1- or T2-weighted images. T2-weighted signal intensities of the wall and mesentery correlated with biologic activity (P < .001, r of 0.774 and 0.712, respectively). Interobserver agreement was 0.642-1.00 for T2-weighted and 0.711-1.00 for T1-weighted images.

CONCLUSION

T2-weighted MR can depict Crohn disease lesions and help assess mural and transmural inflammation with the same accuracy as gadolinium-enhanced T1-weighted MR. Combination of gadolinium-enhanced T1- and T2-weighted sequences is useful in the assessment of Crohn disease.

The role of total parenteral nutrition in the management of patients with acute attacks of inflammatory bowel disease

The aim of this study was to evaluate the effects of the prolonged duration of total parenteral nutrition (TPN) on the clinical, laboratory, and nutritional parameters and short-term outcome in acute attacks of ulcerative colitis and Crohn's colitis, and the difference in the response to TPN between the two diseases. Twenty-two patients with severely and moderately active ulcerative colitis (8 severe and 14 moderate) and 12 patients with Crohn's colitis were analyzed retrospectively. Eleven of 22 patients with ulcerative colitis were treated with TPN and corticosteroids (TPN group). The remaining 11 patients were treated with corticosteroids alone and hospital meals (oral diet group). Both groups were matched regarding disease severity at pretreatment. The clinical characteristics, and the initial and total dosages of corticosteroids for 3 weeks were similar between the two groups. The authors compared the changes in the clinical, inflammatory, and nutritional parameters and short-term outcome between the TPN and the oral diet groups with ulcerative colitis. The same evaluations were also made for 12 patients with Crohn's colitis who received TPN (CD group). The TPN group did not show any significant improvement in the clinical parameter, inflammatory signs, or nutritional state compared with the oral diet group with ulcerative colitis. The remission rate after 3 weeks of therapy and a colectomy rate also showed no significant difference between the two groups. In contrast, TPN resulted in a disappearance of clinical symptoms and an improvement in both the inflammatory and nutritional parameters in the CD group. Only one of the 12 patients with Crohn's colitis underwent colectomy. TPN induced no additional benefit in corticosteroid therapy in an acute attack of ulcerative colitis. In contrast, TPN may have primary effects on Crohn's colitis.

Clinical relevance of serum interleukin-6 in Crohn's disease: single point measurements, therapy monitoring, and prediction of clinical relapse

OBJECTIVE

To investigate the clinical relevance of interleukin-6 (IL-6) serum levels in patients with Crohn's disease (CD), single point IL-6 measurements in sera from consecutive CD patients and healthy donors (HD), as well as longitudinal measurements during the course of steroid therapy for active CD were performed. Patients with steroid-induced remission were followed until clinical relapse.

METHODS

One hundred thirty-six CD patients without steroid or other immunosuppressive treatment within 2 months and surgical procedures within 3 months before study entry were investigated; 63 patients with active CD were enrolled into the follow-up program. Clinical activity was evaluated by the Crohn's disease activity index (CDAI) and serum IL-6 levels measured by enzyme-linked immunosorbent assay.

RESULTS

IL-6 serum levels were significantly elevated in CD patients compared to HD (p < 0.001). In individual patients serum IL-6 levels correlated with corresponding CDAI scores in a subgroup referred to as primarily inflammatory patients presenting without bowel stenosis, previous intestinal resection, or concomitant inflammatory disorders (r = 0.72, p < 0.001). Primarily inflammatory patients displayed higher serum IL-6 levels (median: 6.0 pg/ml; range: 1.3-25) than CD patients with bowel stenosis (median: 2.0; range: 1.3-4.9; p < 0.01) or extensive intestinal resection (median: 1.5; range: 1.3-13.7; p < 0.001). Longitudinally measured serum IL-6 levels reflected the clinical response during steroid therapy and predicted clinical relapse after steroid-induced remission at week 9 of the treatment protocol.

CONCLUSIONS

Serum IL-6 is a clinically relevant parameter for CD that correlates with inflammatory activity and implies a prognostic value after steroid-induced remission.

Clinical subtypes of Crohn's disease according to surgical outcome

Patients with Crohn's disease are typically classified into perforator or nonperforator groups. The perforator group includes those who present with acute perforation, fistulas, or abscess formation. The nonperforator group presents with stricture, obstruction, or unresponsiveness to medical therapy. Our purpose was to investigate whether perianal disease constitutes a separate predictor of surgical outcome. The form of presentation was classified as perforator, nonperforator, or perianal disease in 91 patients undergoing 232 operations for Crohn's disease. Those with perforating complications presented with the highest Crohn's Disease Activity Index, followed by those with nonperforating complications, and then the perianal disease group. However, the perianal disease group appeared to have the most rapid rate of recurrence and subsequent surgery, followed next by the perforator, and then the nonperforator group. Recurrence rate and subsequent operation intervals for the perforator group appeared to lengthen when those patients were treated with steroids and/or immunosuppressants, as compared to nonsteroidal and/or antimicrobial agents. Recurrence rate and subsequent operation intervals appeared to lengthen for the nonperforator and perianal disease groups when they were treated with nonsteroidal and/or antimicrobial therapy, as compared to steroids and/or immunosuppressants. Our data indicate that perianal disease, as a form of presentation of Crohn's disease, has independent predictive value, although this is not accurately reflected by the Crohn's Disease Activity Index.

Correlation between endoscopic severity and the clinical activity index in ulcerative colitis

OBJECTIVE

The aim of this study was to examine the relationship between a new activity index and the endoscopic severity assessed by sigmoidoscopy in patients with ulcerative colitis.

METHODS

We evaluated the sigmoidoscopic severity and Activity Index (AI) in 37 patients with distal colitis, 23 with left-sided colitis, and 36 with total colitis, in which the severity was divided into three categories: grade 1 = mildly active, grade 2 = moderately active, and grade 3 = severely active. We examined the relationship between the AI or clinical parameters and the endoscopic severity in all 96 cases.

RESULTS

The AI was found to be significantly correlated with the degree of sigmoidoscopic activity in all cases, as well as in those with distal colitis, left-sided colitis, or total colitis. When patients with both grade 1 sigmoidoscopic activity and AI values of less than 150 were regarded to have mild colitis and patients with either grade 2 or grade 3 sigmoidoscopic activity and AI values of more than 150 were regarded to have moderate or severe colitis, 10 of 37 (27%) in the distal colitis, one of 23 (4.3%) in the left-sided colitis, and four of 36 (11.1%) in the total colitis groups were thus misclassified regarding the distinction between mild colitis and moderate or severe colitis. Three of four patients with severity of grade 1, indicating AI values of more than 150, had total colitis, whereas the remaining one had left-sided colitis. On the other hand, 10 of 11 patients with severity of grades 2 or 3 with AI values of less than 150 had distal colonic involvement. When the endoscopic activity was equivalent, the highest mean AI values occurred in total colitis whereas the lowest mean AI values were found in distal colitis.

CONCLUSIONS

The AI well reflects the sigmoidoscopic activity. High AI values with a low sigmoidoscopic severity are thus considered to reflect extensive involvement, whereas a high sigmoidoscopic severity with low AI values is thought to indicate the involvement of the distal colon.

Management of the first presentation of severe acute colitis

Prompt diagnosis and exclusion of infection requires a minimum of rigid sigmoidoscopy, rectal mucosal biopsy and stool culture. Admission to hospital is mandatory for patients with features of severe disease, or who are in their first attack of ulcerative colitis and have bloody diarrhoea, even if the criteria for severe disease are not met. Once admitted, the patient should be monitored by plain abdominal X-ray, full blood count, serum albumin and C reactive protein on alternate days; temperature and pulse rate should be recorded four times per day. Treatment should be instituted as soon as the diagnosis is made with an intravenous corticosteroid (hydrocortisone 100 mg intravenously, four times daily, or equivalent). Antibiotics may be included if infection cannot be confidently excluded. Free diet can be allowed but attention should be given to nutritional, fluid and electrolyte status with intravenous replacement if necessary. Any evidence of colonic dilatation occurring despite maximal therapy should be regarded as an absolute indication for colectomy. The patient should be kept fully informed from an early stage about the likely natural history of the condition and about the possible therapeutic options including surgery. Cyclosporin therapy should be reserved for patients who have a poor response to the first 3-4 days of corticosteroid therapy, particularly those with serum C reactive protein > 45 mg/l and who do not yet have absolute indications for colectomy. Most patients who have not convincingly responded within 10 days of starting full medical therapy should undergo colectomy, although partial responders who are afebrile may reasonably continue for up to 14 days before a final decision. Approximately 30-40% of patients with severe colitis will need colectomy within the first 6 months. With optimal management, mortality should be zero, but better medical therapies are urgently needed to reduce the colectomy rate.

Correlation of various Crohn's disease activity indexes in subgroups of patients with primarily inflammatory or fibrostenosing clinical characteristics

Several activity indexes, including clinical variables, laboratory variables or both, have been proposed to assess the activity and severity of Crohn's disease (CD). Although activity indexes are commonly used in clinical trials, doubts exist as to whether it is correct to group together and quantify under the same numerical expression the very heterogeneous clinical manifestations of CD. The aim of our study was to try to establish a correlation between clinical and laboratory activity indexes of CD in subgroups of patients with primarily inflammatory or primarily fibrostenosing clinical characteristics. At least two activity indexes were calculated among 232 outpatient examinations in 61 CD patients. Indexes were classified as clinical, laboratory, or both. A close correlation was observed when indexes calculated on clinical variables were compared or when those that include only or prevalently laboratory parameters were compared. Conversely, the correlation between clinical and laboratory indexes tended to be poor. Taking into consideration the subgroups of patients, the correlation between clinical and laboratory indexes was high in primarily inflammatory disease but low in the primarily fibrostenosing form. The clinical activity of CD does not always reflect the quantity of inflammation measured by laboratory parameters. This is particularly true in primarily fibrostenosing disease. Different clinical patterns of CD should always be considered in the attempt to quantify with an activity index the activity and severity of disease.

The myeloic related protein MRP8/14 (27E10 antigen)--usefulness as a potential marker for disease activity in ulcerative colitis and putative biological function

MRP8, MRP14 and their heterodimer MRP8/14 (27E10 antigen) are myeloic related proteins which have been shown to have a major role in inflammatory and immunological responses. In the present study monospecific antibodies against MRPs were used to investigate immunohistochemically the distribution of these proteins in routinely processed bowel tissues from 23 patients with ulcerative colitis (UC). MRP8, MRP14 and their heterocomplex MRP8/14 were demonstrated in the majority of granulocytes and macrophages in tissues of patients with active UC. Furthermore by employing the ELISA technique we measured MRP8/14 serum levels in 62 patients with UC and the results were compared with those for healthy controls. Disease activities were determined by established clinical activity indices. Serum MRP8/14 concentrations were significantly (P < 0.0001) increased in patients with active ulcerative colitis. No enhancement of serum levels were found for MRP14 and MRP8 alone, respectively. The follow-up of individual patients with initially active disease showed a decrease of MRP8/14 serum levels in parallel with clinical improvement following the start of therapy. It is thus concluded that MRP8/14 accurately reflects the degree of disease activity in UC. Further, possible biological function of MRPs seems to be associated with the heterodimeric form (27E10 antigen) rather than with individual proteins. Our morphological results confirm the finding of enhanced MRP8/14 serum levels in patients with active UC.

Increased leucocyte adhesiveness/aggregation is a most useful indicator of disease activity in patients with inflammatory bowel disease

The aim of the study was to determine the comparative usefulness of inflammatory markers, in evaluating disease activity in patients with inflammatory bowel disease. Disease activity was assessed by the Mayo Clinic score for ulcerative colitis, and Harvey-Bradshaw score for Crohn's disease. Five hundred normal blood donors who had no underlying inflammatory condition served as controls. The erythrocyte sedimentation rate, platelet and white blood cell count, C reactive protein, and the leucocyte adhesiveness/aggregation test (LAAT) were determined in each patient. One hundred and twenty four patients with inflammatory bowel disease were tested while in remission and 128 in relapse. Their mean (SD) per cent of aggregated white blood cells in the peripheral blood was 8 (5) and 17 (10) respectively compared with controls 6 (4) (p < 0.0001). Moreover, the LAAT could effectively discriminate between various grades of disease activity, the values in patients with active disease being 13 (6)% in mild, 17 (10)% in moderate, and 26 (10)% in severe disease (p < 0.0001). Other acute phase reactants including the erythrocyte sedimentation rate, the white blood cell count, the platelet count, neutrophil count, as well as, the C reactive protein concentration did not differentiate as well between the various groups. Using logistic regression analysis to differentiate between inflammatory bowel disease patients in remission or relapse, the LAAT was the single best indicator. The addition of any other test did not contribute to the discrimination. Among the different laboratory variables tested only the LAAT significantly discriminated between the five different subgroups of controls, remission and mild, moderate or severe disease activity.

Gut lavage fluid protein concentrations: objective measures of disease activity in inflammatory bowel disease

BACKGROUND

Fluid obtained by whole gut lavage normally contains traces of immunoglobulin (Ig) G, albumin, and alpha-1-antitrypsin; higher concentrations have been found in patients with inflammatory bowel disease (IBD).

METHODS

In a prospective study, 53 lavages were performed in 45 IBD patients (27 Crohn's disease, 18 ulcerative colitis), in whom disease activity was simultaneously assessed by Crohn's Disease Activity Index or Powell Tuck index. Concentration of IgG in lavage fluid was measured by enzyme-linked immunosorbent assay, and of albumin and alpha-1-antitrypsin by immunoturbidimetry.

RESULTS

For IgG, concentrations in lavage fluid correlated closely with activity indices: in Crohn's disease, r = 0.723 (P < 0.0001), in ulcerative colitis, r = 0.714 (P < 0.0001). Results for albumin and alpha-1-antitrypsin concentrations were similar to those for IgG, but they were less sensitive in detecting active disease. However, this method cannot be used as a diagnostic test for IBD; normal results were obtained for IgG in 6 (all inactive) of 42 lavages in patients who had unequivocal radiological or endoscopic abnormalities.

CONCLUSIONS

Assay of protein concentrations in gut lavage fluid is a simple, objective means of grading disease activity in patients with IBD; its potential uses are likely to be in the evaluation of complex cases and in clinical trials.

Evaluation of different laboratory tests and activity indices reflecting the inflammatory activity of Crohn's disease

In a prospective study we compared the usefulness of various laboratory tests (albumin, alpha-1-proteinase inhibitor (A1PI), cholinesterase (CHE), C-reactive protein, erythrocyte sedimentation rate, hematocrit) and activity indices (CDAI, VHAI) in relation to the disease activity by endoscopic criteria. Except for hematocrit highly significant differences (p less than 0.0005) of the mean values of all test results were found for patients without or with slight mucosal lesions compared with patients with severe inflammation of the mucosa. Further analysis of the data indicates the highest test efficiency (84%), sensitivity (80%), and specificity (88.6%) for CHE. CHE showed good correlations to all other tests; the highest correlation was found between CHE and VHAI (r = -0.78). We suggest that a suppression of CHE synthesis mediated by endotoxins and cytokines rather than an increased intestinal loss explains the decreased CHE in severe Crohn's disease. It is concluded from the data that CHE is a useful test to assess the inflammatory activity of Crohn's disease.

Review article: assessment of drug therapy in inflammatory bowel disease

This review article surveys the clinical and laboratory parameters used to assess and quantitate inflammation in ulcerative colitis and Crohn's disease, with particular reference to their usage in controlled trials of drugs in inflammatory bowel disease.

Ursodeoxycholic acid for the treatment of primary sclerosing cholangitis: a 30-month pilot study

We investigated the effects of once-daily oral administration of 10 mg/kg ursodeoxycholic acid (generic name, ursodiol) on elevated serum enzyme activities, bilirubin, cholesterol, bile acids and symptoms in patients with primary sclerosing cholangitis. A 30-mo, open-label, pilot trial was designed to cover four periods: (a) 3 mo of pretreatment observation (period 1), (b) 6 mo on ursodiol (period 2), (c) 3 mo withdrawal of treatment (period 3) and (d) 18 mo of extended retreatment (period 4). Diagnosis was confirmed by cholangiography and liver biopsy specimens. We enrolled 12 patients with persistently elevated pretreatment alkaline phosphatase and gamma-glutamyltransferase levels (at least twice the upper limit of normal), and observed them for a median of 37 mo. Significant reductions in serum total cholesterol levels and in serum enzyme activities indicating cholestasis and hepatocellular injury occurred during ursodiol treatment in both treatment periods 2 and 4 and relapsed with treatment interruption in period 3. Elevated serum bilirubin and symptoms of disabling fatigue, pruritus and diarrhea were improved by ursodiol. Improvements have continued after 2 yr of treatment in 10 patients (1 patient had a transplantation after he relapsed on withdrawal of ursodiol therapy; another died of postoperative complications of colon resection for carcinoma). No other cases of clinical deterioration were observed in the retreatment period. The longer term reductions of alkaline phosphatase, transaminases, bilirubin and cholesterol after 2 yr of treatment were even greater than the initial reductions after 6 mo of treatment. These results justify initiation of larger, controlled clinical trials, with serial morphological evaluations of the liver and biliary tree.

Health status in inflammatory bowel disease. Biological and behavioral considerations

The existing clinical measures of disease activity for inflammatory bowel disease are insufficient to explain a patient's illness experience or health outcomes. Although many disease activity measures have been devised, they are not widely accepted by clinicians because existing ones are no better than a carefully obtained clinical assessment. Furthermore, health status is determined not only by disease activity, but also by the psychological state, cultural influences, degree of social support, and effects of complications, previous surgery, and medication. To develop more accurate appraisals of the impact and severity of IBD, we must prospectively evaluate the biological and psychosocial measures that predict clinically relevant outcomes. We should then be able to develop statistically weighted scales related to specific outcome variables. Such knowledge will help us to develop more sensitive measures of illness, particularly in patients with mild disease for whom present indices are insensitive. This type of assessment should also aid in the understanding of health care utilization, medical vs. surgical options, resource allocation, and the efficacy of therapeutic trials.

Clinical, biological, and endoscopic picture of attacks of Crohn's disease. Evolution on prednisolone. Groupe d'Etude Thérapeutique des Affections Inflammatoires Digestives

One hundred forty-two patients with active colonic or ileocolonic Crohn's disease were included in a multicenter prospective study. Data collection included 28 clinical, biological, and endoscopic items; the latter were recorded according to a standardized colonoscopic protocol; a previously validated endoscopic index of severity was calculated. Oral prednisolone (1 mg/kg body wt per day) was started and maintained until clinical remission and for at least 3 and at most 7 wk. A second clinical biological and endoscopic evaluation was then performed. At initial colonoscopy, mucosal lesions were, by decreasing order of frequency, superficial ulcerations, deep ulcerations, mucosal edema, erythema, pseudopolyps, aphthoid ulcers, ulcerated stenosis, and nonulcerated stenosis (93%, 74%, 48%, 44%, 41%, 35%, 10%, 8%, and 2% of cases, respectively). No correlation was found between the clinical activity index and any of the endoscopical data (lesion frequency and surface, endoscopic severity index). Ninety-two percent of patients underwent clinical remission within 7 wk of treatment. None of the 28 clinical biological and endoscopical items collected just before treatment could predict clinical response to steroids. Only 38 of the 131 patients in clinical remission were also in endoscopic remission. In conclusion, (a) the description and severity of colonoscopic lesions in active Crohn's disease have been quantified; (b) no correlation exists between clinical severity and nature, surface, or severity of endoscopic lesions; (c) Oral prednisolone (1 mg/kg body wt per day) induces a clinical remission in 92% of patients within 7 wk; (d) resistance to steroids cannot be predicted from the data collected before treatment onset; and (e) only 29% of patients in clinical remission also achieve endoscopic remission.