Upper Gastrointestinal Manifestations of Inflammatory Bowel Disease

Severe Disease Activity May Predispose Patients to Post-colectomy Duodenitis Associated with Ulcerative Colitis

Objective Diffuse mucosal inflammation in the duodenum, distinct from peptic ulcer disease, has been repeatedly reported in patients with ulcerative colitis (UC). The pathogenesis of this complication remains uncertain; however, colectomy for medically refractory UC appears to trigger duodenitis. Cases in which colectomy was performed for UC were analyzed to characterize UC-related duodenitis after colectomy. Methods A retrospective case-control study of UC-related duodenitis that developed after colectomy in medically refractory UC between January 2011 and June 2020 was conducted. UC-related duodenitis was diagnosed based on typical clinical, endoscopic, and histological findings, and no duodenitis was endoscopically defined by the normal duodenal mucosa. Clinical and laboratory data, disease severity, and medications used were collected and compared between the UC-related and non-duodenitis cases. Results Ten UC-related duodenitis and 35 non-duodenitis cases were identified among 45 patients with UC who underwent esophagogastroduodenoscopy after colectomy. Disease severity, defined by the C-reactive protein level and partial Mayo score prior to colectomy, was significantly higher in duodenitis patients than in non-duodenitis patients. In comparison to non-duodenitis patients, duodenitis patients more frequently received rescue therapies with calcineurin inhibitors or anti-tumor necrosis factor (TNF)-α agents at the time of colectomy (100% vs. 65.7%). Conclusion Patients with UC with higher disease activity, especially those who require rescue therapies with calcineurin inhibitors and anti-TNF-α agents, may be prone to developing UC-related duodenitis after colectomy.

Objective and Subjective Dysphagia Assessment in Inflammatory Bowel Diseases

INTRODUCTION

Inflammatory bowel disease (IBD) is a chronic gastrointestinal disease that is separated into two types: ulcerative colitis (UC) and Crohn's disease (CD). Although dysphagia is a well-studied and important topic in head and neck cancers and neurological disorders, research on the relationship between IBD and swallowing problems is not yet elucidated. The aim of this study was to compare swallowing function in the UC and CD using objective and patient-reported evaluation modalities.

METHODS

This was a prospective cross-sectional research with 86 patients (50 UC and 36 CD) treated at the gastroenterology department. The assessment includes flexible fiberoptic endoscopic examination (FEES). The penetration-aspiration scale, the functional oral intake scale (FOIS), the functional outcome swallowing scale (FOSS), the Eating Assessment Tool-10 (EAT-10) test, the Yale Pharyngeal Residue Severity Scale for vallecula (Yale PRSS-vallecula) and pyriform sinus (Yale PRSS-PS) were all used to determine extent of dysphagia.

RESULTS

The CD group had higher EAT-10 scores than UC group (p = 0.014). In terms of PAS scores, there was no significant difference between the two groups in all three food types (water, yogurt, and crackers) (p > 0.05). There was not a statistically significant variance between the groups in terms of vallecular residue (p > 0.05) according to the Yale PRSS-vallecula. Based on the Yale PRSS-PS, the CD group had significantly more residue than the UC group with yogurt and cracker (p = 0.014 and 0.030, respectively). FOSS and FOIS scores did not vary significantly between the two groups (p > 0.05).

CONCLUSION

CD impairs subjective and pharyngeal swallowing functions more than UC. It is obvious that swallowing should be assessed in patients with IBD.

Automated analysis of small intestinal lamina propria to distinguish normal, Celiac Disease, and Non-Celiac Duodenitis biopsy images

BACKGROUND AND OBJECTIVE

Celiac Disease (CD) is characterized by gluten intolerance in genetically predisposed individuals. High disease prevalence, absence of a cure, and low diagnosis rates make this disease a public health problem. The diagnosis of CD predominantly relies on recognizing characteristic mucosal alterations of the small intestine, such as villous atrophy, crypt hyperplasia, and intraepithelial lymphocytosis. However, these changes are not entirely specific to CD and overlap with Non-Celiac Duodenitis (NCD) due to various etiologies. We investigated whether Artificial Intelligence (AI) models could assist in distinguishing normal, CD, and NCD (and unaffected individuals) based on the characteristics of small intestinal lamina propria (LP).

METHODS

Our method was developed using a dataset comprising high magnification biopsy images of the duodenal LP compartment of CD patients with different clinical stages of CD, those with NCD, and individuals lacking an intestinal inflammatory disorder (controls). A pre-processing step was used to standardize and enhance the acquired images.

RESULTS

For the normal controls versus CD use case, a Support Vector Machine (SVM) achieved an Accuracy (ACC) of 98.53%. For a second use case, we investigated the ability of the classification algorithm to differentiate between normal controls and NCD. In this use case, the SVM algorithm with linear kernel outperformed all the tested classifiers by achieving 98.55% ACC.

CONCLUSIONS

To the best of our knowledge, this is the first study that documents automated differentiation between normal, NCD, and CD biopsy images. These findings are a stepping stone toward automated biopsy image analysis that can significantly benefit patients and healthcare providers.

[Inflammatory bowel diseases and upper gastrointestinal tract]

Inflammatory bowel diseases (IBD), Crohn's disease and ulcerative colitis are inflammatory diseases with a flare-up evolution and an unknown etiology. Inflammatory lesions of the upper gastrointestinal tract are more and more often described in Crohn's disease and ulcerative colitis. The aim of this article was to review the inflammatory lesions of the esophagus, stomach and duodenum currently described in the IBD.

A Practical Index to Distinguish Backwash Ileitis From Crohn's Terminal Ileitis in MR Enterography

BACKGROUND

Differentiating ulcerative colitis-associated "backwash" ileitis (BWI) from Crohn's terminal ileitis (CTI) is a diagnostic challenge and highly affects patient's management. This study aimed to investigate magnetic resonance enterography (MRE) features including ileocecal valve patency index (ICPI) in patients with BWI and CTI and distinguish these entities based on MRE findings.

METHODS

After obtaining institutional review board approval, we reviewed 1654 MREs; 60 patients with pathologically proven BWI (n = 30) and CTI (n = 30) were enrolled. Two radiologists who were blinded to the clinical diagnosis analyzed MREs. We evaluated bowel wall thickness and enhancement pattern, ileocecal valve (ICV) diameter, and lip thickness. Ileocecal valve patency index-T and ICPI-C were calculated to normalize the ICV diameter with respect to terminal ileum (TI) and cecum, respectively. An additional group of non-BWI-UC patients (n = 30) was also included to validate indices.

RESULTS

Circumferential mural thickening (90% vs 1%, P < .001) and inner-wall enhancement (P < .001) of TI were more frequent in BWI patients than CTI. Serosal irregularity (53% vs 13%, P = .002), higher mural thickness (5mm vs 3mm, P < .001), and asymmetric hyperenhancement (P < .001) of TI were more prevalent in CTI than BWI. Ileocecal valve patency and lip atrophy were significantly higher in BWI than CTI and non-BWI-UC groups (both P < .001). Ileocecal valve patency indices-C and ICPI-T indices were able to accurately distinguish BWI from CTI (area under the ROC curve [AUC], 0.864 and 0.847 for ICPI-T and ICPI-C, respectively) and non-BWI-UC (AUC, 0.777 and 0.791 for ICPI-T and ICPI-C, respectively). Ileocecal valve patency indices-T  ≥31.5% were 100% specific to distinguish BWI from CTI, but sensitivity was 63%.

CONCLUSIONS

Magnetic resonance enterography features of ICV and TI can accurately differentiate BWI from CTI. Two practical indices introduced in this study showed high specificity to distinguish BWI from CTI.

Critical diagnoses in paediatric gastrointestinal diseases

Gastrointestinal biopsies represent an increasing proportion of the paediatric pathologist's workload, an increase fundamentally due to an expansion of the understanding of the basic clinical, molecular, genetic, and histopathological features of paediatric gastrointestinal disorders. The histological interpretation of endoscopically retrieved gastrointestinal biopsies in children requires a unique set of diagnostic expertise and detailed knowledge of various gastrointestinal disorders that have a predilection for the paediatric population. This article's major role is to highlight the unique problems inherent to paediatric gastrointestinal disorders that require immediate communication with the paediatric surgeon or the gastroenterologist. For this, we tried to cover the most important diseases that a paediatric pathologist might encounter in daily practice. Some of these diseases are relatively rare, such as microvillous inclusion disease and tufting enteropathy, but some are more common such as eosinophilic disorders and inflammatory bowel disease. Awareness of the histopathological features of these diseases, particularly those that are relatively uncommon, is crucial to spare the patient a lengthy and costly evaluation. We made a particular effort to abundantly reference this article should the reader wish to expand on the content of any section.

Clinicopathological Characteristics and Etiological Factors of Granulomatous Gastritis

AIMS

To examine the clinicopathological characteristics of granulomatous gastritis (GG) among different etiologies, particularly Crohn disease (CD), and determine the contribution of H. pylori and the clinical significance of isolated GG.

METHODS/RESULTS

We identified 269 GG cases overall (0.19% prevalence): 220 had an underlying granulomatous disease (CD, sarcoidosis, tuberculosis) and only 8 of these (3.6%) had H. pylori, fewer than the 10.3% rate among non-GG biopsies (p<.001). Conversely, among 49 GG cases without known cause (foreign body, undetermined, idiopathic), 13 (26.5%) had H. pylori, more than background (p=.001). Most patients (n=185/68.8%) had CD and these were more likely male (p<.001), younger (p<.001), white (p<.001), and had single (p=.010), smaller (p=.005), antral (p=.027) granulomas, amid inflammation (p=.005), compared to non-CD GG cases; younger age was independently associated with CD (p=.003; OR=1.13, 95% CI: 1.04-1.22). Among CD patients, younger age (p=.003; OR=1.04, 95% CI: 1.01-1.07) and upper gastrointestinal (GI) symptoms (p=.017; OR=2.53, 95% CI: 1.18-5.43) were associated with new (vs. established) diagnosis, whereas multiple gastric granulomas (p=.003; OR=4.67, 95% CI: 1.67-13.04) and lack of upper GI symptoms (p<.001; OR=6.75, 95% CI: 2.94-15.49) were associated with lower GI granulomas. Of 86 isolated GG cases (i.e., no prior diagnosis or lower GI granulomas), 51 (59.3%) were eventually diagnosed with CD, and this was independently associated with younger age (p=.014; OR=1.11, 95% CI: 1.02-1.21) and upper GI symptoms (p=.033; OR=19.27, 95% CI: 1.27-293.31). The positive predictive value of finding isolated GG towards a CD diagnosis in patients <30 years-old was 91%, increasing in males (93%), with single (94%), antral (97%) granulomas, or upper GI symptoms (94%).

CONCLUSIONS

GG does not correlate with H. pylori in patients with granulomatous disease, but may be associated with the organism when such diagnosis is lacking. In CD patients with GG, younger age and upper GI symptoms are associated with a new CD diagnosis, whereas multiple gastric granulomas and lack of upper GI symptoms correlate with lower GI granulomas. GG, including in isolated cases with no prior clinical history or granuloma, likely signifies CD, particularly in younger, male patients, or those with single, antral granulomas, or upper GI symptoms.

Development of an easy-to-use urease kit for detecting Helicobacter pylori in canine gastric mucosa

BACKGROUND AND AIM

Helicobacter pylori is an important pathogen in humans and animals involved in chronic gastritis, leading to the development of gastric cancer. Urease produced by H. pylori is an enzyme that promotes bacterial colonization and can be used clinically as a biomarker of H. pylori infection as part of a rapid urease test (RUT). A test with high specificity (95-100%) would be more convenient and faster than histopathology, bacterial culture, and polymerase chain reaction (PCR). The aim of this study was to develop a simple, cheap, and fast kit for detecting H. pylori infection in the gastric mucosa of canines, which can be used in clinical practice for diagnosing infection with this bacterium.

MATERIALS AND METHODS

The RUT assays developed were prepared using 1% agar, 1% sodium phosphate monobasic, and 1% urea followed by the addition of 3% methyl red indicator. The cutoff value of sensitivity of the RUT assay was established using the urease of H. pylori ATCC 43504 and color change was monitored for 24 h. Comparisons of the sensitivity to H. pylori ATCC 43504 were made between the developed RUT assays and the Hp Fast™ commercial kit. Then, the limit of detection for H. pylori ATCC 43504 number was analyzed by the SYBR Green real-time PCR assay to measure the copy number of the ureC gene. Gastric biopsy samples from the antrum, body, and fundus of the stomach were collected from eight canines presenting with vomiting and gastroenteritis. Analyses were performed on fresh samples using the developed RUT assays and the Hp Fast™ commercial kit, which were read within 24 h; then, the results were confirmed with SYBR Green real-time PCR. The specificity of the RUT assays was tested with a number of different bacteria, including Staphylococcus pseudintermedius, Proteus spp., Pseudomonas aeruginosa, Klebsiella pneumoniae, Enterococcus spp., Escherichia coli, and Salmonella spp.; H. pylori ATCC 43504 was used as a positive control.

RESULTS

The results showed that the developed assays were sensitive to the urease enzyme at 0.1 mg/mL. The lowest detection limit of this assay for H. pylori ATCC 43504 was found to be 102 copies at 30 min. The sensitivity of detection of H. pylori in gastric biopsies of canines occurred in a minimum of 30 min. The RUT showed similar results to the Hp Fast™ commercial kit. In the developed RUT, the color change of the test from red to yellow could be clearly distinguished between the color of the positive test and the negative one; however, in the commercial Hp Fast™, it was difficult to observe the gel color changein the negative pH range of 5.8 and the positive pH of 6.5. The developed RUT was specific for H. pylori and did not detect any of the other tested bacteria. The test kit can also be stored for 6 months at 4°C.

CONCLUSION

The sensitivity of the developed assays allowed the detection of urease enzyme at a minimum concentration of 0.1 mg/mL. Our RUT could also detect H. pylori from one in eight canine specimens at a minimum of 102 copies within 30 min. This RUT is specific to H. pylori as it did not detect any of the other tested bacteria.

Mucosal lesions of the upper gastrointestinal tract in patients with ulcerative colitis: A review

Ulcerative colitis (UC) is a chronic, nonspecific, relapsing inflammatory bowel disease. The colorectum is considered the chief target organ of UC, whereas upper gastrointestinal (UGI) tract manifestations are infrequent. Recently, emerging evidence has suggested that UC presents complications in esophageal, stomachic, and duodenal mucosal injuries. However, UC-related UGI tract manifestations are varied and frequently silenced or concealed. Moreover, the endoscopic and microscopic characteristics of UGI tract complicated with UC are nonspecific. Therefore, UGI involvement may be ignored by many clinicians. In addition, no standard criteria have been established for patients with UC who should undergo fibrogastroduodenoscopy. Furthermore, specific treatment recommendations may be needed for patients with UC-associated UGI lesions. Herein, we review the esophageal, gastric, and duodenal mucosal lesions of the UC-associated UGI tract, as well as the potential pathogenesis and therapy.

Exploring scientific validation of Triphala Rasayana in ayurveda as a source of rejuvenation for contemporary healthcare: An update

ETHNOPHARMACOLOGICAL RELEVANCE

Ayurveda remains the classical and comprehensive part of the ancient Indian medicine system for well-being promotive, disease preventive, and revival approach for the human body. Triphala Rasayana is mentioned in Ayurveda, comprising fruits of three plant species viz. Phyllanthus emblica L. (P. emblica), Terminalia chebula Retz (T. chebula), and Terminalia bellirica Roxb (T.bellirica). Triphala Rasayana has been utilized in various traditional medicine systems, viz., Ayurveda, Siddha, and Unani. Traditionally Rasayana based drugs are utilized in different kinds of diseases without pathophysiological associations as indicated by current medication. Various medicinal attributes of Triphala Rasayana include antioxidant, anticancer, antidiabetic, antimicrobial, immunomodulatory, and anticataract and is also considered as a pillar for gastrointestinal treatment, specifically in functional gastrointestinal disorders (FGIDs). Due to Rasayana's accessible mode of administration, availability, and affordability, there is an increase in its global acceptance.

AIM OF REVIEW

This review article summarizes the scientific validation, traditional uses, bioactive compounds, and ethnopharmacological properties of Triphala Rasayana. It also documents recent data on in vivo and in vitro pharmacological studies and clinical effects of Triphala Rasayana.

MATERIAL AND METHOD

A literature review is carried out using PubMed, ScienceDirect, Scopus, web of science, Ayush Research Portal, and Clinical Trials Registry-India. In addition to an electronic search, traditional ayurvedic texts and books were used as sources of information.

RESULTS

Traditionally, "Triphala Rasayana" is classified as a tridoshic rasayana and one of the most well-studied ayurvedic Rasayana. It showed various pharmacological activities such as anticancer, antioxidant, antibacterial, immunomodulatory, cardioprotective, and antidiabetic. Besides this, Rasayana has reported ethnopharmacological activities such as antimicrobial, anticataract, wound healing, and radioprotection. It has shown a good impact on the gastrointestinal tract (GIT) system with the reported pharmacological activities in gastrointestinal disorders such as constipation, gastric ulcer, and inflammatory bowel disease (IBD). Phytochemical studies of Triphala Rasayana revealed chemical constituents like gallic acid, ellagic acid, chebulic acid, chebulinic acid, methyl gallate, emblicanin A, and emblicanin B. Additionally, clinical studies found Triphala Rasayana to be effective against diabetes, constipation, and obesity.

CONCLUSION

The present review revealed that Triphala Rasayana may treat a diverse range of diseases, especially GIT disorders. Considering the beneficial properties of Triphala Rasayana and it's proven non-toxic nature could be a source of rejuvenation in contemporary healthcare. Nevertheless, its clinical data effectively provided precious signals to correlate ayurvedic biology and modern medicine.

Histopathologic Manifestations of Crohn Disease in Duodenal Endoscopy Biopsy: The Value of Different Patterns of Involvement of Brunner Glands

Crohn disease (CD) not uncommonly involves the upper gastrointestinal tract, usually gastric antrum and proximal duodenum. The most consistent histopathologic manifestations of CD in duodenal biopsies are mucosal erosion, focal active inflammation, and granulomas. Since CD is a transmural inflammation and since duodenal biopsy may include submucosal Brunner glands, we aimed to find if CD has any specific histopathologic manifestations in Brunner gland lobules and their ducts compared to other duodenal inflammatory lesions. We carried out a retrospective review study over 6 years retrieving duodenal biopsy specimens in CD patients. We compared duodenal specimens involved by CD with other inflammatory lesions, for example, ulcerative colitis (UC), Helicobacter pylori-associated gastritis, non-Helicobacter gastritis, Celiac sprue, infections, and drugs. We found focal active duodenitis and erosion in CD cases and non-CD cases. Granulomas were found in CD cases. Five cases of CD showed inflammatory and degenerative changes of Brunner glands. Focal patchy active inflammation of only portion of submucosal Brunner gland lobule, mucosal Brunner glands, and their ducts was solely found in CD cases. This focally enhanced inflammation of Brunner glands was not found in other lesions. Whether this phenomenon of focal active "lobulitis" and "ductitis" is a specific sign of duodenal CD compared to UC and other inflammatory lesions warrants verification. We encourage endoscopists to include submucosal Brunner lobules in their duodenal biopsy samples and pathologists to look for these patterns of involvement particularly in patients suspected of CD.