Non-IBD and noninfectious colitis

Rapid Endoscopic Diagnosis of Benign Ulcerative Colorectal Diseases With an Artificial Intelligence Contextual Framework

BACKGROUND & AIMS

Benign ulcerative colorectal diseases (UCDs) such as ulcerative colitis, Crohn's disease, ischemic colitis, and intestinal tuberculosis share similar phenotypes with different etiologies and treatment strategies. To accurately diagnose closely related diseases like UCDs, we hypothesize that contextual learning is critical in enhancing the ability of the artificial intelligence models to differentiate the subtle differences in lesions amidst the vastly divergent spatial contexts.

METHODS

White-light colonoscopy datasets of patients with confirmed UCDs and healthy controls were retrospectively collected. We developed a Multiclass Contextual Classification (MCC) model that can differentiate among the mentioned UCDs and healthy controls by incorporating the tissue object contexts surrounding the individual lesion region in a scene and spatial information from other endoscopic frames (video-level) into a unified framework. Internal and external datasets were used to validate the model's performance.

RESULTS

Training datasets included 762 patients, and the internal and external testing cohorts included 257 patients and 293 patients, respectively. Our MCC model provided a rapid reference diagnosis on internal test sets with a high averaged area under the receiver operating characteristic curve (image-level: 0.950 and video-level: 0.973) and balanced accuracy (image-level: 76.1% and video-level: 80.8%), which was superior to junior endoscopists (accuracy: 71.8%, P < .0001) and similar to experts (accuracy: 79.7%, P = .732). The MCC model achieved an area under the receiver operating characteristic curve of 0.988 and balanced accuracy of 85.8% using external testing datasets.

CONCLUSIONS

These results enable this model to fit in the routine endoscopic workflow, and the contextual framework to be adopted for diagnosing other closely related diseases.

Serum Leucine-Rich α2 Glycoprotein Could Be a Useful Biomarker to Differentiate Patients with Normal Colonic Mucosa from Those with Inflammatory Bowel Disease or Other Forms of Colitis

(1) Background: Serum leucine-rich α2 glycoprotein (LRG) has been reported as a useful biomarker for monitoring disease activity in patients with inflammatory bowel disease (IBD). We investigated whether serum LRG can differentiate patients with normal colonic mucosa from those with IBD or other forms of colitis. (2) Methods: Patients with diarrhea, abdominal pain, or bloody stools were consecutively enrolled at their initial visit to our hospital. Serum LRG and C-reactive protein were measured, and a colonoscopy and histology were performed. (3) Results: We enrolled 317 patients (181 men, 136 women; median age: 51 years). Based on the endoscopic and histological criteria, 260 patients were diagnosed with ulcerative colitis (n = 134), Crohn's disease (n = 10), infectious colitis (n = 43), diverticular colitis (n = 17), or nonspecific colitis (n = 56). The remaining 57 patients were diagnosed with normal colonic mucosa including histology. The latter group's median LRG value (9.5 µg/mL, range: 5.8-13.5) was significantly lower than that of the other 260 patients (13.6 µg/mL, range: 6.8-62.7, p < 0.0001). The optimal LRG cut-off value of <10.4 µg/mL was derived from the receiver operating characteristic (ROC) curve, showing a 91% sensitivity and 77% specificity for identifying patients with normal colonic mucosa. (4) Conclusions: serum LRG values < 10.4 µg/mL could be a useful biomarker for predicting patients with normal colonic mucosa.

Exploring the impact of miR-128 in inflammatory diseases: A comprehensive study on autoimmune diseases

microRNAs (miRNAs) play a crucial role in various biological processes, including immune system regulation, such as cell proliferation, tolerance (central and peripheral), and T helper cell development. Dysregulation of miRNA expression and activity can disrupt immune responses and increase susceptibility to neuroimmune disorders. Conversely, miRNAs have been shown to have a protective role in modulating immune responses and preventing autoimmunity. Specifically, reducing the expression of miRNA-128 (miR-128) in an Alzheimer's disease (AD) mouse model has been found to improve cognitive deficits and reduce neuropathology. This comprehensive review focuses on the significance of miR-128 in the pathogenesis of neuroautoimmune disorders, including multiple sclerosis (MS), AD, Parkinson's disease (PD), Huntington's disease (HD), epilepsy, as well as other immune-mediated diseases such as inflammatory bowel disease (IBD) and rheumatoid arthritis (RA). Additionally, we present compelling evidence supporting the potential use of miR-128 as a diagnostic or therapeutic biomarker for neuroimmune disorders. Collectively, the available literature suggests that targeting miR-128 could be a promising strategy to alleviate the behavioral symptoms associated with neuroimmune diseases. Furthermore, further research in this area may uncover new insights into the molecular mechanisms underlying these disorders and potentially lead to the development of novel therapeutic approaches.

Z, Shalileh S, Salemizadeh Parizi M, Vanaei S, Ghaderinia M, Abadijoo H, Taheri P, Reza Esmailinejad M, Sanati H, Reza Rostami M, Sadeghian R, Kordehlachin Y, Sadegh Mousavi‐kiasary SM, Mamdouh A, Hossein Miraghaie S, Baharvand H, Abdolahad M. Positive electrostatic therapy of metastatic tumors: selective induction of apoptosis in cancer cells by pure charges

BACKGROUND

We discovered that pure positive electrostatic charges (PECs) have an intrinsic suppressive effect on the proliferation and metabolism of invasive cancer cells (cell lines and animal models) without affecting normal tissues.

METHODS

We interacted normal and cancer cell lines and animal tumors with PECs by connecting a charged patch to cancer cells and animal tumors. many biochemical, molecular and radiological assays were carried out on PEC treated and control samples.

RESULTS

Correlative interactions between electrostatic charges and cancer cells contain critical unknown factors that influence cancer diagnosis and treatment. Different types of cell analyses prove PEC-based apoptosis induction in malignant cell lines. Flowcytometry and viability assay depict selective destructive effects of PEC on malignant breast cancer cells. Additionally, strong patterns of pyknotic apoptosis, as well as downregulation of proliferative-associated proteins (Ki67, CD31, and HIF-1α), were observed in histopathological and immunohistochemical patterns of treated mouse malignant tumors, respectively. Quantitative real-time polymerase chain reaction results demonstrate up/down-regulated apoptotic/proliferative transcriptomes (P21, P27, P53/CD34, integrin α5, vascular endothelial growth factor, and vascular endothelial growth factor receptor) in treated animal tumors. Expression of propidium iodide in confocal microscopy images of treated malignant tissues was another indication of the destructive effects of PECs on such cells. Significant tumor size reduction and prognosis improvement were seen in over 95% of treated mouse models with no adverse effects on normal tissues.

CONCLUSION

We discovered that pure positive electrostatic charges (PECs) have an intrinsic suppressive effect on the proliferation and metabolism of invasive cancer cells (cell lines and animal models) without affecting normal tissues. The findings were statistically and observationally significant when compared to radio/chemotherapy-treated mouse models. As a result, this nonionizing radiation may be used as a practical complementary approach with no discernible side effects after passing future human model studies.

Histopathology of non-IBD colitis practical recommendations from pathologists of IG-IBD Group

Pathologists are often called upon to diagnose colitides that differ from the two main forms of inflammatory bowel disease (IBD). These non-IBD colitides include infectious colitis, microscopic colitis, ischemic colitis, eosinophilic colitis, autoimmune enterocolitis, segmental colitis associated with diverticulosis, drug-induced colitis, radiation colitis and diversion colitis. The diagnosis of these different disease entities relies on the histopathological examination of endoscopic biopsies of the gastrointestinal tract. This paper reviews the main histomorphological characteristics of the various Non-IBD colitides.

Dosimetric Parameters Predicting Late Small Bowel Toxicity in Patients With Rectal Cancer Receiving Neoadjuvant Chemoradiation

PURPOSE

The aim of this study was to identify dosimetric parameters that predict late small bowel (SB) toxicity after neoadjuvant long course chemoradiation (CRT) for rectal cancer.

METHODS AND MATERIALS

Four hundred eighty-six consecutive patients with locally advanced rectal cancers (clinical T3/T4 or N1/N2) who received CRT followed by surgery and had dosimetric data available for analysis were included in this study. The dose-volume relationship between small bowel irradiation and late small bowel toxicity was evaluated and a mathematical model to predict for late SB toxicity was derived.

RESULTS

Among the 486 patients with a median follow-up of 60 months from completion of radiation, 36 (7.4%) patients experienced ≥ grade 2 and 21 (4.3%) developed ≥ grade 3 late SB toxicity. A statistically significant association between the development of grade ≥3 late small bowel toxicity and the volume of small bowel irradiated was found at each dose level from 5 to 40 Gy (P < .001 for all dose volumes) in 5 Gy intervals. The average SB volume for patients who experienced grade ≥2 SB toxicity was 2149.9 cm³ and the average SB volume for patients who experienced grade ≥3 SB toxicity was 2179.9 cm³. The predicted V30 for a 5% risk for grade ≥2 SB toxicity was 101.5 cm³ and for grade ≥3 SB toxicity was 201.5 cm³. The volume of small bowel receiving at least 30 Gy (V30) was most strongly associated with grade ≥3 SB toxicity.

CONCLUSIONS

This study demonstrates the significant dose-volume relationship between volume of small bowel receiving 30 Gy (V30 Gy) and late grade ≥3 SB toxicity. When planning CRT for patients with rectal cancer, restricting V30 to <200 cm³ will be a useful guideline to minimize the 5 year grade ≥3 late SB toxicity to <5%.

Histopathological Mimics of Inflammatory Bowel Disease

This review article discusses the challenges of making a firm histopathological diagnosis of inflammatory bowel disease (IBD) on biopsy and resection material and the importance of its distinction from a range of other inflammatory and infective conditions that may closely mimic IBD. In many cases, the diagnosis of ulcerative colitis or Crohn's disease is straightforward, especially when patients have a typical presentation and characteristic histopathological features. Knowledge of the full clinical history is very important, particularly past and recent medical history, drug history, foreign travel, or known contact with individuals with specific infection. Discussion of all cases of suspected IBD within a multidisciplinary team meeting is required to ensure that clinical, radiological, and pathological features can be correlated. Mimics of IBD can be divided into 4 categories: 1) those due to specific infection, 2) those due to a specific localized inflammatory process, 3) those due to iatrogenic causes, and 4) other rarer causes. Accurate diagnosis of IBD and exclusion of these mimics are crucial for patient management. Once a diagnosis of IBD has been proffered by a pathologist, it is very difficult to "undiagnose" the condition when an alternative diagnosis or "mimic" has been subsequently identified. The histological diagnosis of each of these IBD mimics is discussed in detail, with guidance on how to avoid the pitfall of missing these sometimes very subtle and "difficult to diagnose" conditions.

Inflammatory polyps occur more frequently in inflammatory bowel disease than other colitis patients

BACKGROUND

Colitis is generally considered a risk factor for colon neoplasia. However, not all types of colitis seem to have equal neoplastic transformation potential.

AIM

To determine the prevalence of colorectal polyps in a predominantly African American population with inflammatory bowel disease (IBD) and Non-IBD/Non-Infectious Colitis (NIC).

METHODS

We retrospectively evaluated medical records of 1060 patients previously identified with colitis at Howard University Hospital, based on ICD-10 code. Among these, 485 patients were included in the study: 70 IBD and 415 NIC based on a thorough review of colonoscopy, pathology and clinical reports. Logistic regression analysis was applied to estimate the risk of polyps in patients with IBD compared to those with NIC after adjusting for age and sex. A subgroup analysis within the IBD group was performed.

RESULTS

Of the 485 patients, 415 were NIC and 70 were IBD. Seventy-three percent of the NIC patients and 81% of the IBD patients were African Americans. Forty six percent of IBD and 41% of NIC cases were male. IBD patients were younger than NIC patients (median age of 38 years vs. 50, P < 0.001). The prevalence of all types of polyps was 15.7 and 8.2% in the IBD and NIC groups, respectively (P = 0.045). Among patients with polyps, the prevalence of inflammatory polyps was higher in the IBD group (55%) compared to the NIC group (12%). After adjusting for age, sex and race, odds ratio of inflammatory polyps in IBD patients was 6.0 (P = 0.016). Adenoma prevalence was 4.3% (3/70) in IBD patients and 3.9% (16/415) in the NIC patients (p = 0.75). The anatomic distribution of lesions and colitis shows that polyps occur predominantly in the colitis field regardless of colitis type. More polyps were present in the ulcerative colitis patients when compared to Crohn's disease patients (27% vs. 5%, P < 0.001) within the IBD group.

CONCLUSION

Our study shows that inflammatory polyps are more common in IBD patients when compared to NIC patients. Most polyps were in the same location as the colitis.

Corrupted Colonic Crypts Bordering Regenerating Mucosal Ulcers in Ulcerative Colitis

BACKGROUND/AIM

Histology in protracted ulcerative colitis (UC) discloses high numbers of chronic inflammatory cells and crypts with architectural distortions. In severe cases, ulcerations are frequently found. The histogenesis of colonic crypts with architectural distortions in UC remains elusive. A recent review of colectomy specimens from patients with UC revealed crypts surrounding mucosal ulcerations exhibiting severe architectural distortions. They were called corrupted colonic crypts, CCCs.

MATERIAL AND METHODS

Archival hematoxylin and eosin (H&E)-stained sections from three colectomies having several mucosal ulcers were selected for the study. The mucosa bordering mucosal ulcers was particularly scrutinized.

RESULTS

The review of 49 sections (mean=16.3, range=14-20) in the three colectomies revealed 60 ulcers (mean=20, range=13-27). The following CCC phenotypes were found bordering mucosal ulcers: with asymmetric lateral fission (n=11), with dual or three-foiled corrupted fission (n=19), with cystic dilatations (n=3), L-shaped crypts (n=7), T-inverted crypts (n=6), shoe-shaped crypts (n=3), horizontal crypts (n=14), multi-lobate crypts (n=2), and/or inter-connecting crypts (n=5).

CONCLUSION

The regeneration of ulcers in UC seems to proceed with neo-formation of corrupted crypts. In the same colectomies, none to occasional CCCs were found in large areas of the mucosa having severe chronic inflammation. Importantly, none of the occasional CCCs were found in other diseases of the colonic mucosa with chronic inflammation or in unspecific ulcers of the colon. Since neither chronic mucosal inflammation per se, nor unspecific ulcers of the colon are central for the formation of CCCs, it is suggested that crypt distortions of the non-ulcerated colonic mucosa in patients with UC might mirror formerly healed mucosal ulcerations.

Deviation of the Fecal Stream in Colonic Bowel Segments Results in Increased Numbers of Isolated Lymphoid Follicles in the Submucosal Compartment in a Novel Murine Model of Diversion Colitis

INTRODUCTION

Diversion colitis is a significant health problem due to its high incidence in patients with diverting enterostomy. This mucosal inflammation presents characteristic histopathological features allowing for the differentiation of this entity from other inflammatory bowel diseases. The pathophysiology of this disease remains ill-defined, in part due to the lack of appropriate animal models. The present study was performed in order to develop and characterize a murine model of diversion colitis.

METHODS

A diverting loop colostomy was performed in C57BL/6 mice either in the ascending colon or in the transverse colon. Animals were assessed for clinical and histopathological parameters during short-term and long-term survival.

RESULTS

Animals with a colostomy in the transverse colon showed a good long-term survival and developed a mild colitis in the bypassed bowel closely resembling the human pathology on a histopathological level.

CONCLUSION

This model is a promising tool to further elucidate the pathomechanism leading to impaired mucosal homeostasis in bypassed colonic segments. Moreover, the establishment of the model in the C57BL/6 background allows the combination of this colitis model with various transgenic mouse strains to investigate the effect of locally deregulated mucosal immunity on systemic immune homeostasis and to develop specific therapeutic strategies.

Involvement of Activated Cdc42 Kinase1 in Colitis and Colorectal Neoplasms

BACKGROUND Activated Cdc42 kinase1 (ACK1) is a non-receptor tyrosine kinase which is critical for cell survival, proliferation, and migration. Genomic amplification of ACK1 has been reported in multiple human cancers. We aimed to investigate ACK1 protein expression in colorectal mucosa with inflammation and neoplasm, and to evaluate its correlation with disease activity and severity. MATERIAL AND METHODS A total of 250 individuals who underwent total colonoscopy were collected randomly from January 2007 to May 2013 in Nanfang Hospital, Guangzhou, China. Colorectal mucosal biopsy specimens were obtained by endoscopy from 78 patients with ulcerative colitis (UC), 22 with Crohn's disease (CD), 20 with infectious colitis, 26 with non-IBD and noninfectious colitis, 16 with sporadic adenomas, 4 with dysplasia-associated lesions or masses, 10 with sporadic colorectal cancer (CRC), 4 with UC-related CRC, 10 with hyperplastic polyps, and 60 without colonic abnormalities. ACK1 protein levels were determined immunohistochemically. The correlations of ACK1 expression with disease activity and severity were also evaluated. RESULTS Significantly increased ACK1 expression was observed in epithelial cells of colorectal mucosa with inflammation and dysplasia compared to controls (P<0.05). ACK1 expression correlated with clinical activity in IBD (χ²=4.57, P=0.033 for UC; χ²=5.68, P=0.017 for CD), as well as grade of dysplasia in preneoplastic lesions (P<0.05). No significant differences in ACK1 expression were found between UC and CD, or between IBD and non-IBD conditions (P>0.05). CONCLUSIONS ACK1 protein is increased extensively in colitis and colorectal dysplasia. ACK1 overexpression may play a role in colorectal inflammation and neoplasms.

The First Endoscopy in Suspected Inflammatory Bowel Disease

In a patient presenting with suspected inflammatory bowel disease, the initial endoscopic evaluation is a valuable tool for determining the correct disease diagnosis and the extent and severity of disease. A full colonoscopy and ileoscopy should be performed when possible, with systematic biopsies from each segment. When a diagnosis of inflammatory bowel disease is established, it is possible to distinguish between Crohn disease and ulcerative colitis, and specific endoscopic features may assist in this categorization. Because patchy healing can occur with treatment, it is important to obtain a thorough and accurate assessment of disease characteristics and distribution before initiating therapy.

Iatrogenic pathology of the intestines

Many drugs and chemical agents can cause enteritis and colitis, producing clinical gastrointestinal side effects, the most common of which are diarrhoea, constipation, nausea and vomiting. Significant histological overlap exists between some patterns of medication or chemical injury and various disease entities. A particular medication may cause multiple patterns of injury and may mimic common entities such as coeliac disease, Crohn's disease, infectious enteritis and colitis. Thus, given the common absence of specific histopathological features, the diagnosis often relies upon thorough clinicopathological correlation. This review concentrates on selected examples of medication-induced injury of the intestinal tract in which the pathology can be recognized, particularly on biopsies, with a focus on newly described medication-induced gastrointestinal effects.

Pathogenesis, diagnosis, and management of ulcerative proctitis, chronic radiation proctopathy, and diversion proctitis

Chronic proctitis refers to persistent or relapsing inflammation of the rectum, which results from a wide range of etiologies with various pathogenic mechanisms. The patients may share similar clinical presentations. Ulcerative proctitis, chronic radiation proctitis or proctopathy, and diversion proctitis are the 3 most common forms of chronic proctitis. Although the diagnosis of these disease entities may be straightforward in the most instances based on the clinical history, endoscopic, and histologic features, differential diagnosis may sometimes become problematic, especially when their etiologies and the disease processes overlap. The treatment for the 3 forms of chronic proctitis is different, which may shed some lights on their pathogenetic pathway. This article provides an overview of the latest data on the clinical features, etiologies, diagnosis, and management of ulcerative proctitis, chronic radiation proctopathy, and diversion proctitis.

Therapeutic inhibition of prolyl hydroxylase domain-containing enzymes in surgery: putative applications and challenges

Oxygen is essential for metazoans to generate energy. Upon oxygen deprivation adaptive and protective pathways are induced, mediated by hypoxia-inducible factors (HIFs) and prolyl hydroxylase domain-containing enzymes (PHDs). Both play a pivotal role in various conditions associated with prolonged ischemia and inflammation, and are promising targets for therapeutic intervention. This review focuses on aspects of therapeutic PHD modulation in surgically relevant disease conditions such as hepatic and intestinal disorders, wound healing, innate immune responses, and tumorigenesis, and discusses the therapeutic potential and challenges of PHD inhibition in surgical patients.

Management of the elderly patients with inflammatory bowel disease: practical considerations

The aging U.S. population will approach 20% of the total population by 2030. The number of older patients with inflammatory bowel disease is anticipated to increase accordingly bringing the burden of multiple comorbidities, polypharmacy with drug interactions, the aging immune system, and extended social and financial issues to overall management of an already challenging management of these patients. Each of these concerns is measured by the metric of distinguishing the "fit versus frail" elderly and will be discussed in this review with an emphasis on a practical guide to therapy.

MicroRNAs in inflammatory bowel disease - pathogenesis, diagnostics and therapeutics

The pathogenesis of inflammatory bowel disease (IBD) is complex and largely unknown. Until recently, research has focused on the study of protein regulators in inflammation to reveal the cellular and molecular networks in the pathogenesis of IBD. However, in the last few years, new and promising insights have been generated from studies describing an association between an altered expression of a specific class of non-coding RNAs, called microRNAs (miRs or miRNAs) and IBD. The short (approximately 22 nucleotides), endogenous, single-stranded RNAs are evolutionary conserved in animals and plants, and regulate specific target mRNAs at the post-transcriptional level. MiRNAs are involved in several biological processes, including development, cell differentiation, proliferation and apoptosis. Furthermore, it is estimated that miRNAs may be responsible for regulating the expression of nearly one-third of the genes in the human genome. Thus, miRNA deregulation often results in an impaired cellular function, and a disturbance of downstream gene regulation and signaling cascades, suggesting their implication in disease etiology. Despite the identification of more than 1900 mature human miRNAs, very little is known about their biological functions and functional targets. Recent studies have identified dysregulated miRNAs in tissue samples of IBD patients and have demonstrated similar differences in circulating miRNAs in the serum of IBD patients. Thus, there is great promise that miRNAs will aid in the early diagnosis of IBD, and in the development of personalized therapies. Here, we provide a short review of the current state-of-the-art of miRNAs in IBD pathogenesis, diagnostics and therapeutics.

Colorectal normal histology and histopathologic findings in patients with chronic diarrhea

Collagenous and lymphocytic colitis are common causes of chronic watery diarrhea that are characterized by distinct histopathologic abnormalities without endoscopically visible lesions and are summarized as microscopic colitis. Several variants of microscopic colitis have been described, although their clinical significance still has to be defined. Preserved mucosal architecture is a histologic hallmark of microscopic colitis and distinguishes the disease from inflammatory bowel disease (IBD). In addition to architectural abnormalities, the diagnosis of IBD rests on characteristic inflammatory changes. Differential diagnosis of IBD mainly includes prolonged infection and diverticular disease-associated colitis, also known as segmental colitis associated with diverticulosis.

Biopsy interpretation of colonic biopsies when inflammatory bowel disease is excluded

The interpretation of colonic biopsies related to inflammatory conditions can be challenging because the colorectal mucosa has a limited repertoire of morphologic responses to various injurious agents. Only few processes have specific diagnostic features, and many of the various histological patterns reflect severity and duration of the disease. Importantly the correlation with endoscopic and clinical information is often cardinal to arrive at a specific diagnosis in many cases.

Ulcerative colitis of the neovagina as a postsurgical complication of persistent cloaca

Persistent cloaca is characterized by a common vestibule connected to the bladder, uterus, and rectum and a single perineal orifice to the exterior. Treatment can involve vaginal reconstruction with sigmoid/descending colon. We report a case of an 8-year-old girl who, as an infant, underwent vaginoplasty using sigmoid colon for persistent cloaca and developed a fulminant colitis that also affected the colonic neovagina 2 years after her reconstruction.

Organic colonic lesions in 3,332 patients with suspected irritable bowel syndrome and lacking warning signs, a retrospective case--control study

PURPOSE

The diagnosis of irritable bowel syndrome is symptom based, and colonoscopy is the most direct way to rule out organic colonic diseases. It is controversial on the necessity of colonoscopy for patients with suspected irritable bowel syndrome and lacking alarm features. This study was designed to verify the organic lesions and discuss the value of colonoscopy in this type of patients.

METHODS

Colonoscopy of 3,332 patients with suspected irritable bowel syndrome and lacking warning signs from 2000 to 2009 were reviewed. One thousand five hundred eighty-eight patients under 50 years of age who underwent colonoscopy screening for health care in the same period were used as controls. The prevalence of different colonic organic lesions was compared between two groups.

RESULTS

Organic colonic lesions were found in 30.3% of the patients with suspected irritable bowel syndrome (1,010/3,332) and 39.0% of the controls (619/1,588). Compared with controls, patients with suspected irritable bowel syndrome had higher prevalence of noninflammatory bowel disease and noninfectious colitis and terminal ileitis, however, had lower prevalence of diverticular disease, adenomatous polyps, and non-adenomatous polyps (all P < 0.001).

CONCLUSIONS

The diagnostic sensitivity of symptom criteria on irritable bowel syndrome without colonoscopy is not more than 69.7% in patients with suspected irritable bowel syndrome lacking warning signs. Though the method of colonoscopy is hard to screen tumor in this type of patients, it is beneficial to uncover some other relevant organic lesions such as terminal ileitis. Colonoscopy should not be refused to suspected irritable bowel syndrome patients without warning signs.

The spectrum of drug-related colitides: important entities, though frequently overlooked

BACKGROUND

There is at present a relative lack of knowledge concerning drug-related colitides, although these may be not infrequent entities in clinical practice.

AIMS

To assess the frequency and the clinical-pathological subtypes of drug-related colitides in a gastrointestinal pathology referral centre.

METHODS

All charts of endoscopic biopsy samples referred for colitis in a eight-year period were reviewed. To be classified as drug related colitis, patients' charts should report the use of any drug in a two month period before colonoscopy and no other obvious cases of colitis be present. For analysis, we considered only patients taking one drug in this period.

RESULTS

We found 122 cases of drug-related colitis out of 3877 charts reviewed (3% of the overall colitis group). These cases were represented by microscopic colitis (50%), eosinophil rich infiltrate of the left colon (34%), ischemic colitis (11%), pseudomembranous colitis (3%), apoptotic colopathy (2%). The drugs most frequently associated with these colitides were represented by non-steroidal anti-inflammatory drugs.

CONCLUSION

It is important to raise awareness concerning drug-related colitides, to avoid diagnostic errors and provide a better therapeutic approach to patients with these conditions.

L-arginine and glycine supplementation in the repair of the irradiated colonic wall of rats

PURPOSE

Radiotherapy is widely used for cancer treatment but has harmful effects. This study aimed to assess the effects of L-arginine and glycine supplementation on the colon wall of rats submitted to abdominal irradiation.

METHODS

Forty male Wistar rats were randomly divided into four groups: I-healthy, II-irradiated with no amino acid supplementation, III-irradiated and supplemented with L-arginine, and IV-irradiated and supplemented with glycine. The animals received supplementation for 14 days, with irradiation being applied on the eighth day of the experiment. All animals underwent laparotomy on the 15th day for resection of a colonic segment for stereologic analysis. Parametric and nonparametric tests were used for statistical analysis, with the level of significance set at p ≤0.05.

RESULTS

Stereologic analysis showed that irradiation induced a reduction of the total volume of the colon wall of group II and III animals compared to healthy controls, but not of group IV animals supplemented with glycine. The mucosal layer of the irradiated animals of all groups was reduced compared to healthy group I animals, but supplementation with L-arginine and glycine was effective in maintaining the epithelial surface of the mucosal layer.

CONCLUSION

The present results suggest that glycine supplementation had a superior effect on the irradiated colon wall compared to L-arginine supplementation since it was able to maintain the thickness of the wall and the epithelial surface of the mucosa, whereas L-arginine maintained the partial volume of the epithelium and the epithelial surface, but not the total volume of the intestinal wall.

[When only the pathologist may help. Limitation and possibilities of biopsies in Internal Medicine]

Histological evaluation after biopsy remains the gold standard for the diagnosis of numerous diseases in Internal Medicine. The gastrointestinal tract (e. g. esophagus, liver and large intestine), the kidneys or bone marrow are organs, where biopsy-driven diagnosis and evaluation of therapeutic regimens are of major relevance. Improvement in blood analysis, endoscopic techniques and radiology could significantly reduce the number of biopsies. Hence under certain circumstances, the risk of biopsy can be avoided and non-invasive markers can sufficiently substitute the histological evaluation. However, histological evaluation derived from biopsies remains the standard of diagnosis in many cases in Internal Medicine. In the present review the current standards and future developments of pathologic diagnosis through biopsy are illustrated.

Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee

Guidelines for clinical practice are aimed to indicate preferred approaches to medical problems as established by scientifically valid research. Double-blind placebo controlled studies are preferable, but compassionate-use reports and expert review articles are used in a thorough review of the literature conducted through Medline with the National Library of Medicine. When only data that will not withstand objective scrutiny are available, a recommendation is identified as a consensus of experts. Guidelines are applicable to all physicians who address the subject regardless of specialty training or interests and are aimed to indicate the preferable but not necessarily the only acceptable approach to a specific problem. Guidelines are intended to be flexible and must be distinguished from standards of care, which are inflexible and rarely violated. Given the wide range of specifics in any health-care problem, the physician must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. Guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the board of trustees. Each has been intensely reviewed and revised by the Committee, other experts in the field, physicians who will use them, and specialists in the science of decision analysis. The recommendations of each guideline are therefore considered valid at the time of composition based on the data available. New developments in medical research and practice pertinent to each guideline will be reviewed at a time established and indicated at publication to assure continued validity. The recommendations made are based on the level of evidence found. Grade A recommendations imply that there is consistent level 1 evidence (randomized controlled trials), grade B indicates that the evidence would be level 2 or 3, which are cohort studies or case-control studies. Grade C recommendations are based on level 4 studies, meaning case series or poor-quality cohort studies, and grade D recommendations are based on level 5 evidence, meaning expert opinion.

Extraintestinal manifestations of inflammatory bowel disease: epidemiology, diagnosis, and management

Abstract Extraintestinal manifestations occur rather frequently in inflammatory bowel disease (IBD), e.g. ulcerative colitis (UC) and Crohn's disease (CD). The present paper provides an overview of the epidemiology, clinical characteristics, diagnostic process, and management of rheumatic, metabolic, dermatologic (mucocutaneous), ophthalmologic, hepatobiliary, hematologic, thromboembolic, urinary tract, pulmonary, and pancreatic extraintestinal manifestations related to IBD. Articles were identified through search of the PubMed and Embase databases, the Cochrane Library, and the web sites of the European Agency for the Evaluation of Medicinal Products (EMEA) and the US Food and Drug Administration (FDA) (cut-off date October 2009). The search terms 'Crohn's disease', 'inflammatory bowel disease', or 'ulcerative colitis' were combined with the terms 'adalimumab', 'anemia', 'arthritis', 'bronchiectasis', 'bronchitis', 'cutaneous manifestations', 'erythema nodosum', 'extraintestinal manifestations', 'hyperhomocysteinemia', 'infliximab', 'iridocyclitis', 'lung disease', 'ocular manifestations', 'osteomalacia', 'pancreatitis', 'primary sclerosing cholangitis', 'renal stones', 'sulfasalazine', 'thromboembolism', and 'treatment'. The search was performed on English-language reviews, practical guidelines, letters, and editorials. Articles were selected based on their relevance, and additional papers were retrieved from their reference lists. Since some of the diseases discussed are uncommon, valid evidence of treatment was difficult to obtain, and epidemiologic data on the rarer forms of extraintestinal manifestations are scarce. However, updates on the pathophysiology and treatment regimens are given for each of these disorders. This paper offers a current review of original research papers and randomized clinical trials, if any, within the field and makes an attempt to point out practical guidelines for the diagnosis and treatment of various extraintestinal manifestations related to IBD.

Rifaximin in the management of colonic diverticular disease

Rifaximin is a rifamycin derivative that acts by inhibiting bacterial RNA synthesis. Since it is virtually unabsorbed after oral administration, its bioavailability within the GI tract is high, with intraluminal and fecal drug concentrations largely exceeding the minimum inhibitory concentration values observed in vitro against a broad spectrum of bacteria, including Gram-positive and Gram-negative bacteria, both aerobes and anaerobes. The GI tract, therefore, represents the primary therapeutic target and the disorders in which intestinal bacteria have a pathogenic role represent the main indication. This is the case with colonic diverticular disease. As a consequence, the broad antibacterial activity of rifaximin appears to be of value in the treatment of this clinical condition. Clinical trials have provided evidence of the substantial benefit of rifaximin in diverticular disease. Indeed, available data show the efficacy of the drug in achieving symptomatic relief in patients with uncomplicated disease. A therapeutic gain of approximately 30%, compared with fiber supplementation only, can be expected after cyclic administration of rifaximin for 12 months. However, its value in the prevention of inflammatory complications of the disease needs to be further explored. Recent studies have shown some evidence of synergy between rifaximin and mesalazine and suggest that a combined treatment could be worthwhile in selected subsets of patients with diverticular disease.

Inflammatory bowel disease in the elderly

This article reviews the epidemiology, clinical manifestations, diagnosis, prognosis, and treatment of inflammatory bowel disease (IBD), which will grow in prevalence as the population ages. Prognosis of late-onset ulcerative colitis (UC) is generally similar to that of early-onset UC, whereas in Crohn disease it is probably better because of a tendency for colonic involvement. Disease complications are related more to the duration of the inflammatory bowel disease than the subject's current age. The diagnosis in elderly patients can be challenging due to the large number of conditions that mimic IBD on radiologic, endoscopic, and histologic testing. Distinguishing these conditions from IBD will significantly alter prognosis and treatment. Complications related to IBD and its treatment are common and must be recognized early to limit their impact in a vulnerable elderly population.

Diagnosis of ulcerative colitis before onset of inflammation by multivariate modeling of genome-wide gene expression data

BACKGROUND

Endoscopically obtained mucosal biopsies play an important role in the differential diagnosis between ulcerative colitis (UC) and Crohn's disease (CD), but in some cases where neither macroscopic nor microscopic signs of inflammation are present the biopsies provide only inconclusive information. Previous studies indicate that CD cannot be diagnosed by molecular and histological diagnostic tools using colonic biopsies without microscopic signs of inflammation, but it is unknown if this is also the case for UC.

METHODS

The aim of the present study was to apply multivariate modeling of genome-wide gene expression to investigate if a diagnosable preinflammatory state exists in biopsies of noninflamed UC colon, and to exploit such information to build a diagnostic tool.

RESULTS

Genome-wide gene expression data were obtained from control subjects and UC and CD patients. In total, 89 biopsies from 78 patients were included. A diagnostic model was derived with the random forest method based on 71 biopsies from 60 patients. The model-internal out-of-bag performance measure yielded perfect classification. Furthermore, the model was validated in independent 18 noninflamed biopsies from 18 patients (7 UC, 7 CD, 4 control) where the model achieved 100% sensitivity (95% confidence limits: 60.0-100) and 100% specificity (95% confidence limits: 71.5-100).

CONCLUSIONS

The present study demonstrates a preinflammatory state in patients diagnosed with UC. In addition, we demonstrate the usefulness of random forest modeling of genome-wide gene expression data for distinguishing quiescent and active UC colonic mucosa versus control and CD colonic mucosa.

Colonic left-side increase of eosinophils: a clue to drug-related colitis in adults

BACKGROUND

The colon shows frequent eosinophilic infiltration in allergic proctocolitis of infants, whereas in adults, eosinophilic infiltration of the colon is less defined and may be found in different conditions including drug-induced colitis, even though the pathological findings are often inconsistent.

AIM

To quantify eosinophils in the mucosa of normal controls and to compare them with those of patients with abdominal symptoms related to 'drug colitis'.

METHODS

Mucosal biopsies were obtained during colonoscopy in 15 controls and in 27 patients with abdominal symptoms, a history of probable 'drug-related colitis' and without obvious causes of eosinophilia.

RESULTS

The drugs related to the patient symptoms were nonsteroidal anti-inflammatory drugs (70%), antiplatelet agents (19%) and oestroprogestinic agents (11%). Colonoscopy was normal in 30% of patients and abnormal in 70%. Histology showed low content of inflammatory cells and normal crypt architecture in-patients with endoscopy similar to inflammatory bowel diseases. The eosinophil score was significantly higher in the left side of the colon in the patient group compared with controls.

CONCLUSIONS

The finding of an increased eosinophil count limited to the left (descending and sigmoid) colon is an important clue towards a diagnosis of drug-related colitis.

How to treat diversion colitis?--Current state of medical knowledge, own research and experience

The aim of this study was to present current knowledge about a nospecific inflammation of mucosa within segments of colon excluded from normal bowel passage called as a "diversion colitis" (DC) and to try to determine the role of factors which might modify the clinical course of DC. We also unswered the question; how to treat DC: conservatively or surgically? Our own experience with DC concerns 145 patents (which is most numerous and well exactly examined series presented in literature). In the group of patients studied, clinical signs of DC were present in over 70% of patients (early signs were low abdominal pain and tenesmus, while anal oozing appeared later). Predominating endoscopic features of DC in the group of patients studied were: a. blurring of vascular pattern (in app. 90% of patients); b. contact bleeding (in app. 80% of patients); c. mucosal oedema (in app. 60% of patients). Results of own observations and literature data indicate, that morphologic alterations in the segment of bowel excluded from normal passage are probably vasogenic consisting in atrophy and inflammation of the allergic type (this would confirm the theory about vascular etiology of DC). In our material, we have not noticed any trend toward hyperproliferation or dysplasia in the excluded segment of colon, supporting the thesis that these disturbances are largely reversible. Clinical pathology of DC does not depend on age, sex, cause and type of surgical procedure performed, mode of surgery or concomitant diseases. Authors suggested an alternative algorithm of diagnostic work-up in patients suspected of DC, and proposed that patients with a segment of bowel excluded from normal passage be subdivided into three groups: 1. Patients with no clinical, endoscopic nor morphologic signs of DC. 2. Patients with moderate signs of DC. 3. Patients with severe signs of DC. Patients in the group 1 should remain under continuous specialised supervision, because they are at risk of developing DC, while patients in the groups 2 and 3 should undergo surgical restoration of bowel continuity. This applies particularly to group 3, where indications for surgery do not stem from risk of hyperproliferation, dysplasia or malignant transformation, but from that of a massive inflammation, which may constitute a danger for patientis health and even life. Authors also underline that DC can be treated conservatively but the best and most successful and remained method of treatment of DC is the operation of decolostomy, which means restoration continuity of digestive tract.

A case of fulminant diversion pan-colitis presenting 19 years after colonic diversion for neuronal intestinal dysplasia

A 20-year old woman with a long history of abdominal symptoms presented with acute abdominal pain associated with nausea and vomiting. She had had a right iliac fossa end-ileostomy previously fashioned at the age of 11 months for neuronal intestinal dysplasia. A few days after her admission she suffered a hypokalaemic cardiac arrest from which she was resuscitated. Her clinical condition deteriorated as she became increasingly septic. She was diagnosed with a fulminant colitis based on the clinical picture and the finding of fluid filled, thick walled rectum suggestive of proctocolitis on a pelvic magnetic resonance imaging scan. She was taken to the operating theatre where she had a subtotal colectomy. The histopathological diagnosis was that of fulminant diversion colitis. The patient recovered from surgery and was discharged home 5 weeks later.

Recent advances in the management of radiation colitis

Radiation colitis, an insidious, progressive disease of increasing frequency, develops 6 mo to 5 years after regional radiotherapy for malignancy, owing to the deleterious effects of the latter on the colon and the small intestine. When dealing with radiation colitis and its complications, the most conservative modality should be employed because the areas of intestinal injury do not tend to heal. Acute radiation colitis is mostly self-limited, and usually, only supportive management is required. Chronic radiation colitis, a poorly predictable progressive disease, is considered as a precancerous lesion; radiation-associated malignancy has a tendency to be diagnosed at an advanced stage and to bear a dismal prognosis. Therefore, management of chronic radiation colitis remains a major challenge owing to the progressive evolution of the disease, including development of fibrosis, endarteritis, edema, fragility, perforation, partial obstruction, and cancer. Patients are commonly managed conservatively. Surgical intervention is difficult to perform because of the extension of fibrosis and alterations in the gut and mesentery, and should be reserved for intestinal obstruction, perforation, fistulas, and severe bleeding. Owing to the difficulty in managing the complications of acute and chronic radiation colitis, particular attention should be focused onto the prevention strategies. Uncovering the fibrosis mechanisms and the molecular events underlying radiation bowel disease could lead to the introduction of new therapeutic and/or preventive approaches. A variety of novel, mostly experimental, agents have been used mainly as a prophylaxis, and improvements have been made in radiotherapy delivery, including techniques to reduce the amount of exposed intestine in the radiation field, as a critical strategy for prevention.

Lymphocytic, collagenous and other microscopic colitides: pathology and the relationship with idiopathic inflammatory bowel diseases

SUMMARY

Collagenous colitis and lymphocytic colitis are the two major conditions characterized by chronic watery diarrhoea, without endoscopic or radiological lesions, but with histological abnormalities and therefore considered as "microscopic colitis". The histology of colonic biopsies shows inflammation of the mucosa, and either thickening of the subepithelial collagen band or an increase of lymphocytes in the surface epithelium. Different variant forms have been reported under separate names. These are probably not specific entities. The incidence of microscopic colitis is slightly less than the incidence of chronic idiopathic inflammatory bowel diseases (IBD). Microscopic colitis and IBD are clearly different entities. The relation between both entities is weak but double. Biopsy samples from patients with IBD may mimic the features of lymphocytic or collagenous colitis, both in the initial onset and during follow-up. In the large majority of these cases, endoscopy shows or has shown mucosal lesions. In rare cases, however, a double diagnosis was made. Certain patients, usually of older age, presented first with a microscopic, usually collagenous colitis and developed subsequently genuine ulcerative colitis.