Long term metabolic consequences of ileal pouch-anal anastomosis for ulcerative colitis

Hepatobiliary manifestations following two-stages elective laparoscopic restorative proctocolectomy for patients with ulcerative colitis: A prospective observational study

BACKGROUND

Hepatobiliary manifestations occur in ulcerative colitis (UC) patients. The effect of laparoscopic restorative proctocolectomy (LRP) with ileal pouch anal anastomosis (IPAA) on hepatobiliary manifestations is debated.

AIM

To evaluate hepatobiliary changes after two-stages elective laparoscopic restorative proctocolectomy for patients with UC.

METHODS

Between June 2013 and June 2018, 167 patients with hepatobiliary symptoms underwent two-stage elective LRP for UC in a prospective observational study. Patients with UC and having at least one hepatobiliary manifestation who underwent LRP with IPAA were included in the study. The patients were followed up for four years to assess the outcomes of hepatobiliary manifestations.

RESULTS

The patients' mean age was 36 ± 8 years, and males predominated (67.1%). The most common hepatobiliary diagnostic method was liver biopsy (85.6%), followed by Magnetic resonance cholangiopancreatography (63.5%), Antineutrophil cytoplasmic antibodies (62.5%), abdominal ultrasonography (35.9%), and Endoscopic retrograde cholangiopancreatography (6%). The most common hepatobiliary symptom was Primary sclerosing cholangitis (PSC) (62.3%), followed by fatty liver (16.8%) and gallbladder stone (10.2%). 66.4% of patients showed a stable course after surgery. Progressive or regressive courses occurred in 16.8% of each. Mortality was 6%, and recurrence or progression of symptoms required surgery for 15%. Most PSC patients (87.5%) had a stable course, and only 12.5% became worse. Two-thirds (64.3%) of fatty liver patients showed a regressive course, while one-third (35.7%) showed a stable course. Survival rates were 98.8%, 97%, 95.8%, and 94% at 12 mo, 24 mo, 36 mo, and at the end of the follow-up.

CONCLUSION

In patients with UC who had LRP, there is a positive impact on hepatobiliary disease. It caused an improvement in PSC and fatty liver disease. The most prevalent unchanged course was PSC, while the most common improvement was fatty liver disease.

Intake of Lutein and Zeaxanthin as a Possible Factor Influencing Gastrointestinal Symptoms in Caucasian Individuals with Ulcerative Colitis in Remission Phase

The vitamin A deficiencies are commonly observed in the case of ulcerative colitis individuals. The decreased antioxidant defence may influence the intestine, inducing higher susceptibility to oxidative damage of tissues and altering the symptoms and course of disease. Intestinal symptoms, ranging from diarrhea to constipation, occur more commonly in remission ulcerative colitis individuals than in general population. The aim of the study was to analyze the association between retinoid intake and gastrointestinal symptoms in Caucasian individuals in the remission phase of ulcerative colitis. Reitnoid (total vitamin A, retinol, β-carotene, α-carotene, β-cryptoxanthin, lycopene, as well as lutein and zeaxanthin) intakes were analyzed on the basis of three-day dietary records. Gastrointestinal symptoms (daily number of bowel movements, and the presence of painful tenesmus, flatulence, and constipation) were self-reported. The study was conducted in a group of 56 ulcerative colitis remission individuals, stratified by the gastrointestinal symptoms. One in every seven individuals reported recurring constipation. Higher intake of lutein and zeaxanthin (median 1386.2 µg, 289.0–13221.3 µg vs. median 639.0 µg, 432.7–1309.0 µg) may lower the incidence of constipation (p = 0.013). The intake of retinoids other than lutein and zeaxanthin was not associated with the incidence of constipation or other gastrointestinal symptoms.

Lycopene, Lutein and Zeaxanthin May Reduce Faecal Blood, Mucus and Pus but not Abdominal Pain in Individuals with Ulcerative Colitis

BACKGROUND

The main symptom of ulcerative colitis is diarrhoea, which is often accompanied by painful tenesmus and faecal blood and mucus. It sometimes co-occurs with abdominal pain, fever, feeling of fatigue, loss of appetite and weight loss. Some dietary factors have been indicated as important in the treatment of ulcerative colitis. The aim of the study was to analyse the association between retinoid intake (total vitamin A, retinol, β-carotene, α-carotene, β-cryptoxanthin, lycopene, lutein and zeaxanthin) and ulcerative colitis symptoms (abdominal pain, faecal blood, faecal mucus, faecal pus) in individuals with ulcerative colitis in remission.

METHODS

Assessment of diet was based on self-reported data from each patient's dietary records taken over a period of three typical, random days (2 weekdays and 1 day of the weekend).

RESULTS

A total of 56 individuals with ulcerative colitis in remission (19 males and 37 females) were recruited for the study. One in every four individuals with ulcerative colitis in remission was characterised as having inadequate vitamin A intake. Higher lycopene, lutein and zeaxanthin intakes in individuals with ulcerative colitis in remission were associated with lower faecal blood, mucus and pus but not with lower incidence of abdominal pain. Higher carotene intake in individuals with ulcerative colitis in remission may contribute to higher incidence of faecal mucus.

CONCLUSIONS

Optimising intake of specific retinoids may enhance disease control in individuals with ulcerative colitis. Prospective studies, including patient reported and objective outcomes, are required to confirm this.

Eosinophilic Enteritis in Horses with Motor Neuron Disease

BACKGROUND

Equine motor neuron disease (EMND) is a neuromuscular disorder that affects adult horses. Although EMND has been linked to vitamin E deficiency, its etiopathogenesis is poorly understood.

OBJECTIVES

To describe clinical features, laboratory results, and postmortem findings in a series of young horses with motor neuron disease (MND).

ANIMALS

A herd of 15 young Andalusian horses with weakness, weight loss, muscle atrophy, and muscle fasciculations related to restricted intake of green forage.

METHODS

A case series is presented in which horses were subjected to a clinical examination and plasma vitamin E measurement. Five severely affected horses were euthanized for detailed postmortem examination. Muscle specimens were taken from the M. sacrocaudalis dorsalis medialis and the M. gluteus medius for histopathologic and morphometric evaluation.

RESULTS

MND was diagnosed in 5 horses based on clinical signs, low serum levels of vitamin E (0.11 ± 0.05 mg/dL; normal range,: 0.3-1.5 mg/dL), changes in muscle histopathology (neurogenic atrophy), and spinal cord lesions (neuronal chromatolysis in ventral horns). An unexpected postmortem finding was the presence of intestinal inflammation (catarrhal enteritis, edema, and eosinophilic infiltrate) associated with the presence of giant ciliated protozoa in all of the horses.

CONCLUSIONS

Although a mechanistic link could not be established, it is hypothesized that intestinal inflammation may have been involved in the decreased absorption of vitamin E, thus favoring the development of MND.

The presence of primary sclerosing cholangitis in patients with ileal pouch anal- anastomosis is associated with an additional risk for vitamin D deficiency

Objective: Vitamin D deficiency is common in patients with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). Whether vitamin D levels are further lowered in patients with concomitant IPAA and primary sclerosing cholangitis (PSC) is not known. The aim of this study was to evaluate the presence of PSC as a risk factor for vitamin D deficiency in patients with UC and IPAA.

Methods: In this case control study, 74 patients with concurrent IPAA and PSC were included in the study group, and 79 patients with IPAA, but without PSC, served as controls. Forty-four variables were analyzed. Univariate analysis and multivariate analysis with stepwise logistic regression were performed.

Results: A total 153 eligible patients were included, with 74 (48.4%) in the study group and 79 (51.6%) in the control group. Vitamin D level in the study group was 18.9 ± 1.4 ng/dL compared with 30.3 ± 1.7 ng/d in the control group (P = 0.011). Vitamin D deficiency (≤ 20 ng/dL) was present in 65 (42.5%) patients. PSC occurred in 49 (75.4%) of the 65 patients with vitamin D deficiency. In the multivariate analysis, only the presence of PSC (odds ratio [OR]: 7.56; 95% confidence interval [CI]: 2.39–24.08; P = 0.001) and vitamin D supplementation (OR: 2.58; 95% CI: 1.57–9.19; P = 0.018) remained associated with vitamin D deficiency.

Conclusion: The presence of PSC was found to be an independent risk factor for vitamin D deficiency in UC patients with IPAA. These patients should be routinely screened and closely monitored for vitamin D deficiency.

Diagnosis and management of pouchitis and ileoanal pouch dysfunction

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the surgical treatment of choice for patients with medically refractory ulcerative colitis (UC) or UC with dysplasia and for the majority of patients with familial adenomatous polyposis. However, UC patients with IPAA are susceptible to inflammatory and noninflammatory sequelae, such as pouchitis, Crohn's disease of the pouch, cuffitis, and irritable pouch syndrome, in addition to common surgery-associated complications, which adversely affect the surgical outcome and compromise health-related quality of life. Pouchitis is the most frequent long-term complication of IPAA in patients with UC, with a cumulative prevalence of up to 50%. Pouchitis may be classified based on the etiology into idiopathic and secondary types, and the management is often different. Pouchoscopy is the most important tool for the diagnosis and differential diagnosis in patients with pouch dysfunction. Antibiotic therapy is the mainstay of treatment for active pouchitis. Some patients may develop dependency on antibiotics, requiring long-term maintenance therapy. Although management of antibiotic-dependent or antibiotic-refractory pouchitis has been challenging, secondary etiology for pouchitis should be evaluated and modified, if possible.

Serum nutrients and habitual dietary intake in colectomized FAP patients in Norway

BACKGROUND

Patients with familial adenomatous polyposis (FAP) are colectomized in young age in order to avoid development of colorectal cancer. Because colectomy radically changes gastrointestinal physiology, and food avoidance may be present, colectomized patients may be at risk for nutritional deficiency.

AIM OF THE STUDY

to evaluate: (1) serum biochemical levels as compared to reference; (2) dietary intake as compared to the recommendations.

METHODS

Blood samples, interviews and food frequency questionnaire were collected from 38 colectomized FAP patients with duodenal adenomas (mean age 40 years, range: 24-70). They were recruited from the Norwegian database on FAP.

RESULTS

Serum albumin was significantly higher (P < or = 0.0001), and Mg (P = 0.02), ferritin (P < or = 0.001), and cholesterol (P = 0.03) significantly lower, than reference levels. Compared to recommendations, a low intake was seen for folate and fiber (<50%), iron, thiamin, riboflavin (< 25%), and omega-3 fatty acids (8%). Sugar intake exceeded the recommendation, mainly due to a high intake of soft drinks. Food avoidance was reported by 53%.

CONCLUSIONS

We would suggest that the nutrient intake among FAP patients should at least meet the recommendations for healthy subjects. Their risk of metachronous cancers should also cause special attention to dietary factors that may prevent nutritional deficiency and carcinogenesis.

Vitamin B12 deficiency following restorative proctocolectomy

OBJECTIVE

Restorative proctocolectomy (RP) involves terminal ileal resection and formation of a small bowel reservoir that predisposes to bacterial overgrowth. It was anticipated that these patients would be at risk of vitamin B12 deficiency.

METHOD

Vitamin B12 levels were measured sequentially in 171 patients who underwent RP. Prospective results were obtained from all 20 patients undergoing pouch formation after the commencement of the study. Further results were obtained retrospectively from case notes and computerized laboratory records of the 151 patients who underwent RP prior to the commencement of the study and these were correlated with the results of follow-up samples taken prospectively from the same patients after the commencement of the study. The median age of the patients was 40 years (range: 13-67) and the median duration of follow up was 5.4 years (range: 1-12). Patients with an abnormally low serum B12 level underwent both a Schilling and a hydrogen breath test. Eight of these patients were then treated with oral vitamin B12.

RESULTS

Abnormally low serum B12 levels were found in 25% of patients. Forty per cent of our patient group had three or more sequential B12 measurements and of these, 66% showed steadily declining B12 levels. Ninety-four per cent of patients with low B12 had a normal Schilling test and were negative for bacterial overgrowth.

CONCLUSION

Subnormal vitamin B12 levels develop in almost one-quarter of patients after pouch surgery. The exact mechanism for B12 deficiency in these patients is uncertain. In the majority of patients undergoing RP, vitamin B12 levels fall on sequential measurement. Serum B12 levels should be measured during follow up and pouch patients with subnormal B12 levels, should see them successfully restored to a normal value after treatment with oral B12 replacement therapy.

Serum biochemical evaluation of patients with functional pouches ten to 20 years after restorative proctocolectomy

BACKGROUND

Restorative proctocolectomy with an ileal pouch-anal anastomosis is a surgical treatment of choice for ulcerative colitis and familial adenomatous polyposis (FAP). Pouchitis is a significant enigmatic morbidity. In the long-term, these patients, we anticipated, would experience biochemical profiling alterations after years of retaining functionally acceptable pouches. This pilot study was aimed at assessing results of essential biochemical variables more than 10 years after surgery.

METHODS

The investigation was carried out in 91 patients; 39 were women. Eight-eight had ulcerative colitis, while three had FAPs. The hand-sewn ileal reservoirs after mucoso-proctocolectomy were 66 S and 25 J. The analyses were compared short-term vs long-term. Patients were investigated and were their own control.

RESULTS

Long-term, incidence of acute and chronic pouchitis was 2 and 13%. Eleven and 4% of patients had hypomagnesaemia and hypocalcaemia. Mean levels were significantly enhanced (p<0.01 and p<0.0002). Hypomagnesaemia corresponded to episodes of pouchitis and was corrected with oral magnesium and antibiotics. Hypoferric anaemia was diagnosed in 7% and treated with oral iron tablets. Chronic pouchitis and recurrent pouch mucosa bleeding were the cause. Hypohemoglobinemia and hypocyanocobalaminemia were noted in 5% and 5%, respectively. Erythrocyte sedimentation rate and white blood cells were supra-normal in 13 and 10%, which corresponded with pouchitis. A significant (p<0.03) steady rise of mean serum immunoglobulin G without correlation to pouchitis was noted.

CONCLUSION

Long-term functional results did not deteriorate. Pouchitis was a significant enigmatic morbidity. Severe or chronic pouchitis complicated hypoferric and vitamin B(12) anemia and hypomagnesaemia.

Pre-pouch ileitis: a disease of the ileum in ulcerative colitis after restorative proctocolectomy

OBJECTIVE

Ileal inflammation in ulcerative colitis can occur as backwash ileitis or prestomal ileitis. After restorative proctocolectomy (RPC), ileal inflammation may be present in the pouch (pouchitis) but inflammation proximal to the pouch in the neo-terminal ileum, so called pre-pouch ileitis (PI), has also been observed. As pouchitis is increasingly common and PI can mimic it, our aim was to characterize this condition.

SUBJECTS AND METHODS

A review of prospectively collected data on 571 inflammatory bowel disease patients undergoing follow-up after RPC in a single centre over 22 years was performed. The histology of biopsy material was reviewed and staining for colonic mucosal phenotypic changes was undertaken. It was not routine practice to prospectively assess all patients for pre-pouch ileitis when the database was constructed.

RESULTS

Of 19 patients with inflammation of the pre-pouch neo-terminal ileum (NTI) identified three had Crohn's disease and one a NSAID stricture. The remaining 15 had a characteristic diffuse inflammation extending from the NTI-pouch junction proximally: pre-pouch ileitis. The inflammation extended proximally for up to 50 cm. Fistula formation was seen in only one. Seven (47%) of 15 had pouchitis but only two had suffered backwash ileitis pre-operatively. Seven responded to medical therapy and four to surgery. The histological appearances including staining for colonic phenotypic change were similar in PI and pouchitis.

CONCLUSION

Pre-pouch ileitis is uncommon. As the patients' previous diagnosis of UC was confirmed and there was no radiological or histological evidence of Crohn's disease, PI appears to have a distinct pathogenesis from Crohn's disease.

Chronic pouchitis after ileal pouch-anal anastomosis for ulcerative colitis: effect on quality of life

Chronic pouchitis can be observed in up to 30% of patients after proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). It remains a poorly understood complication and often requires chronic antibiotic and antidiarrheal treatment. We hypothesized that its occurrence can be predicted by distinct clinical parameters and that it adversely affects quality of life. Sixty-eight of 129 consecutive UC patients who underwent IPAA over a 10-year period were evaluated by Cleveland Clinic Global Quality of Life questionnaires, telephone interviews, and by chart review. Using bivariate comparison, clinical predictors for the occurrence of chronic pouchitis were sought, and postoperative data analyzed with regard to functional results and quality of life. Nineteen of 68 patients (28%) experienced chronic pouchitis, but its occurrence could not be predicted by any variable assessed. Patients with chronic pouchitis complained of more frequent fecal incontinence (32% vs. 4% in controls; P < 0.01), of more frequent bowel movements (7.7/day vs. 6.2/day; P < 0.05), and experienced severe abdominal pain more often (P < 0.05). Overall quality of life and satisfaction with surgery, as well as subjective health and energy levels were lower in patients with chronic pouchitis (P < 0.01); however, greater than 80% of these patients would consider undergoing the same procedure again.

Myosin-1a is critical for normal brush border structure and composition

To develop our understanding of myosin-1a function in vivo, we have created a mouse line null for the myosin-1a gene. Myosin-1a knockout mice demonstrate no overt phenotypes at the whole animal level but exhibit significant perturbations and signs of stress at the cellular level. Among these are defects in microvillar membrane morphology, distinct changes in brush-border organization, loss of numerous cytoskeletal and membrane components from the brush border, and redistribution of intermediate filament proteins into the brush border. We also observed significant ectopic recruitment of another short-tailed class I motor, myosin-1c, into the brush border of knockout enterocytes. This latter finding, a clear demonstration of functional redundancy among vertebrate myosins-I, may account for the lack of a whole animal phenotype. Nevertheless, these results indicate that myosin-1a is a critical multifunctional component of the enterocyte, required for maintaining the normal composition and highly ordered structure of the brush border.

A neurokinin 1 receptor antagonist reduces an ongoing ileal pouch inflammation and the response to a subsequent inflammatory stimulus

Ileal pouch-anal anastomosis (IPAA) is an excellent surgical option for patients with chronic ulcerative colitis (CUC) requiring colectomy; however, persistent episodes of ileal pouch inflammation, or pouchitis, may result in debilitating postoperative complications. Because considerable evidence implicates substance P (SP) as an inflammatory mediator of CUC, we investigated whether SP participates in the pathophysiology of pouchitis. With the use of a rat model of IPAA that we developed, we showed that ileal pouch MPO levels and neurokinin 1 receptor (NK-1R) protein expression by Western blot analysis were significantly elevated 28 days after IPAA surgery. In situ hybridization and immunohistochemistry showed that the increase in NK-1R protein expression was localized to the lamina propria and epithelia of pouch ileum. The intraperitoneal administration of the NK-1R antagonist (NK-1RA) CJ-12,255 for 4 days, starting on day 28, was effective in reducing MPO levels. Starting on day 28, animals with IPAA were given 5% dextran sulfate sodium (DSS) in their drinking water for 4 days, which caused histological and physical signs of clinical pouchitis concomitant with significant increases in ileal pouch MPO concentrations as well as NK-1R protein expression by Western blot analysis. In situ hybridization and immunohistochemistry showed that the increase in NK-1R protein expression was especially evident in crypt epithelia of pouch ileum. When the NK-1RA was administered 1 day before starting DSS and continued for the duration of DSS administration, the physical signs of clinical pouchitis and the rise in MPO were prevented. These data implicate SP in the pathophysiology of pouchitis and suggest that NK-1RA may be of therapeutic value in the management of clinical pouchitis.