Bradykinin regulates human colonic ion transport in vitro

BACKGROUND AND PURPOSE

Kinins are acknowledged as important regulators of intestinal function during inflammation; however, their effects on human intestinal ion transport have not been reported. Here, we used muscle-stripped human colonic tissue and cultured T(84)-cell monolayers to study bradykinin (BK) actions on human intestinal ion transport.

EXPERIMENTAL APPROACH

Ion transport was measured as changes in short-circuit current (I(sc)) across colonic epithelia mounted in Ussing chambers.

KEY RESULTS

In intact tissue, there was a distinct polarity to BK-elicited I(sc) responses. Whereas basolateral BK stimulated sustained responses (EC(50)=0.5+/-0.1 microM), those to apical BK were more rapid and transient (EC(50)=4.1+/-1.2 nM). In T(84) cells, responses to both apical and basolateral BK were similar to those seen upon apical addition to intact tissues. Cross-desensitization between apical and basolateral domains was not observed. BK-induced responses were largely due to Cl(-) secretion as shown by their sensitivity to bumetanide and removal of Cl(-) from the bathing solution. Studies using selective agonists and antagonists indicate responses to BK are mediated by B(2) receptors. Finally, responses to basolateral BK in intact tissues were inhibited by tetrodotoxin (1 microM), atropine (1 microM), capsaicin (100 microM) and piroxicam (10 microM). BK-stimulated prostaglandin (PG)E(2) release from colonic tissue.

CONCLUSIONS

BK stimulates human colonic Cl(-) secretion by activation of apical and basolateral B(2) receptors. Responses to apical BK reflect a direct action on epithelial cells, whereas those to basolateral BK are amplified by stimulation of enteric nerves and PG synthesis.

Infliximab therapy in Crohn's disease: a pragmatic approach?

BACKGROUND

Infliximab is recognized as an effective therapy in unresponsive luminal and fistulating Crohn's disease. The use of maintenance or 'on demand' therapy thereafter is controversial.

AIM

To assess the need for maintenance infliximab therapy in a clinical setting where immunomodulatory agents are widely used and where episodic therapy is used in preference to maintenance therapy.

METHODS

Ninety-three patients with Crohn's disease receiving infliximab; 72 with unresponsive luminal disease and 21 with fistulous disease. Data collected included disease site and duration, surgical and smoking history, initial response rates, duration of response maintenance and concomitant medications.

RESULTS

Fifty-six of 72 (78%) patients with luminal disease and 11 of 21 (52%) with fistulous disease achieved an initial response. Ten of 67 responders required conversion to maintenance infliximab infusions, while 31 remain in remission. Patients with luminal disease and those who had not taken previous surgery had higher response rates to infliximab. Younger patients and those with small bowel disease had higher relapse rates following initial response. Three patients developed allergic reactions to infliximab and one patient died of progressive pulmonary disease 6 weeks after their first infusion.

CONCLUSIONS

Many patients with Crohn's disease can be maintained successfully with an episodic infliximab regimen.

Functional categories of TP53 mutation in colorectal cancer: results of an International Collaborative Study

BACKGROUND

Loss of TP53 function through gene mutation is a critical event in the development and progression of many tumour types including colorectal cancer (CRC). In vitro studies have found considerable heterogeneity amongst different TP53 mutants in terms of their transactivating abilities. The aim of this work was to evaluate whether TP53 mutations classified as functionally inactive (< or=20% of wildtype transactivation ability) had different prognostic and predictive values in CRC compared with mutations that retained significant activity.

MATERIALS AND METHODS

TP53 mutations within a large, international database of CRC (n = 3583) were classified according to functional status for transactivation.

RESULTS

Inactive TP53 mutations were found in 29% of all CRCs and were more frequent in rectal (32%) than proximal colon (22%) tumours (P < 0.001). Higher frequencies of inactive TP53 mutations were also seen in advanced stage tumours (P = 0.0003) and in tumours with the poor prognostic features of vascular (P = 0.006) and lymphatic invasion (P = 0.002). Inactive TP53 mutations were associated with significantly worse outcome only in patients with Dukes' stage D tumours (RR = 1.71, 95%CI 1.25-2.33, P < 0.001). Patients with Dukes' C stage tumours appeared to gain a survival benefit from 5-fluorouracil-based chemotherapy regardless of TP53 functional status for transactivation ability.

CONCLUSIONS

Mutations that inactivate the transactivational ability of TP53 are more frequent in advanced CRC and are associated with worse prognosis in this stage of disease.

Pathological response following long-course neoadjuvant chemoradiotherapy for locally advanced rectal cancer

AIMS

To standardize the pathological analysis of total mesorectal excision specimens of rectal cancer following neoadjuvant chemoradiotherapy for locally advanced disease (T3/T4), including tumour regression.

METHODS AND RESULTS

Standardized dissection and reporting was used for 60 patients who underwent total mesorectal excision following long-course chemoradiotherapy. Tumour regression was scored by two pathologists (K.S., D.G.) using both an established 5-point tumour regression grade (TRG), and a novel 3-point grade. Both scores were evaluated for interobserver variability. A complete or near-complete pathological response (3-point TRG 1) was found in 10 patients (17%). Using the 5-point TRG, there was good agreement between both pathologists (kappa = 0.64). Using the 3-point grade, agreement was excellent (kappa = 0.84). No disease recurrence has been reported in patients with a complete, or near complete pathological response (3-point TRG 1), after a mean follow-up of 22 months.

CONCLUSION

Tumour regression grade is a useful method of scoring tumour response to chemoradiotherapy in rectal cancer. TRG 1 and 2 can be regarded as a complete pathological response (ypT0). A modified 3-point grade has the advantage of better reproducibility, with similar prognostic significance.

Expression of Cathepsin B and L antigen and activity is associated with early colorectal cancer progression

Cathepsin B and Cathepsin L are cysteine proteases important in the process of invasion and metastasis. The aim of our study was to assay antigen and activity levels of these enzymes and to correlate these with established clinical and pathological prognostic parameters including patient survival. 99 patients undergoing operations for colorectal cancer were included in this study. We quantitated cathepsin B and L levels in matched normal mucosa and cancer samples using an enzyme-linked immunosorbent assay (ELISA) and specific activity assays and expressed the results as tumour/normal ratios. Significant correlations were found between tumour/normal cathepsin B and L antigen and activity ratios. Cathepsin B and L tumour/normal activity ratios were greater than 1 in early stage disease and there were gradual reductions in cathepsin B (P = 0.02) and L (P = 0.03) activity ratios with advancing tumour stage. Survival of patients with potentially curative disease was inversely related to both cathepsin B (P = 0.007) and L (P = 0.001) activity ratio, in addition to cathepsin L antigen ratio (P = 0.008). Our findings suggest that cysteine proteases play an important role in colorectal cancer progression.

Percutaneous endoscopic gastrostomy: 5 years of clinical experience on 238 patients

Since Percutaneous Endoscopic Gastrostomy (PEG) feeding was introduced, 20 years ago it has been increasingly utilised in medical practice. The aim of this study was to assess the current indications and complications associated with PEG feeding. This study was a retrospective review of hospital charts dealing with PEG placement over a period of five years. The indications for insertion were, central nervous disease 76% (n = 156), other benign disease 14% (n = 28) and malignancy 10% (n = 21). Cerebrovascular accidents (CVA) alone accounted for 47% (n = 97). Ninety seven (50%) patients had minor complications, which included 43 (22%) wound infections. There were 6 (3%) major complications, including peritonitis, perforation and aspiration pneumonia. There were four deaths (2%) related to PEG placement, of whom three developed aspiration pneumonia and one peritonitis. The overall 30 day mortality rate was 16%. There was a 75% increase in the use of PEG placement over the five year period. PEG placements were associated with a 53% morbidity and a 2% procedure related mortality. There was a 16% 30 day mortality following PEG placement suggesting that the selection criteria for PEG placement may need to be refined further.

Peritoneal involvement in stage II colon cancer

A pathologist (K.S.) reviewed histologic slides for peritoneal involvement by tumor cells for 118 patients with stage II colon cancer. Patients were followed up for a median of 6 years. Tumor cells were found free in the peritoneal space in 16 cases (13.6%). The presence of cancer cells free in the peritoneal space was associated with lymphovascular invasion (P = .001) and neural invasion (P < .001). The overall 5-year survival was 80% in the patient population, but was 39% and 86% for those with and without tumor cells free in the peritoneal space, respectively (P < .0001). Multivariate analysis confirmed that free tumor cells within the peritoneal space (P < .0001) and lymphovascular invasion (P = .007) were related independently to outcome. Peritoneal involvement with tumor cells free in the peritoneal space in stage II colon cancer is a powerful indicator of outcome; patients have a survival similar to that for patients with stage III disease.

Oxygen metabolites in immune- stimulated ion transport in rat colon: modulation by taurine

BACKGROUND/AIMS

Activation of cells within the lamina propria can cause electrogenic chloride secretion across intestinal epithelia by release and/or synthesis of mediator molecules, including reactive oxygen metabolites (ROMs). In this investigation we examined whether indirect (immune) stimulation of ion transport across rat colon was ROM-mediated.

METHODS

Paired segments of rat colon, stripped of underlying smooth muscle, were mounted on Ussing chambers in order to measure electrogenic ion transport. Changes in short circuit current (SCC) were used as a measure of net electrogenic ion transport measured in response to the bacterial tri-peptide formyl-Met-Leu-Phe (fMLP) which was used to activate lamina propria neutrophils. The effect of the established anti-oxidants catalase and diethyldithiocarbamate (DDTC) and the putative anti-oxidant taurine upon immune-stimulated ion transport was examined.

RESULTS

The anti-oxidant DDTC but not catalase significantly attenuated ion transport responses to fMLP. Taurine applied basolaterally reduced ion transport response to fMLP but not to the directly acting secretagogues forskolin. Taurine applied apically enhanced ion transport responses to fMLP.

CONCLUSION

Anti-oxidants, including taurine, may be useful in treatment of colitis. The enhancement of effect seen when taurine was applied apically may have negative implications regarding the therapeutic usefulness of taurine administration to the lumenal compartment.

Sources of calcium in neurokinin A-induced contractions of human colonic smooth muscle in vitro

OBJECTIVES

Tachykinins have been implicated in the pathogenesis of colonic dysmotility. The sources of activator calcium for neurokinin A (NKA)-induced contraction of human colonic smooth muscle have not been assessed. We evaluated the contribution of extracellular and intracellular Ca2+ to NKA-induced contractions.

METHODS

Circular smooth muscle strips of human colon were suspended under 1 g of tension in organ baths containing Krebs solution at 37 degrees C gased with 95% O2/5% CO2. Contractile activity was recorded isometrically.

RESULTS

Cumulatively applied NKA (0.1 nmol/L-0.3 micromol/L), produced concentration-dependent contractions of human colonic smooth muscle strips that were not affected by tetrodotoxin (1 micromol/L). The contractile response to NKA was abolished in a Ca2+-free medium containing ethylenediaminetetraacetate (EDTA) (1 mmol/L). Pretreatment of muscle strips with nifedipine (1 micromol/L), an L-type voltage-operated Ca2+ channel antagonist, abolished the contractile responses to NKA. Pretreatment with SK&F 96365 (10 micromol/L and 30 micromol/L), a putative receptor-activated and voltage-operated Ca2+ channel antagonist, attenuated the contractile responses. Depletion of intracellular Ca2+ stores with thapsigargin (1 micromol/L), an inhibitor of the sarcoplasmic reticulum Ca2+ ATP-ase, had no effect on NKA-induced contractions.

CONCLUSIONS

NKA-mediated contraction of human colonic smooth muscle is dependent on an influx of extracellular Ca2+ through L-type voltage-operated Ca2+ channels. Intracellular Ca2+ release seems to have little role to play in NKA-mediated contractions.

Tissue cytokine and chemokine expression in inflammatory bowel disease

OBJECTIVE AND DESIGN

This study aimed to determine if mucosal expression of the chemokines IL-8, RANTES and MCP-1 and the pro-inflammatory cytokines TNFalpha and IL-6 are elevated in patients with inflammatory bowel disease.

MATERIALS AND SUBJECTS

Intestinal mucosa samples were obtained at the time of surgical resection, n = 16 from each of the following groups: normal/control, CD and UC.

METHODS

An homogenate was prepared of each tissue sample and cytokines measured by ELISA.

RESULTS

IL-8 was significantly increased in both disease groups compared to controls Similarly, RANTES levels were also significantly increased. MCP-1 levels were increased in both disease groups, this increase was statistically significant in the UC group only. TNFalpha and IL-6 were significantly increased in the CD group only.

CONCLUSIONS

Chemokines, together with key cytokines that promote their release are elevated in mucosal tissues from patients with IBD. It is likely that these chemokines play an important role in the perpetuation of tissue destructive inflammatory processes.

Kirsten ras mutations in patients with colorectal cancer: the 'RASCAL II' study

Researchers worldwide with information about the Kirsten ras (Ki-ras) tumour genotype and outcome of patients with colorectal cancer were invited to provide that data in a schematized format for inclusion in a collaborative database called RASCAL (The Kirsten ras in-colorectal-cancer collaborative group). Our results from 2721 such patients have been presented previously and for the first time in any common cancer, showed conclusively that different gene mutations have different impacts on outcome, even when the mutations occur at the same site on the genome. To explore the effect of Ki-ras mutations at different stages of colorectal cancer, more patients were recruited to the database, which was reanalysed when information on 4268 patients from 42 centres in 21 countries had been entered. After predetermined exclusion criteria were applied, data on 3439 patients were entered into a multivariate analysis. This found that of the 12 possible mutations on codons 12 and 13 of Kirsten ras, only one mutation on codon 12, glycine to valine, found in 8.6% of all patients, had a statistically significant impact on failure-free survival (P = 0.004, HR 1.3) and overall survival (P = 0.008, HR 1.29). This mutation appeared to have a greater impact on outcome in Dukes' C cancers (failure-free survival, P = 0.008, HR 1.5; overall survival P = 0.02, HR 1.45) than in Dukes' B tumours (failure-free survival, P = 0.46, HR 1.12; overall survival P = 0.36, HR 1.15). Ki-ras mutations may occur early in the development of pre-cancerous adenomas in the colon and rectum. However, this collaborative study suggests that not only is the presence of a codon 12 glycine to valine mutation important for cancer progression but also that it may predispose to more aggressive biological behaviour in patients with advanced colorectal cancer.

Flow cytometric analysis of Clostridium difficile adherence to human intestinal epithelial cells

Clostridium difficile is the most common cause of diarrhoea in hospitalised patients. Bacterial adherence to gut epithelial cells is a likely prerequisite to infection and toxin production. A novel flow cytometric method was developed for detecting adherence of C. difficile to human colonic and small intestinal epithelial cells (EC) and human intestinal cell lines. Small intestinal and colonic EC were isolated from biopsy specimens with mucolytic and chelating agents. Adherence of fluorochrome-labelled C. difficile to EC was measured by flow cytometry and was calculated as increase in median fluorescent intensity (deltaMFI). Cells with bacteria attached could be distinguished easily from cells alone or cells with unlabelled bacteria attached. Toxin-positive C. difficile adhered to colonic and small intestinal EC (deltaMFI mean 21.2 SD 16.7, n = 33 and 16.5 SD 20.7, n = 19 respectively). The toxin-negative strain also adhered to both epithelial cell types (deltaMFI 26.1 SD 32.5, n = 17 and 18.3 SD 31.3, n = 16). Adherence of toxin-positive C. difficile to the intestinal cell lines Caco-2 (deltaMFI 9.4 SD 4.4, n = 14) and HT29 (deltaMFI 8.1 SD 3.1, n = 12) was quantifiable, although at a significantly lower level than with primary colonic epithelial cells. Adherence of the toxin-negative strain was slightly lower, deltaMFI 6.5 SD 1.8, n = 9 with Caco-2 cells and deltaMFI 6.0 SD 2.0, n = 10 with HT29 cells. Adherence of C. difficile to epithelial cell lines was blocked with C. difficile antiserum, confirming specificity of adherence. In conclusion, flow cytometry is a useful approach to quantifying adherence of C. difficile to human colonic and small intestinal epithelial cells. Binding of toxin-negative as well as toxin-positive bacteria was detectable by this approach. Analysis of C. difficile adherence to target cells may have important implications for the understanding of the pathogenesis of C. difficile-related disease.

Replication error phenotype, clinicopathological variables, and patient outcome in Dukes' B stage II (T3,N0,M0) colorectal cancer

AIMS

To examine the relation between the replication error (RER) phenotype and other genetic events, clinical features, and long term survival in patients with Dukes' B stage II (T3,N0,M0) colorectal cancer.

METHODS

RER phenotype was investigated in 159 patients by PCR amplification of microsatellite marker loci on chromosomes 5q, 17p, 17q, and 18q from tumour DNA extracted from archival tissue. Data on activating c-Ki-ras mutations were available from a previous study. Immunohistochemical detection of p53 and c-erbB-2 expression was performed on paraffin wax embedded tissue.

RESULTS

Of 159 colorectal cancers studied, 22 (14%) were RER+ while 137 (86%) were RER- for two or more loci. RER+ tumours were more commonly located in the right colon, tended to be larger than RER- tumours, and were more often poorly differentiated than RER- cancers. No significant associations were seen between RER status and the presence of a mutant c-Ki-ras gene, or between RER status and p53, c-erbB-2, or c-myc gene expression. Univariate survival analysis showed that outcome was similar in RER+ and RER- cases. Multivariate survival analysis showed that the relative risk of death for patients with RER+ cancers was 0.95 that of patients with RER- cancers.

CONCLUSIONS

The results suggest that, while the RER phenotype may be associated with some differences in tumour pathology (site, size, differentiation), it is not associated with the genetic alterations studied or with significant differences in long term survival.

Sacral dysgenesis associated with terminal deletion of chromosome 7q: a report of two families

Most cases of sacral dysgenesis are considered to be sporadic events. We present two families in whom the presence of associated clinical features prompted specific investigation of chromosome 7, leading to the identification of an underlying chromosome 7q deletion causing sacral dysgenesis. All affected individuals had microcephaly and developmental delay. Detailed cytogenetic studies confirmed that all three affected individuals had a deletion of chromosome 7q associated with their sacral dysgenesis, developmental delay and related problems. The three affected patients were studied clinically, radiologically and cytogenetically. Eleven unaffected individuals from the two families were also investigated by genetic studies, specifically evaluating chromosome 7.

CONCLUSION

It is important that detailed family history, evaluation of associated malformations and the overall clinical picture be considered in identifying the underlying diagnosis in cases of anal stenosis/sacral agenesis. The cases we present demonstrate the value of detailed chromosome studies in such situations.

The relationship between cyclooxygenase-2 expression and colorectal cancer

CONTEXT

Epidemiological studies have implicated the inducible form of cyclooxygenase (COX-2) in the pathogenesis of colorectal cancer; however, its role is not fully understood.

OBJECTIVE

To examine the relationship between the expression of COX-2 in human colorectal cancer and patient survival.

DESIGN

Patients diagnosed as having colorectal cancer were evaluated and followed up for up to 9.4 years (median follow-up, 2.7 years). Tumor sections were stained for COX-2 using a rabbit polyclonal antibody raised against human COX-2. The extent of COX-2 staining was graded by 2 observers blinded to outcome. Preabsorption of the anti-COX-2 antibody with a COX-2 peptide abolished the staining, demonstrating the specificity of the assay.

SETTING

Gastrointestinal unit of a large general teaching hospital in Dublin, Ireland.

PARTICIPANTS

Seventy-six patients (median age, 66.5 years) with colorectal cancer (Dukes tumor stage A, n = 9; Dukes B, n = 30; Dukes C, n = 25; Dukes D, n = 12) whose diagnosis was made between 1988 and 1991. Fourteen normal colon biopsies were stained for COX-2 as controls.

MAIN OUTCOME MEASURES

Survival in years following diagnosis compared by extent of COX-2 epithelial staining (grade 1, <1%; grade 2, 1%-19%; grade 3, 20%-49%; grade 4, > or = 50%), Dukes stage, tumor size, and lymph mode metastasis.

RESULTS

COX-2 was found in tumor epithelial cells, inflammatory cells, vascular endothelium, and/or fibroblasts. The extent of epithelial staining was heterogeneous, varying markedly among different tumors. Normal tissue adjacent to the tumors also stained weakly for COX-2. No COX-2 was detected in control tissue samples. The Kaplan-Meier survival estimate was 68% in patients who had grade 1 tumor epithelial staining compared with 35% in those with higher grades combined (log-rank chi2 = 5.7; P = .02). Greater expression of COX-2 correlated with more advanced Dukes stage (Kendall tau-b, 0.22; P = .03) and larger tumor size (Kendall tau-b, 0.21; P = .02) and was particularly evident in tumors with lymph node involvement (Kendall tau-b, 0.26; P = .02).

CONCLUSIONS

Our data indicate that COX-2 expression in colorectal cancer may be related to survival. These data add to the growing epidemiological and experimental evidence that COX-2 may play a role in colorectal tumorigenesis.

bcl-2 protein expression is associated with better prognosis in colorectal cancer

AIMS

To investigate the expression of bcl-2 in colorectal carcinoma and to examine its association with mediators of apoptosis (p53 and mdm-2), clinicopathological features and long-term outcome.

METHODS AND RESULTS

We determined by immunohistochemistry the expression of bcl-2 in 102 colorectal carcinomas with 10-year follow-up. In 66 of these cases in which we had previously assessed p53 status, no correlation was seen between bcl-2 and p53. The mdm-2 protein was not detected in any of the 66 cases. Cytoplasmic staining of the bcl-2 gene product was seen in the tumour cells of 22 cases (22%). Using a polymerase chain reaction technique we showed that overexpression of bcl-2 was not due to rearrangement of the bcl-2 gene. Expression of bcl-2 protein was related to tumour grade but was unrelated to patient age, sex, tumour site, tumour size or Dukes' stage. There was a trend towards increased survival in those whose tumours expressed bcl-2 protein (P = 0.055). When entered into a multivariate analysis, this survival difference was independent of tumour stage (P = 0.05).

CONCLUSIONS

These results suggest that bcl-2 expression in colorectal carcinoma is associated with a better long-term prognosis.

Berberine inhibits ion transport in human colonic epithelia

The effects of berberine on ion transport in both human colonic mucosal epithelia and an intestinal epithelial cell line (T84) were examined. Berberine (concentration range 0-500 microM) reduced both basal and stimulated ion transport responses in human colonic mucosae in a manner which was non-specific for Ca2+ -or cAMP-mediated signals. Similarly, in cultured intestinal epithelial monolayers, berberine inhibited Ca2+ -and cAMP-mediated responses indicating an inhibitory activity directly at the level of the epithelium rather than an indirect effect through other mucosal element(s). Berberine did not alter the rate of generation of cAMP by adenylyl cyclase or the activity of protein kinase A, the effector enzyme of the cAMP pathway. Berberine inhibited carbachol-stimulated 86Rb+ efflux from T84 monolayers. Berberine also inhibited K+ conductance in apically-permeabilised re-sected mucosae. These results indicate i) that berberine exerts an anti-secretory action directly upon epithelial cells and ii) the mechanism of action may be at the level of blockade of K+ channels.

Crohn's colitis: the fate of the rectum

Previous reports suggest that up to 70% of patients undergoing surgery for Crohn's disease of the large bowel do not have gastrointestinal continuity restored and require a permanent ileostomy. In this study the experience with patients requiring surgical treatment of large bowel Crohn's disease is reviewed with particular reference to the management of the rectum. The records of 19 elective and 25 urgent colonic resections performed for large bowel Crohn's disease in 44 patients (16 males, 28 females; mean age 41 years, range 17-76) between 1983 and 1995 were reviewed. Staged proctectomy was performed in 5 of 12 patients who had colectomy for acute colitis and in one patient who had had an elective colectomy. Permanent ileostomy was required in 72% of patients with acute Crohn's colitis and 84% of patients who had elective surgery for large bowel Crohn's. Over 70% of patients having surgical treatment of Crohn's disease of the large bowel required permanent ileostomy. No cases of cancer developed in patients with retained rectal stumps.

Fulminant colitis in inflammatory bowel disease: detailed pathologic and clinical analysis

PURPOSE

The morphologic features of fulminant colitis may be nonspecific, making differentiation between ulcerative colitis and Crohn's disease difficult, even after colectomy. The aims of this study were 1) to identify histologic features that accurately differentiated ulcerative colitis, Crohn's disease, and indeterminate colitis in fulminant colectomy specimens; 2) to determine how frequently subsequent clinical course altered the pathologic diagnosis; and 3) to evaluate the natural history of histologically diagnosed indeterminate colitis.

METHODS

Ninety-five fulminant colectomy specimens were evaluated, of which 85 had an original diagnosis of fulminant inflammatory bowel disease. Complete pathologic material and comprehensive clinical follow-up information was available on 67 cases of inflammatory bowel disease. These were re-evaluated in a blinded fashion, and histopathologic features were compared with the original diagnosis and reviewed in the light of subsequent clinical behavior to reach a final diagnosis.

RESULTS

Evaluation of macroscopic features was not helpful in differentiating ulcerative colitis from Crohn's disease. Microscopic examination correctly diagnosed ulcerative colitis or Crohn's disease in only 58 of 67 (87 percent) cases. A further three cases (4 percent) were definitively classified after correlation with clinical data, leaving a residual six cases that were diagnosed as indeterminate colitis. Granulomas and lymphoid aggregates were the two most specific indicators of Crohn's disease.

CONCLUSIONS

Histopathologic evaluation alone has limitations in the accurate classification of fulminant inflammatory bowel disease. Histologically diagnosed indeterminate colitis is a heterogeneous group that may include some patients who subsequently prove to have ulcerative colitis or Crohn's disease.

CD4+ CD8+ and CD8alpha+ beta- T lymphocytes in human small intestinal lamina propria

OBJECTIVE

To examine CD8 expression by T-lymphocyte subpopulations from disease-free human lamina propria.

METHODS

Single-cell suspensions were prepared from the epithelial layer and the lamina propria of small intestinal biopsies obtained endoscopically from disease-free patients. Monoclonal antibodies against CD3, CD4, CD8, CD56, CD8alphabeta, CD8alpha, TCR alphabeta and TCR gammadelta were used for dual and three-colour flow cytometric analysis.

RESULTS

In addition to classical CD4+ and CD8+ T lymphocytes a substantial proportion of lamina propria T lymphocytes were CD4+ CD8+ or 'double positive' (mean 14%, range 4-26%). This population was significantly lower in the epithelial layer of the same patients (mean 7%, range 3-21%, P < 0.007). Three-colour flow cytometric analysis revealed that expression of the CD8 molecule on double positive T cells in the lamina propria was limited to the CD8alpha chain. Furthermore, of the CD8+ population, CD8+ T cells which only expressed the alpha chain were present in greater numbers in the lamina propria (mean 35%, range 14-54%) than in the epithelial layer (mean 18%, range 5-37%, P < 0.02). NK (CD56+) cells were not detected and few gammadeltaTCR+ T lymphocytes were detected in the lamina propria (mean 2%, range 0.5-6.6%) when compared with the epithelial layer (mean 8%, range 0.2-14%, P < 0.008).

CONCLUSION

A significant population of CD4+ CD8alpha+ T lymphocytes which are CD8beta chain negative have been detected in the intestinal lamina propria. These cells form a more significant component of the lamina propria than the epithelial layer T-cell repertoire and may have a unique function in intestinal immunoregulation.

Human small intestinal epithelial cells secrete interleukin-7 and differentially express two different interleukin-7 mRNA Transcripts: implications for extrathymic T-cell differentiation

The small intestinal epithelium, composed of epithelial cells (EC) and intraepithelial T lymphocytes, is exposed to numerous ingested antigens. Small intestinal EC may act as accessory and/or antigen presenting cells for intestinal T cells, some of which may mature extrathymically and regulate local immunity and tolerance. Since interleukin-7 (IL-7) plays an essential role in T cell maturation and activation, we examined its expression by human small intestinal EC. IL-7 was detected by ELISA in supernatants from 4 of 4 epithelial layer (EpL) cultures. Using RT-PCR, IL-7 mRNA was detected in 4 EpL studied, and two distinct IL-7 transcripts were identified in 3 of the 4. The ratios of the intensities of the larger to the smaller bands varied amongst individuals. Furthermore, the intensity ratios were higher in whole-thickness intestine and lamina propria preparations than in their corresponding EpL. This is the first report of the expression of two IL-7 transcripts in human intestine and of IL-7 secretion by human small intestinal EpL cells. This supports the hypothesis that small intestinal EC may influence differentiation and/or activation of neighboring T cells. The differential expression of the two transcripts may have important implications for immune regulation in the intestinal epithelium.

Urokinase-type plasminogen activator in colorectal cancer: relationship with clinicopathological features and patient outcome

Urokinase-type plasminogen activator (u-PA) is a serine protease that has been implicated in cancer invasion and metastasis. We quantitated u-PA levels in normal colorectal mucosa, adenomatous polyps, and colorectal cancers and correlated these levels with clinicopathological features and patient survival. Detergent extracts were prepared from 133 colorectal cancers, 133 corresponding colorectal mucosal samples, and 15 synchronous adenomatous polyps. u-PA levels were determined using an ELISA, and a cancer:normal u-PA ratio was calculated for each case. u-PA levels were higher in cancers than in normal tissues, whereas adenomas had intermediate levels (P < 0.0001). u-PA levels were unrelated to clinical or pathological features. Survival was decreased in patients with a high cancer:normal u-PA ratio (P = 0.007). Multivariate survival analysis of patients undergoing curative surgery confirmed that the u-PA cancer:normal ratio was related to outcome (relative risk, 2.67; P = 0.02) and was independent of tumor stage (relative risk, 2.26; P = 0.03). Our study suggests that a high ratio of cancer to normal mucosal u-PA indicates an increased risk of colorectal cancer progression. Measurement of u-PA may provide useful prognostic information in patients undergoing curative surgery for colorectal cancer. The aggressive behavior of colorectal cancers with a high u-PA ratio suggests that the protease might be a suitable target for the development of therapeutic agents to prevent invasion and metastasis.

Duration of colorectal cancer symptoms and survival: the effect of confounding clinical and pathological variables

The relationship between symptom duration and long-term survival following colorectal cancer is complex, and a number of factors may influence the length of time from onset of symptoms of cancer diagnosis. We prospectively studied 777 consecutive colorectal cancer patients to determine the association between symptom duration and survival independent of other clinical and pathological features. We used survival curves, the logrank test and Cox's proportional hazards model to assess possible changes in relative risk of death with increasing symptom duration, without making any a priori assumptions. We found that symptom duration shortened with advanced tumour stage (P < 0.0006) and was also shorter for patients presenting with bowel obstruction (P < 0.0001). Univariate survival analysis showed that long-term survival increased consistently with symptom duration (P < 0.001). However, when the effect of tumour stage and bowel obstruction were accounted for in a multivariate analysis, no decrease in the relative risk of death was seen as symptom duration increased. The addition of other variables to the proportional hazards model such as age, sex or tumour site did not further influence the risk function form of symptom duration. Our results suggest that early diagnosis of colorectal cancer should remain our goal when assessing patients with suggestive gastrointestinal symptoms.

Perianal Crohn's disease

Perianal involvement in Crohn's disease is common but often mild and asymptomatic. Medical treatment of more severe disease has met with limited success. The guiding surgical principle in the management of perianal Crohn's disease is the drainage of sepsis and the preservation of sphincter integrity.

Identifying stage B colorectal cancer patients at high risk of tumor recurrence and death

PURPOSE

This study was designed to determine clinical and pathologic variables associated with poor outcome following resection of Stage B colorectal cancer.

METHODS

This was a retrospective study of 117 patients with Stage B cancer who underwent curative surgery and survived the postoperative period. Fourteen clinical and pathologic features were studied. Clinical data were extracted from a prospective colorectal cancer database, and histologic slides were retreived and examined by a pathologist blinded as to clinical details and outcome.

RESULTS

After a median follow-up period of 8.2 years, bowel obstruction was significantly related to a poor prognosis (log-rank test; P = 0.03). Extensive necrosis (P = 0.01) and perineural invasion (P = 0.03) were also associated with decreased survival. Vascular invasion was associated with poor long-term outcome in the subgroup of patients with rectal (P = 0.07) but not colonic (P = 0.57) cancer. Multivariate regression analysis identified both tumor necrosis (P = 0.01) and perineural invasion (P = 0.03) as independently related to outcome.

CONCLUSION

Further study of prognostic indicators might result in an algorithm to distinguish Stage B cases at high risk of tumor recurrence and death. Such patients could be included in future trials of adjuvant therapies.

Prognostic significance of p53 abnormalities in colorectal carcinoma detected by PCR-SSCP and immunohistochemical analysis

Abnormalities in the p53 tumour suppressor gene and in the expression of its protein are common in colorectal carcinoma. The prognostic significance of these p53 abnormalities was studied in 66 patients with colorectal cancer, followed for more than 10 years. Single-strand conformation polymorphism (SSCP) analysis was used to detect alterations in exons 5-8 of the p53 gene. Paraffin sections were examined immunohistochemically for p53 overexpression with the monoclonal antibody DO-7 (Dako) both with and without microwave antigen retrieval. Abnormalities of the p53 gene were found in 41 per cent of cases by SSCP analysis. Outcome was unrelated to SSCP abnormalities (P = 0.19), except for the Dukes' A and B subgroup, where decreased survival was found in cases with abnormal SSCP (P = 0.01). Overexpression of p53 protein was seen by immunohistochemistry in 47 per cent of cases without, and in 52 per cent of cases with microwave antigen retrieval. Immunohistochemical overexpression of p53 protein either with or without microwave antigen retrieval was an independent prognostic indicator of poor survival. These results suggest that for routine purposes, immunohistochemical detection of the p53 protein product may be more useful than SSCP analysis of the encoding p53 gene in identifying those at high risk of colorectal cancer recurrence and death.

Bone remodeling indices and secondary hyperparathyroidism in celiac disease

OBJECTIVES

To determine the prevalence of hypovitaminosis D and secondary hyperparathyroidism (SHPT) and to assess bone turnover by using markers of bone formation and resorption in celiac disease (CD).

METHODS

Forty-three patients with CD were investigated: group 1, newly diagnosed celiacs (n = 19); group 2, treated celiacs responding histologically to a gluten-free diet (n = 16); group 3, refractory celiacs, unresponsive to a gluten-free diet and immunosuppressive therapy (n = 8). Serum was drawn for intact parathyroid hormone (PTH), 25-hydroxyvitamin D [25(OH)D], ionized calcium (Cai), total alkaline phosphatase (AP), and biochemical markers of bone formation: procollagen I carboxyterminal propeptide (PICP) and osteocalcin (Oc). Urinary indices of bone resorption, deoxypyridinoline (DPD), pyridinoline (PyD), and hydroxyproline (OHP), were measured in a 2-h fasting urine. In 22 patients, computerized tomographic scan for bone mineral density (BMD) was performed.

RESULTS

The prevalence in groups 1, 2, and 3, respectively, of hypovitaminosis D (< 50 nmol/L) was 58%, 25%, and 88%, and the prevalence of SHPT (> 5.4 pmol/L) was 25%, 19%, and 25%. Bone resorption markers were significantly elevated in all groups, and bone formation indices were elevated in the newly diagnosed celiacs compared with a group of healthy adults. Low BMD (T-score greater than -1 SD unit) was found in 68% of patients assessed; 36% of patients had a T-score greater than -2.5 SD units.

CONCLUSIONS

Hypovitaminosis D and SHPT are common in newly diagnosed and refractory celiacs but are less common in those who respond to a gluten-free diet. Newly diagnosed patients have a high bone turnover state with elevation of both bone formation and resorption indices. Those with refractory disease demonstrate a remodeling imbalance with high bone resorption.

An image analysis study of DNA content in early colorectal cancer

The DNA content of 168 consecutive T3,N0,M0 (Dukes' B, Astler-Coller B2) colorectal cancers was studied using image analysis on formalin-fixed paraffin-embedded tissues. 72 cases (43%) were classified as diploid and the remaining 96 (57%) as non-diploid. After a median follow-up period of 6.7 years, a significant survival advantage was found for diploid compared with non-diploid cases (logrank test; P = 0.008). The long-term (8 year) survival rate was 70% for diploid and 46% for non-diploid tumours. Subgroup analysis showed that the survival advantage conferred by tumour diploidy was greatest in large (> or = 5 cm) cancers and was found both in colonic and rectal cancer cases. These data indicate that tumour ploidy status measured by image analysis might be useful in determining risk of colorectal cancer recurrence and death in patients following resection of early colorectal cancer.

Long-term outcome following curative surgery for malignant large bowel obstruction

This study determined whether the long-term outcome of patients with obstructing colorectal cancer could be related to conventional pathological prognostic variables or to other clinical, operative or histological features. Ninety-eight patients with bowel obstruction who had undergone potentially curative surgery and survived the postoperative period were studied. Features related to poor long-term outcome after a median follow-up of 5 years included bowel perforation at initial operation (P = 0.007), advanced tumour stage (P < 0.001), poor tumour differentiation (P = 0.02), mucin production by tumour (P = 0.004) and the presence of vascular (P = 0.08) and neural (P = 0.004) invasion. Outcome was not significantly related to the seniority of the operating surgeon (P = 0.52), even when this was adjusted for potentially confounding variables (adjusted hazard rate ratio for trainee surgeons 1.4 (95 per cent confidence interval 0.9-2.4), P = 0.16). Conventional prognostic features may help to identify the majority of patients with obstructed colorectal cancer at high risk of tumour recurrence and death.

Embolotherapy for massive upper gastrointestinal haemorrhage secondary to metastatic renal cell carcinoma: report of three cases

Three cases are reported in which angiographic embolisation therapy was effective in arresting upper gastrointestinal bleeding secondary to metastatic hypernephroma. Each patient had histologically confirmed disseminated renal cell carcinoma and presented with recurrent haematemeses with a successful outcome following palliative embolisation therapy.

Regulation of ion transport by histamine in human colon

Histamine, added to the basolateral side of voltage clamped human colon in vitro, induced a rapid onset, transient inward short circuit current which was concentration dependent over the range 0.01-3 mM. This response was largely due to electrogenic chloride section since it was virtually abolished by bumetanide or by chloride replacement in the bathing solutions. Responses were unaffected by amiloride or acetazolamide. Neither the histamine H2 receptor agonist dimaprit (1 mM) nor the histamine H3 receptor agonist S-(+)-alpha-methyl histamine (1 mM) altered short circuit current. Responses to histamine were significantly reduced by the histamine H1 receptor antagonist mepyramine (1-10 microM) but not altered by the histamine H2 receptor antagonist cimetidine (100 microM) or by the histamine H3 receptor antagonist thioperamide (1 microM). Short circuit current responses to histamine were not altered by tetrodotoxin (1 microM). Piroxicam (10 microM) and nordihydroguaiaretic acid (100 microM) were without effect when used individually but significantly reduced responses to histamine when used simultaneously. These results indicate that histamine stimulates chloride secretion across human colonic epithelium by a mechanism which is mediated exclusively via histamine H1 receptors. This action does not involve intrinsic nerves but appears to be dependent upon eicosanoid synthesis.

Pharmacological manipulation of gastric juice: thrombelastographic assessment and implications for treatment of gastrointestinal haemorrhage

The impairment of formation and maintenance of a formed fibrin clot contributes to the prolonged bleeding and high incidence of rebleeding in upper gastrointestinal haemorrhage. To investigate the basis for the use of drug therapy in gastric bleeding, this study used thrombelastography to determine the effects of pharmacological manipulation of gastric juice on coagulation and fibrinolysis. The thrombelastograph is a mechanical device that provides a visual assessment of all stages of coagulation and fibrinolysis. The effects of fresh and pharmacologically changed gastric juice was assessed after its addition to fresh whole blood in the thrombelastograph cuvette. Pharmacological manipulation was achieved through alkalisation or through addition of tranexamic acid, aprotinin, or sucralfate. Fresh gastric juice delayed clot formation, decreased maximum clot amplitude, and stimulated clot lysis. Alkalisation inhibited the lytic effects of fresh gastric juice and improved the induced abnormalities in coagulation. Tranexamic acid partially inhibited gastric juice induced clot lysis but did not exhibit a beneficial effect on coagulation. Sucralfate, and to a lesser extent aprotinin significantly inhibited fibrinolysis but exacerbated the detrimental effect of gastric juice on the parameters of coagulation. Alkalisation of gastric juice reduces the adverse effect on coagulation and fibrinolysis. Tranexamic acid, aprotinin, and sucralfate can all reduce or inhibit clot lysis, but the adverse effects on clot formation may outweigh any potential benefit in the treatment of gastrointestinal bleeding.

Immune regulation of human colonic electrolyte transport in vitro

The role of lamina propria cells in regulating human colonic ion transport was investigated in vitro. Normal human colonic mucosae were mounted in Ussing chambers, and short circuit current changes (delta SCC) were monitored in response to immune cell activation. Anti-human immunoglobulin E (anti-IgE) and formyl-Methionyl-Leucyl-Phenylalanine (fMLP) were used to stimulate mast cells and phagocytes respectively. Anti-IgE (100 micrograms/ml) and fMLP (100 microM) evoked rapid onset, inward delta SCC (mean (SEM) max delta SCC 19.3 (2.8) and 29.4 (4.7) microA/0.63 cm2 respectively). A pharmacological approach was used to identify the charge carrying ion species and to characterise mediators involved in the SCC response. Responses to each secretagogue were significantly attenuated by bumetanide, indicating that the delta SCC was at least partly due to electrogenic chloride secretion. Piroxicam reduced the delta SCC to mast cell and phagocyte activation by 91.1 (3.4)% and 48.2 (25.2)% respectively, implicating eicosanoids as mediators of the responses. Mepyramine (100 microM) reduced the SCC responses to anti-IgE by 79.6 (12.0)% but did not significantly alter delta SCC responses to fMLP. Desensitisation to repeated anti-IgE or fMLP stimulation, and cross desensitisation between each of the stimuli, were features of immune cell activation. In summary, we have shown that activation of immune cells can stimulate electrogenic chloride secretion. Such events in vivo will result in gradient driven secretory diarrhoea, which may occur as a protective response to enteric-dwelling parasites, or as a feature of local bowel inflammation.

Urokinase-type plasminogen activator and outcome in Dukes' B colorectal cancer

Urokinase-type plasminogen activator (u-PA) is a serine protease involved in cancer metastasis. Using immunohistochemical methods, we examined the relation between u-PA and long-term survival in 70 patients with Dukes' B colorectal cancer. 8-year survival was 81% in patients whose tumours demonstrated low-grade epithelial u-PA staining and 43% in those with high-grade staining (log-rank test, p = 0.01). Survival was unrelated to stromal u-PA staining. These results suggest that u-PA may be useful in the identification of patients with non-metastatic colorectal cancer at risk of tumour recurrence.

Prognosis of elderly patients with large bowel cancer

The effect of age on the presentation, diagnosis, management and survival of patients with colorectal cancer was studied prospectively in 512 patients admitted to a single institution. In all, 225 patients were aged 70 years or more and 287 less than 70 years. Older patients had a significant excess of emergency presentations (18 versus 11 per cent). Methods of diagnosis, proportion of curative operations performed, stage and histological grade were similar in the two age groups. The postoperative mortality rate was 6 per cent in the elderly group and 3 per cent in younger patients. The postoperative mortality rate rose to 15 and 12 per cent respectively in those undergoing emergency surgery. The relative 5-year survival rate standardized for age and sex was 52 per cent for older patients and 45 per cent for younger patients; for those undergoing curative surgery it was 68 and 59 per cent respectively. The behaviour of colorectal carcinoma changes little with age and, allowing for population mortality, age has no effect on the long-term survival of elderly patients with large bowel cancer.

The prognostic significance of immunohistochemically detected lymph node micrometastases in colorectal carcinoma

Micrometastases have been detected by immunocytochemical means in the lymph nodes of patients with otherwise node-negative cancer of the colon and rectum. This study examines the incidence and prognostic significance of nodal micrometastases in Dukes' B carcinoma. Five hundred and fifty-nine lymph nodes from 77 cases of Dukes' B carcinoma were examined for lymph node micrometastases by immunocytochemical staining for cytokeratin AE1:AE3. Micrometastases were detected in 19 cases (25 per cent). Cell clusters were present in ten cases, the remaining nine cases displaying only single cells. The presence of micrometastases was unrelated to age (P = 0.06), sex (P = 0.32), tumour site (P = 0.37), tumour size (P = 0.67), or tumour differentiation (P = 0.66). Ten-year survival estimates by the Kaplan-Meier lifetable method was 47 per cent in patients with and without micrometastases (chi 2 = 0.35 and 1 df, P = ns). The presence of nodal micrometastases detectable only by immunocytochemistry in patients with Dukes' B colorectal cancer does not justify reassignment to a more advanced disease stage.

Colonoscopic surveillance after curative resection for colorectal cancer

Colonoscopic surveillance after resection for colorectal cancer has been advocated to improve detection of anastomotic recurrence, and of synchronous and metachronous tumours. The benefit provided by colonoscopy remains unproven, and the best timing of examination is unclear. To determine the value of colonoscopy after curative resection for large bowel cancer, the efficacy of an endoscopic surveillance programme in the early detection of intraluminal bowel recurrence in a series of patients admitted with colorectal cancer was examined. Between April 1983 and December 1988, 132 patients underwent colonoscopy. Eight (6.1 per cent) were found to have intraluminal recurrence without evidence of extraluminal spread. Six of these recurrences were at the site of anastomosis and two represented metachronous tumour development. All of these patients were symptomatic at the time of diagnosis. In 15 patients (11.4 per cent), adenomatous polyps were discovered during the initial endoscopic examination. These results indicate that colonoscopic surveillance will rarely allow early detection of asymptomatic intraluminal bowel recurrence, but is valuable in the detection of synchronous lesions. Frequent surveillance is not justified in the early postoperative years and colonoscopy should probably be confined to a single procedure to exclude synchronous lesions.

Impaired fatty-meal-stimulated gallbladder contractility in patients with Crohn's disease

1. The incidence of gallstones in patients with Crohn's disease is increased compared with that in healthy control subjects. This is in part due to reduced terminal ileal bile salt absorption and consequent increased cholesterol saturation in bile. The aim of this study was to evaluate gallbladder contractility, a second important factor in the pathogenesis of gallstones, in Crohn's disease. 2. Thirty patients with Crohn's disease and no known biliary tract disease and nine healthy control subjects were studied. After an overnight fast, gallbladder volume was determined by real-time ultrasonography before and 10, 20, 30, 40, and 50 min after ingestion of a standard liquid fatty meal. 3. Compared with healthy control subjects, patients with Crohn's disease had similar fasting gallbladder volumes (control, 18.7 +/- 2.3 ml; Crohn's disease, 18.2 +/- 2.3 ml). Percentage emptying was significantly impaired at 30, 40 and 50 min in patients with Crohn's disease compared with control subjects. Patients with Crohn's disease limited to the small bowel had gallbladder contractility that was comparable with that of control subjects, whereas in those with large-bowel disease, minimum residual gallbladder volume was significantly smaller than in control subjects. Patients with both large- and small-bowel Crohn's disease demonstrated the most marked abnormalities, with gallbladder volumes significantly larger than those of control subjects at 30, 40 and 50 min. Likewise, patients with Crohn's disease who had undergone previous bowel resection had impaired emptying at 30, 40 and 50 min.(ABSTRACT TRUNCATED AT 250 WORDS)

Controlled trial of antimycobacterial therapy in Crohn's disease. Clofazimine versus placebo

In order to study the effect of clofazimine, a powerful antimycobacterial and antiinflammatory agent, 49 patients with active Crohn's disease were randomized to either corticosteroids plus clofazimine 100 mg daily (N = 25) or to steroids and matching placebo (N = 24). A total of 28 patients (58%) went into disease remission (clofazimine 16, placebo 12; P = NS) with a fall in disease activity score from 10.5 +/- 4.4 to 3.3 +/- 3.5. Patients were treated for a further eight months with clofazimine or placebo and 18 of 28 maintained their remission and completed the study (clofazimine 12, placebo 6; P = NS). Side effects were minor and consisted of skin rash and increased pigmentation. Clofazimine as a solitary antimycobacterial agent appears ineffective in inducing remission in Crohn's disease but may have a role in either disease maintenance or combination chemotherapy.

Omeprazole provides quicker symptom relief and duodenal ulcer healing than ranitidine

In a double-blind, parallel-group clinical trial in 248 patients with symptomatic duodenal ulcers [97% greater than 5 mm diameter], 126 were randomized to receive omeprazole 20 mg once daily in the morning and 122 were randomized to receive ranitidine 300 mg once daily at night for 2 wk and if the ulcers were unhealed for a total of 4 wk. When ulcer healing was assessed on an intention-to-treat basis, 79% of those receiving omeprazole had healed ulcers after 2 wk compared with 62% of those receiving ranitidine (p less than 0.005; therapeutic gain for omeprazole, 18%; 95% confidence intervals, +6% to +29%). At 4 wk the figures were 91% (omeprazole) and 80% (ranitidine) (p less than 0.05). After 2 wk, 77% of omeprazole-treated and 59% of ranitidine-treated patients were free of ulcer pain (p = 0.005). Assessed by diary cards (successfully completed by 92% of patients), daytime pain resolved more quickly in omeprazole-treated patients than in those receiving ranitidine (p less than 0.01). Omeprazole-treated patients took fewer antacids (p less than 0.05) over the first 2 wk. Omeprazole, 20 mg each morning, provides more rapid relief of the symptoms of duodenal ulcer and heals a greater proportion of duodenal ulcers within 2 and 4 wk than ranitidine, 300 mg each night.

Clot lysis by gastric juice: an in vitro study

Gastric juice from patients with peptic ulcer disease and from patients with no upper gastrointestinal abnormality was studied in order to assess its effect on a formed fibrin clot. In both groups of patients gastric juice caused a marked increase in fibrinolysis as evidenced by a shortening of the euglobulin clot lysis time. This plasmin mediated fibrinolytic activity was found to be heat labile and only present in an acid environment. Addition of tranexamic acid or sucralfate to gastric juice almost completely reversed this effect, whereas pepstatin was only partially effective. It is probable that acid dependent proteases other than pepsin are responsible for the marked fibrinolysis. The ulcer healing agent sucralfate might be useful in those patients at risk of bleeding or rebleeding from active peptic ulcer disease.

Remission induction in refractory Crohns disease using a high calorie whole diet

Eleven patients with severe refractory Crohns disease were treated with a high calorie, whole diet. Eight patients achieved remission with a drop in DAS from 13 to 4 (t = 6.31, p less than 0.001) and reversal of subacute obstruction in all cases. Nutritional parameters including weight, triceps skinfold thickness, arm muscle area, and serum albumin increased in all patients. The diet was well tolerated with a mean treatment period of 20 days. Clinical relapse of disease occurred in all cases within 9 months (mean 6 +/- 2 months). The mechanism of action of a high calorie diet (HCD) is unclear and warrants further study but antigen or specific food exclusion does not appear to be required as judged by this study.

Altered gastrointestinal immune response in sarcoidosis

Because of the possible clinical association between coeliac disease and sarcoidosis, the incidence of humoral sensitivity to dietary proteins was examined in patients with sarcoidosis. Raised concentrations of circulating IgG antibodies to alpha gliadin were found in 41/99 sarcoid patients whereas antibody levels to casein, beta lactoglobulin and ovalbumin were similar to normal controls. Subsequently, a group of 26 sarcoid patients were selected for small intestinal biopsy; 11 had raised and 15 normal alpha gliadin antibody (AGA) levels. One AGA positive patient had villous atrophy consistent with coeliac disease. Intraepithelial lymphocyte (IEL) counts were raised in AGA positive (median 30; 95% confidence limits 22-46) and AGA negative (median 24; 95% confidence limits 19-32) sarcoid patients when compared with a control group (median 13.5; 95% confidence limits 10-18) p less than 0.01. Serum IgG concentrations were raised in 11/52 patients tested but there was no correlation between IgG levels and the presence of IgG antigliadin antibodies. HLA Dr typing was done in 21 of the 26 biopsied patients. The coeliac disease associated antigen Dr3 was present in eight of 21 (38%) which is very similar to the prevalence in unselected blood donors (34%). There was no significant difference in IEL counts between Dr3 positive and Dr3 negative sarcoid patients. These findings suggest that in patients with sarcoidosis, there is an altered gastrointestinal mucosal immune response, accompanied in about 40% of patients by specific sensitisation to wheat protein.

Effect of intravenous infusion of adrenaline on the cardiovascular responses to distal body subatmospheric pressure in man

1. On two separate occasions, at least 1 week apart, seven young healthy male subjects received intravenous infusions of either adrenaline [0.27 nmol (50 ng) min-1 kg-1] or saline (154 mmol/l NaCl), plus ascorbic acid (5.68 mmol/l), over 30 min. 2. On each occasion, the subjects were exposed to distal body subatmospheric pressure (DBSP), 0 to 50 mmHg (0 to 6.65 kPa) in 10 mmHg (1.33 kPa) steps, before infusion, during the final 15 min of the infusion, and at 15 min and 30 min after the cessation of the infusion. 3. Venous adrenaline concentrations of 2.85 +/- 0.22 nmol/l were achieved during the adrenaline infusion, compared with 0.49 +/- 0.07 nmol/l during the saline infusion (P less than 0.001). At 15 min and at 30 min after cessation of the adrenaline infusion, venous adrenaline concentrations had fallen to levels similar to those achieved after the cessation of the saline infusion. 4. Heart rate rose significantly from 58 +/- 4 beats/min to 67 +/- 4 beats/min during the adrenaline infusion (P less than 0.05), but there was no further significant change in response to 50 mmHg (6.65 kPa) DBSP. At 30 min after the cessation of the adrenaline infusion, heart rate rose from 60 +/- 4 beats/min to 78 +/- 7 beats/min in response to 50 mmHg DBSP. This increase was significantly greater than that observed before the adrenaline infusion [58 +/- 4 beats/min to 69 +/- 7 beats/min during 50 mmHg (6.65 kPa) DBSP; P less than 0.01].(ABSTRACT TRUNCATED AT 250 WORDS)

Immunohistochemical Cal9-9 in primary colonic polyps and polyps synchronous with colorectal cancer

A prospective study was undertaken to examine the immunohistochemical expression of tumor antigen Cal9-9 in 56 colorectal cancers and 95 colonic adenomas, divided into 65 primary polyps and 30 polyps synchronous with colorectal cancer. Seventy five per cent of tumours were positive for Cal9-9. Antigen was expressed more frequently in advanced Duke's C and D and poorly differentiated colorectal cancer. Overall 51% of adenomas were positive for Cal9-9. Antigen expression correlated significantly with increasing size (p less than 0.001), synchronicity with colorectal cancer (p less than 0.001), severe dysplasia (p less than 0.001) and villous typing (p less than 0.003). Discriminate analysis using the first three variables correctly classified 79% of positive and 89% of negative Cal9-9 results. The similar frequency of antigen expression seen in colorectal cancers and their synchronous adenoma suggests a field change in the tumour bearing colon. Adenomas positive for Cal9-9 may have a greater malignant potential for carcinomatous change.

Computed tomography of the liver after biopsy

Angiographic studies suggest that needle biopsy of the liver is invariably associated with some degree of haemorrhage (Wallace et al., 1972). The appearances of the liver on computed tomography after percutaneous biopsy have not been described. As an aid to the interpretation of scans in patients referred because of clinical complications of biopsy, we performed unenhanced computed tomography of the liver in 30 patients within 72 h of biopsy. None of these patients would ordinarily have been referred for computed tomography. Only one of the scans showed a parenchymal abnormality attributable to biopsy. We conclude that post-biopsy changes on unenhanced computed tomography scans of the liver are uncommon and that the needle tracks and vascular anomalies commented on by angiographers are not usually shown.