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Xu H, Bayless TM, Østbye T, Dupre ME. Care sequences leading to the diagnosis of Alzheimer's disease and related dementias: An analysis of electronic health records. Alzheimers Dement 2024; 20:2155-2164. [PMID: 38270269 PMCID: PMC10984433 DOI: 10.1002/alz.13669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/24/2023] [Accepted: 12/03/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND We examined the sequences of clinical care leading to diagnoses of Alzheimer's disease and related dementias (ADRD) using electronic health records from a large academic medical center. METHODS We included patients aged 65+ with their first ADRD diagnoses from January 1, 2014 to December 31, 2019. Using state sequence analysis, care sequences were defined by the ordering of healthcare utilizations occurred in the 2 years before ADRD diagnosis. RESULTS Of 3621 patients (median age 80), nearly half followed a care sequence of having one primary care visit close to their ADRD diagnosis. Additional care sequences included periodic (n = 322, 8.9%) and multiple (n = 416, 11.5%) outpatient visits to primary care and having one (n = 395, 10.9%), multiple (n = 469, 13.0%), or highly frequent (n = 357, 10.7%) outpatient visits to other specialties. Patients' sociodemographic traits contributed to the variability in care sequences. CONCLUSIONS Several distinct patterns of care leading to ADRD diagnoses were identified. Integrated care models are needed to promote early identification of ADRD. HIGHLIGHTS Dementia patients followed distinct care pathways prior to their dementia diagnoses. Key sociodemographic traits contributed to the variation in the sequences of care. Racial differences in the sequencing of care were also found, but only in women.
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Affiliation(s)
- Hanzhang Xu
- Department of Family Medicine and Community HealthDuke UniversityDurhamNorth CarolinaUSA
- Duke University School of NursingDuke UniversityDurhamNorth CarolinaUSA
- Center for the Study of Aging and Human DevelopmentDuke UniversityDurhamNorth CarolinaUSA
| | - Teah M. Bayless
- Department of Family Medicine and Community HealthDuke UniversityDurhamNorth CarolinaUSA
| | - Truls Østbye
- Department of Family Medicine and Community HealthDuke UniversityDurhamNorth CarolinaUSA
- Duke University School of NursingDuke UniversityDurhamNorth CarolinaUSA
- Center for the Study of Aging and Human DevelopmentDuke UniversityDurhamNorth CarolinaUSA
| | - Matthew E. Dupre
- Center for the Study of Aging and Human DevelopmentDuke UniversityDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke UniversityDurhamNorth CarolinaUSA
- Duke Clinical Research InstituteDuke UniversityDurhamNorth CarolinaUSA
- Department of SociologyDuke UniversityDurhamNorth CarolinaUSA
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Limketkai BN, Bayless TM, Brant SR, Hutfless SM. Lower regional and temporal ultraviolet exposure is associated with increased rates and severity of inflammatory bowel disease hospitalisation. Aliment Pharmacol Ther 2014; 40:508-17. [PMID: 24943863 DOI: 10.1111/apt.12845] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 04/30/2014] [Accepted: 05/29/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND In the northern hemisphere, the incidence of inflammatory bowel diseases (IBD) has a north-south gradient, suggesting a link between ultraviolet (UV) exposure or vitamin D status and the pathogenesis of IBD. AIM To test the association of UV exposure with the rates and severity of IBD hospitalisation. METHODS We conducted a retrospective nationwide analysis of 649 932 Crohn's disease (CD), 384 267 ulcerative colitis (UC), and 288 894 297 non-IBD hospitalisations in the US between 1998 and 2010. Mean UV exposure was assigned to each hospitalisation using surface measures from the National Oceanic and Atmospheric Administration. Relative rates across UV exposures were estimated for IBD hospitalisations, prolonged hospitalisations, bowel surgeries and deaths. RESULTS Among IBD patients, lower UV exposures had increased hospitalisation rates for CD (217.8 vs. 182.5 per 100 000 overall hospitalisations with low and very high UV, respectively; P trend <0.001) and UC (123.2 vs. 113.8 per 100 000; P trend = 0.033). Low UV groups had greater relative rates of prolonged hospitalisations [CD: 1.13, 95% confidence interval (CI) 1.07-1.19; UC: 1.21, 95% CI 1.13-1.30], bowel surgeries (CD: 1.24, 95% CI 1.16-1.32; UC: 1.21, 95% CI 1.09-1.33), and CD deaths (CD: 1.76, 95% CI 1.14-2.71; UC: 1.24, 95% CI 0.92-1.67). Among non-IBD patients, low UV was associated with prolonged hospitalisations (1.09; 95% CI 1.07-1.11) and deaths (1.13; 95% CI 1.09-1.17), but not bowel surgeries (1.01; 95% CI 0.99-1.03). CONCLUSIONS Lower ultraviolet exposure is associated with greater rates of hospitalisation, prolonged hospitalisation and the need for bowel surgery in IBD. This trend for bowel surgery was not seen with non-IBD encounters.
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Affiliation(s)
- B N Limketkai
- Division of Gastroenterology, Harvey M. and Lyn P. Meyerhoff Inflammatory Bowel Disease Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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3
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Cuffari C, Li DY, Mahoney J, Barnes Y, Bayless TM. Peripheral blood mononuclear cell DNA 6-thioguanine metabolite levels correlate with decreased interferon-gamma production in patients with Crohn's disease on AZA therapy. Dig Dis Sci 2004; 49:133-7. [PMID: 14992447 DOI: 10.1023/b:ddas.0000011614.88494.ee] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
6-Mercaptopurine (6-MP) and its prodrug azathioprine (AZA) are well known for their lymphocytotoxic and bone marrow suppressive effects in the management of patients with leukemia. Although their immunosuppressive properties are mediated by the active AZA antimetabolite 6-thioguanine (6-TG), its mechanism of action is largely unknown. In IBD, a significant inverse correlation has been shown between erythrocyte 6-TG metabolite levels and disease activity, further supporting the proposed immunosuppressive role for 6-TG. Since leukocytes possess quantitatively different purine metabolic pathways compared to erythrocytes, this study aims to measure lymphocyte DNA 6-TG metabolites and correlate levels with the INF-gamma and IL-10 cytokine profile in patients with Crohn's disease (CD). Forty-six adult patients with CD, either naive (17) or on long-term (>4-month) AZA therapy (29), had erythrocyte and lymphocyte DNA 6-TG levels measured by reverse-phase HPLC under UV detection (6-TG, 340 nm). Lymphocyte DNA 6-TG was expressed as picomoles per milligram of DNA. Lymphocyte DNA 6-TG metabolite levels were correlated with INF-gamma and IL-10 cytokine profiles using the OptEIA kit (Pharmigen). Lymphocyte DNA 6-TG metabolite levels correlate with erythrocyte 6-TG levels (P < 0.03) but not total patient leukocyte levels. Erythrocyte 6-TG metabolite levels correlated (P < 0.01) inversely with INF-gamma but not IL-10 cytokine levels. This study suggests a preferential dampening of the TH1 response on exposure to 6-TG and a possible immunosuppressive mechanism of action for AZA. Future studies are needed to determine if cytokine profiles can be used to predict recalcitrant CD to AZA therapy.
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Affiliation(s)
- C Cuffari
- Department of Pediatrics, Division of Gastroenterology and Nutrition, The Johns Hopkins University, Baltimore, Maryland, USA
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4
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Cruz-Correa M, Milligan F, Giardiello FM, Bayless TM, Torbenson M, Yardley JH, Jackson FW, Wilson Jackson F. Collagenous colitis with mucosal tears on endoscopic insufflation: a unique presentation. Gut 2002; 51:600. [PMID: 12235088 PMCID: PMC1773384 DOI: 10.1136/gut.51.4.600] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- M Cruz-Correa
- Department of Medicine, Johns Hopkins University School of Medicine, Meyerhoff Digestive Disease IBD Center, Baltimore, Maryland, USA.
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5
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Song DY, Lawrie WT, Abrams RA, Kafonek DR, Bayless TM, Welsh JS, DeWeese TL. Acute and late radiotherapy toxicity in patients with inflammatory bowel disease. Int J Radiat Oncol Biol Phys 2001; 51:455-9. [PMID: 11567821 DOI: 10.1016/s0360-3016(01)01629-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE To evaluate the incidence of gastrointestinal complications in patients with inflammatory bowel disease (IBD) receiving radiotherapy (RT) and to identify possibly avoidable factors associated with these complications. METHODS AND MATERIALS Twenty-four patients were identified and their records reviewed; all had a history of IBD before receiving RT to fields encompassing some portion of the gastrointestinal tract (Crohn's disease) or to the abdomen or pelvis (ulcerative colitis or IBD not otherwise specified). RESULTS Five of 24 patients (21%) experienced Grade > or =3 acute gastrointestinal toxicity; all 5 received concurrent chemotherapy. Two of 24 patients (8%) experienced Grade > or =3 late gastrointestinal toxicity. There were no significant correlations between complications and IBD type, prior IBD-related surgery, use of medications for IBD, or status of IBD. CONCLUSION Patients with IBD may have an increased risk for severe acute RT-related gastrointestinal complications that is more modest than generally perceived, because all patients who had Grade > or =3 acute complications in this study had received concurrent chemotherapy (p = 0.04). Further study is needed to assess this risk, as well as the impact of RT on these patients' future gastrointestinal morbidity.
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Affiliation(s)
- D Y Song
- Division of Radiation Oncology, Johns Hopkins Hospital, Baltimore, MD, USA
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Abstract
BACKGROUND The term genetic anticipation is used when genetically transmitted disease manifests at increasingly younger ages with each succeeding generation: that is, if the offspring of patients develop the disease, they will tend to do so at an earlier age than their parents. In some monogenetic disorders, genetic anticipation has a biological basis in expanded genetic triplet repeats; however, some have claimed that it occurs in polygenic disorders, such as Crohn disease, in which its mechanism cannot be explained. OBJECTIVE To show how apparent changes in age at diagnosis of Crohn disease between generations, which could suggest genetic anticipation, can be an artifact of inadequate analysis based on age at diagnosis in cohorts that have not been followed for a sufficiently long time. DESIGN Comparison of ages at diagnosis of Crohn disease among different birth cohorts, before and after adjustment for observation time. SETTING Meyerhoff Center for Inflammatory Bowel Disease, Johns Hopkins Hospital, Baltimore, Maryland. PATIENTS 928 consecutive outpatients with Crohn disease. MEASUREMENTS Trends in age at diagnosis of Crohn disease among birth cohorts were determined by calculating Pearson correlation coefficients and performing Kaplan-Meyer analysis before and after adjustment for observation time. Adjustment for observation time was performed by ensuring that the time during which all included patients were at risk for Crohn disease was equal and that all patients had developed disease by the end of the risk period. RESULTS Mean age at diagnosis decreased by approximately 5 years with each subsequent 10-year birth cohort on the basis of crude cross-sectional data that could suggest genetic anticipation between generations. However, after adjustment for observation time, the age at diagnosis decreased minimally, if at all, with each successive generation. CONCLUSIONS Apparent genetic anticipation can be explained by observational biases without invoking any additional genetic influences. Claims for genetic anticipation must be based on methods that properly account for the duration of observation in all persons being studied.
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Affiliation(s)
- M F Picco
- Mayo Clinic Jacksonville, 4500 San Pablo Road, Jacksonville, FL 32224, USA
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Ogura Y, Bonen DK, Inohara N, Nicolae DL, Chen FF, Ramos R, Britton H, Moran T, Karaliuskas R, Duerr RH, Achkar JP, Brant SR, Bayless TM, Kirschner BS, Hanauer SB, Nuñez G, Cho JH. A frameshift mutation in NOD2 associated with susceptibility to Crohn's disease. Nature 2001; 411:603-6. [PMID: 11385577 DOI: 10.1038/35079114] [Citation(s) in RCA: 3393] [Impact Index Per Article: 147.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Crohn's disease is a chronic inflammatory disorder of the gastrointestinal tract, which is thought to result from the effect of environmental factors in a genetically predisposed host. A gene location in the pericentromeric region of chromosome 16, IBD1, that contributes to susceptibility to Crohn's disease has been established through multiple linkage studies, but the specific gene(s) has not been identified. NOD2, a gene that encodes a protein with homology to plant disease resistance gene products is located in the peak region of linkage on chromosome 16 (ref. 7). Here we show, by using the transmission disequilibium test and case-control analysis, that a frameshift mutation caused by a cytosine insertion, 3020insC, which is expected to encode a truncated NOD2 protein, is associated with Crohn's disease. Wild-type NOD2 activates nuclear factor NF-kappaB, making it responsive to bacterial lipopolysaccharides; however, this induction was deficient in mutant NOD2. These results implicate NOD2 in susceptibility to Crohn's disease, and suggest a link between an innate immune response to bacterial components and development of disease.
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Affiliation(s)
- Y Ogura
- Department of Pathology and Comprehensive Cancer Center, The University of Michigan Medical School, Ann Arbor, Michigan 48109, USA
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Brant SR, Panhuysen CI, Bailey-Wilson JE, Rohal PM, Lee S, Mann J, Ravenhill G, Kirschner BS, Hanauer SB, Cho JH, Bayless TM. Linkage heterogeneity for the IBD1 locus in Crohn's disease pedigrees by disease onset and severity. Gastroenterology 2000; 119:1483-90. [PMID: 11113069 DOI: 10.1053/gast.2000.20245] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS There is evidence for the IBD1 Crohn's disease (CD) susceptibility locus on chromosome 16 in several but not all populations studied. Genetic and phenotypic heterogeneity may underlie ability to replicate IBD1. We determined if age and severity stratification could identify a clinical subgroup at risk for IBD1. METHODS Linkage analysis at microsatellites spanning chromosome 16 was performed in 2 groups of CD pedigrees: group 1, 57 pedigrees with at least one affected relative classified as having "severe" disease, by history of surgical resection or immunomodulator therapy, and with disease diagnosed before age 22; and group 2, 33 pedigrees with no history of early-onset, severe CD. RESULTS Group 1 pedigrees demonstrated genomewide significant linkage evidence for the IBD1 locus (nonparametric multipoint logarithm of the odds [Mlod], 3.84; P = 1.3 x 10(-5)) with linkage evidence greater than all 90 pedigrees (Mlod, 2.12; P = 9.0 x 10(-4)). Group 2 pedigrees had near zero nonparametric 2-point and Mlod scores for the IBD1 region. Heterogeneity between groups 1 and 2 was significant (P = 0.002). CONCLUSIONS Presence of early-onset, more severe CD identifies pedigrees at high risk for IBD1. These pedigrees will have more power to refine the IBD1 locus and identify the causative gene.
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Affiliation(s)
- S R Brant
- Harvey M. and Lyn P. Meyerhoff Inflammatory Bowel Disease Center, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA
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Abstract
The delayed diagnosis of musculoskeletal complications of Crohn's disease may produce major morbidity in patients. This study compared abdominal and pelvic computed tomography (CT) with conventional radiography in the diagnosis of musculoskeletal complications in 23 of 552 patients with Crohn's disease examined by CT over a 7-year period. Surgical confirmation was available in 15 of 21 patients. The clinical features of psoas/gluteal abscesses, abdominal wall fistulae, and sacral osteomyelitis are described. Because the clinical manifestations of these musculoskeletal complications are often nonspecific, CT is often useful in diagnosing and directing therapeutic interventions.
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Cuffari C, Hunt S, Bayless TM. Enhanced bioavailability of azathioprine compared to 6-mercaptopurine therapy in inflammatory bowel disease: correlation with treatment efficacy. Aliment Pharmacol Ther 2000; 14:1009-14. [PMID: 10930894 DOI: 10.1046/j.1365-2036.2000.00812.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Azathioprine and 6-mercaptopurine have proven efficacy in the treatment of Crohn's disease. Immunosuppression is mediated by their intracellular metabolism into active 6-thioguanine metabolites, and clinical responsiveness to therapy in patients with inflammatory bowel disease has been correlated with the measure of erythrocyte 6-thioguanine levels. AIMS AND METHODS To perform a dosing equivalency analysis and comparison of clinical efficacy in 82 patients with inflammatory bowel disease on long-term (> 2 months) therapy with either branded azathioprine (Imuran) (n=26), generic azathioprine (n=38), or 6-mercaptopurine (n=18), based on the measurement of erythrocyte 6-thioguanine metabolite levels. RESULTS Disease remission was achieved in 51% (42 out of 82) of patients treated with either azathioprine or 6-mercaptopurine therapy, and correlated well with high erythrocyte 6-thioguanine levels (> 250 pmoles/8 x 108 RBCs). Patients treated with either branded azathioprine or 6-mercaptopurine achieved significantly higher erythrocyte 6-thioguanine levels than patients treated with generic azathioprine, thereby suggesting that branded azathioprine has improved oral bioavailability compared to generic azathioprine. These data are consistent with the putative immunosuppressive role of 6-thioguanine metabolites in the treatment of inflammatory bowel disease, and provides a basis for developing a therapeutic index of clinical efficacy based on the measurement of erythrocyte 6-thioguanine metabolite levels. CONCLUSIONS Our results suggest that differences in bioavailability may have clinical relevance when considering the need to optimize erythrocyte 6-thioguanine metabolite levels in patients deemed unresponsive to treatment on conventional drug dosages.
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Affiliation(s)
- C Cuffari
- Department of Paediatrics, The Johns Hopkins Hospital, Baltimore, MD 21287, USA.
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Abstract
Three atypical colitides (and enterides) are collagenous colitis, lymphocytic colitis, and ileal pouchitis. Collagenous and lymphocytic colitis are similar inflammatory bowel disorders of unknown cause with symptoms including chronic watery diarrhea, occurring in middle age. Pouchitis is the most significant long-term complication in patients with ileoanal pouch anastomosis. The clinical and histologic features and management of these entities are discussed.
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Affiliation(s)
- M Cruz-Correa
- Division of Gastroenterology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA
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13
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Abstract
Collagenous colitis is a recently described form of chronic inflammatory bowel disease. Other inflammatory bowel disorders are associated with increased risk of colorectal and extracolonic malignancies, but this has not been evaluated in collagenous colitis. Colorectal and extracolonic malignancies were identified in 117 patients with collagenous colitis from the Johns Hopkins Registry. The incidence rates of identified tumors, overall incidence rate of tumors, and overall mortality were then compared with general population through person year analysis with adjustment for population. No cases of colorectal cancer were found in collagenous colitis patients during a mean follow-up period of 7.0 years (range 2-12 years) after the diagnosis of colitis. Two patients developed colorectal cancer prior to the diagnosis of colitis, but no increase in life-time relative risk of colorectal cancer was found (relative risk 0.52; 95% confidence limits 0.05-1.5). An increased relative risk of lung cancer in women (relative risk 3.7; 95% confidence limits 1.0-9.6; p = 0.048) was noted. The relative risk of overall malignancy and overall mortality was not different than the general population. In collagenous colitis patients the life-time relative risk of colorectal cancer and the relative risk after the diagnosis of colitis with a mean observation period of 7 years was not increased. An increase in relative risk of lung cancer in women with collagenous colitis argues for further investigation of the role of smoking and other factors in this disorder.
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Affiliation(s)
- J L Chan
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA
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Brant SR, Fu Y, Fields CT, Baltazar R, Ravenhill G, Pickles MR, Rohal PM, Mann J, Kirschner BS, Jabs EW, Bayless TM, Hanauer SB, Cho JH. American families with Crohn's disease have strong evidence for linkage to chromosome 16 but not chromosome 12. Gastroenterology 1998; 115:1056-61. [PMID: 9797357 DOI: 10.1016/s0016-5085(98)70073-3] [Citation(s) in RCA: 95] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND & AIMS Two European genome-wide screens for inflammatory bowel disease have identified two significant regions of linkage on chromosomes 16 (IBD1) and 12 (IBD2) and two regions with suggestive levels of significance (chromosomes 3p and 7q). The aim of this study was to determine if there was evidence for linkage to these regions in non-Jewish and Ashkenazi Jewish families multiplex for Crohn's disease from the United States. METHODS One hundred forty-eight affected relative pairs, 34% Ashkenazim, were genotyped with 10-14 highly polymorphic markers overlying each candidate region. Nonparametric multipoint and two-point linkage analyses were performed. RESULTS Significant evidence for replication of linkage was found only for the chromosome 16 locus, IBD1, maximal at D16S769 (nonparametric linkage score [NPL], 2.49; P = 0.007). Analysis by ethnicity showed stronger evidence for Ashkenazim (D16S769; NPL = 2. 52; P = 0.007) than for non-Jewish white populations (D16S401; NPL = 1.40; P = 0.082). There was no significant evidence for replication on chromosome 12 (IBD2). Minimal evidence for extension of linkage evidence was observed for the chromosomes 3p and 7q regions. CONCLUSIONS American families, particularly Ashkenazim, have significant evidence for the Crohn's disease susceptibility locus, IBD1, on chromosome 16, but not for IBD2 on chromosome 12.
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Affiliation(s)
- S R Brant
- Harvey M. and Lynn P. Meyerhoff Inflammatory Bowel Disease Center, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Cho JH, Nicolae DL, Gold LH, Fields CT, LaBuda MC, Rohal PM, Pickles MR, Qin L, Fu Y, Mann JS, Kirschner BS, Jabs EW, Weber J, Hanauer SB, Bayless TM, Brant SR. Identification of novel susceptibility loci for inflammatory bowel disease on chromosomes 1p, 3q, and 4q: evidence for epistasis between 1p and IBD1. Proc Natl Acad Sci U S A 1998; 95:7502-7. [PMID: 9636179 PMCID: PMC22666 DOI: 10.1073/pnas.95.13.7502] [Citation(s) in RCA: 293] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/1998] [Accepted: 04/20/1998] [Indexed: 02/07/2023] Open
Abstract
The idiopathic inflammatory bowel diseases, Crohn's disease (CD) and ulcerative colitis (UC), are chronic, frequently disabling diseases of the intestines. Segregation analyses, twin concordance, and ethnic differences in familial risks have established that CD and UC are complex, non-Mendelian, related genetic disorders. We performed a genome-wide screen using 377 autosomal markers, on 297 CD, UC, or mixed relative pairs from 174 families, 37% Ashkenazim. We observed evidence for linkage at 3q for all families (multipoint logarithm of the odds score (MLod) = 2.29, P = 5.7 x 10(-4)), with greatest significance for non-Ashkenazim Caucasians (MLod = 3.39, P = 3.92 x 10(-5)), and at chromosome 1p (MLod = 2.65, P = 2.4 x 10(-4)) for all families. In a limited subset of mixed families (containing one member with CD and another with UC), evidence for linkage was observed on chromosome 4q (MLod = 2.76, P = 1.9 x 10(-4)), especially among Ashkenazim. There was confirmatory evidence for a CD locus, overlapping IBD1, in the pericentromeric region of chromosome 16 (MLod = 1.69, P = 2.6 x 10(-3)), particularly among Ashkenazim (MLod = 1.51, P = 7.8 x 10(-3)); however, positive MLod scores were observed over a very broad region of chromosome 16. Furthermore, evidence for epistasis between IBD1 and chromosome 1p was observed. Thirteen additional loci demonstrated nominal (MLod > 1.0, P < 0.016) evidence for linkage. This screen provides strong evidence that there are several major susceptibility loci contributing to the genetic risk for CD and UC.
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MESH Headings
- Chromosome Mapping
- Chromosomes, Human, Pair 1
- Chromosomes, Human, Pair 16
- Chromosomes, Human, Pair 3
- Chromosomes, Human, Pair 4
- Colitis, Ulcerative/genetics
- Crohn Disease/genetics
- Disease Susceptibility
- Epistasis, Genetic
- Genetic Linkage
- Genetic Markers
- Genotype
- Humans
- Lod Score
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Affiliation(s)
- J H Cho
- The Emma Getz Inflammatory Bowel Disease Research Center, Department of Medicine, The University of Chicago Hospitals, 5841 S. Maryland Avenue, MC6084, Chicago, IL 60637, USA
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17
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Abstract
BACKGROUND & AIMS Crohn's disease has a bimodal age distribution of disease onset diagnosis. The peaks (20 and 50 years) may represent different phenotypes or different genetic and/or environmental influences between younger- and older-onset individuals. The aim of this study was to examine the influences of age at diagnosis of Crohn's disease on disease site, type, and course. METHODS Records of 552 consecutive patients with Crohn's disease were reviewed retrospectively. RESULTS Younger age at diagnosis (younger than 20 years), compared with an older age (40 years or older), was associated with a greater prevalence of a family history of Crohn's disease (29.9% vs. 13.6%), greater small bowel involvement (88.7% vs. 57.5%), more stricturing disease (45.8% vs. 28.8%), and a higher frequency of surgery (70.6% vs. 55.3%). Older age at diagnosis was associated with a greater prevalence of colonic disease (84.8% vs. 71.2%) and the inflammatory subtype (54.5% vs. 34.4%). A conditional logistic regression analysis confirmed an independent effect of age at diagnosis on ileal disease and surgery for intractable disease. CONCLUSIONS In Crohn's disease, early age at diagnosis is associated with more complicated disease and a greater likelihood of having affected relatives. Stratification of Crohn's disease by age at diagnosis provides support for the concept of genetic heterogeneity.
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Affiliation(s)
- J M Polito
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Bayless TM, Tokayer AZ, Polito JM, Quaskey SA, Mellits ED, Harris ML. Crohn's disease: concordance for site and clinical type in affected family members--potential hereditary influences. Gastroenterology 1996; 111:573-9. [PMID: 8780559 DOI: 10.1053/gast.1996.v111.pm8780559] [Citation(s) in RCA: 140] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS The association of genetic influences between bowel location and clinical type of Crohn's disease may provide more information on the genetic heterogeneity of inflammatory bowel disease. The aim of this study was to analyze familial occurrences of Crohn's disease for concordance for site and type. METHODS Of 554 consecutive patients, 95 (17%) had a family history of Crohn's disease. Sixty families were analyzed for concordance for site and clinical type and by a series of conditional logistic regression models to test the significance of concordance within families. RESULTS Eighty-six percent of families were concordant in at least 2 members for the site of Crohn's disease, and 82% were concordant for clinical type. Pairing family members together, concordance greater than expected in an unrelated population was observed. Using a conditional logistic regression model, a statistically significant role for concordance in predicting site and type of Crohn's disease in other affected family members was found. CONCLUSIONS Greater-than-expected concordance for site and clinical type of Crohn's disease within individual families is compatible with a concept of multiple, distinct forms of Crohn's disease, which, although possibly influenced by environment, seem more likely to be separate inheritable forms or phenotypes.
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Affiliation(s)
- T M Bayless
- Gastroenterology Division, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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20
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Abstract
BACKGROUND The term genetic anticipation is used to describe earlier onset of disease, increased severity, or both, in succeeding generations of families affected by a particular disease. This process has been linked with expanded genomic trinucleotide repeat regions in some neurological disorders. Crohn's disease, an inflammatory bowel disorder, has genetic influences, which remain undefined. We studied pairs of two-generation first-degree relatives with Crohn's disease to seek evidence for genetic anticipation in this disorder. METHODS Through retrospective review of the records of 552 patients treated for Crohn's disease at Johns Hopkins Hospital, we identified 27 pairs of two-generation first-degree relatives. We also studied 32 such pairs identified through a multicentre survey. After exploratory analyses by t tests, a generalised estimating equations approach was used to fit a marginal regression model. FINDINGS The age at diagnosis was earlier in the younger member of the pair both in the Johns Hopkins Hospital dataset (18.9 [SE 6.9] vs 31.4 [12.0] years) and in the multicentre survey dataset (16.9 [7.4] vs 33.1 [11.9] years). The regression model confirmed the findings: the best-fitting model for the Johns Hopkins Hospital data showed an average 10.8 (SE 4.2) year difference in age at diagnosis between parent and child; that for the multicentre data showed an average difference of 15.1 (1.5) years. There was evidence of a further difference between the second and third generations. Disease was more extensive in the offspring than in the parent for 15 of the 27 pairs at Johns Hopkins Hospital; in 13 of these pairs the affected parent was the father. INTERPRETATION The evidence of a lower age at diagnosis and a greater extent of disease in the younger member of two-generation pairs affected by Crohn's disease, as well as the association with paternal transmission, suggest that genetic anticipation does occur in Crohn's disease. A search for triplet repeat regions is warranted.
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Affiliation(s)
- J M Polito
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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22
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Bayless TM, Paige DM, Bedine MS. Lactose intolerance. N Engl J Med 1995; 333:1358-9. [PMID: 7566040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Shermak MA, Saavedra JM, Jackson TL, Huang SS, Bayless TM, Perman JA. Effect of yogurt on symptoms and kinetics of hydrogen production in lactose-malabsorbing children. Am J Clin Nutr 1995; 62:1003-6. [PMID: 7572723 DOI: 10.1093/ajcn/62.5.1003] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Lactase-deficient adults demonstrate improved lactose absorption and fewer symptoms when consuming yogurt than when consuming milk containing equivalent amounts of lactose. To examine this effect and its mechanisms in children, we compared symptoms and hydrogen production as an index of lactose malabsorption after typical servings of milk, pasteurized yogurt, and yogurt containing active live culture in 14 lactose-malabsorbing children (mean age 9.5 y). Symptoms and interval breath-hydrogen concentrations were recorded for 8 h after ingestion of 12 g lactose served as milk and yogurts. Lactose-malabsorbing children experienced significantly fewer symptoms after consuming yogurt containing active cultures than after consuming milk (P < 0.005). Pasteurized yogurt showed an intermediate effect. Lactose from yogurt was not better absorbed than was lactose from milk, as indicated by similar areas under the hydrogen curve; however, yogurt was associated with a delayed time to rise and lower rate of rise of the hydrogen curve. The rate of hydrogen rise correlated with the degree of symptoms. In children, mechanisms other than enhanced lactose absorption from yogurt may lead to changes in the kinetics of hydrogen production, which in turn are associated with improved tolerance.
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Affiliation(s)
- M A Shermak
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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24
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Abstract
BACKGROUND The ileal anal pull-through procedure has become the most frequently used cointinence sparing procedure for patients with ulcerative colitis or familial polyposis. Areas of controversy concern the use of temporary ileostomies, and the extent of the rectal mucosectomy. The current report presents a single surgeon's experience with mucosectomy to the perianal skin (squamous mucosectomy), with ileal J-pouch reservoir construction and temporary ileostomy. METHODS We reviewed the records of 105 consecutive patients undergoing this procedure by a single surgeon during a 5-year period. One hundred percent follow-up was achieved. RESULTS There was 100% gross fecal continence, with 5% of patients expressing rare day time leakage, and 28% having intermittent nocturnal leakage. There were no instances of pelvic sepsis, and no pouches have been removed. The diverting ileostomy was associated with 6% morbidity. CONCLUSIONS We conclude that the rectal mucosectomy can be safely extended to the levels of perianal skin with no loss in continence or function. We recommend that this be adopted as the standard for this procedure to ensure complete eradication of the underlying pathologic condition.
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Affiliation(s)
- J V Sitzmann
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287-4665, USA
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25
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Giardiello FM, Lazenby AJ, Bayless TM. The new colitides, Collagenous, lymphocytic, and diversion colitis. Gastroenterol Clin North Am 1995; 24:717-29. [PMID: 8809245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Three recently described colitides are collagenous, lymphocytic, and diversion colitis. Collagenous and lymphocytic colitis are similar inflammatory bowel disorders of unknown cause that present as chronic watery diarrhea in middle age. Diversion colitis occurs as the result of surgery in which segments of the large intestine are excluded from the fecal stream. The clinical and histologic features of these entities are discussed.
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Affiliation(s)
- F M Giardiello
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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26
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Montes RG, Bayless TM, Saavedra JM, Perman JA. Effect of milks inoculated with Lactobacillus acidophilus or a yogurt starter culture in lactose-maldigesting children. J Dairy Sci 1995; 78:1657-64. [PMID: 8786251 DOI: 10.3168/jds.s0022-0302(95)76790-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Dairy products containing live bacteria that possess lactase activity are used for dietary management of lactose maldigestion. The efficacy of acidophilus milk and the effect of consuming unfermented milk that had been inoculated with yogurt bacteria have not been examined in children. We compared scores for breath H2 excretion and symptoms of 20 lactose-maldigesting children following ingestion of 250 ml of uninoculated milk with two identical milks inoculated with 10(10) cells of Lactobacillus acidophilus or with a commercial yogurt starter culture containing 10(8) cells of Lactobacillus lactis and 10(10) cells of Streptococcus thermophilus. Nine of 10 subjects who were symptomatic following ingestion of uninoculated milk experienced a reduction in symptoms following ingestion of milk inoculated with L. acidophilus, without a decline in H2 excretion. Five of 6 subjects who were symptomatic following uninoculated milk had decreased symptoms and a significant reduction in H2 excretion following milk inoculated with the yogurt culture. For lactose-maldigesting children, milks inoculated with L. acidophilus or with a yogurt culture were associated with decreased symptoms compared with those with uninoculated milk.
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Affiliation(s)
- R G Montes
- Department of Pediatrics, David Grant US Air Force Medical Center, Travis Air Force Base, CA 94535, USA
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27
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Abstract
PURPOSE Most patients with primary sclerosing cholangitis also have ulcerative colitis. It has been suggested that in the presence of primary sclerosing cholangitis the risk of colorectal dysplasia and carcinoma is greater than in patients with ulcerative colitis alone. METHODS In a retrospective study, we evaluated the possibility of colorectal cancer or dysplasia in 35 consecutive patients with primary sclerosing cholangitis and ulcerative colitis seen at The Johns Hopkins Hospital between 1979 and 1991. RESULTS Thirteen of the 35 patients (37 percent) with ulcerative colitis and primary sclerosing cholangitis had colorectal neoplasia (5 with adenocarcinoma and 8 with dysplasia). In the 27 patients undergoing colonoscopic biopsy surveillance, the cumulative incidence at 28 years of colorectal cancer was 18.5 percent and for colorectal dysplasia it was 29.6 percent. The high incidence of colorectal cancer was less than the rate of colorectal cancer in patients with extensive colitis of childhood onset without primary sclerosing cholangitis (35 percent), but the rate of colorectal cancer and dysplasia (48.1 percent) is similar to the highest rates of cancer noted in the comparison group. Because patients had subtle, quiescent colitis, a short time from diagnosis of ulcerative colitis to diagnosis of colorectal neoplasia was noted (mean, 12.2 +/- 9 years; less than 8 years in 5/13 (38.5 percent) patients). CONCLUSION Ulcerative colitis patients with primary sclerosing cholangitis appear to have a high frequency of colorectal cancer but a rate lower than expected in patients with extensive quiescent ulcerative colitis of childhood onset alone. However, exact conclusions are complicated by the high incidence of colorectal dysplasia found, which portends malignant transformation. Because of the subtle nature of colitis, the diagnosis of ulcerative colitis is often delayed, and surveillance programs should start as soon as ulcerative colitis is diagnosed.
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Affiliation(s)
- A K Gurbuz
- Meyerhoff Digestive Disease and Inflammatory Bowel Disease Center, Department of Medicine, Johns Hopkins University School of Medicine and Hospital, Baltimore, Maryland 21287-4461
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28
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Abstract
Two patients presented to their clinicians with bowel complaints thought to be suggestive of Crohn's disease. The patients were sent for radiological studies to confirm that diagnosis. The radiologic findings in both patients were thought to be consistent with Crohn's disease, although not classical. No further diagnostic studies were initially undertaken. Each patient suffered small bowel obstruction and at surgery each was found to have a mucinous adenocarcinoma of the ileocecal valve. No evidence of Crohn's disease was found. At pathologic examination some interesting characteristics of the tumors were observed, which perhaps accounted for the misdiagnosis of Crohn's disease. It also was evident that the clinical information supplied to the radiologist may have influenced the radiologic interpretations. These cases stress the importance of obtaining tissue diagnoses in situations where radiographic findings are consistent but atypical with the clinical diagnosis of Crohn's disease.
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Affiliation(s)
- K M Horton
- Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland 21287
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29
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Abstract
BACKGROUND Lack of a suitable model has hindered efforts to understand inflammation and granuloma formation in Crohn's disease. METHODS Granulomalike aggregates of circulating mononuclear cells are produced in vitro by cultures of cells with polyacrylamide beads. To identify features of in vitro aggregates, which are similar to tissue granulomas of Crohn's disease, the gross morphology and immunohistological appearance of the aggregates produced with peripheral blood mononuclear cells from patients with Crohn's disease were analyzed, and the size of in vitro aggregates was correlated with clinical activity of the disease. Blocking antibodies were used to evaluate the role of cell-adhesion molecules in the formation of in vitro aggregates. RESULTS The size of in vitro aggregates correlates very significantly with clinical activity (P < 0.001). In active Crohn's disease, in vitro aggregates show immunohistological features of hypersensitivity type granulomas. Blocking antibodies against leukocyte function associated antigen LFA-2 (CD2), LFA-3 (CD58), and Mac-1 (CD11b/CD18) inhibit in vitro aggregate formation. CONCLUSION In vitro aggregates model in vivo granulomas in size and organization. Cell adhesion molecules like CD2, CD58, and CD11b/CD18 may be involved in granuloma-formation of Crohn's disease.
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Affiliation(s)
- L Mishra
- Department of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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31
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Abstract
To gain information on the pathogenesis of ileal recurrence, 86 patients with Crohn's disease undergoing their first ileocolic resection were randomized to receive either an end-to-end (n = 47) or side-to-end (n = 39) anastomosis. The demographic and clinical characteristics of both groups were similar. There were no statistically significant differences between the two groups in postoperative complications or in the subsequent development of symptomatic or documented recurrences. Among the 43 patients with follow-up in the end-to-end anastomosis group, there were 10 documented ileal recurrences (23%), and all involved distal ileum in the characteristic preanastomotic location. Among the 35 patients with follow-up in the side-to-end anastomosis group, there were 11 documented recurrences (31%, not significant). The ileal recurrence pattern could be determined accurately in five of these 11 patients and involved the ileum adjacent to the colon, but spared the distal ileum in the blind pouch. This study suggests that the fecal stream and reflux of colonic contents are important factors in determining the pattern of ileal recurrence after ileocolectomy for Crohn's disease.
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Affiliation(s)
- J L Cameron
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
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32
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Mullin GE, Lazenby AJ, Harris ML, Bayless TM, James SP. Increased interleukin-2 messenger RNA in the intestinal mucosal lesions of Crohn's disease but not ulcerative colitis. Gastroenterology 1992; 102:1620-7. [PMID: 1568572 DOI: 10.1016/0016-5085(92)91722-g] [Citation(s) in RCA: 140] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Crohn's disease (CD) is characterized by granulomatous inflammation of the intestinal mucosa, but the etiology and pathogenesis of the inflammatory lesions are unknown. The aim of this study was to determine whether T-cell activation and lymphokine production occurs in the mucosal lesions of this disease. Total cellular RNA was isolated from peripheral blood lymphocytes and from colonoscopic mucosal biopsies of normal individuals and patients with CD of the colon or ulcerative colitis (UC). Levels of interleukin-2 (IL-2) messenger RNA (mRNA) transcripts in samples were determined using a quantitative reverse transcriptase polymerase chain reaction method. IL-2 mRNA transcripts were detected in histologically normal intestinal mucosal biopsies obtained from control subjects. In CD, higher levels of IL-2 mRNA transcripts were detected in the mucosa from areas of active inflammation, but in areas that were histologically normal, levels were similar to control subjects. The levels of IL-2 mRNA transcripts in biopsies from active and inactive UC were similar to control subjects. Levels of IL-2 mRNA in peripheral blood lymphocytes were low and not significantly different in all groups of subjects. In conclusion, the normal intestinal mucosa contains IL-2 mRNA transcripts and may be an important source of IL-2. Furthermore, the inflammatory lesions of CD, but not UC, have higher levels of IL-2 mRNA transcripts, suggesting that T-cell activation and lymphokine secretion in the intestine may be important in the pathogenesis of CD. These data provide further evidence that the pathogenesis of CD and UC are different.
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Affiliation(s)
- G E Mullin
- Mucosal Immunity Section, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
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33
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Giardiello FM, Lazenby AJ, Yardley JH, Bias WB, Johnson J, Alianiello RG, Bedine MS, Bayless TM. Increased HLA A1 and diminished HLA A3 in lymphocytic colitis compared to controls and patients with collagenous colitis. Dig Dis Sci 1992; 37:496-9. [PMID: 1551336 DOI: 10.1007/bf01307569] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Lymphocytic colitis is a newly described chronic diarrheal disorder. Although its etiology is unknown, the possibility has been raised that autoimmunity may play a role in both lymphocytic and collagenous colitis, a similar clinicopathologic illness. The frequencies of HLA class I and class II antigens were examined in 24 white patients with lymphocytic colitis and in 47 white patients with collagenous colitis. Frequencies in these two disorders were compared to control white populations and to each other. An increased frequency of HLA-A1 was noted in 16 of 24 lymphocytic colitis patients (66.6%) compared with 1089 of 3942 controls (27.6%) (P less than 0.005; relative risk 5.2). Furthermore, HLA-A3 was found in decreased frequency in lymphocytic colitis patients: 0 of 24 (0%) compared with 1017 of 3942 controls (25.8%) (P less than 0.05; relative risk 0.0). Collagenous colitis patients had no significant deviation from control frequencies of HLA antigens. In lymphocytic colitis, there was no significant increase in B8 or DR3 antigens, which are found in linkage disequilibrium with A1 and associated with many autoimmune diseases. Moreover, the frequency of autoimmune-associated class I HLA antigens was not increased in lymphocytic colitis. Statistically significant differences existed between lymphocytic and collagenous colitis in HLA-A1, A3, Bw6, and B7 antigen frequencies. The HLA patterns noted previously in other gastrointestinal disorders, including ulcerative colitis and Crohn's disease, were not apparent in lymphocytic or collagenous colitis. HLA typing provides further evidence that lymphocytic colitis is a distinct form of chronic intestinal inflammatory disease associated with HLA class I phenotypes.
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Affiliation(s)
- F M Giardiello
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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35
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Merine D, Jones B, Ghahremani GG, Hamilton SR, Bayless TM. Hyperplasia of Brunner glands: the spectrum of its radiographic manifestations. Gastrointest Radiol 1991; 16:104-8. [PMID: 2016018 DOI: 10.1007/bf01887320] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Radiographic features of the duodenal mucosa were analyzed in a series of 26 patients in whom the diagnosis of Brunner gland hyperplasis (BGH) had been established by endoscopic biopsies. The observed mucosal patterns could be classified into five categories: (1) focal BGH causing a solitary submucosal adenoma or a cluster of sessile polyps in the otherwise smooth duodenal bulb surface (five cases); (2) diffuse BGH manifested by a myriad of small and uniform mucosal elevations (six cases); (3) multifocal BGH producing large and well-demarcated polygonal masses (six cases); (4) BGH with concomitant acute and/or chronic duodenitis showing marked thickening and nodularity of duodenal folds (four cases); or (5) BGH with predominant erosive duodenitis, leading to ulcerations (five cases). These radiographic findings showed a good correlation with the endoscopic and histopathologic manifestations of BGH and the frequently coexistent duodenitis.
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Affiliation(s)
- D Merine
- Department of Radiology and Radiological Sciences, Johns Hopkins Medical Institutions, Baltimore, Maryland
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36
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Abstract
The efficacy and safety of therapy with azathioprine/6-mercaptopurine was studied in 78 patients with Crohn's disease. Mean duration of therapy was 1.6 years; 52 patients were treated greater than or equal to 6 months. All patients were also on other antiinflammatory medications. Evaluations included self-assessment and physician's assessment of well-being, functional capacity, general clinical response, clinical activities indices (National Foundation for Ileitis and Colitis/International Organization for the Study of Inflammatory Bowel Disease and Harvey-Bradshaw), and achievement of specific therapeutic goals. General clinical condition improved in 70% of the patients. Median response time was 3 months. The average Harvey-Bradshaw score decreased 37% with therapy, and a decrease of greater than or equal to 30% occurred in 66% of the subjects. An overall 72% achievement rate for specified therapeutic goals included controlling refractory disease, 73%; corticosteroid "sparing," 76%; and lessening fistulization, 63%. Nine patients got worse despite therapy. Adverse effects requiring discontinuation of therapy occurred in 10%, whereas dosages were briefly lowered for mild side effects in another 10%. This study demonstrates the effectiveness and safety of azathioprine/6-mercaptopurine in the majority of selected patients with chronic, unremitting, or steroid-requiring Crohn's disease.
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Affiliation(s)
- J J O'Brien
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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37
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Sitzmann JV, Converse RL, Bayless TM. Favorable response to parenteral nutrition and medical therapy in Crohn's colitis. A report of 38 patients comparing severe Crohn's and ulcerative colitis. Gastroenterology 1990; 99:1647-52. [PMID: 2121580 DOI: 10.1016/0016-5085(90)90470-l] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The courses of 38 patients with severe, uncomplicated acute colitis (16 with Crohn's colitis and 22 with ulcerative colitis) were analyzed retrospectively. The patients were placed on total parenteral nutrition and treated concomitantly with corticosteroids, antibiotics (often metronidazole), sulfasalazine, and/or azathioprine. Fifteen of the 16 Crohn's colitis patients were initially managed without surgery. Four patients subsequently relapsed, two responded to reinstituted medical therapy, and two underwent colon resection 2 and 4 years later. Of 22 ulcerative colitis patients, 16 required surgery during the initial hospitalization, one patient subsequently had surgery, and one died after refusing surgery. Three of the other four continue in remission on medical therapy. Thus, there were significant differences in this series between the clinical courses of severe ulcerative colitis and severe Crohn's colitis. While most of the ulcerative colitis patients with severe disease underwent colectomy, most of the patients with severe but uncomplicated Crohn's colitis responded to aggressive medical therapy, of which total parenteral nutrition and perhaps bowel rest seemed to be an important part. Afterwards, the majority remained in remission on long-term medical therapy.
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Affiliation(s)
- J V Sitzmann
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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38
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39
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Kern SE, Yardley JH, Lazenby AJ, Boitnott JK, Yang VW, Bayless TM, Sitzmann JV. Reversal by antrectomy of endocrine cell hyperplasia in the gastric body in pernicious anemia: a morphometric study. Mod Pathol 1990; 3:561-6. [PMID: 2235980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Multifocal gastric carcinoid tumors occasionally develop in patients with pernicious anemia, associated with hyperplasia of endocrine cells in the atrophic and metaplastic gastric body mucosa. This constellation of findings probably requires a trophic drive from hypergastrinemia associated with antral G cell hyperplasia, a consequence of achlorhydria in these patients. We report a case in which antrectomy was performed on such a patient in order to abrogate the trophic stimulus. Antrectomy was followed by resolution of hypergastrinemia and a decrease in the size of polyps endoscopically. Nine months later, the gastric remnant was resected. Using morphometric techniques, endocrine cells in the initial antrectomy specimen (which included body mucosa at the resection line) were compared with those in the subsequently removed gastric body. Antrectomy resulted in striking decreases in number (137 versus 34/mm2; P = 0.0001) and size (93 versus 56 microns2; P = 0.0001) of endocrine cells of body mucosa. The findings suggest that antrectomy may be useful in the management of endocrine cell hyperplasia, and possibly also associated carcinoid tumors, in pernicious anemia.
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Affiliation(s)
- S E Kern
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland
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40
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Abstract
To further define the role of mast cells in the idiopathic inflammatory bowel diseases, mediator release from intestinal mast cells derived from actively inflamed and relatively quiescent areas of ulcerative colitis was studied. It was hypothesized that mast cells in the actively diseased segments would indicate involvement in the disease process by releasing a different profile of mediators than cells in uninflammed tissue. Mast cell-containing suspensions derived from matched segments of 12 ulcerative colitis specimens were compared for responsiveness to the mast cell stimulus goat anti-human immunoglobulin E. Supernatants from challenged cells were analyzed for levels of three mast cell mediators, histamine, prostaglandin D2, and the sulfidopeptide leukotriene C. Mast cells from the actively involved areas released significantly greater amounts of histamine, prostaglandin D2, and sulfidopeptide leukotriene. The difference in histamine release was not a result of greater stores of histamine in the active tissue cells, because the total histamine content of the mast cells from the active areas was not significantly greater. The enhanced release of both preformed and newly generated mediators indicates activation of those cells in the course of the disease and points to the mast cell contribution to the inflammatory process in these disorders.
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Affiliation(s)
- C C Fox
- Johns Hopkins Asthma and Allergy Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Greenson JK, Giardiello FM, Lazenby AJ, Peña SA, Bayless TM, Yardley JH. Antireticulin antibodies in collagenous and lymphocytic (microscopic) colitis. Mod Pathol 1990; 3:259-60. [PMID: 2362935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Serum antireticulin antibodies (ARAs) are often present in patients with dermatitis herpetiformis and celiac disease (CD), especially before instituting a gluten-free diet. In both collagenous colitis (CC) and lymphocytic (microscopic) colitis (LC) the colorectal mucosa shows surface epithelial damage with intraepithelial lymphocytes that is strikingly comparable to the small intestinal findings in CD. Also, CD may show subepithelial collagen deposition resembling that seen in CC. Because of these similarities, ARAs were measured in sera from patients with biopsy-proven CC and LC and compared with sera tested from CD patients. Antibody binding to reticulin was detected in frozen sections of rat liver and kidney by indirect immunofluorescent techniques. Whereas five of 14 CD patients (35.7%) had ARAs, only one of 29 CC patients (3.4%) (P = 0.010 versus CD) and none of 17 LC patients (0%) (P = 0.012 versus CD) had ARAs. The positive CC patient had IgA ARA titers of 1:20 noted in two sera taken 2 mo apart. The five positive CD patients had IgA ARA titers ranging from 1:20 to 1:320. The rare presence of ARAs noted in collagenous colitis and lymphocytic colitis was similar to its occurrence in normals, whereas the frequency of ARAs found in celiac disease (35.7%) was within the range reported for that disorder. Therefore, ARAs do not appear to be associated with CC or LC despite the morphologic similarities to CD.
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Affiliation(s)
- J K Greenson
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
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42
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Scott WW, Fishman EK, Kuhlman JE, Caskey CI, O'Brien JJ, Walia GS, Bayless TM. Computed tomography evaluation of the sacroiliac joints in Crohn disease. Radiologic/clinical correlation. Skeletal Radiol 1990; 19:207-10. [PMID: 2333561 DOI: 10.1007/bf00204098] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Computed tomography (CT) was used in a prospective study of the sacroiliac joints in 86 patients with Crohn disease to determine the type and frequency of sacroiliac joint abnormalities present in this population. The CT findings were correlated with review of the clinical history in 64 patients. Computed tomography demonstrated changes of sacroiliitis in 29% of the study group. This high prevalence of sacroiliac joint abnormality was found even in those under 30 years of age. It exceeds the 11-19% previously reported from plain film examination, reflecting the greater sensitivity of CT. In the subgroup of 64 patients studied clinically, 19 (30%) had abnormal sacroiliac joints on CT, but only 2 (3%) reported symptoms related to the sacroiliac joints.
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Affiliation(s)
- W W Scott
- Russell H. Morgan Department of Radiology, Johns Hopkins Medical Institutions, Baltimore, Maryland
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43
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Giardiello FM, Hansen FC, Lazenby AJ, Hellman DB, Milligan FD, Bayless TM, Yardley JH. Collagenous colitis in setting of nonsteroidal antiinflammatory drugs and antibiotics. Dig Dis Sci 1990; 35:257-60. [PMID: 2302984 DOI: 10.1007/bf01536772] [Citation(s) in RCA: 155] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Collagenous colitis is a clinicopathologic syndrome characterized by chronic watery diarrhea and a mucosal inflammatory process with increased subepithelial collagen band on colonic biopsy. This disorder occurs primarily in females, and the etiology is unknown. We report the atypical presentation of collagenous colitis in two older-aged men following prolonged use of nonsteroidal antiinflammatory agents and short-term use of antibiotics. Although one patient had colonic pseudomembranes, neither patient had microbiological evidence of C. difficile toxin or infection. A variety of medications were initially given to these patients without resolution of diarrhea. Only after the diagnosis of collagenous colitis was made and antiinflammatory drugs directed at the colitis given did the diarrhea abate. These cases illustrate an unusual presentation of collagenous colitis with possible implications for pathogenesis.
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Affiliation(s)
- F M Giardiello
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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44
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Abstract
The irritable bowel syndrome accounts for 30 to 50 per cent of patients cared for by gastroenterology practices. Irritable bowel syndrome is more common than inflammatory bowel disease. Therefore, it should not be surprising that some patients with inflammatory bowel disease are initially told that they have irritable bowel syndrome before a diagnosis of inflammatory bowel disease is firmly established. This article contends that many people have both irritable bowel syndrome and inflammatory bowel disease.
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Affiliation(s)
- T M Bayless
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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Giardiello FM, Lazenby AJ, Bayless TM, Levine EJ, Bias WB, Ladenson PW, Hutcheon DF, Derevjanik NL, Yardley JH. Lymphocytic (microscopic) colitis. Clinicopathologic study of 18 patients and comparison to collagenous colitis. Dig Dis Sci 1989; 34:1730-8. [PMID: 2582986 DOI: 10.1007/bf01540051] [Citation(s) in RCA: 102] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Lymphocytic colitis, formerly called microscopic colitis, is a clinicopathologic syndrome with chronic watery diarrhea and diffuse mucosal inflammatory changes with prominent intraepithelial lymphocytes. The 18 lymphocytic colitis patients studied presented with chronic watery diarrhea at a mean age of 53.8 +/- 17 years (+/- 1 SD). Roentgenographic, endoscopic, and culture data were not diagnostic. In patients tested, there was a high prevalence of arthritis (82%) and autoantibodies (50%) but no increase in frequency of histocompatibility antigens associated with well-defined autoimmune disease (DR3, B8). Lymphocytic colitis patients were compared to 21 patients with collagenous colitis. Similarities included age, symptomatology, and nondiagnostic radiographic and endoscopic studies. However, the sex distribution was statistically different, with an equal male-to-female ratio in lymphocytic colitis and female predominance (80%) in collagenous colitis. Other differences included dissimilar histocompatibility phenotypes and collagen band on biopsies of collagenous but not lymphocytic colitis. These findings suggest that lymphocytic and collagenous colitis may be related yet distinct disorders.
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Affiliation(s)
- F M Giardiello
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Abstract
We describe a patient with refractory sprue with malabsorption, a flat small-bowel biopsy specimen unresponsive to a gluten-free diet, and colonic biopsy specimens consistent with lymphocytic (microscopic) colitis. To investigate further the relation between celiac disease and lymphocytic or collagenous colitis (a similar and possibly related entity), we examined colorectal and small-bowel biopsy specimens in patients indexed histologically as having celiac disease who have been seen at The Johns Hopkins Hospital since 1958. Of 135 indexed patients, 21 had colorectal biopsies. Colorectal biopsy specimens were abnormal in 7 of the 21 patients. Four patients had biopsy specimens resembling lymphocytic colitis, 2 patients had acute colitis, and another patient had both lymphocytic and acute colitis. No patients had collagenous colitis. Three of the patients with lymphocytic colitis and celiac-like changes of the small bowel never responded to a gluten-free diet and may represent a distinctive panintestinal disease for which the term "lymphocytic enterocolitis" with malabsorption is proposed.
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Affiliation(s)
- R N DuBois
- Department of Internal Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD
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Affiliation(s)
- M C Knowles
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, MD 21205
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Giardiello FM, Bayless TM, Yardley JH. Collagenous colitis. Compr Ther 1989; 15:49-54. [PMID: 2647387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- F M Giardiello
- Department of Medicine, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, MD 21205
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Bayless TM. Chronic diarrhea: newly appreciated syndromes. Hosp Pract (Off Ed) 1989; 24:117-22, 124-6, 131-2 passim. [PMID: 2492029 DOI: 10.1080/21548331.1989.11703646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- T M Bayless
- Meyerhoff Digestive Disease-Inflammatory Bowel Disease Center, Johns Hopkins University School of Medicine
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