Biomedical subjects
Publications and source records attributed to R N Allan.
Six bacteria believed to be associated with IBD and/or AS and ReA were investigated for antigenic cross-reactivity using an ELISA. Considerable degrees of cross-reactivity were detected and it is suggested that if bacterial antigens are involved aetiologically in the diseases, no specific bacterium is concerned.
A retrospective cohort of 823 patients with ulcerative colitis who resided at the time of diagnosis in one of three defined geographical areas (West Midlands region, Oxford region, England and Stockholm County, Sweden) was assembled. The patients were first seen at named hospitals in these areas and the diagnosis of ulcerative colitis established within five years of onset of symptoms between 1945-1965. All patients were 15 years of age or more at onset of disease and were followed for a minimum of 17 years and a maximum of 38 years. Ninety seven per cent completeness of follow up was achieved. Examining the colorectal cancer risk in the series relative to the risk in the general population by standardised morbidity ratios, there was an eight fold increased risk of cancer in the series as a whole. Dividing the series by extent of colitis, extensive colitis patients showed a 19 fold increase in risk. A four fold increased risk was shown in the remainder of the series (left sided colitis, proctitis and extent unknown). Life table analyses in extensive colitis gave cumulative risks of 7.2% (CI 3.6-10.8) at 20 years from onset of disease and 16.5% (CI 9.0-24.0) at 30 years from onset. No significant effect of age at onset, sex or referral centre could be detected. Examination of the data by interval from onset to cancer and by actual age at development of cancer suggests that patients who develop colorectal cancer will do so in a distribution around 50 years of age independent of duration of disease in adult onset ulcerative colitis (greater than 15 years at onset of disease). An inverse relationship was shown between age at onset of disease and interval from onset of disease to cancer. Further age specific rates for cancer increased up to 50 years and decreased thereafter. These results suggest that extensive colitis patients have a genetic predisposition to colorectal cancer and that longstanding inflammation is not of primary importance in the initiation/promotion of cancer in this disease.
Fifty male patients with proctitis were examined and the clinical, microbiological, serological and proctological features compared with 51 known male homosexuals attending the genitourinary (GU) clinic at the same hospital. The homosexuals had a short history of bowel symptoms, minor sigmoidoscopic and histological changes on rectal biopsy and many positive serological markers of sexually transmitted infection. There was some evidence of sexually transmitted disease in the IBD patients and three were homosexuals. IgG antibodies were positive for chlamydia trachomatis (n = 10) and hepatitis A (n = 7). One had a positive screening test for syphilis. Stool examination and rectal swab cultures were positive in two patients for cryptosporidium and cytomegalovirus respectively. Gastroenterologists must be aware of the possibility of specific infection in IBD patients and a clinical history should include sexual preferences and practices. If homosexuality is admitted, specific infection must be sought and excluded.
A random sample of 170 patients (88 men) with chronic inflammatory bowel disease (75 ulcerative colitis) were first interviewed in 1978 about their employment status, problems at work, and influence of surgery. Surgery had been carried out on 120 and 53 had an ileostomy. After six years 144 (92%) of the 156 survivors replied to a follow up postal questionnaire. Of the initial sample, 122 (72%) were working and there were only three (1%) registered unemployed. After six years a similar proportion were working and only seven (5%) were unemployed. Continuity of employment was good with 57% in the same job. Changes in work because of health had been made by 72 patients mainly caused by bowel disease. After surgery 10% completely changed and 22% modified their work while a few had to retrain or retire. Panproctocolectomy and ileostomy resulted in more changes and longer time off work after surgery than colectomy and ileorectal anastomosis, with 35% and 17% respectively off work after one year. Problems at work, in particular general malaise and arthritis were experienced by 34 (28%) patients. Fewer problems were experienced by patients with a stoma who also had less sickness absence than those without a stoma. Colleagues and employers were usually supportive although some patients encountered discrimination especially those with a stoma or working in the food industry. Few patients had been counselled on their work. In general employment prospects and time off work were good and employers should be encouraged to take an optimistic and supportive role. Doctors should consider that convalescence after surgery may be longer than they perceive and must provide better counselling for patients.
Shigella usually causes a self-limited infection which untreated lasts on average seven days (range one to 30 days). We report a patient who had persistent symptoms for 10 months caused by Shigella flexneri which was finally identified on cultures from a rectal swab.
We report a patient with ulcerative colitis who underwent colectomy when aged 25 years for multifocal high grade dysplasia which had developed within 2 years of diagnosis, and only 5 1/2 years after his first symptoms. The implications of this case for the management of ulcerative colitis are discussed.
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Seventy-four patients have had a one-stage proctocolectomy for the management of Crohn's disease. Indications for operation were: acute colitis 28 per cent, chronic colitis 39 per cent, perianal disease 13 per cent, proctitis and perianal disease 8 per cent, bleeding 5 per cent, coexisting colonic malignancy 7 per cent. There were two hospital deaths (2.7 per cent), both associated with sepsis. Late deaths (n = 13) were most commonly associated with reoperations for recurrent disease (n = 3), cardiovascular disease (n = 4) and colorectal carcinoma (n = 1). Postoperative complications were principally associated with sepsis. Cumulative reoperation rates at 5 and 10 years were 19 and 24 per cent respectively. Recurrence was unrelated to the age of the patients, the duration of disease, or the presence of ileal disease at the time of colectomy.
Cell wall deficient forms of bacteria were isolated from 40-60% of patients with active inflammatory bowel disease, 15-25% of patients with inactive disease and only 5-7% of controls. The recovery rate from Crohn's disease and ulcerative colitis tissue filtrates did not differ significantly, but was raised in both groups in comparison with controls (p less than 0.01). It is concluded that a range of such bacteria have a possible aetiological role in inflammatory bowel disease.
ELISA and immunofluorescence tests were carried out on sera from patients with Crohn's disease and ulcerative colitis. The results indicate that mean antibody levels to Yersinia enterocolitica types O:9 and O:3 and Klebsiella pneumoniae, but not Pseudomonas maltophilia, are significantly higher in these patients than in control subjects. There are differing antibody levels in ileal and colonic disease, and there is a significant fall in antibody levels 9-12 months after remission from clinical symptoms in patients providing serial serum samples. However, there is no correlation between the severity of the disease and antibody titres.
One hundred and sixty two consecutive patients attending a clinic for inflammatory bowel disease (91 Crohn's, 71 ulcerative colitis) were assessed for the presence of anxiety and depression using a simple self-rating questionnaire (HAD scale) and a detailed evaluation (DSM-III). The overall prevalence of psychiatric illness (DSM-III) in ulcerative colitis and Crohn's disease was 34% and 33% respectively. There was no statistically significant association in ulcerative colitis patients between the presence of psychiatric illness and the present physical illness. Psychiatric illness was more common in the physically ill patients with Crohn's disease, compared with those who were well: 50% v 8% (p less than 0.01), using (HAD) criteria 66% v 37% (p less than 0.001). The presence of patients between the presence of psychiatric illness and the presence of physical illness. Psychiatric who were well: 50% v 8% (p less than 0.01) by DSM-III criteria, using (HAD) criteria 66% v 37% (p less than 0.001). The presence of psychiatric illness adversely affected physical recovery. Seventeen percent recovered when psychiatrically ill v 53% when psychiatrically well (p less than 0.025). The HAD scale was assessed as a screening method for psychiatric illness in this medical setting and had a sensitivity of 76% and a specificity of 79%.
Restorative proctocolectomy has become a realistic alternative to construction of a permanent stoma for patients with ulcerative colitis and familial polyposis coli. The operation restores intestinal continuity but continent patients have to open their bowels 4-5 times during the day, and over half have to rise at night to defaecate. The potential complications are considerable, but their frequency decreases with experience with the operation. This article reviews the place and results of ileoanal pouch anastomosis.
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Two hundred and two patients with Crohn's disease have been examined during the year 1984 to assess the frequency of perianal disease. One hundred and ten have had evidence of perianal complications (54%). In 30% of patients with perianal disease, the anal manifestations preceded any evidence of intestinal disease. Perianal disease was associated with pain in only 39%. Operations for perianal disease rarely achieved healing and were frequently associated with complications. Attempts to lay open a fistula-in-ano caused healing in only one of 12 cases and 6 developed incontinence. A high proportion of patients with Crohn's ulcers and strictures required proctectomy (87%). Proctectomy was performed in 27 patients with perianal disease of whom only 8 (30%) had primary healing of the proctectomy wound compared with complete healing in all 9 patients having a proctectomy without perianal disease (p less than 0.01). These results imply that patients with perianal Crohn's disease should be treated conservatively and that proctectomy, particularly in patients with rectal strictures, is associated with very high incidence of persistent perineal sinus.
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The first large cluster of patients with Crohn's disease, identified in the parish of Blockley, Gloucestershire is reported. Twelve patients with Crohn's disease have been identified of whom only two (a father and daughter) are known to be related. The age and sex distribution and macroscopic site of disease at diagnosis is similar to that expected in an unselected series. The identification of such a cluster suggests that environmental factors may be important in pathogenesis.