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PubMed2003

Patterns of disease and surgical treatment among United States veterans more than 50 years of age with ulcerative colitis.

BACKGROUND: Ulcerative colitis (UC) is a clinical entity that predominantly affects young adults yet large series of middle age or elderly patients with UC are infrequently reported. The aim of this study is to identify patterns of disease, indications for operation, surgical treatment, and outcome of patients more than 50 years of age who required surgery for UC in Department of Veterans Affairs (DVA) Medical Centers. METHODS: A population-based study on all patients in 159 hospitals of the DVA from 1997 to 2001 was carried out. Data were compiled from several national computerized VA data sets. Supplementary information including demographic information, discharge summaries, operative reports and pathology reports were obtained from local medical records. Patient variables were entered into a computerized database and analyzed using the Pearson chi-square and Fisher's exact tests. Statistical significance is designated as P < 0.05. RESULTS: One hundred fifty-eight patients were evaluable. The mean age was 59 years (range 51-81); 99% were male. The mean duration of UC was 23 years (range 2 to 50). One hundred of the 158 patients had proctocolitis; 58 had either left-sided colitis or proctosigmoiditis. The mean dose of prednisone prior to surgery was 20 mg; the mean duration of steroid use was 8 years. The indications for elective surgery were intractability (59%), mass or stricture (27%), and dysplasia (14%). Twenty of the 158 patients (12%) were operated on emergently for either toxic colitis, perforation, or hemorrhage. One hundred three of the 158 underwent proctocolectomy and permanent ileostomy, 55 underwent a restorative proctocolectomy, and underwent a segmental colectomy. Twenty of the 158 patients were found to have dysplasia in their colectomy specimens; an additional 10 (7%) were found to have invasive cancer. Surgical morbidity was 22%. Overall mortality was 4% (7 of 158); all but 1 death occurred after emergent surgery. Mean hospitalization was 36 days (range 2 to 297). CONCLUSIONS: Restorative proctocolectomy was performed in 36% of veterans more than 50 years of age requiring surgery for UC. The majority required surgery for intractable symptoms. Dysplasia and invasive cancer was found in 18% of patients. Mortality after surgery for acute surgical emergencies remains high.

Case-Control Studies↗
PubMed1982

Dietary protein-induced colitis in breast-fed infants.

Six infants are reported who developed an inflammatory proctocolitis in the first month of life while being breast fed exclusively. All has been born at term and had normal perinatal courses. None had growth failure or constitutional symptoms other than bloody diarrhea. No toxic, bacterial, viral, or parasitic cause was established. Rectal inflammation was suggested by the presence of fecal leukocytes and was confirmed by sigmoidoscopic observation of focal ulcerations, edema, and increased friability. Rectal biopsies demonstrated a wide spectrum of acute and chronic inflammatory changes. All infants responded clinically to initiation of feeding with either a hydrolyzed casein or a soy protein-based formula. Breast-feeding was subsequently resumed in five of the six infants; all experienced immediate recurrence of symptoms. Elimination of cow milk protein from the maternal diet led to tolerance of breast-feeding in two infants but there was no change in the other three. We believe that dietary protein-induced enterocolitis, previously reported in formula-fed infants, occurs occasionally in the exclusively breast-fed infant as well.

Breast Feeding↗
PubMed1992

Vascular malformations of the gastrointestinal tract.

The advent of fiberoptic endoscopy, which became widespread in the evaluation of gastrointestinal bleeding throughout the late 1970s and 1980s, has dramatically changed both our understanding of the extent to which vascular malformations account for gastrointestinal blood loss and our ability to treat these lesions at the time of diagnosis. Colonic vascular malformations appear to be the single most common cause of acute or recurrent gastrointestinal bleeding episodes in patients over 60 years of age, being responsible for the bleeding in as many as 35% of such patients. Although less common as a cause of upper gastrointestinal bleeding, these lesions still account for 2% to 5% of bleeding lesions in older patients. Diagnosis is accomplished by endoscopy, and the vascular malformations can then be coagulated via the endoscope using one of a number of thermal systems. The argon laser, the heater probe, and the BICAP system are all effective and safe throughout the gastrointestinal tract, especially in the cecum and right colon, where the majority of sporadic vascular malformations occur. Monopolar cautery and the Nd:YAG laser are equally efficacious, but their greater and less predictable depth of coagulation make them much less safe in the cecum and right colon. There are no apparent advantages in terms of efficacy and safety between laser treatment and the other thermal modalities. The laser has the advantage of being quicker, which is especially important when treating large or multiple lesions. The other modalities have the advantages of portability and low relative cost. Endoscopic therapy with lasers or other thermal devices is nonspecific. The effects are achieved by thermally coagulating the mucosal vascular lesions, allowing the coagulated tissue to slough, and leaving a mucosal ulceration that subsequently heals with re-epithelialization. Endoscopic coagulation has thus been reported effective in the treatment of gastrointestinal mucosal vascular lesions regardless of their etiology or characteristics. It has been effective for sporadic vascular malformations, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease), radiation proctocolitis, the blue rubber-bleb nevus syndrome, and diffuse gastric antral vascular ectasia (the watermelon stomach). As we move through the 1990s and beyond, these endoscopic modalities offer an effective, relatively safe, and clearly less invasive treatment option for the many patients who experience acute, recurrent, or chronic gastrointestinal bleeding from any of these lesions.

Blood Vessels↗
PubMed2003

[Hemorrhagic colitis in exclusively breast-fed infants].

INTRODUCTION: Authors report clinical, biological and endoscopic data of six children aged less 3 months with bloody stools while they were exclusively breast-fed. RESULTS: Two girls and four boys aged 1 to 2 months presented with isolated but recurrent rectal bleeding. All were explored by fiberoptic rectosigmoidoscopy between 1 and 3,2 months. Macroscopic aspects were congestion (6 cases), petechial and ecchymotic (4 cases), with normal mucosal areas (5 cases). Histopathology showed eosinophilic infiltrates in all 5 children with rectal biopsy. Evolution was satisfactory after cow's milk protein exclusion in maternal diet for five children and after weaning in 1. All children were weaned with protein hydrolysate. Cow's milk protein were later introduced without adverse reactions at 6 to 23 months. CONCLUSION: Food allergy can be considered in proctocolitis including exclusive breast-fed children. Evolution after maternal diet is, as usual, simple.

Adult↗
PubMed2001

Survival and causes of death in Italian patients with ulcerative colitis. A GISC nationwide study.

BACKGROUND: Death rate for patients with ulcerative colitis has changed over last few decades. Recent studies indicate that cumulative long-term mortality is comparable to that in general population, and that deaths may depend on causes not strictly related to colonic disease. AIM: To evaluate overall and cause-specific mortality rate in a large group of Italian patients with ulcerative colitis. METHODS: A total of 2,066 ulcerative colitis patients aged >18 years consecutively diagnosed in twenty Italian Gastroenterology Units between 1964 and 1995 were followed-up from diagnosis until 1997. Standardised Mortality Ratios and Relative Survival Ratios were calculated. RESULTS: Overall mortality of patients with ulcerative colitis was comparable to that in general population with 93 deaths observed versus 92.1 expected (standardises mortality ratio, 1.0; 95% confidence interval, 0.8-1.2). Significantly higher mortality was observed in patients under 30 years of age at diagnosis (standardised mortality ratio, 2.7; 95% confidence interval, 1.3-4.9), and in those diagnosed before 1974 (standardised mortality ratio, 2.7; 95% confidence interval, 1.1-5.7). Proctocolitis and complications from surgery were mentioned in 11 and 5 certificates, respectively. A significant excess of deaths was observed for colorectal cancer (colon: standardised mortality ratio, 3.0; 95% confidence interval, 1.0-6.9; rectum: standardised mortality ratio, 4.4; 95% confidence interval, 1.2-11.3), and haemolymphopoietic neoplasms (standardised mortality ratio, 2.8; 95% confidence interval, 1.0-6.1), in particular multiple myeloma and non-Hodgkin lymphoma. A significant deficit of deaths was observed for cancer of the respiratory system (standardised mortality ratio, 0.3; 95% confidence interval, 0.1-1.0). CONCLUSIONS: This study confirms that, also in Italy, mortality of patients with ulcerative colitis is comparable to that in general population. Only 12% of deaths were due to ulcerative colitis itself, whereas 10% of deaths were attributed to colorectal cancer. Deaths from colorectal cancer occurred, on average, 9 years after diagnosis of ulcerative colitis, suggesting that the risk of cancer is not limited to patients with long-standing colitis. As to mortality for causes unrelated to colitis, there was an excess of deaths due to malignancies of the haemolymphopoietic system.

Adult↗
PubMed1999

Diversion colitis--new light through old windows.

Diversion proctocolitis is an iatrogenic disorder caused by surgical diversion of the faecal stream away from the colorectal mucosa. Such surgery may be necessary in cases of tumour, trauma or inflammatory conditions of the colorectum. Histopathological change is characterized by a chronic lymphoplasmacytic inflammatory infiltrate, and the hallmark feature, lymphoid follicular hyperplasia. Histological appearances are determined by the disease state of the colonic mucosa prior to faecal diversion. Macroscopic appearances may vary considerably, but often include aphthoid ulceration. The exact pathogenesis of the condition remains unclear, but the removal of short-chain fatty acids, present in the faecal stream, is considered an important aetiological factor. Current research areas, including the microbiology and cellular kinetics of diversion colitis, are discussed along with clinical features and treatments.

Bacteria↗
PubMed1979

Methylene blue dye spraying method in patients with ulcerative proctitis: a comparative study with morphological findings and functional capacity of the rectal epithelium.

Methylene Blue dye spraying method is currently used in the endoscopic assessment of the colonic mucosa of patients with chronic ulcerative proctocolitis. We have assessed the validity of this method in the evaluation of the functional capacity of the rectal mucosa in 17 patients with ulcerative proctitis and in 5 normal subjects. The ionic transmucosal fluxes of Na+ and K+ and the potential difference were used as parameters of the mucosal function. Our results indicate that methylene blue dye spraying method can be useful in the functional assessment of the rectal epithelium, especially for differentiating normal subjects and patients with mild ulcerative proctitis.

Adolescent↗
PubMed1989

[Virus-associated hemorrhagic colitis in the differential diagnosis of peracute rectal bleeding].

Severe anal bleeding together with increasing abdominal discomfort occurred in an 81-year-old woman previously hospitalized numerous times because of decompensated type II B diabetes. A suspected rectal cancer was excluded by biopsy from the lower to middle rectum, but the biopsy revealed histologically indurated and bleeding ulcerations. Typical nuclear inclusion bodies provided the diagnosis of virus-associated proctocolitis. Serological tests supported the diagnosis of infection with herpes simplex and cytomegalic virus. Laser coagulation stopped the bleeding. At the same time a Guillain-Barré syndrome was noted which improved after administration of cortisone and high parenteral doses of acyclovir.

Acute Disease↗
PubMed1985

Campylobacter cinaedi (sp. nov.) and Campylobacter fennelliae (sp. nov.): two new Campylobacter species associated with enteric disease in homosexual men.

In a recent study in Seattle, we isolated Campylobacter-like organisms (CLOs) significantly more often from homosexual men with intestinal symptoms than from asymptomatic heterosexual and homosexual control subjects. Biochemical tests, morphology, and guanine-plus-cytosine content of whole-cell DNA showed that these organisms were similar to, but distinguishable from, other species in the genus Campylobacter. DNA homology tests showed that the Campylobacter-like organisms belong to four unique genetic groups, two of which were phenotypically identical. We developed a rapid screening test to genetically group these organisms and to assess the correlation of each genotype with enteric disease in homosexual men. Three of the four CLO groups were isolated only from men with proctitis, proctocolitis, and/or enteritis. The remaining group, isolated from both symptomatic and asymptomatic homosexual men, was significantly correlated with the presence of polymorphonuclear leukocytes in the rectal secretions of asymptomatic men, a finding that suggests subclinical disease. We have tentatively classified two of the CLO groups into species, Campylobacter cinaedi sp. nov. and Campylobacter fennelliae sp. nov.

Campylobacter↗
PubMed1982

The occurrence of severe epithelial dysplasia and its bearing on treatment of longstanding ulcerative colitis.

One hundred twenty-four patients with extensive ulcerative proctocolitis were operated upon with proctocolectomy. The mean observation time was 10.3 years. Before surgery rectal biopsies were taken in all patients. The relationship between precancerous lesion in rectal biopsies and the presence of precancer and/or cancer in the rectum or colon in the removed specimen was evaluated. Thirteen out of 14 patients showed evidence of severe rectal dysplasia as well as severe dysplasia in the large bowel specimen, and five of these patients had a carcinoma as well. The 14th patient showed severe dysplasia only in the rectum as well as a rectal carcinoma. Of 110 patients without severe rectal dysplasia, 36 showed evidence of severe colon dysplasia, and three of these patients had a large bowel carcinoma as well. Only one patient had a large bowel carcinoma without evidence of severe dysplasia in the rectum or colon. Thus, nine patients out of ten with large bowel carcinoma showed severe dysplasia in rectum and/or colon. Four of these carcinomas were unknown before surgery. Although severe dysplasia in the rectal biopsy is a strong indication of a large bowel carcinoma (6/14), a negative rectal biopsy does not exclude a large bowel carcinoma (4/110). Proctocolectomy cannot be looked upon only as a prophylactic procedure in patients with severe dysplasia in the rectal biopsy, but also as an attempt to curative surgery, as large bowel carcinoma may have already developed in a considerable number of patients where precancer is diagnosed in biopsies.

Adolescent↗
PubMed1990

Cow's milk protein-induced colitis in the breast-fed infant.

A 3-month-old boy is described who developed an inflammatory proctocolitis during exclusive breast feeding. The major symptom was bloody diarrhea. No growth failure or constitutional symptoms were present. Bacterial, viral, and parasitic infection was excluded. The colonoscopic findings of focal ulceration, edema, and increased friability and the histologic picture with a marked eosinophilic infiltration were indicative of an allergic intestinal reaction. The infant responded favorably to the withdrawal of the mother's milk and the initiation of hydrolyzed casein formula. The challenge with cow's milk led to a clinical relapse resembling the initial manifestation.

Animals↗
PubMed1990

Eosinophilic proctitis with giant cells: a manifestation of cow's milk protein intolerance.

Two infants, subsequently shown to have cow's milk protein intolerance, presented with rectal bleeding in the first week of life. Rectal biopsies showed eosinophilic infiltration of the mucosa with several multinucleated giant cells. IgG, IgM, and IgA containing plasma cells were present but IgE could not be detected in rectal biopsies. While cow's milk protein intolerance is a well-recognized cause of proctocolitis in infancy, eosinophilic granulomatous-like lesions with giant cells may be a prominent feature and do not exclude the diagnosis.

Biopsy↗
PubMed2002

Cow's milk allergy in infancy.

Cow's milk allergy affects approximately 2% of infants under 2 years of age. This review summarizes the recent advances in understanding its pathophysiology and immunological mechanisms. Apart from IgE-mediated atopic manifestations, T cell-mediated reactions have been demonstrated in infants with cow's milk allergy. The clinical spectrum ranges from immediate-type reactions, presenting with urticaria and angioedema to intermediate and late-onset reactions, including atopic dermatitis, infantile colic, gastro-oesophageal reflux, oesophagitis, infantile proctocolitis, food-associated enterocolitis and constipation. The exact mechanisms of these disorders are still poorly understood. Double-blind, placebo controlled food challenge, the definitive diagnostic test for cow's milk allergy, is increasingly being replaced by the measurement of food-specific antibodies, in combination with skin-prick or atopy patch testing. The treatment of cow's milk allergy relies on allergen avoidance and hypoallergenic formulae, or maternal elimination diets in breast-fed infants.

Allergens↗
PubMed2006

Antibodies to I2 predict clinical response to fecal diversion in Crohn's disease.

OBJECTIVES: Fecal diversion is occasionally indicated in patients with advanced perianal or colorectal Crohn's disease (CD). Because CD may result from an aberrant immunologic response to bacteria within the gut lumen, fecal diversion should be effective in managing these complications. However, not all patients achieve a clinical response after fecal diversion. CD patients can be characterized by their antibody responses against Pseudomonas fluorescens (I2), E.coli outer membrane porin C (OmpC), oligomannan (anti-Saccharomyces cerevisiae antibodies [ASCA]), and antinuclear antigens (perinuclear antineutrophil cytoplasmic antibodies [pANCA]). This study examines the association between clinical features and seroreactivity to these microbial and auto-antigens in predicting a clinical response to fecal diversion. METHODS: Twenty-seven consecutive CD patients undergoing fecal diversion were included. Sera were drawn and tested for anti-I2, anti-OmpC, ASCA, and pANCA in a blinded fashion. Response was assessed using clinical parameters. RESULTS: Seventeen (63%) patients underwent fecal diversion for medically resistant proctocolitis and 10 (37%) for severe perianal disease. Median follow-up was 41 months. Seventeen (63%) patients achieved a clinical response. No preoperative clinical or surgical factor predicted response to diversion. Clinical response after fecal diversion was seen in 15 of 16 (94%) patients who were I2 positive compared with only 2 of 11 (18%) patients who were I2 negative (P = 0.0001). Seroreactivity to OmpC, ASCA, or pANCA was not associated with a clinical response to diversion. CONCLUSION: Expression of I2 antibodies against a bacterial antigen of Pseudomonas fluorescens was highly associated with clinical response to fecal diversion in CD patients.

Adult↗
PubMed1990

Experimental infection of pig-tailed macaques (Macaca nemestrina) with Campylobacter cinaedi and Campylobacter fennelliae.

Campylobacter cinaedi and C. fennelliae have been associated with proctocolitis, bacteremia, and asymptomatic rectal infection, primarily in homosexual men. To more directly assess the pathogenic role of these organisms, we studied their disease-producing potential in 12- to 25-day-old pig-tailed macaques (Macaca nemestrina). Four infant monkeys were challenged with 10(8) to 10(9) C. cinaedi, three were challenged with C. fennelliae, two were challenged with C. jejuni, and one received no microorganisms. Watery or loose stools without associated fever or fecal leukocytes developed 3 to 7 days postinoculation in all of the animals given C. cinaedi, C. fennelliae, and C. jejuni, but not in the control animal. Stool cultures were simultaneously positive and remained so in the animals challenged with C. cinaedi or C. fennelliae for 3 weeks after inoculation despite the resolution of clinical illness. All of the animals challenged with C. cinaedi and C. fennelliae became bacteremic, and three had clinical evidence of septicemia. Histopathologic evaluation of rectal biopsies (five animals) and necropsy (one animal) showed no evidence of mucosal disruption. Specific immunoglobulin M and immunoglobulin G antibody responses occurred in all of the animals challenged with C. cinaedi and C. fennelliae, as determined by enzyme-linked immunosorbent assay and immunoblotting. We conclude that C. cinaedi and C. fennelliae consistently produce a diarrheal illness accompanied by bacteremia and followed by prolonged gastrointestinal colonization in M. nemestrina.

Animals↗
PubMed1993

Septicemia and meningitis caused by Helicobacter cinaedi in a neonate.

Helicobacter cinaedi has been most frequently isolated from rectal swabs of homosexual men with proctocolitis. The microorganism is a normal intestinal inhabitant of hamsters. We report a case of septicemia and meningitis by H. cinaedi in a neonate whose mother cared for pet hamsters during the first two trimesters of her pregnancy. The isolate was detected after 3 days of incubation in a Bact/Alert pediatric blood culture vial and an enrichment broth culture of the cerebrospinal fluid. H. cinaedi should be added to the list of unusual fastidious organisms that cause sepsis and meningitis in the newborn.

Animals↗
PubMed2002

Captive rhesus monkeys (Macaca mulatta) are commonly infected with Helicobacter cinaedi.

Helicobacter cinaedi may cause proctocolitis or bacteremia in homosexual men infected with human immunodeficiency virus or occasionally in other immunocompromised hosts. There are scattered reports of H. cinaedi isolated from a variety of animal hosts, but to date only hamsters have been found to be a common natural reservoir. Microaerophillic cultures of feces from 5 of 16 asymptomatic rhesus monkeys (Macaca mulatta) (31%) were positive for a curved gram-negative rod. A polyphasic taxonomic approach was used to identify the organism as H. cinaedi. These results show that H. cinaedi frequently colonizes asymptomatic captive rhesus monkeys, which may serve as another potential reservoir for human infection.

Animals↗
PubMed1975

Recurrent aphthae: treatment with vitamin B12, folic acid, and iron.

A series of 130 consecutive outpatients with recurrent aphthous stomatitis were screened at the oral medicine department, Glasgow Dental Hospital, for deficienciesin vitamin b12, folic acid, and iron. In 23 patients (17.7%) such deficiencies werefound; five were deficient in vitamin B12, seven in folic acid, and 15 in iron. Four had more than one deficiency. Out of 130 controls matched for age and sex 11 (8.5%) were found to have deficiencies. The 23 deficient patients with recurrent aphthaewere treated with specific replacement therapy, and all 130 patients were followed up for at least one year. Of the 23 patients on replacement therapy 15 showed complete remission of ulceration and eight definite improvement. Of the 107 patientswith no deficiency receiving local symptomatic treatment only 33 had a remission or wereimproved. This difference was significant (P less than 0.001). Most patients withproved vitamin B12 or folic acid deficiency improved rapidly on replacement therapy;those with iron deficiency showed a less dramatic response. The 23 deficient patientswere further investigated to determine the cause of their deficiencies and detect the presence of any associated conditions. Four were found to have Addisonian perniciousanaemia. Seven had a malabsorption syndrome, which in five proved to be a gluten-induced enteropathy. In addition, there were single patients with idiopathic proctocolitis, diverticular disease of the colon, regional enterocolitis, and adenocarcinoma of thecaecum. We suggest that the high incidence of deficiencies found in this series andthe good response to replacement therapy shows the need for haematological screening of such patients.

Adenocarcinoma↗