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PubMed2003

Bile acid malabsorption in patients with chronic diarrhoea: clinical value of SeHCAT test.

BACKGROUND: Bile acid malabsorption (BAM), a cause of chronic diarrhoea, can be diagnosed by the SeHCAT test. The purpose of this study was to evaluate the usefulness of SeHCAT testing by assessing the extent of BAM and describing the clinical characteristics in a group of patients with chronic diarrhoea. Clinical outcome after treatment with cholestyramine was also evaluated. METHODS: During a 5-year period (1997-2001) the SeHCAT test was performed in 135 patients in whom a primary programme for diagnostic evaluation of chronic diarrhoea had not revealed a cause. File data from 133 patients could be evaluated. RESULTS: In 44% of patients, bile acid absorption was normal with SeHCAT retention > or = 15%. Impaired SeHCAT retention was found in 56%. All patients with ileocaecal resections had retention values < 10%. Patients with microscopic colitis presented with BAM in 39%. Only one patient with idiopathic BAM presented with steatorrhoea as opposed to 11 patients with type 1 and 3 BAM. Patients with idiopathic BAM and/or SeHCAT retention values < 5% had the best response to treatment with cholestyramine. CONCLUSIONS: The SeHCAT test is of value in evaluation of patients with chronic diarrhoea as a second-line investigation with a high diagnostic yield. The only a priori parameter to predict BAM was the existence of ileocaecal resections. The result of the SeHCAT test seems to predict the benefit of treatment with cholestyramine.

Adult↗
PubMed2005

Irritable bowel syndrome.

Irritable bowel syndrome (IBS) is one of the most common 'functional' gastrointestinal disorders accounting for 3% of all primary care consultations, with a strong female predominance. Although most of the literature comes from Western industrialized societies, when it has been looked for, this disorder appears to be equally common in the Third World. It is characterized by chronic abdominal pain or discomfort associated with disordered bowel habit and visceral hypersensitivity. Anxiety and somatization are more common in IBS than in the general population and may encourage consultation; however, they correlate poorly with symptoms. Bacterial gastroenteritis may be followed by the development of IBS in 5-10% of patients, depending on the severity of initial illness and prior anxiety or depression. The Rome criteria allow reliable diagnosis provided that there are no 'alarm' features which mandate further investigation. Microscopic colitis and bile salt malabsorption can easily be mistaken for IBS, as can chronic infestations or infections which should be considered, while recognizing that these are extremely uncommon in westernized societies. Some patients respond to exclusion diets as lactose and wheat intolerance are common. Others with prominent anxiety and/or depression respond to psychotherapy or antidepressants. Diarrhoeal symptoms respond to loperamide and 5HT3 receptor antagonists, while constipation responds to 5HT4 agonists. Antispasmodics may have limited benefit in treating pain. Low-dose tricyclic antidepressants are also helpful in alleviating pain and anxiety, even in those without obvious psychiatric disorders. If diagnostic criteria are met, then once diagnosed, new diagnoses rarely appear.

Diagnosis, Differential↗
PubMed1985

Autoimmunity in diarrhoeal disease.

Evidence for autoimmunity in diarrhoeal disease is reviewed. Firstly, coeliac disease (CD) is considered. The incidence of tissue-reactive autoantibodies in both adults and children with CD (68% and 65%, respectively) is higher than the incidence of these autoantibodies in controls (6% in normal adults, and 14% and 9% in disease controls drawn respectively from adult and child populations). The R1 antireticulin antibody, when present, was found to disappear after several weeks on a gluten-free diet, but in contrast, other autoantibodies persisted. Secondly, a case is argued for a new disease category, namely "autoimmune enteropathy." Seven cases are reviewed in which patients presented with protracted diarrhoea, a small intestinal enteropathy which failed to heal during periods of total parenteral nutrition, and evidence of a predisposition to autoimmunity (namely, the presence of high titre autoantibodies including one specific for gut epithelium, and/or the presence of associated diseases regarded to be autoimmune). Thirdly, evidence for autoimmunity in inflammatory bowel disease is reviewed and includes discussion of serum goblet cell antibodies and of circulating T cells which participate in antibody-dependent cellular cytotoxicity in vitro using colonic epithelial cells as targets. Finally, an unusual child is described who presented with chronic diarrhoea and a flat small intestinal mucosa, who responded to gluten withdrawal but who later relapsed spontaneously during a strict gluten-free diet. Her mucosa healed only after a period of total parenteral nutrition and treatment with oral steroids. This child's enteropathy was also associated with thyrotoxicosis and a microscopic colitis.

Adult↗
PubMed1997

Primary sclerosing cholangitis in Arab children: report of four cases and literature review.

BACKGROUND: The prevalence of primary sclerosing cholangitis, a rare progressive liver disorder, is increasing with the advent of endoscopic retrograde cholangiography in the investigation of children with obscure liver disease. The etiology of primary sclerosing cholangitis is not known, clinical presentation is variable, treatment is only of limited success and long-term studies on prognosis in children are incomplete. Primary sclerosing cholangitis has not been described in Arab children. METHODS: To describe detailed clinical, laboratory, histologic and radiological features in 4 children with primary sclerosing cholangitis identified over a 2-year period at a tertiary referral center in Riyadh Saudi Arabia. RESULTS: Four children, all females, between the ages of 4 and 11 years with primary sclerosing cholangitis are identified. The diagnosis was suggested by the histology and confirmed by the characteristic cholangiographic findings. Clinical findings were itching in all 4 children, hepatomegaly in 3 and splenomegaly in 4 patients. Three of 4 patients had portal hypertension and 2 of these three variceal hemorrhage. Antinuclear and smooth muscle antibodies were negative in all four patients. None had clinical manifestations of chronic inflammatory bowel disease but microscopic colitis was documented in all 4 patients. CONCLUSIONS: Primary sclerosing cholangitis is present in Arab children with a prevalence rate of 5% in our study population.

Bile Ducts, Intrahepatic↗
PubMed2005

Are lower gastrointestinal investigations necessary in patients with coeliac disease?

BACKGROUND: Colonoscopy may be indicated in patients with coeliac disease who present with iron deficiency anaemia or in coeliac disease patients who have persisting diarrhoea despite being on a gluten-free diet. However, there are limited data to support this approach. METHODS: We prospectively recruited patients who were found to have coeliac disease, having been referred with newly diagnosed iron deficiency anaemia. We also recruited a second group of patients with known coeliac disease. These patients had persisting diarrhoea despite being on a gluten-free diet for 6 months. All patients had colonoscopy and were matched with controls (without coeliac disease) who had similar indications for colonoscopy. RESULTS: Ninety-eight consecutive new patients with coeliac disease and concurrent iron deficiency anaemia had colonoscopy performed. Twelve (12.2%) had pathology, three of which were carcinomas. This diagnostic yield was not significantly different from the findings in the control group 62/362 (17.1%) P=0.24. In coeliac disease patients with persisting diarrhoea (n=37), the diagnostic yield at colonoscopy was 1/37 (2.7%). This was significantly lower than our findings in the control group with chronic diarrhoea 55/390 (14%) P=0.05. CONCLUSION: Colonoscopy should be considered in patients with coeliac disease (over the age of 45 years) who present with iron deficiency anaemia. Whilst, for coeliac disease patients with persisting diarrhoea (on a gluten-free diet) in the absence of sinister symptoms, a flexible sigmoidoscopy may be the initial investigation in order to exclude microscopic colitis. However, further larger prospective studies are required to evaluate this approach.

Adolescent↗
PubMed1998

Three paediatric cases of primary sclerosing cholangitis treated with ursodeoxycholic acid and sulphasalazine.

We present here three paediatric patients with primary sclerosing cholangitis. In case 1, the serum gamma-glutamyl transpeptidase was decreased only temporarily by ursodeoxycholic acid (UDCA) treatment and 34 months later, sulphasalazine was added because of microscopic colitis. The enzyme level decreased with dual therapy. Similarly, in case 3, first diagnosed as autoimmune hepatitis, the transpeptidase levels remained elevated for 18 months during treatment with UDCA, prednisolone and mizoribin. The enzyme decreased only after a diagnosis of primary sclerosing cholangitis complicated with ulcerative colitis was established and sulphasalazine was introduced. Case 2 also had Crohn's colitis and was put on UDCA and sulphasalazine from the start. The enzyme level was normalized within 1 month and has remained normal for the following 5 years. Liver biopsies were analysed repeatedly in these three patients. In case 1, periductal fibrosis remained unchanged while being treated by UDCA. There appeared to be no progression in liver cirrhosis in case 3 while being treated by UDCA, prednisolone, and mizoribin. In case 2, who has been treated with both UDCA and sulphasalazine from the start, periductal fibrosis and portal fibrosis were remarkably improved 45 months later. We suggest that sulphasalazine in addition to UDCA might be a viable treatment for children with primary sclerosing cholangitis.

Adolescent↗
PubMed1986

Histological abnormalities in biopsies from macroscopically normal colonoscopies.

One hundred and nineteen children with gastrointestinal symptoms underwent colonoscopy during the course of one year. Out of 39 children that were reported as yielding normal results on endoscopic examination, six had disease detectable only by histology. The pathology included cases of microscopic colitis, Crohn's disease, and indeterminate colitis. To exclude large bowel inflammation as a cause of gastrointestinal symptoms biopsy specimens should always be taken at endoscopy.

Adolescent↗
PubMed2004

Enteric neurones modulate the colonic permeability response to luminal bile acids in rat colon in vivo.

BACKGROUND: The mechanisms behind microscopic colitis and exacerbations of ulcerative colitis are incompletely understood. It seems highly likely that both luminal antigens and bile are involved. The aim of this study was to test the hypothesis that bile acids increase colonic mucosal permeability by activating enteric neurones. METHOD: The effect of 4 mM deoxycholic acid (DCA) on the appearance rate of intravenously administered (3)H-mannitol and (14)C-urea into the lumen of the proximal and distal rat colon was measured in vivo and expressed as clearance. The nerve blocking agents atropine and hexamethonium were given intravenously, and lidocaine was applied onto the serosal surface of the colon, before and after DCA exposure RESULTS: DCA markedly increased clearance of the permeability probes into the lumen in both colonic segments and also the ratio of mannitol/urea clearance, particularly in the distal colon. Pretreatment with atropine, hexamethonium, and lidocaine significantly inhibited the increase in clearance by approximately 65-80% but did not affect the clearance ratio. In the distal colon, the inhibitory effect of lidocaine was not statistically significant. Also, administration of atropine and hexamethonium after DCA exposure significantly inhibited the DCA effect on clearance of the probes. CONCLUSION: The results suggest that in vivo, the permeability increase induced by a moderate concentration of bile acid is to a large extent mediated by a neural mechanism involving muscarinic and nicotinic receptors. This mechanism may be a link between the central nervous system and colonic mucosal barrier function, and may be a new target for treatment.

Animals↗
PubMed1994

Studies on the enteropathy associated with primary hypogammaglobulinaemia.

Twelve patients with primary hypogammaglobulinaemia with diarrhoea not associated with known microbial pathogens were investigated. Histological evidence of inflammation was common in the stomach and jejunum. Moreover, eight of 10 patients undergoing colonoscopy had low grade 'microscopic colitis' with raised intraepithelial lymphocytes and an intact crypt architecture. Five of 12 patients had small intestinal inflammation on 111indium leucocyte scintigrams and all had increased faecal excretion (normal < 1%) of 111indium (over four days), which varied in intensity from mild (faecal excretion of 111indium = 1-3%) to that comparable with moderately active (7-14.5%) Crohn's disease. Three patients had small intestinal strictures superficially resembling Crohn's disease. Histologically, however, these lacked characteristic diagnostic features of Crohn's disease in two and the third patient had non-steroidal anti-inflammatory drug induced diaphragm like strictures. Six of seven who were most severely symptomatic were successfully treated with an elemental diet with rapid improvement of symptoms. The faecal excretion of 111indium was repeated in five and all improved but histologically the colitis remained unchanged. These studies show that some patients with primary hypogammaglobulinaemia have intestinal inflammation unlike that found in classic inflammatory bowel disease. Elemental diet is a useful temporary measure in the treatment of these patients.

Agammaglobulinemia↗
PubMed2001

Colonic disorders in adult cystic fibrosis.

By 1996, the median survival of patients with cystic fibrosis (CF) in North America had increased to 31 years. With the markedly improved life expectancy, many CF patients are now adults. There is an associated increased risk of certain colonic disorders, and the emergence of other previously unrecognized disorders, in adult CF patients. The distal intestinal obstruction syndrome (DIOS), which is more common in older patients, is a frequent cause of abdominal pain. Intussusception may complicate DIOS; other differential diagnoses include appendiceal disease, volvolus, Crohn's disease, fibrosing colonopathy and colonic carcinoma. The diagnosis of acute appendicitis, although uncommon in patients with CF, is often delayed, and appendiceal abscess is a frequent complication. The prevalence of Crohn's disease in CF has been shown to be 17 times that of the general population. Right-sided microscopic colitis is a recently recognized entity in CF of uncertain clinical significance. Fibrosing colonopathy has been confined mostly to children with CF, attributed to the use of high strength pancreatic enzyme supplements, but it has been reported in three adults. Nine cases of carcinoma of the large intestine have been reported worldwide, associated with an apparent excess risk of digestive tract cancers in CF. Despite high carrier rates of Clostridium difficile in patients with CF, pseudomembranous colitis is distinctly rare, but severe cases complicated by toxic megacolon have been reported. In these patients, watery diarrhea is often absent. Adult CF patients with refractory or unexplained intestinal symptoms merit thorough investigations.

Adult↗
PubMed2003

Gastrointestinal side effects of drugs.

Drugs can have adverse effects on any part of the gastrointestinal (GI) tract from mouth to colon. It is essential that a detailed and accurate drug history is taken in patients presenting with GI complaints. Many drug-induced effects will regress or heal on cessation of treatment. NSAIDs are usually associated with gastric and duodenal ulcers but are also recognised to cause lichen planus in the mouth, oesophageal inflammation and strictures, and small bowel and colonic ulcers and strictures. A newer class of anti-inflammatory drugs, the cyclooxygenase-2 (COX-2)-selective inhibitors, have been developed and have a more favourable GI safety profile than standard NSAIDs. Acute diarrhoea, relapse of inflammatory bowel disease (IBD), microscopic colitis and acute pancreatitis are also induced by ingestion of standard NSAIDs. The calcium antagonists, phenytoin and cyclosporin, induce gum hyperplasia, particularly in patients with poor oral hygiene. Alendronate, a bisphosphonate, has been associated with development of oesophageal ulcers, and specific recommendations are now given to reduce this complication. Of the many different forms of colitis associated with drug ingestion, the most frequent is pseudomembranous colitis. This is a complication of antibiotics and is caused by the toxin produced by Clostridium difficile. Many drugs have been associated with the development of acute pancreatitis, although a definite cause and effect relationship has been shown for only a few drugs. These include didanosine, furosomide, corticosteroids, azathioprine and sodium valproate.

Drug-Related Side Effects and Adverse Reactions↗
PubMed2006

Drug-induced side effects affecting the gastrointestinal tract.

With the ever-growing armamentarium of pharmacological agents, the gastrointestinal drug-induced side effects of dyspepsia, nausea, vomiting, diarrhoea and constipation are increasingly seen. They are often self-limiting and without serious sequelae, but of greater concern is drug-induced mucosal ulceration that can manifest as gastrointestinal haemorrhage, stricture and perforation. These complications are mainly attributable to NSAIDs and aspirin, which can injure the mucosa anywhere along the gastrointestinal tract. These iatrogenic serious side effects can be reduced with co-prescription of a proton pump inhibitor, substitution of a COX-2 inhibitor and eradication of Helicobacter pylori when the bacterium is present. Other recognised gastrointestinal complications include small intestinal diaphragm, microscopic colitis, a range of hepatotoxic effects and pancreatitis. The introduction of new classes of drugs has resulted in new adverse effects that require consideration in patients presenting with gastroenterological symptoms. These include pill oesophagitis from bisphosphonates and ischaemic colitis relating to serotonin antagonists. Here, the authors review the literature on drug-induced complications of the gastrointestinal tract and present the pertinent management issues relevant to clinical practice.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed1999

Newer diarrheal syndromes.

Aetiological diagnosis of protracted diarrhoea remains obscure in as many as 30% of cases despite extensive investigations. A number of newer syndromes have been recognized amongst this "idiopathic group" which includes microvillous inclusion disease, "tufting" enteropathy and epithelial dysplasia, autoimmune enteropathy and "syndromic" immunodeficiency with characteristic facial abnormalities, woolly hair and intractable diarrhea. The molecular basis of some of these syndromes has been reviewed but in only a small series of patients has the functional defect been characterized. If a case is suspected the antenatal history, family history and history of consanguinity should be sought. Extra-intestinal manifestations, presence of gut or other auto-antibodies, together with phenotypic abnormalities should be looked for. Careful light and electron microscopy is done of small bowel biopsies, although microvillous inclusion disease can be usually suspected on PAS staining. Large bowel biopsy may be needed to exclude an unsuspected microscopic colitis. The prognosis of this group of conditions is poor with an overall 50-85% mortality. Although successful gut transplantation has been reported, genetic counselling may be one of the more important aspects of the clinicians' role.

Age Distribution↗
PubMed2004

[The conservative treatment of nonspecific inflammatory bowel diseases].

The treatment of inflammatory bowel diseases includes the nutritional management, the pharmacotherapy and the surgical treatment. The main aim of treatment is to achieve the remission, to prevent a relapse and to take a decision of surgical treatment. The treatment is introduced in the relevance to the intensification of disease. To assess properly the level of the intensification of disease there is a need of deep knowledge of clinical manifestations of the disease. In the treatment the corticosteroids, 5-aminosalicylic acid (5-ASA) or immunosuppressive treatment are used. Immunosuppressive treatment is now a widely accepted standard in Crohn's disease treatment. Some cases of Crohn's disease could be treated with anti-TNFalpha antibodies that successfully treat the relapses of disease. This treatment is especially well suited to cases that are not successfully treated with the standard pharmacological treatment. The nonsurgical treatment is successful in most cases. There are no standards of treatment of microscopic colitis. We usually start the treatment with 5-ASA and an antidiarrheal agent. In case of failure of this treatment we introduce corticosteroids. In this paper authors present basic information about the current state of knowledge about inflammatory bowel diseases treatment.

Anti-Inflammatory Agents↗
PubMed2006

[Intestinal side effects of COX-2 inhibitors].

COX-2 inhibitors and NSAIDs have similar analgesic, anti-inflammatory and severe upper intestinal side effects. Adding to the sparse and casuistic reports, a further five cases of severe lower intestinal illness associated with COX-2 inhibitor ingestion are presented. Diarrhoea due to microscopic colitis was associated with short-time ingestion of refecoxib and celecoxib by two patients. Refecoxib intake for two months was associated with spontaneous perforation of a well-functioning J-pouch in a patient with ulcerative colitis. Intake of celecoxib and etodolac was associated with colonic ulceration and stricture. Side effects related to COX-2 inhibitors are similar to those related to NSAIDs.

Adult↗
PubMed1989

Morphometric study of colonic biopsies: a new method of estimating inflammatory diseases.

In this study, colonic biopsy specimens from 87 subjects (37 men and 50 women; mean age 51 +/- 14 years) were investigated by a new method of quantitation morphometric analysis. Subjects were classified in 3 groups: I, control group (25 cases); II, constipation and/or abdominal pain (36 cases); III, diarrhea (26 cases). All biopsy specimens were considered normal by both colonoscopic and microscopic observations. Morphometric analysis was performed with a specialized automated image processor. Complete analysis of 1 biopsy specimen required about 10 minutes. Glandular area showed no difference in the ascending, transverse, and descending colonic sites in the three groups. By contrast, the rectal glandular area was significantly larger than those from the 3 colonic sites in all groups (p less than 0.001). The mean cellular density in the control group was 172.7 +/- 24 nuclei/unit area of lamina propria at all biopsy sites. The cellular densities of groups II and III were significantly increased in the ascending colon as compared with the group I subjects (195.1 +/- 22.8, p less than 0.01 and 198.2 +/- 24.7 p less than 0.001, respectively). The cellular density in group III was significantly increased in the other sites as compared with group I (p less than 0.01). Morphometric analysis does provide a definition of the normal range of the lamina propria cellularity and can identify mild abnormalities in patients in whose both colonoscopy and conventional histologic interpretation have been considered as normal by experienced endoscopists and pathologists. A statistical increase in cellular density in groups of patients with clinical symptoms should be regarded as consistent with the concept of microscopic colitis and detectable by morphometry. Such a method reduces interobserver bias and permits objective comparison of groups.

Biopsy↗
PubMed1989

Lymphocytic enterocolitis in patients with 'refractory sprue'.

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.

Adult↗
PubMed2004

Clinical characteristics of collagenous and lymphocytic colitis.

BACKGROUND: Microscopic colitides (MC), collagenous colitis (CC) and lymphocytic colitis (LC) share clinical features, but their mutual relationship is unclear, and clinical comparative studies are rare. We aimed to examine the clinical features in CC and LC by focusing on concomitant diseases. METHODS: Patients with MC (30 with CC, 54 with LC) were identified in the pathology databases and by reviewing biopsies. Controls included 84 age- and sex-matched persons. The clinical data collected from patient records were prospectively completed by interviews. RESULTS: The female:male ratio was 2:1 in CC and 5.75:1 in LC. Mean age at diagnosis was 53 in CC and 55.4 years in LC. There were no differences in the pattern of symptoms. Concomitant autoimmune diseases were more common in CC (53.3%) than in LC (25.9%; P = 0.017). Celiac disease was common in both CC (20%) and LC (14.8%). Bronchial asthma was associated with LC (25.9%), but not with CC (6.7%; P = 0.042). Colon diverticulosis was rare in MC (16%) compared with the controls (39%; P = 0.001). Hypolactasia was common in MC (45%; 76% in CC, 54% in LC) compared to its prevalence in the Finnish general population (17%). CONCLUSIONS: CC and LC are largely similar clinically, but the differences in the occurrence of autoimmune conditions and bronchial asthma suggest that they differ in immunopathogenesis. MC is associated with reduced lactose tolerance and shows a negative association with diverticular disease, possibly related to the small intestinal pathology and abnormal stool consistency.

Age Distribution↗