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PubMed1992

Drug therapy for inflammatory bowel disease: Part II.

Part II of this two-part article (See The American Journal of Surgery 1992; 164: 85-9) reviews the current definition of the role of immunosuppressive therapy in inflammatory bowel disease (IBD) and the use of antibiotics in IBD, as well as summarizes the uses of the new agents on the horizon for the treatment of IBD. Azathioprine and 6-mercaptopurine have steroid-sparing effects in patients with refractory Crohn's disease and ulcerative colitis, treat Crohn's disease-associated fistulas, and are the first agents to demonstrate efficacy in the prophylaxis of Crohn's disease. Their low risk for the development of lymphoreticular malignancy remains a factor in decisions regarding their long-term use. Cyclosporine is steroid sparing in active chronic Crohn's disease and, given intravenously, may help treat severe, refractory ulcerative colitis. Antibiotics have expanding roles: metronidazole is effective for the primary treatment of Crohn's disease, fistulas, abscess, bacterial overgrowth, and pouchitis (after ileoanal anastomosis). Other potential agents show promise in pilot studies but await controlled trials.

Anti-Bacterial Agents↗
PubMed1993

Similar functional results after restorative proctocolectomy in patients with familial adenomatous polyposis and mucosal ulcerative colitis.

Restorative proctocolectomy (RP) is generally considered to achieve better results in patients with familial adenomatous polyposis (FAP) than in those with mucosal ulcerative colitis (MUC). We studied 39 pairs of patients (FAP versus MUC), individually matched for surgeon (n = 4), types of ileal pouch (19 S-pouches and 20 J-pouches), technique of ileal pouch-anal anastomosis (21 stapled, 18 handsewn with mucosectomy), duration of follow-up after pouch function (median: 32 months; range: 6 months to 8.5 years), age (median: 30 years; range: 12 to 60 years), and gender (male-to-female ratio: 1.4:1.0). The median duration of operation (3.2 hours), hospital stay (9 days), and the amount of blood loss (about 650 mL) were similar between the two groups. The patients in the MUC group tended to have a higher overall complication rate (28% versus 21%) and more pouch-related septic complications (13% versus 8%, p = 0.6 by chi 2 analysis). Functional results were similar for daytime (median: 5 per day) and nighttime (median: 1 per night) stool frequency and the median duration that defecation could be deferred (median: about 1.5 hours). Perfect continence was present in 34 (87%) patients during the day and in 19 (49%) patients during the night in each group. The use of antidiarrheal medications did not differ between the two groups. According to an analogue scale (from 1 to 10, with 10 being best), the quality of life and health and satisfaction with outcome (median score: 9) were identical between the groups. Thus, in closely matched groups of patients with FAP and MUC, the functional outcome after RP was similar. However, pouchitis was more common in the MUC group (33% versus 10%, p < 0.05 by chi 2 analysis).

Adenomatous Polyposis Coli↗
PubMed1990

Reconstruction of malfunctioning ileoanal pouch procedures as an alternative to permanent ileostomy.

During the past 13 years, 261 patients with ulcerative colitis and 29 with colonic polyposis underwent endorectal pullthrough (ERP) at UCLA Medical Center. Of the first 111 consecutive patients to undergo ERP, 5 returned to a permanent ileostomy because of persistent symptoms related to reservoir stasis. Transabdominal shortening of the reservoir was performed in 38 of the 111 patients; 24 experienced marked clinical improvement. Fourteen of the 38 patients had persistent stasis and required shortening of the ileal spout either transanally (5 patients) or via an abdominoperineal approach (9 patients). Eighteen of the initial 111 patients underwent one-stage abdominoperineal reservoir reconstruction. During the past 4 years, 8 of 149 consecutive patients with a primary lateral isoperistaltic reservoir underwent subsequent abdominoperineal reservoir reconstruction. Fourteen of 18 patients with a straight pullthrough with reservoir underwent reconstruction to a lateral isoperistaltic reservoir. An aggressive operative approach to the management of pouchitis and reservoir stasis (diarrhea, frequency, urgency, incomplete emptying) has resulted in only 4 of the last 246 consecutive patients returning to a permanent ileostomy. Several changes in the operative technique have evolved during the 13-year period. Important features for optimal pouch function appear to include: (1) a short rectal muscle cuff, (2) a small ileal reservoir, (3) a short ileal spout, (4) removal of all rectal mucosa, and (5) aggressive correction of rectal strictures.

Adenomatous Polyposis Coli↗
PubMed1982

Five years of the pediatric Kock pouch.

Since 1976, 16 teenagers at the Hospital for Sick Children, Toronto, have had a Kock pouch constructed. This group consists of 10 females and 6 males ranging in age from 13 to 19 yr. These were all elective pouches: 9 were converted from standard ileostomies, 5 were converted along with proctectomy or Hartmann procedure, and 2 had total colectomies along with a Kock pouch. Two of these conversions were for failed Swenson and Soave procedures. The complications directly related to the Kock pouch were stoma stricture, prolapsed nipple valve, long outflow tract, fecal fistula, salt loss, slipped nipple valve, chronic small bowel obstruction, and "pouchitis." These 8 complications required a total of 16 operations to correct (1.4 operations per patient). The 100% follow-up shows all but 3 followed for more than 1 yr. They are all well, continent, happy, and back to a virtually normal life that includes marriage in 3. The Kock pouch should be an elective procedure and must be done only when the total colon has been removed. There must be rigid selection of pediatric patients for this operation and no children younger than teenage should receive this pouch. Moreover, it may even by worthwhile letting such a child have a standard ileostomy for a while until his or her general condition (both physical and mental) is best able to cope with a Kock pouch.

Adolescent↗
PubMed1987

A ten-year experience with the pediatric Kock pouch.

In 1981, a five-year experience with the pediatric Kock pouch was reported. This series has now increased to 20 patients with an overall experience of 10 years. There were 12 females and eight males ranging in age from 13 to 19 years. These pouches were all elective: 18 were converted from standard ileostomies, (six with proctectomy or Hartmann procedure), and two had a total proctocolectomy. Three of these conversions were for failed Swenson, Soave, and Duhamel procedures. Sixteen children had ulcerative colitis, three Hirschsprung's disease (one with colon atresia and imperforate anus with rectovaginal fistula), and one colonic polyposis (Gardner's syndrome). None had Crohn's disease. The 100% follow-up shows that 19 of the 20 teenagers have been followed for more than 1 year. The most important conclusions from this 10-year review of 20 teenage Kock pouch patients are (1) this continues to be a difficult operation with a significant potential for complications. (2) After 15 months, there is a very small incidence of nipple valve and outflow tract problems, but the possibility of pouchitis remains between 15 months and 5 years. (3) After 5 years, the chances of any kind of a problem with the Kock pouch are minimal. These children are all well, continent, happy, and back to a virtually normal life that includes marriage and pregnancy. The pediatric Kock pouch continues to be a reasonable alternative for the appropriate teenager, when a standard ileostomy is not desired and/or a pelvic pouch is impossible. It must be done by a surgeon with the necessary interest and experience. Long-term follow-up is essential.

Adolescent↗
PubMed1996

Restorative proctocolectomy in children and adolescents.

Children and adolescents with colitis present specific problems for surgeons. There has been a fashion, particularly in North America, for restoring continuity after colectomy by a direct ileo-anal anastomosis. The authors reviewed their experience with restorative proctocolectomy with ileal reservoir (RPC) in patients under 18 years of age to evaluate the outcome and to discuss the problems and challenges associated with the procedure in this age group. Fifteen patients (6 boys, 9 girls) were operated on between 1984 and 1995. The diagnoses included 12 patients with ulcerative colitis (UC), two with familial adenomatous polyposis (FAP), and one with total colonic neuronal dysplasia. The median age of the patients at the time of ileal pouch formation was 15 years, and follow-up data were available for all patients at a median of 43 months. Ten patients with UC underwent pouch surgery 4 to 14 months after initial total abdominal colectomy (7 for acute severe disease, 3 for chronic disease). Four patients (2 with chronic UC, 2 with FAP) underwent primary RPC. There were no deaths in this series. Three (20%) patients suffered serious early morbidity (pouch hemorrhage, pelvic sepsis, severe psychological crisis). Late morbidity included three patients who had small bowel obstruction, one who required laparotomy, two who required pouch revision, and five of 12 (42%) patients with UC who presented with a documented episode of pouchitis between 2 and 72 months after ileostomy closure. All patients had acceptable bowel frequency and quality of continence. This experience suggests that RPC provides an important surgical option for children and adolescents with UC or FAP.

Adenomatous Polyposis Coli↗
PubMed1996

Ileal pouch-anal anastomosis as the first choice operation in patients with familial adenomatous polyposis: a ten-year experience.

BACKGROUND: The choice between ileal pouch-anal anastomosis (IPAA) and ileorectal anastomosis (IRA) in the treatment of patients with familial adenomatous polyposis remains controversial. The aims of this study were to assess our 10-year experience with proctocolectomy, endoanal mucosectomy, construction of an ileal reservoir pouch, and IPAA in a series of 171 patients with familial adenomatous polyposis and to compare the functional results after IPAA with those after IRA. METHODS: Data from patients treated by IPAA at one institution were prospectively accumulated from October 1983 to October 1993. Medical records of 171 consecutive patients were studied regarding morbidity and functional results. These functional results were compared with those of a series of 23 patients who underwent IRA at the same institution. RESULTS: One patient (0.6%) died after operation. Sixty-two patients (36%) had concomitant colorectal carcinoma, 36 of which tumors were invasive (15 stage A, 13 stage B, and 8 stage C). Forty-six patients (27%) had at least one postoperative complication, with 14 patients requiring reoperation (8%). Twenty-six patients (15%) had obstruction. Seven patients (4%) had pelvic sepsis, and one had transient impotence (0.6%). Only two patients (1%) had a typical episode of pouchitis. The mean follow-up was 29 months (range, 3 to 100 months); 101 patients were monitored for more than 1 year. Little difference was noted between bowel function after IRA and that after IPAA. The mean daytime stool frequency after IPAA was 4.2 with 26% of patients having an average of 1 bowel movement at nighttime, compared with a stool frequency of 3.0 and 13% of patients having night evacuation after IRA. Daytime continence was normal for 98% of patients after IPAA and for all the patients after IRA. Nighttime continence was normal in 96% and 98% of patients, respectively. CONCLUSIONS: Morbidity and functional results after IPAA for familial adenomatous polyposis do not differ from those reported after IRA. For this reason and because of the risk of rectal cancer after ileorectal anastomosis, IPAA with endoanal mucosectomy is our first choice in the treatment of patients with familial adenomatous polyposis.

Adenomatous Polyposis Coli↗
PubMed1993

The ileal pouch operation for ulcerative colitis.

Ileal pouch-anal anastomosis cures chronic ulcerative colitis with an acceptable perioperative morbidity and mortality. The great majority of patients achieve satisfactory continence with an excellent quality of life. However, continence is not perfect, and fecal soilage is a troublesome problem for a small number of patients. Moreover, as many as one third of patients develop pouchitis, for which an effective means of long-term prevention or treatment has yet to be developed. Finally, controversial issues such as optimal pouch design or technique of anastomosis will be resolved only when long-term follow-up of randomized trials has been completed.

Colitis, Ulcerative↗
PubMed1995

Increased expression of CD44v6 and CD44v3 in ulcerative colitis but not colonic Crohn's disease.

Immune mechanisms, possibly involving cell-surface molecules such as CD44, have been invoked to explain the pathogenesis of inflammatory bowel disease. We used monoclonal antibodies against epitopes encoded within the variable region of CD44 to investigate CD44 isoform expression in colon, small intestine, and liver in patients with various intestinal disorders and in controls. Biopsy samples from patients with ulcerative colitis showed significantly increased epithelial expression of CD44 isoforms containing the v6 and v3 epitopes, detected with antibodies 2F10 and 3G5, respectively. CD44v6 was detected on colonic crypt epithelial cells in 23 of 25 ulcerative colitis samples compared with 3 of 18 colonic Crohn's disease samples (p = 3.0 x 10(-6); odds ratio 57.5 [95% CI 6.83-702]) and 3 of 52 controls (22 normal colon, 10 infective colitis, 2 radiation colitis, and 18 colonic Crohn's disease; p < 1 x 10(-8); odds ratio 199 [25.5-2294]). No significant expression of CD44v6, CD44v3, or CD44v8/9 was found in samples of normal proximal colon from 4 patients with distal ulcerative colitis, whereas samples from the affected area showed staining for CD44v6 and CD44v3. No expression of CD44 variants was found in 15 samples of normal small intestine, 11 small-bowel pouchitis, 8 coeliac disease, 3 small-bowel Crohn's disease, 6 normal liver, 6 primary biliary cirrhosis, or 9 primary sclerosing cholangitis. The high intensity of CD44v6 and v3 epitope expression on crypt epithelial cells in ulcerative colitis suggests that CD44 isoforms may have an important role in ulcerative colitis. Their detection could have diagnostic potential in differentiating ulcerative colitis from other forms of colonic inflammation including Crohn's disease.

Antibodies, Monoclonal↗
PubMed1997

Inflammatory fibroid polyp in a continent ileo-anal pouch after colectomy for ulcerative colitis--case report.

The most frequent complication occurring in continent ileo-anal pouches after colectomy for ulcerative colitis (UC) is pouchitis. Recurrences of adenomas or carcinomas in pouches of familial adenomatous polyposis (FAP) patients are exceptional, whereas in those with ulcerative colitis dysplasia it is a very rare occurrence. We describe the case of a young woman who developed a mass in a J pouch three years after its construction following colectomy for ulcerative colitis. Histological and immunohistochemical studies showed that this mass had the features of an inflammatory fibroid polyp. A review of the literature of lesions observed in continent ileo-anal pouches after colectomy for UC would suggest that this lesion is an exceedingly rare complication of those devices.

Adult↗
PubMed2006

[Nutritional therapy in inflammatory bowel disease].

Protein-energy malnutrition and specific nutrient deficiencies are common in inflammatory bowel diseases (IBD), more particularly in Crohn's disease. In adults, the use of artificial nutrition is indicated in the event of malnutrition, short bowel syndrome, or IBD refractory to all other treatments. In children, enteral nutrition has a place as first-line treatment to avoid side effects of corticosteroids on growth. The use, as a therapeutic tool, of specific nutrients (n-3 fatty acids, glutamine, antioxydant vitamins and minerals, TGF-beta, probiotics...) seems interesting at the pathophysiological level. Nevertheless, these nutrients are still under evaluation and there are not enough available studies to recommend them in clinical routine. A very promising solution is the use of probiotics for the treatment of refractory pouchitis.

Antioxidants↗
PubMed2002

Nutritional factors in inflammatory bowel disease.

Dietary antigens may act as important stimuli of the mucosal immune system and have led to the study of nutritional therapy for IBD. Patients with active CD respond to bowel rest, along with total enteral nutrition or TPN. Bowel rest and TPN are as effective as corticosteroids at inducing remission for patients with active CD, although benefits are short-lived. Enteral nutrition is consistently less effective than conventional corticosteroids for treatment of active CD. Use of palatable, liquid polymeric diets in active CD is controversial, but these diets are of equal efficacy when compared with elemental diets. UC has not been treated effectively with either elemental diets or TPN. Fish oil contains n-3-PUFA, which inhibits production of proinflammatory cytokines and has some benefit in the treatment of CD. Topical applications of short-chain fatty acids have benefited diversion colitis and distal UC, whereas probiotics hold promise in the treatment of pouchitis.

Diet↗
PubMedDate not supplied

Gastroesophageal reflux after intact vertical banded gastroplasty: correction by conversion to Roux-en-Y gastric bypass.

Symptomatic gastroesophageal reflux disease is common in our experience after vertical banded gastroplasty. Our aim was to determine the safety and efficacy of Roux-en-Y gastric bypass in the treatment of symptomatic gastroesophageal reflux disease complicating vertical banded gastroplasty. We evaluated prospectively collected data on 25 patients who underwent revisional bariatric surgery because of severe gastroesophageal reflux disease after vertical banded gastroplasty. Only 4 of 25 patients had gastroesophageal reflux disease symptoms prior to vertical banded gastroplasty. Endoscopic findings in 24 patients included esophagitis (58%), Barrett's esophagus (28%), pouchitis (29%), and gastritis (21%);7 (28%) of 25 patients had evidence of stenosis at the pouch outlet. Mean follow-up (complete in all 25) after Roux-en-Y gastric bypass was 37 +/- 7 months (range 3 to 102 months). There were no deaths. Postoperative complications occurred in six patients: pneumonia in two, wound infection in two, prolonged drainage of the defunctionalized stomach via gastrostomy in one, and fever in one. Median hospitalization was 7 days (range 5 to 43 days). At follow-up (37 +/- 7 months), 24 (96%) of 25 are completely or almost completely symptom free. Body mass index was 33 +/- 2 kg/m(2) before and 28 +/- 2 kg/m(2) after Roux-en-Y gastric bypass (P = 0. 001). Symptoms of gastroesophageal reflux disease are common after vertical banded gastroplasty. Conversion to Roux-en-Y gastric bypass is safe, relieves gastroesophageal reflux disease, and promotes further weight loss. Moreover, maladaptive eating (vomiting, and so forth) induced by vertical banded gastroplasty is relieved.

Adult↗
PubMedDate not supplied

The continent ileostomy: long-term durability and patient satisfaction.

The long-term results of the continent ileostomy are controversial. Durability and patient satisfaction were evaluated by analyzing the outcome in 129 consecutive patients who had a continent ileostomy performed by one surgeon at the University of California, San Francisco, between 1975 and 1995. A quality-of-life questionnaire was sent to all patients for whom addresses were available (n = 121). Late outcome data could be obtained for 85 (66%) of the 129 patients. Three of the 85 patients died with their continent ileostomies but of unrelated causes. Fifty-one (60%) of 85 patients currently have the continent ileostomy (group A) (mean 15.1 years, range 2.7 to 21.7 years), whereas 31 (36%) of 85 have undergone conversion of continent ileostomy to conventional ileostomy (group B) (mean 5.4 years, range 0.2 to 20.4 years). Patients in group A underwent fewer major postoperative revisions (mean 0.7, range 0 to 4) than patients in group B (mean 1.3, range 0 to 8) (t test, P = 0. 088). The indications for pouch removal included valve dysfunction (42%), refractory pouchitis (23%), multiple fistulas (26%), Crohn's disease (6%), and other (16%) (four patients had two indications). Eighty-seven percent of survey respondents in group A considered their present state of health to be better than before their continent ileostomies. Fifty-seven percent and 82% of respondents in group A were not limited at all in regard to vigorous or moderate activity, respectively. Although in approximately one third of patients the pouch had to be removed, 97% of the remaining two thirds have a good to excellent outcome.

Adenomatous Polyposis Coli↗
PubMed2004

Complementary and alternative medicine in gastroenterology: the good, the bad, and the ugly.

A large proportion of the American population avails itself of a variety of complementary and alternative medicine (CAM) interventions. Allopathic practitioners often dismiss CAM because of distrust or a belief that there is no sound scientific evidence that has established its utility. However, although not widely appreciated, there are thousands of randomized controlled trials (RCTs) that have addressed the efficacy of CAM. We reviewed the RCTs of herbal and other natural products, acupuncture, and homeopathy as examples of typical CAM modalities, focusing on conditions of interest to gastroenterologists. Peppermint (alone or in combination) has supportive evidence for use in patients with dyspepsia, irritable bowel syndrome, and as an intraluminal spasmolytic agent during barium enemas or endoscopy. Ginger appeared to be effective in relieving nausea and vomiting due to motion sickness or pregnancy. Probiotics were useful in childhood diarrhea or in diarrhea due to antibiotics; one particular formulation (VSL#3) prevented pouchitis. Acupuncture appeared to ameliorate postoperative nausea and vomiting and might be useful elsewhere. There is even a suggestion that homeopathy has efficacy in treatment of gastrointestinal problems or symptoms. The major problem in interpreting these CAM data is the generally low quality of the RCTs, although that quality might not be different compared to RCTs in the general medical literature. Gastroenterologists should become familiar with these techniques; it is likely that their patients already are.

Acupuncture Therapy↗
PubMed2002

Review article: ulcerative colitis--surgical indications and treatment.

The indication for surgery is a balance between the severity of the disease despite full medical treatment and the potential disadvantages of surgery. The decision requires cooperation between gastroenterologist and surgeon. Colectomy with ileostomy and preservation of the rectum in the emergency setting is the accepted procedure and can rapidly restore the patient to normal health allowing withdrawal of anti-inflammatory medication. After recovery all surgical possibilities are then open for the future. The elective indications for surgery include failure of medical treatment, retardation of growth in a child or adolescent and neoplastic transformation. The choice of operation includes conventional proctocolectomy, restorative proctocolectomy (RPC) and colectomy with ileo-rectal anastomosis. Each has relative advantages and disadvantages. RPC is the commonest procedure. It offers a satisfactory outcome in 70-90% of patients with a cumulative failure rate of 10-15% over a 10 year period. Causes of failure include sepsis (50%), dysfunction (30%) and pouchitis (10%). In selected cases salvage surgery to avoid failure can be successful with rates of around 70% for outlet obstruction and fistulation and 50% for pelvic sepsis.

Colectomy↗
PubMed1998

Review article: short chain fatty acids in health and disease.

Short chain fatty acids (SCFAs) have been the subject of much research over the past few decades. They play a vital role in maintenance of colonic integrity and metabolism. They are produced when dietary fibre is fermented by colonic bacteria. SCFAs are avidly absorbed in the colon, at the same time as sodium and water absorption and bicarbonate secretion. Once absorbed, SCFAs are used preferentially as fuel for colonic epithelial cells and have trophic effects on the epithelium. Clinically, SCFAs have been studied as possible therapeutic agents in diversion colitis, ulcerative colitis, radiation proctitis, pouchitis and antibiotic-associated diarrhoea. Although some promising effects have been observed in uncontrolled studies, a specific therapeutic role for SCFAs remains to be defined. SCFAs may be the effector of the beneficial role of fibre in prevention of colon cancer.

Animals↗
PubMed2003

Rescue therapy with tacrolimus is effective in patients with severe and refractory inflammatory bowel disease.

BACKGROUND: Oral tacrolimus, approved for the prophylaxis of organ rejection in liver or kidney transplants, has been reported to be effective in anecdotal cases of refractory inflammatory bowel disease. AIM: To evaluate the usefulness of low-dose oral tacrolimus in refractory inflammatory bowel disease. METHODS: Thirty-one adult Caucasian patients with steroid-dependent (n = 15) or steroid-refractory (n = 16) inflammatory bowel disease (Crohn's disease, n = 6; ulcerative colitis, n = 23; pouchitis, n = 2) were enrolled. Tacrolimus (0.1 mg/kg body weight per day) was administered orally in 30 patients and initially intravenously in one patient (0.01 mg/kg body weight per day), aiming for serum trough levels of 4-6 ng/mL. The median treatment duration was 12 months (range, 1-137 months). RESULTS: Twenty-eight patients (90.3%) experienced a clinical and laboratory response and 20 (64.5%) went into remission. One ulcerative colitis patient and two Crohn's disease patients did not improve. Three ulcerative colitis patients (9.7%) were colectomized at 1, 12 and 24 months after tacrolimus initiation. In 19 of 23 patients (82.6%) taking steroids, steroids were reduced or discontinued. Side-effects included a temporary rise of creatinine (n = 3, 9.7%), tremor or paraesthesias (n = 3, 9.7%), hyperkalaemia (n = 1, 3.2%), hypertension (n = 1, 3.2%) and an opportunistic infection (n = 1, 3.2%). CONCLUSION: Oral tacrolimus is safe and effective in refractory inflammatory bowel disease.

Administration, Oral↗