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PubMed2004

Low-dose balsalazide plus a high-potency probiotic preparation is more effective than balsalazide alone or mesalazine in the treatment of acute mild-to-moderate ulcerative colitis.

BACKGROUND: Balsalazide is well tolerated and effective in treating acute ulcerative colitis. VSL#3 is a probiotic cocktail proven to be effective in preventing flare-ups of chronic pouchitis. We compared the efficacy and safety of low-dose balsalazide (2.25 g/day) plus 3 g/day VLS#3 (group A) with medium-dose balsalazide alone (group B) and with mesalazine (group C) in the treatment of mild-to-moderate active ulcerative colitis. MATERIAL/METHODS: Ninety patients (30 per group) were randomly enrolled, with a treatment duration of 8 weeks. Efficacy was assessed by symptoms assessment, endoscopic appearance, and histological evaluation. RESULTS: Balsalazide/VSL#3 was significantly superior to balsalazide alone and to mesalazine in obtaining remission: 24 patients of group A were in remission [per-protocol: 85.71% (C.I.95%: 62-96), on intention-to-treat: 80% (C.I.95%: 59-91)], while 21 group B [per-protocol: 80.77% (C.I. 95%: 51-82), on intention-to-treat: 77% (C.I.95%: 43-81)] and 16 group C patients [per-protocol: 72.73% (C.I. 95%: 30-75), on intention-to-treat: 53.33% (C.I.95%: 42-62)] were in remission (p<0.02). Balsalazide with or without VSL#3 was better tolerated than mesalazine: two group C patients were withdrawn from the study because of severe side-effects; 1 group A (3.33%), 3 group B (10%) and 4 group C (13.33%) patients experienced slight side-effects. The balsalazide/VSL#3 combination was faster in obtaining remission than balsalazide alone or mesalazine (4, 7.5, and 13 days in groups A, B and C, respectively) and also better in improving all parameters evaluated. CONCLUSIONS: Balsalazide/VSL#3 may be a very good choice in the treatment of active mild-to-moderate active ulcerative colitis instead of balsalazide alone or mesalazine.

Adult↗
PubMed2005

Rifaximin: a nonabsorbed oral antibiotic.

Rifaximin is a rifamycin analogue with a broad spectrum of activity similar to that of rifampin; however, because it is poorly absorbed in the gastrointestinal tract, the focus of its development has been on intestinal infections and diseases. This agent has proven to be as effective as ciprofloxacin in treating travelers' diarrhea due to Escherichia coli, although it is ineffective in treating infections due to Campylobacter jejuni. Other potential uses for rifaximin in gastroenterologic disorders include treatment of hepatic encephalopathy, intestinal gas and gas-related symptoms, diverticular disease, intestinal bacterial overgrowth, pouchitis, ulcerative colitis, and active Crohn's disease. This article highlights several studies demonstrating the efficacy of rifaximin in treating travelers' diarrhea as well as other gastrointestinal diseases and discusses the drug's pharmacokinetics, indications, contraindications, warnings, precautions, adverse reactions, and dosing.

Anti-Infective Agents↗
PubMed2005

Probiotics in inflammatory bowel disease: possible mechanisms of action.

PURPOSE OF REVIEW: Probiotics are live, nonpathogenic bacteria that confer health benefits beyond their nutritional value. In inflammatory bowel disease, where changes in bacterial flora have been demonstrated, there is an increasing interest in modulating the flora with probiotic strains. The beneficial effect of probiotics is demonstrated mainly in pouchitis and ulcerative colitis; however, their mechanisms of action are not well defined. The purpose of this review is to discuss the latest findings related to their mechanism of action. RECENT FINDINGS: A decrease in the secretion of pro-inflammatory cytokines, IFN-gamma, TNF-alpha and IL-12, and interference with bacterial adherence to the epithelium has been demonstrated. At the molecular level, an anti-inflammatory effect associated with NF-kappaB inhibition, heat-shock protein induction and proteasome inhibition has been suggested, although NF-kappaB induction has also been demonstrated. Unexpectedly, the beneficial effects described were achieved not only by live bacteria but also by gamma-irradiated nonviable bacteria, bacterial DNA components and probiotic-cultured media. SUMMARY: Understanding the mechanisms responsible for the beneficial effect of probiotics in inflammatory bowel disease and experimental colitis may help understand the role of bacteria in disease pathogenesis. The findings that live probiotics may not be mandatory to be beneficial, and that therapeutic effects may be obtained by systemic, rather than oral administration could have a major impact on the practical use and manufacturing of probiotics.

Animals↗
PubMed1991

[Treatment of ulcerative colitis and familial polyposis].

Total colectomy with mucosal protectomy and ileal pouchoanal anastomosis (IPAA) is a promising surgical development for the treatment of ulcerative colitis and familial polyposis. It avoids the need for an ostomy to the exterior, removes all affected tissue and maintains reasonable bowel control by the anal sphincter. 58 patients who underwent IPAA (Group A) were compared with 40 who underwent total proctocolectomy with Kock's pouch (KP) or Brooke's ileostomy (BI), or ileorectostomy (Group B). The indications for surgery were intractable disease, recurrent acute colitis, nonresolving acute colitis, dysplasia, toxic megacolon, perforation, hemorrhage and malnutrition. In Groups A and B duration of operation was, respectively, 6.9 and 5 hours (p less than 0.001); postoperative complications were intestinal obstruction (8 cases versus 14, p less than 0.05), pelvic inflammation (4 vs 3), pouchitis (4 vs 2), and wound infection (3 vs 1). Additional complications in Group A were pouchovaginal fistula (2), and single cases of transient brachial plexus palsy, anastomal stenosis, and rectal prolapse. There were no sexual or urinary complications, no cases in which pouch resection was necessary, nor was there any postoperative mortality. Additional complications in Group B were pouchocutaneous fistula (3) and neurogenic bladder (1?). Among those with KP, there were 9 cases of nipple slippage and 2 cases needed total pouch resection. Among those with BI there were 3 cases of ileostomal prolapse. Mortality in Group B was 4. Total hospital stay in groups A and B, respectively, were 30 and 56 days (p less than 0.0005). Fecal output was 6.3 and 5.9 movements per day in Groups A and B, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenomatous Polyposis Coli↗
PubMed1991

[Presence paf-acether mediator of inflammation in stools of patients with inflammatory enterocolitis].

Paf-acether (platelet-activating factor, paf) is one of the most potent inflammatory mediators synthesised by and acting on most inflammatory cells. Paf causes gastric ulcerations and ischemic bowel necrosis. Recently, we described the presence of paf in stools of patients bearing ileal pouch-anal anastomosis with pouchitis. These findings prompted us to search for the presence of paf in stools of patients suffering from inflammatory bowel diseases: Crohn's disease and ulcerative colitis. The fraction corresponding to paf isolated from stools exhibited the same physicochemical and biological characteristics as synthetic paf. Reverse-phase high performance liquid chromatography revealed 80% of C16 and 20% of C18 paf. The presence of a biologically active phospholipid in human stools may bring new perspectives with respect to the study of gastrointestinal diseases as well as the use of paf antagonists in the treatment of inflammatory bowel diseases.

Chromatography, High Pressure Liquid↗
PubMed1990

Restorative proctocolectomy with ileal reservoir: indications and results.

Proctocolectomy with ileal pouch is indicated in patients with diseases of the colon limited to the mucosa. The ileum must not be involved. In order to maintain stool continence, anal sphincter and mucosa must be preserved; however, mucosa of the rectum can be resected. There are three types of pouches possible (S, J, W) with increasing capacity. The distal loop of the ileum must not be longer than 1-2 cm, otherwise the defecation may be inhibited. Between 1977 and 1987 205 patients have been treated by proctocolectomy, most of them for ulcerative colitis of familial polyposis. In 6% the operation was unsuccessful (unknown Crohn's disease, pelvic sepsis or stool incontinence), 27% of the patients suffered from complications when the pouch was constructed or the ileostoma was closed (obstruction, sepsis). The overall mortality was 1%. 2 of 174 patients were incontinent. In all other patients the frequency of defecation was 3-5 per day. Stool continence depends on the shape of the pouch: 75% of the patients with a J-pouch and 93% of the patients with a W-pouch were continent. The overall results were better in patients with familial polyposis than with ulcerative colitis. The latter developed pouchitis in 20%.

Adenomatous Polyposis Coli↗
PubMed1990

The pathological diagnosis and differential diagnosis of Crohn's disease.

Crohn's disease and ulcerative colitis are distinct entities, but in 5 to 10% of patients and resected specimens, a clear separation may not be possible. The pathological diagnosis and differential diagnosis of Crohn's disease, including ulcerative colitis, indeterminate colitis and other diseases that may mimic Crohn's disease are discussed in this review, with particular emphasis on the biopsy diagnosis. It is often difficult or impossible to distinguish diversion colitis and pouchitis from recurrence of Crohn's disease; special measures need to be taken for their identification. The predisposition to cancer, and the presence of dysplasia in Crohn's disease in relation to surveillance, are also discussed.

Adult↗
PubMed1989

Comparative clinical results of ileal-pouch anal anastomosis and ileorectal anastomosis in ulcerative colitis.

The aim of the study was to compare the results of ileal-pouch anal anastomosis (IAA) and total abdominal colectomy with ileorectal anastomosis (IRA) in the treatment of ulcerative colitis. The number of patients included in the comparative trial was 104 (IAA) and 197 (IRA), respectively. No clear advantage of IRA over IAA was seen: postoperative mortality and morbidity were about the same; functional results as shown by the frequency of stools and daytime continence were virtually equal. A factor favoring IAA was, among others, recurrence of proctitis after IRA which is more difficult to treat than the pouchitis occurring after IAA and is associated with a higher rate of secondary permanent end ileostomy; besides, IRA entails the risk of cancer developing in the rectal stump, while at the same time it is difficult to follow up these patients closely enough. IRA is indicated only if the diagnosis of ulcerative colitis is in doubt; if the patient is more than 60 years of age; and if IAA proves technically too difficult, IAA is usually preferable, however, if there is any doubt as to whether the patient is suffering from ulcerative colitis or Crohn's disease, ileorectostomy is preferred which does not preclude IAA at a later date in case of need.

Anal Canal↗
PubMed1989

[Morphologic changes in ileoanal reservoirs 2 years after their construction].

A study was made of the histologic changes in the mucosa of the ileoanal reservoirs of 10 patients who 2 years earlier had undergone ileoanal anastomosis with a J reservoir for ulcerative colitis (CU). In biopsies of the reservoirs were evaluated: 1) basic morphologic changes; 2) morphometric differences with respect to normal ileal mucosa; 3) the immunohistochemical pattern (IHQ) (IgA, IgG, IgM and CEA) of the reservoir mucosa as compared to normal ileum, active ulcerative colitis. Crohn's disease and celiaca; 4) the possible existence of atypias or dysplasias of the reservoir mucosa; and 5) the number of argentaffin cells per field. The basic morphologic alteration consisted of colonic metaplasia. Reservoir biopsies exhibited partial (8 cases) or subtotal atrophy (2 cases) of the mucosa. With respect to the normal ileum there was a decrease in villi height (p less than 0.05), an increase in crypt depth (p less than 0.05) and a higher index of mucosal regeneration, with a larger number of cells and mitoses per crypt (p less than 0.05). Fifty percent of the reservoirs presented a chronic inflammatory pattern with an acute component in 30% of them. The immunohistochemical pattern of the reservoirs not inflamed was similar to that of normal ileum (IgA much greater than IgM greater than IgG) and that of the inflamed reservoirs was similar to that of intestinal inflammatory disease (marked increase in the IgG. CEA (similar to what?) an alteration of local immune homeostasis could have of the genesis of pictures of "pouchitis". No alarming signs of atypia or dysplasia were found, nor changes in the population of argentaffin cells.

Anal Canal↗
PubMed1987

J pouch with ileoanal anastomosis.

The physical inconvenience and adverse psychological impact of ileostomy on patients led surgeons to seek a more normal and acceptable alternative. This is a report of the Mayo Clinic experience with, and modifications of, the ileoanal reservoir procedure. The hospital charts of 188 patients who had a J-pouch construction were reviewed. The operative technique is described. There were no hospital deaths. In 10 patients the operation was a failure. Complications included pelvis sepsis (21 patients), anastomotic sinus (15), anastomotic stricture (22), small-bowel obstruction (43), peritonitis after ileostomy closure (10) and pouchitis (15). Careful patient selection for the procedure is important. Crohn's disease is a contraindication. Of the patients studied, 95% found life more acceptable with an ileoanal anastomosis than with a loop ileostomy.

Adenomatous Polyposis Coli↗
PubMed1987

The ileal pouch-anal anastomosis: surgical technique and current clinical results.

During the six-year period between January 1981 and January 1987, 582 ileal pouch-anal anastomoses were constructed at the Mayo Clinic-affiliated hospitals for either ulcerative colitis (509 patients) or polyposis coli (71 patients). Two patients had Crohn's disease. Two patients died postoperatively. Pelvic sepsis, intestinal obstruction, and pouchitis were seen in 4%, 13%, and 14%, respectively. At one year postoperatively, the mean number of stools was 5.6 during the day and 1.5 during the night. Younger patients and those with polyposis had fewer stools. Incontinence was observed in 2% patients during the day and 3% during the night. Ileal pouch-anal anastomosis is safe, provides satisfactory continence, and improves the quality of life of patients who require proctocolectomy.

Adenomatous Polyposis Coli↗
PubMed1988

Early results with the J-pouch procedure in children.

Mucosal proctectomy with J-pouch construction and ileostomy were performed on eight patients (age range from 4 to 18 years), five with ulcerative colitis and three with familial polyposis coli. Complications of the first stage included transient neuropraxia of the lateral popliteal nerves, partial dehiscence of the ileoanal anastomosis and prolapse of the loop ileostomy. The ileostomy was closed 2 to 7 months after initial surgery and was associated with four further complications: enterocutaneous fistula at the ileostomy site, early and late bowel obstruction and pouchitis. Stool frequency decreased as the length of follow-up increased: 3 to 4 stools daily for three children at 2 years postoperatively compared with 4 to 10 stools daily in all children 1 month after surgery. Functional results were satisfactory and all patients preferred the J pouch to an ileostomy.

Adenomatous Polyposis Coli↗
PubMed1988

Restorative proctocolectomy for ulcerative colitis.

The results of 36 restorative proctocolectomies (with 2-loop reservoir) for ulcerative colitis (UC) performed in a three-year period were surveyed. These patients represented 69% of all those undergoing definitive surgery for UC at the same time at our department. There was no operative mortality. Both early (44.4%) and late complications (45.2%) were quite common, but they were mostly minor and only two were permanent failures (5.6%) requiring construction of conventional ileostomy. Anastomotic retraction and sinus formation (25%), as revealed by pouch x-ray, were the most frequent early complications, occurring in a lesser degree (19.4%) also after stoma closure. Pouchitis was also a common (20%) late complication, but usually resolved promptly with metronidazole treatment. The functional results in the 23 patients evaluated were satisfactory, with a mean defaecation frequency of 5.4 per 24 hour and a minor soiling frequency of 36%. None of the patients had to wear a pad. The over-all results are compatible to those from other centres and suggest that acceptable anal function follows restorative proctocolectomy in most suitable cases with UC. The role of adequate surgical experience and consideration of contraindications must, however, be emphasised, and the surgeon must be ready to handle many minor and even major complications.

Adolescent↗
PubMed1988

Mucosal alterations in pelvic ileal reservoirs. A histological and ultrastructural evaluation in an experimental model.

To study mucosal changes in ileal pouches, three different types of pelvic ileal reservoir (2-loop, 3-loop and 4-loop), interposed in place of resected rectum, were constructed in 12 piglets, 4 animals in each group (n = 12). After a 6 week interval the animals were sacrificed and the reservoirs removed and processed for light and scanning electron microscopy (SEM). Both acute and chronic inflammatory changes were present but not prominent in the pouch mucosa. With the exception of mucosal ulcers both the histological and SEM-findings greatly resembled the atrophic, flat mucosa seen in ileal coeliac disease. Macroscopic findings did not correlate with histological findings. Colonization by bacteria and bacterial overgrowth were noticed in every pouch suggesting a possible link between bacterial invasion and pouch ileitis. No correlation was found, however, between the amount of intraluminal bacteria and the severity of the pouchitis.

Animals↗
PubMed1988

Surgical options in the treatment of ulcerative colitis and Crohn's colitis.

The surgical standard for ulcerative colitis was complete proctocolectomy. Colectomy with mucosal proctectomy reduces the problems of the perineal wound essentially. A conventional ileostomy can be avoided by Kock's pouch technique. Correct operative technique reduces the complications with necessary reoperation to 10-20%. A non-specific pouchitis will develop in 25% of the cases but can mostly be treated with metronidazol. Another option is reconstructive proctocolectomy with ileal reservoir with ileo-anal anastomosis. Its complications rate is about the same, patients integrity and satisfaction remarkably high. Although both techniques are demanding and should be restricted to specialized centers, there is nowadays no indication to amputation of the rectum for ulcerative colitis. An ileorectal anastomosis is an acceptable option under effective supervision of the retained mucosa because of the risk of cancer development. Conservative surgery with resection and reresection remains the therapeutic approach to Crohn's disease until etiology and causal therapy are known although surgery is not curative for Crohn's disease. 10 years recurrence rate is 30-50% and cannot be predicted or definitely influenced. Therefore removal of the rectum and permanent ileostomy should be avoided as long as possible. Pouch procedures are not indicated. Moderate resections and good general care avoid short bowel syndrome and deficiency disease.

Colectomy↗
PubMed1986

Pouch ileitis--recurrence of the inflammatory bowel disease in the ileal reservoir.

"Pouchitis" is an inflammation of the ileal pouch that has been described as occurring after Kock's procedure--the continent ileal pouch. The case presented herein demonstrates clinical and histological features that resemble ulcerative colitis, implying that this disorder may be a recurrence of the patient's original inflammatory bowel disease and not merely a local and nonspecific process as previously suggested.

Adult↗
PubMed1983

The Kock continent ileostomy.

Over a four and one-half year period, we have performed 100 Kock continent ileostomies with one nonpouch-related mortality. The large majority of these operations have been conversions of existing conventional ileostomies. Modifications in the surgical technique have gradually lowered the complication rate, and postoperative revisions are now required less frequently than for conventional ileostomies. Slippage of the nipple valve, the most troublesome complication of the Kock pouch operation, is currently seen in 4.1 per cent of the patients. Eversions of the nipple valve have been eliminated, and fistulas are now seen rarely. The so-called pouchitis, a postoperative complication noted in 10 per cent of the patients, is usually well controlled with metronidazole. Kock pouches performed upon patients in whom the original diagnosis was Crohn's ileocolitis have been followed by a high incidence of postoperative fistulas, but patients with Crohn's colitis have thus far fared as well as patients with ulcerative colitis. The over-all success rate for the Kock pouch operation in this series of patients is 97 per cent.

Adolescent↗
PubMed1995

Functional results of the double-stapled ileoanal reservoir.

BACKGROUND: The preferred method for creation of an ileoanal reservoir is still controversial. We prospectively studied the functional and physiologic outcome of our patients who underwent a double-stapled ileoanal reservoir (DSIAR). STUDY DESIGN: All consecutive patients who underwent restorative proctocolectomy with a DSIAR between 1988 and 1993 were evaluated. Functional results were assessed by questionnaires and anal manometry preoperatively and two, 12, and 24 months postoperatively. RESULTS: One hundred forty patients (90 males and 50 females) with a mean age of 40.7 (range, 12 to 71) years were evaluated. Of these, 107 patients (77 percent) had ulcerative colitis, 21 (15 percent) had familial adenomatous polyposis, six (4 percent) had indeterminate colitis, and six (4 percent) had a post-operative diagnosis of Crohn's disease. One hundred twenty-four (95 percent) of the 131 patients with closed stomas were available for functional and manometric evaluation at a mean follow-up period of 24 months. A 32 percent decline in the mean resting pressure (from 71.3 +/- 4 to 48.2 +/- 3.4 mm Hg) occurred early after DSIAR (p < 0.001) with partial recovery by 24 months. The maximal internal sphincter resting pressure showed a 39 percent decline (from 90.8 +/- 4.9 to 55.3 +/- 5.7 mm Hg, p < 0.005) with recovery after 12 months. There were no significant changes in the length of the high-pressure zone or mean or maximal squeeze pressures. A mean of 5.4 (two to 13) bowel movements occurred during the day and a mean of 1.2 (zero to four) occurred at night. Perfect or almost perfect continence was reported during the day and night, respectively, by 95 and 92 percent of the patients. Overall perioperative complications occurred in 30 patients (21 percent) including septic complications in eight (6 percent), and pouchitis in eight (6 percent). There was one postoperative death (0.7 percent). CONCLUSIONS: Double-stapled ileoanal reservoir is associated with good subjective functional and objective physiologic results and has acceptable rates of morbidity and mortality.

Adenomatous Polyposis Coli↗