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Duodenal Crohn's disease is rare, and patients without obstruction are treated medically. We herein report one case whose duodenal Crohn's disease was successfully managed with low-speed elemental diet infusion through a nasogastric tube. A 28-year-old female developed acute duodenal Crohn's disease. Upper GI radiologic and endoscopic examinations showed a stricture in the duodenal bulb. Using the duodenal biopsy specimens, mucosal cytokine levels were measured; interleukin (IL)-1beta, IL-6, IL-8, and tumor necrosis factor-alpha levels were remarkably elevated. For initial 2 wk, powdered mesalazine was orally given but it was not effective. For the next 2 wk, she was treated with low-speed elemental diet therapy using a commercially available Elental(TM), which was infused continuously through a nasogastric tube using an infusion pump. The tip of the nasogastric tube was placed at an immediate oral side of the pylorus. The infusion speed was 10 mL/h (usual speed, 100 mL/h). After the 2-wk treatment, her symptoms were very much improved, and endoscopically, the duodenal stricture and inflammation improved. The duodenal mucosal cytokine levels remarkably decreased compared with those before the treatment. Although our experience was limited, low-speed elemental diet infusion through a nasogastric tube may be a useful treatment for acute duodenal Crohn's disease.

Objective: The etiology of pouch inflammation after restorative proctocolectomy is unknown. The fecal stream and immunological reactions are potential pathological factors. This study was performed to examine the impact of the fecal stream and stasis on immunological reactions in the pouch., Methods: Patients who underwent a restorative proctocolectomy with a covering ileostomy for ulcerative colitis were studied. Mucosal biopsy specimens were obtained from both the pouch and the proximal ileum at the time of ileostomy closure, and 3, 6, and 12 months after ileostomy closure. As a control group, normal ileal biopsies were obtained from patients with colonic polyps., Results: At the time of ileostomy closure, mucosal interleukin-1beta, interleukin-6, interleukin-8, and tumor necrosis factor-alpha levels in the pouch and the proximal ileum were not significantly different from those in the normal control group. At 3 months after ileostomy closure, the mucosal cytokine levels in the pouch increased significantly compared with those at ileostomy closure, and their levels were significantly higher than those in the proximal ileum. At 6 and 12 months after ileostomy closure, the mucosal cytokine levels in the pouch did not change significantly compared with those at 3 months after ileostomy closure. The mucosal cytokine levels in the proximal ileum did not change significantly during the entire study., Conclusions: The immunological reactions in the pouch occurred soon after ileostomy closure, and continued for at least 1 yr. The fecal stream and stasis play an important part in the pathogenesis of immunological reactions in the ileal pouch.

Purpose: The aim of this prospective blinded study was to examine whether measurement of plasma cytokines is a predictor of strangulation in patients with bowel obstruction., Methods: Seventy-seven consecutive patients diagnosed with bowel obstruction were included. Blood samples were obtained at enrollment in all patients and at surgery (immediately before operation) if patients required surgery., Results: Forty-three patients were managed conservatively (group 1) and 34 patients required surgery, of whom 20 had no bowel strangulation (group 2) and 14 had bowel strangulation (group 3). The mean plasma interleukin (IL)-6 levels at enrollment were significantly higher in group 3 (107.8 pg/ml) than in groups 1 (11.3 pg/ml, P < 0.0001 vs. group 3) and 2 (23.6 pg/ml, P < 0.0001 vs. group 3). The sensitivity and specificity of plasma IL-6 level (> or = 40 pg/ml) in predicting strangulation were 86 percent (95 percent confidence interval, 60-97 percent) and 86 percent (95 percent confidence interval, 80-88 percent), respectively. The plasma IL-6 levels at surgery significantly increased compared to those at enrollment (from 107.8 pg/ml to 205.8 pg/ml, P = 0.0003) in group 3, however, they did not increase significantly in group 2. Among other clinical and laboratory parameters, plasma lactic acid levels (> or = 15 mg/dl) at enrollment were significantly associated with strangulation. In the multivariate analysis, both plasma IL-6 ( or = 40 pg/ml) and lactic acid ( or =15 mg/dl) levels at enrollment were significant predictive factors for strangulation. IL-1beta and tumor necrosis factor-alpha were not detected in the plasma of most patients during the study., Conclusion: Plasma IL-6 measurement might be an additional diagnostic tool that can predict strangulation in patients with bowel obstruction.

Background: The main aim of this prospective study was to examine whether systemic (plasma) and local (mucosal) cytokine production is a predictor of future relapse in patients with quiescent ulcerative colitis (UC). The impact of other clinical and laboratory parameters on relapse was also studied., Methods: Fifty consecutive patients with quiescent UC were included. At enrollment, blood and mucosal (rectal biopsies) samples were collected. All patients were followed up regularly for 1 year after enrollment. Plasma and mucosal cytokine levels were measured by enzyme-linked immunosorbent assay. To identify independent significant predictive factors for relapse, time-dependent analyses using the Kaplan-Meier method and the Cox proportional hazard model were performed., Results: Thirty-four patients remained in remission, and 16 patients relapsed during the 1-year follow-up. Higher interleukin (IL)-8 levels in the rectal mucosa were significantly associated with relapse. In contrast, IL-1beta, IL-6, and tumor necrosis factor-alpha levels in the rectal mucosa were not associated with relapse. Conventional blood markers and plasma cytokines (IL-1beta, IL-6, IL-8, and tumor necrosis factor-alpha) did not correlate with relapse. Among clinical factors, age and number of prior relapses were significantly associated with relapse. In multivariate analysis, a higher rectal mucosal IL-8 level (> or = 160 pg/mg of tissue; hazard ratio, 4.7), younger age (<30 yr; hazard ratio, 7.3), and a greater number of prior relapses (> or = 5; hazard ratio, 4.3) were independent significant risk factors for future relapse., Conclusions: Rectal mucosal IL-8 measurement might be an additional objective diagnostic tool that can predict relapse in patients with quiescent UC.

Background: The aim of this study was to examine the impact of elemental diet on mucosal inflammation in Crohn's disease (CD), mainly by cytokine measurements., Methods: Twenty-eight consecutive patients with active CD were treated with an elemental diet (Elental) for 4 weeks. The mucosal biopsies were obtained from the terminal ileum and large bowel before and after treatment. As a control group, mucosal biopsies were obtained from 20 patients without inflammation. Mucosal cytokine concentrations were measured by enzyme-linked immunosorbent assay., Results: After treatment, clinical remission was achieved in 20 patients (71%). Endoscopic healing and improvement rates were 44% and 76% in the terminal ileum and 39% and 78% in the large bowel, respectively. Histologic healing and improvement rates were 19% and 54% in the terminal ileum and 20% and 55% in the large bowel, respectively. Before treatment, the mucosal concentrations of interleukin (IL)-1beta, IL-1 receptor antagonist (IL-1ra), IL-6, IL-8, and tumor necrosis factor-alpha in the ileum and large bowel were significantly higher than in controls. These cytokine concentrations decreased to the levels of control after treatment. IL-1ra/IL-1beta ratio in the ileum and large bowel was significantly lower than in controls before treatment. The ratio increased to the level of controls after treatment. The endoscopic and histologic healing of the mucosal inflammation was associated with a decline of the mucosal cytokines and an increase of the IL-1ra/IL-1beta ratio., Conclusions: The elemental diet (Elental) reduced mucosal cytokine production and corrected an imbalance between proinflammatory and anti-inflammatory cytokines in CD.

Purpose: This prospective, blinded study was designed to assess intraperitoneal cytokine productions and their relationship to clinical presentations and systemic inflammatory markers in patients with inflammatory bowel disease., Methods: Fifty patients who required abdominal surgery for active inflammatory bowel disease (ulcerative colitis, 27; and Crohn's disease, 23) were investigated. Interleukin-1beta, interleukin-6, and tumor necrosis factor-alpha levels in intraperitoneal fluid (obtained by intraoperative lavage) and plasma were measured by enzyme-linked immunosorbent assay. To compare intraperitoneal cytokine productions between diseases with a different degree of inflammation, intraperitoneal cytokine measurement also was performed for patients who required surgery for colorectal cancer (n = 25) and acute appendicitis (n = 25)., Results: The median intraperitoneal cytokine (interleukin-1beta, interleukin-6, and tumor necrosis factor-alpha) levels were significantly higher in patients with inflammatory bowel disease than in patients with colorectal cancer and acute appendicitis. In patients with inflammatory bowel disease, intraperitoneal cytokine levels were significantly higher in patients with intraperitoneal sepsis (abscess/fistula) than in patients without intraperitoneal sepsis at laparotomy. Intraperitoneal cytokine levels did not correlate with type of disease (ulcerative colitis/Crohn's disease), age, gender, duration of disease before surgery, preoperative medical treatment, and the extent or site of disease. There were no significant correlations between intraperitoneal cytokine levels and the following systemic inflammatory markers: plasma cytokine levels, white blood cell count, platelet count, erythrocyte sedimentation rate, and C-reactive protein levels. Postoperative intraperitoneal septic complications (anastomotic leak/abscess/enterocutaneous fistula) more frequently occurred in patients with higher intraperitoneal cytokine levels., Conclusions: Intraperitoneal cytokine productions were greatly elevated in patients with inflammatory bowel disease, and their levels correlated with the presence of intraperitoneal sepsis at laparotomy and development of postoperative intraperitoneal septic complications. Intraperitoneal cytokine levels showed no correlations with systemic inflammatory markers.

Purpose: This study was designed to examine postoperative change of mucosal inflammation at strictureplasty segment in Crohn's disease mainly by cytokine measurements., Methods: Patients who underwent strictureplasty for Crohn's disease in the terminal ileum were investigated. Mucosal samples at the strictureplasty site were obtained during operation. At 3, 6, and 12 months after operation, biopsy specimens were taken from the strictureplasty site and macroscopically normal ileum at endoscopy. Mucosal cytokine concentrations were measured by enzyme-linked immunosorbent assay., Results: The mucosal concentrations of proinflammatory cytokines (interleukin-1beta, interleukin-6, interleukin-8, and tumor necrosis factor-alpha) and anti-inflammatory mediator (interleukin-1 receptor antagonist) at the strictureplasty segment greatly increased at the time of operation. Interleukin-1beta, interleukin-1 receptor antagonist, interleukin-6, interleukin-8, and tumor necrosis factor-alpha concentrations at the strictureplasty segment decreased during a 12-month period after operation. Twelve months after operation there was no significant difference in each cytokine concentration between the strictureplasty and macroscopically normal segments. The mucosal interleukin-1 receptor antagonist/interleukin-1beta ratio at the strictureplasty segment increased during a 12-month period after operation. Twelve months after operation there was no significant difference in the ratio between the strictureplasty and macroscopically normal segments. The endoscopic and histologic severities of mucosal inflammation at the strictureplasty site also decreased; however, their findings were not normalized during the study., Conclusions: During one year after strictureplasty for Crohn's disease, cytokine production at the strictureplasty segment was decreased to the level of the macroscopically normal ileum and an imbalance between proinflammatory and antiinflammatory cytokines was corrected.