Search

Background and Aim: No marker to categorise the severity of chronic intestinal failure (CIF) has been developed. A 1-year international survey was carried out to investigate whether the European Society for Clinical Nutrition and Metabolism clinical classification of CIF, based on the type and volume of the intravenous supplementation (IVS), could be an indicator of CIF severity., Methods: At baseline, participating home parenteral nutrition (HPN) centres enrolled all adults with ongoing CIF due to non-malignant disease; demographic data, body mass index, CIF mechanism, underlying disease, HPN duration and IVS category were recorded for each patient. The type of IVS was classified as fluid and electrolyte alone (FE) or parenteral nutrition admixture (PN). The mean daily IVS volume, calculated on a weekly basis, was categorised as <1, 1-2, 2-3 and >3 L/day. The severity of CIF was determined by patient outcome (still on HPN, weaned from HPN, deceased) and the occurrence of major HPN/CIF-related complications: intestinal failure-associated liver disease (IFALD), catheter-related venous thrombosis and catheter-related bloodstream infection (CRBSI)., Results: Fifty-one HPN centres included 2194 patients. The analysis showed that both IVS type and volume were independently associated with the odds of weaning from HPN (significantly higher for PN <1 L/day than for FE and all PN >1 L/day), patients' death (lower for FE, p=0.079), presence of IFALD cholestasis/liver failure and occurrence of CRBSI (significantly higher for PN 2-3 and PN >3 L/day)., Conclusions: The type and volume of IVS required by patients with CIF could be indicators to categorise the severity of CIF in both clinical practice and research protocols., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Previous prospective studies have found the incidence of intestinal diverticular disease decreased with increasing intakes of dietary fibre, but associations by the fibre source are less well characterised. We assessed these associations in a large UK prospective study of middle-aged women., Methods and Findings: During 6 (SD 1) years follow-up of 690 075 women without known diverticular disease who had not changed their diet in the last 5 years, 17 325 were admitted to hospital or died with diverticular disease. Dietary fibre intake was assessed using a validated 40-item food questionnaire and remeasured 1 year later in 4265 randomly-selected women. Mean total dietary fibre intake at baseline was 13.8 (SD 5.0) g/day, of which 42% came from cereals, 22% from fruits, 19% from vegetables (not potatoes) and 15% from potatoes. The relative risk (95% CI) for diverticular disease per 5 g/day fibre intake was 0.86 (0.84 to 0.88). There was significant heterogeneity by the four main sources of fibre (p<0.0001), with relative risks, adjusted for each of the other sources of dietary fibre of 0.84 (0.81 to 0.88) per 5 g/day for cereal, 0.81 (0.77 to 0.86) per 5 g/day for fruit, 1.03 (0.93 to 1.14) per 5 g/day for vegetable and 1.04 (1.02 to 1.07) per 1 g/day for potato fibre., Conclusions: A higher intake of dietary fibre is associated with a reduced risk of diverticular disease. The associations with diverticular disease appear to vary by fibre source, and the reasons for this variation are unclear., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Introduction: Crohn's disease is a chronic inflammatory disorder of the gut. It is assumed that a defective interaction between the bacterial flora of the gut and the innate immune system plays a key role in the pathogenesis of the disease. This may lead to specific histological lesions. The epithelioid granuloma is particularly interesting in this regard as it is also observed in several bacterial infections of the gut., Aims and Methods: We hypothesised that genetic or environmental factors with a known influence on inflammation or immunity would lead to an increased prevalence of granulomas. Therefore, surgical specimens from 161 patients were evaluated for the presence of granulomas. Patients were genotyped for the three single nucleotide polymorphisms in caspase recruitment domain 15 (CARD15)/NOD2 associated with CD and for Asp299Gly in Toll-like receptor 4 (TLR4)., Results: The overall prevalence of granulomas was 68.9%. We did not find a significant correlation between granulomas and TLR4 or CARD15 variants. The frequency of granulomas increased with more distal disease (63% small bowel, 72% right colon, 88% left colon, 90% rectum; p=0.01). Granulomas were more frequent in younger patients (odds ratio 0.95 (95% confidence interval 0.92-0.98) p=0.007)., Conclusion: In this study of 161 well documented CD patients, we found no significant association between CARD15 and TLR4 variants and granulomas. This finding seems to refute our initial hypothesis. However, it may be that additional factors are needed for granuloma development. Granulomas may develop only when specific bacterial components are present. Therefore, future research on granuloma pathogenesis should be orientated towards detection and identification of bacterial components in these lesions.

Background and Aims: Epithelioid granulomas is one of the best histological criterion for distinguishing Crohn's disease (CD) from other inflammatory bowel diseases. Few data are available on the time of occurrence of epithelioid granulomas, and the value of epithelioid granulomas in predicting outcome has been determined only in cohorts of prevalent CD cases. Our objective was to evaluate epithelioid granuloma occurrence in incident CD cases and to examine the associations between epithelioid granulomas and outcome., Patients and Methods: We reviewed the histological reports of endoscopic and surgical specimens in a cohort of 188 consecutive incident CD cases seen in 1994 and 1995, and recorded the occurrence of epithelioid granulomas, isolated giant cells, and microgranulomas. Kaplan-Meier curves were plotted for time from CD diagnosis to immunosuppressive treatment or surgery, and associations between epithelioid granulomas and outcome were evaluated in a multivariate analysis. Follow up was at least five years., Results: Granulomas were found in 69 (37%) patients, including 46 (25%) at presentation. Median time from CD diagnosis to epithelioid granuloma detection was 0.16 (0-63) months overall, and 9.59 (0.1-63) months in 23 patients who became epithelioid granuloma positive during follow up. Isolated giant cells were found in 6% of patients and microgranulomas in 12%. Epithelioid granuloma detection increased with the number of endoscopic sampling procedures; sampling site had no influence. By multivariate analysis, epithelioid granulomas were associated with surgical resection but not immunosuppressive therapy., Conclusions: Epithelioid granulomas may separate CD into two pathological subsets and may indicate aggressive disease.

Background and Aims: There is increasing evidence implicating intestinal immune responses to dietary proteins in the pathogenesis of type 1 autoimmune diabetes (T1D). Here we investigated the association between intestinal pathology and dietary factors in T1D by examining the mucosal architecture in the BB rat model., Methods: BB control (BBc) and diabetes prone (BBdp) rats were fed either a diabetes retardant hydrolysed casein based diet or one of two cereal based diets that promote the development of diabetes. Intestinal architecture was assessed in the jejunum by microdissection, histology, and immunohistology, and by measuring peroxidase activity and brush border invertase levels., Results: Enteropathy was present in BBdp rats soon after weaning, as assessed by increases in crypt length and in the proliferative activity of crypt epithelial cells in the jejunum, and this remained constant until 120 days of age. There was also a decrease in invertase activity, as well as increased numbers of intraepithelial lymphocytes, increased levels of mucosal peroxidase activity, and infiltration of the mucosa by CD4(+) T lymphocytes. Equivalent enteropathy was present at all times in BBdp rats and was not influenced by the nature of the diet or by thymectomy at three weeks at age, procedures which prevent the development of diabetes., Conclusion: Enteropathy is a consistent feature in the diabetes prone BB rat but it precedes the onset of insulitis and appears to be due to mechanisms distinct from those which cause diabetes. The beneficial effects of the diabetes retardant hydrolysed casein diet on diabetes are not due to an effect on intestinal architecture per se but mucosal damage may be necessary for the development of autoreactivity in the pancreas.

Background: Little is known about the comparability of outpatients with irritable bowel syndrome (IBS) and patients with IBS in primary care with regard to severity of complaints, perceived limitations, other aspects of the complaints, and sex differences., Aims: To compare outpatients with IBS with primary care patients with IBS., Patients: One hundred and nine patients with IBS were recruited from general practices in Amsterdam and 86 patients with IBS were recruited from the outpatient clinic of the Department of Internal Medicine of the University Hospital in Nijmegen., Methods: Each patient completed a questionnaire on demographic variables, abdominal complaints, related complaints, and attributed causes of their abdominal complaints. The scores of the two groups were compared by univariate and multivariate analysis., Results: The outpatient group contained significantly more men, reported more severe abdominal pain, more frequent complaints, more interference with daily activities, and a higher degree of avoidance of activities (p < 0.01) than the primary care group. When each sex was analysed separately, these differences remained for female (p < 0.01) but not for male patients. Outpatients were more likely to attribute their complaints to somatic causes (p < 0.01), whereas primary care patients were more likely to attribute their complaints to stress (p < 0.01) or their agitated way of life (p < 0.05). Multivariate analysis showed that a high severity score, a large number of additional complaints, and a low score on the stress attribution were important determinants for being in the outpatient group., Conclusions: Female outpatients consider their complaints to be more serious and interfering than do patients with IBS in primary care. Male outpatients were comparable to primary care patients with IBS. More research needs to be done into sex specific differences in IBS and into the factors that influence the decision to refer a patient with IBS.

Background: A study was performed to measure the quality of life of patients receiving home parenteral nutrition (HPN). Quality of life is an important determinant of the effectiveness of health technologies, but it has rarely been assessed in patients receiving HPN., Aims: To measure quality of life and highlight any moderating factors., Patients and Methods: Quality of life was measured using two validated instruments (SF 36 and EuroQol) in 51 patients with intestinal failure. All patients had benign disease, the commonest being Crohn's disease (n = 35)., Results: HPN patient scores were worse for six of eight SF 36 domains (p < 0.05) compared with standard population scores. Younger patients (< 45) had good scores but older patients (> 55 years) scored significantly less. Patients addicted to narcotic substances had very low scores. EuroQol utility scores confirmed the SF results. Forty one patients reported that they felt too ill to work and only five were in full time work or education., Conclusions: The health status profile of our young patients on HPN was good compared with the normal population. The poorest scores were in older patients and those dependent on narcotic drugs. This has clinical and economic relevance when considering such patients for HPN.

Sixty five of 70 consecutive patients with undiagnosed gastrointestinal blood loss were examined using the new technique of small bowel enteroscopy. Using a balloon driven sonde enteroscope (SIF-SW) extended views of the small bowel were obtained as far as the distal ileum. Medium length of small bowel examined was 140 cm (range (30-200 cm). All patients studied had a normal upper gastrointestinal endoscopy. Nineteen (41%) of 46 anaemic rheumatoid arthritis patients taking non-steroidal antiinflammatory drugs (NSAID) and three (27%) of 11 patients with unexplained iron deficiency, were found to have small bowel lesions to account for their anaemia. Small bowel lesions were found in a further three of eight (37%) patients with acute gastrointestinal bleeding. The procedure failed or was terminated in five patients. Small bowel enteroscopy has considerable potential in the investigation of undiagnosed gastrointestinal blood loss and deserves more widespread application.

Non-immunological defence mechanisms represent an important line of intestinal defence in addition to humoral and cellular immunity. This review summarises the evidence for the role of the non-immunological defence system. Protective factors that have been amply documented are gastric juice, intestinal motility, and intestinal flora. Components of pancreatic juice, lysozyme, and epithelial cell turnover may also be involved. Special attention is given to gastric acid, infection with Helicobacter pylori, and hypochlorhydria and their association with infectious diarrhoea. Epidemic hypochlorhydria is discussed since this increases sensitivity to intestinal infections in third world countries.

The pathogenesis and treatment of dysfunction of the continent ileostomy was investigated in 12 patients, five of whom had asymptomatic malabsorption and seven of whom had acute complaints. The number of anaerobic bacteria in jejunal aspirates was increased in patients with pouch malfunction (range 10(3) to 10(8)/g aspirate), but the microbiology of ileal effluent and the morphology of the ileal mucosa could not be correlated with dysfunction. Bile acid breath tests and lactose tolerance tests were not, however, reliable indicators of jejunal bacterial overgrowth. The symptoms, the malabsorption, and the number of jejunal and ileal anaerobic bacteria decreased in patients during treatment with metronidazole, implicating overgrowth of anaerobic bacterial flora in the pathogenesis of the syndrome.

The protein induced modifications of the small bowel mucosa from ovalbumin-sensitised mouse have been studied in organ culture. A decrease in gamma-glutamyl transpeptidase, alkaline phosphatase, lactase, sucrase, and glucoamylase activities was observed in the explants cultured in the presence of ovalbumin. In contrast, a large increase of those enzymatic activities was noted in the culture media, the overall effect observed being a net stimulation of the total enzymatic activities of the culture system. The enzymes accumulated in the particulate fraction of the medium (brush border membrane fraction) suggesting an increased turnover of membrane components by a process of shedding or microvesiculation. This model serves as a useful tool in evaluating the local response of the small bowel mucosa induced by a specific protein.

A case of Wegener's granulomatosis is described, in which the presentation was blood stained mucus diarrhoea. Severe ileal, caecal, and rectal involvement improved rapidly after treatment with cyclophosphamide, azathioprine, and prednisolone. Although intestinal disease is an uncommon feature of Wegener's granulomatosis, both in our own experience (four of 45 cases) and in the literature, this diagnosis should be considered in view of the response to appropriate therapy.

The number of granulomas in sections of bowel involved by Crohn's disease has been counted and related to length of previous history, treatment with steroids, site of involvement, and the subsequent course of the disease. It was found that a high content of granulomas predicted a good prognosis in the large bowel and anus, but was of no prognostic significance in the small bowel. A large regional variation in granuloma counts was observed from an average of 1 per section in the small bowel to 6 in the colon, 18 in the rectum, and 36 in the anus. Those patients with a long clinical history showed a low granuloma content. The findings are consistent with the view that the granuloma represents an adaptive mechanism for the removal or localisation of the causative agent of Crohn's disease.

In an experimental jejunal perfusion study, distress in healthy subjects occurred during eight out of 16 perfusions in which intestinal secretion was provoked. Calculation demonstrates the volumetric consequences of inadequate recovery of secretory perfusates, and analysis of the perfusion studies shows that distress was significantly associated with poor recovery of the perfusate. These observations are pertinent to increasing interest in the phenomenon of intestinal fluid secretion.

An abnormal condition of the large intestine is described in which the surface epithelium is infested by short spirochaetes. Diagnosis can be made by light microscopy. A review of 14 cases diagnosed by rectal biopsy and 62 cases involving the appendix shows no consistent symptom complex. The possible significance is discussed.

A case of intramural cysts of the ileum is described for the first time. The clinical presentation and pathological findings are presented and the possible aetiology is discussed.