Search

Objective: The purpose of the study was to evaluate the incidence of discontinuous inflammation of the appendiceal orifice in patients undergoing colonoscopy for diagnosis or surveillance of colonic disease., Material and Methods: Consecutive and unselected patients subjected to colonoscopy over a 3-year period were included in a prospective study. Biopsies were taken within 2 cm of the orifice of the appendix, from the caecum and from predefined colonic segments. Discontinuous inflammation of the appendiceal orifice was defined as an area of macroscopic inflammatory changes distinct from a normal caecum of ascending colon. The biopsies were graded histologically for the presence and severity of inflammation by a pathologist without knowledge of the endoscopic findings., Results: A total of 271 patients were included. The final diagnoses were: ulcerative colitis (UC) (83 patients), Crohn's disease (CD) (54), indeterminate colitis (12), irritable bowel syndrome (IBS) (54), microscopic colitis (15) and other disease (53). Endoscopic discontinuous inflammation of the appendiceal orifice was found in 27% (95% CI: 17-38%) of patients with UC, 24% (95% CI: 13-39%) with CD, 40% (95% CI: 12-74%) with indeterminate colitis, 8% (95% CI: 0-36%) with microscopic colitis, 10% (95% CI: 3-24%) of patients with IBS and in 9% (95% CI: 2-021%) of other diseases (p<0.05). A correlation was found for endoscopic and histological discrimination between normal and inflamed mucosa (p<0.001). However, in 24% of patients, endoscopic inflammation was without histological signs of inflammation, primarily in an otherwise normal colon., Conclusions: Discontinuous inflammation of the appendiceal orifice is common in patients with IBD irrespective of clinical activity. However, patients with otherwise normal colon may also show congestion of this area without or with minimal microscopic inflammation.

Background: Patients with intestinal disease are at risk of developing selenium deficiency due to impaired intestinal absorption. The aim of the present study was to evaluate selenium status and to identify predictive factors of selenium depletion in patients with gastrointestinal disease., Methods: The concentration of selenium and the activity of glutathione peroxidase in plasma and erythrocytes were measured by fluorometry and by spectrophotometry. Eighty-six patients with Crohn's disease, 40 patients with ulcerative colitis, and 39 patients with various other gastrointestinal diseases were studied. Twenty-seven patients (16%) received home parenteral nutrition. Stool mass, faecal fat, and vitamin B12 absorption were analysed in 100 patients., Results: The plasma selenium concentration was decreased in 85% of the patients receiving supplementary parenteral nutrition and in 20% of the patients receiving oral nutrition, among them in 26% of the patients with Crohn's disease. Almost all patients with ulcerative colitis had normal selenium levels. A statistically significant correlation was found between plasma selenium and vitamin B12 absorption, stool mass, faecal fat excretion, body mass index, P-albumin, P-zinc, and the length of the remaining small bowel. Stepwise regression analyses showed that the strongest predictors of selenium deficiency were stool mass, vitamin B12 absorption, and the length of the small-bowel resection., Conclusion: Selenium deficiency is common in patients with severe gastrointestinal disorders. The deficiency is mainly related to malabsorption, and a low selenium level was almost invariably present in patients who needed parenteral supplementation due to gut failure.

Background: Although suggested, it has never been convincingly documented that food sensitivity is of pathogenetic importance in chronic inflammatory bowel disease. However, many patients may relate their gastrointestinal symptoms to specific food items ingested and may restrict their diet accordingly., Methods: A questionnaire was sent to all patients with chronic inflammatory bowel disease who attended the outpatient clinic, Medical Dept., Roskilde County Hospital in Køge, Denmark, in the year 1993. The patients were asked whether they had problems with any particular food item and, if so, to describe the symptoms experienced from it. A control group of 70 healthy persons were included., Results: Among 189 patients, 132 (70%) responded. One hundred and thirty had completed the questionnaire, 52 males and 78 females aged 13-89 years (median, 43 years). Fifty-three (41%) had Crohn's disease (CD), 69 (53%) ulcerative colitis (UC), and 8 (6%) unclassified colitis. Forty-one patients (31 CD, 10 UC) were-operated on; 51 (19 CD, 32 UC) had disease activity. Sixty-five per cent of the patients and 14% of the controls reported being intolerant to one or more food items (P < 0.0001). The intolerance covered a wide range of food products. The commonest symptoms among patients were diarrhoea, abdominal pain, and meteorism and among controls, regurgitation. Food intolerance was equally common in CD (66%) and UC (64%) and was not related to previous operation, disease activity or disease location., Conclusion: Most patients with chronic inflammatory bowel intolerance disease feel intolerant to different food items and may restrict their diet accordingly. The frequency and pattern of food intolerance did not differ between patients with CD and UC. The food intolerance was probably unspecific rather than of pathogenetic importance.

Background: Denmark has in recent years experienced an increase in the number of bacterial gastrointestinal infections., Methods: We have reviewed patients hospitalized with culture-confirmed bacterial gastroenteritis in Roskilde County during 1991-93., Results: Two hundred and seven patients were included; 68 were children (< 15 years). The microorganism isolated was Salmonella in 61% of the cases, Campylobacter in 20% and Yersinia enterocolitica in 13%. Ninety-three per cent of the patients had diarrhea, 74% had fever (> 38 degrees C), and 66% abdominal pain. Blood in stools was most frequent in patients infected with Campylobacter. Leukocytosis was rare. Twenty-four patients had bacteremia. Reactive arthritis occurred in 4.8%. Three patients died, all infected with zoonotic Salmonella types. Three stool cultures were made for 115 patients, and in 73% all 3 cultures were positive., Conclusions: Bacterial gastroenteritis requiring hospitalization affects mainly children and young adults. Infections due to zoonotic Salmonella types were more severe than Campylobacter and Y. enterocolitica gastroenteritis. It seems necessary to make at least three stool cultures to secure a bacteriologic diagnosis.

Background: The aim of the study was to present our preliminary results with laparoscopic-assisted ileocecal resection in Crohn's disease of the terminal ileum., Methods: Eight patients were operated on. The operations were assessed with regard to duration of operation, rate of conversion to open procedure, complications, time for discharge from hospital, and ability to take up work., Results: Median operation time was 145 min. One operation (12.5%) was converted to open procedure. Minor complications occurred in one patient (12.5%). Median postoperative time for discharge was 5 days. Median time to return to work was 21 days., Conclusions: Laparoscopic-assisted ileocecal resection seems suited to Crohn's disease, but the benefit of the method needs confirmation in controlled, randomized studies.

Calcium absorption and bone mineral content were studied prospectively in 30 patients with familial hypercholesterolaemia subjected to partial ileal bypass surgery. One-third of the patients were followed up for 10 years after the operation. Six months postoperatively calcium absorption decreased significantly, from a median of 16% to 13%. The effect persisted up to 5 years of follow-up study. Ten years after the operation the absorption of calcium (median, 14.5%) was not significantly different from the preoperative calcium absorption (median, 16%). Bone mineral content, measured in 76% of the patients, was retained in all patients studied. A significant correlation was present between calcium absorption and urinary calcium. The reduction in calcium absorption did not correlate with increases in faecal fat. Other long-term side effects were persistent diarrhoea and moderate steatorrhoea. A significant weight loss was slowly regained in most patients. An increase of renal oxalate excretion was only small and transient in most patients. The study shows that bypass of the terminal 200 cm of ileum for familial hypercholesterolaemia causes moderate diarrhoea and steatorrhoea in most patients but only a slight reduction of intestinal calcium absorption and apparently no risk of bone demineralization. A benefit of a postoperative calcium and vitamin D supply cannot be excluded.

Calcium absorption was studied in 62 patients with Crohn's disease during a 1-week admission on a standardized diet supplying 70 g fat, 800 mg calcium, and 200 mg oxalate. All patients had been subjected to a distal small-bowel resection of at least 50 cm. Twenty-two had an ileostomy, and 40 had at least half of the colon in function. In all patients the disease was inactive. Calcium absorption was determined by the fractional accumulation in the skeleton of the antebrachium of an intravenous and oral dose of 47Ca. Calcium absorption was significantly lower in patients with ileostomy (median, 10%; range, 5-18%) than in patients with part of or the whole colon in function (median, 14%; range, 6-22%). The present study shows that in patients with extensive small-bowel resection preservation of at least half of the colon improves calcium absorption.

Forty-three patients received home parenteral nutrition (HPN) for 4 to 13 months (median, 30 months) with a total treatment period of 153 patient-years. All patients had central venous catheters; 71 PVC subclavian catheters, 138 Broviac catheters, and 16 other catheters were used. Broviac catheters were introduced into the central veins via a tunnel on the chest (94 catheters) or on the thigh (44 catheters). Eighty-two episodes of catheter septicaemia occurred in 28 (65%) of the patients, corresponding to an incidence of catheter septicaemia of 1 in 1.9 patient-years. The commonest microorganisms grown from the blood were coagulase-negative staphylococci, Klebsiella pneumoniae, Escherichia coli, Staphylococcus aureus, and Candida species. Septicaemia incidence was 1 in 2.6 catheter-years with the Broviac catheter on the chest and 1 in 1.6 catheter-years with the Broviac catheter on the thigh. In 49 cases the patient was treated with both antibiotics and change of the catheters, in 26 cases with antibiotics alone, and in 5 cases with change of the catheter alone. The antibiotic therapy was given for 3 to 15 days (median, 7 days). No patient died of catheter septicaemia. The relapse rate was low (less than 10%) and did not differ significantly between the three treatment groups. It is concluded that catheter septicaemia is a common complication of HPN. In most cases it runs a mild course. Bacteriaemia can often be eradicated by a brief antibiotic therapy without catheter exchange.

A nitrogen balance study was performed in 40 patients with various small-bowel resections. Twenty-two patients had part of or the whole colon in function; 18 had an ileostomy. The patients had body weights that were about 95% of their ideal body weight (range, 133% to 71%). Net nitrogen absorption was significantly lower in patients with extensive small-bowel resection (greater than or equal to 150 cm) (median, 8.0 g/day approximately 64% of the dietary nitrogen intake) compared with patients with small-bowel resection less than 150 cm (median, 9.6/day approximately 82% of the dietary nitrogen intake). No difference in nitrogen balance was observed between the two groups. The median nitrogen balance was not significantly different from zero. No difference in nitrogen absorption, nitrogen balance, or body weight could be demonstrated between patients with part of or the whole colon in function and patients with an ileostomy. We conclude that patients with extensive small-bowel resection may have a significant nitrogen absorption, even in the presence of an ileostomy.

Bile acid metabolism was studied in 26 patients with a continent ileostomy (Kock's reservoir) and 32 patients with conventional ileostomy. All had been colectomized for ulcerative colitis. In patients with a continent ileostomy the 14C-glycocholic acid breath test showed increased pulmonary 14CO2 excretion as evidence of abnormal bacterial deconjugation of bile acids and increased faecal 14C excretion as evidence of bile acid malabsorption. Faecal bile acid excretion, determined chemically, and, by inference, bile acid synthesis were only moderately increased (median, 1.8 mmol/day). The disturbance of bile acid metabolism was similar to that found in 32 patients with conventional ileostomy, but more pronounced with higher faecal 14C. A significant difference was that no abnormal bacterial deconjugation took place in patients with conventional ileostomy, since their pulmonary 14CO2 excretion was subnormal. Stool mass was almost identical in the two groups, with median values of 665 and 663 g/day, respectively. Faecal fat excretion was normal in most in both groups. Thus bile acid metabolism is slightly more disturbed in patients with a continent ileostomy than in patients with conventional ileostomy. The resulting malabsorption was modest in both groups.

Osmolality, pH, and electrolyte concentrations in faecal fluid were measured in 23 patients referred to our department because of diarrhoeal disorders. The aim of the study was to ascertain whether such measurements could provide valuable diagnostic information in patients with diarrhoea. The patients were studied on a fat-restricted diet (70 g fat/day) and during fasting. Osmolality, pH, and concentrations of electrolytes in faecal water showed wide variations but were within normal ranges in most of the patients. The patients were grouped into secretory and osmotic diarrhoea on the basis of: 1) current assumptions on the pathogenesis of diarrhoea in different disorders; 2) persistence versus resolution of diarrhoea during fasting (resolution = decrease of stool mass to less than 200 g/24 h); and 3) an osmotic gap (measured osmolality -2 X (Na + K]. The accordance between these three ways of grouping was very incomplete. It is concluded that measurements of faecal fluid osmolality and electrolyte concentrations are of little value as diagnostic procedures in chronic diarrhoea. Determination of the osmotic gap and/or of the decrease of stool mass during fasting may help to elucidate the pathogenesis of diarrhoea in different disorders but does not seem diagnostically useful. Three patients turned out to be laxative abusers, and laxative ingestion should always be considered in chronic unsettled diarrhoea.

In 16 small-bowel-resected patients, 8 with ileostomy and 8 with at least half of the colon in function, plasma volume, plasma aldosterone concentration, plasma renin activity, and the 4-day excretion of sodium and potassium in urine and stools were determined. Patients with ileostomy had a high faecal loss of sodium: 85-181 (median, 149) mmol/24 h, and were all more or less sodium-depleted with decreased plasma volume of 1.4-2.5 (median, 2.0) l/175 cm (normal range, 2.3-3.8l/175 cm), increased plasma aldosterone of 742-2250 (median, 1131) pg/ml (normal range, 33-220 pg/ml), and extremely low sodium excretion in the urine of 0-3 (median, 1) mmol/24 h. Patients with similar small-bowel resection but with at least half of the colon in function had a much smaller faecal sodium loss of 1-66 (median, 8) mmol/24 h. They showed significantly higher plasma volume, 2.2-3.7 (median, 2.6) l/175 cm; normal plasma aldosterone, 25-232 (median, 124) pg/ml; and normal or almost normal sodium excretion in the urine, 49-168 (median, 118) mmol/24 h. Six jejunostomy patients, who sustained a normal or almost normal sodium balance thanks to parenteral saline, had intravenous infusion over 6 h of 1000 ml isotonic sodium chloride with or without aldosterone added. During aldosterone infusion plasma aldosterone increased to the level in the sodium-depleted ileostomy patients. Urinary sodium excretion decreased significantly. Stomal sodium loss did not change. It is concluded that small-bowel resection in ileostomized patients causes excessive faecal sodium loss and results in chronic sodium depletion with severe secondary hyperaldosteronism.(ABSTRACT TRUNCATED AT 250 WORDS)

We report three cases of severe chronic intestinal pseudo-obstruction after extensive bowel resection for Crohn's disease. The patients retained less than or equal to 150 cm jejunum in continuity with the left half of the colon and had no evidence of inflammatory activity in the remaining bowel. Total parenteral nutrition was required, since even very small meals caused abdominal distention, pain, and vomiting. Two patients had a sigmoidostomy constructed, which alleviated the symptoms and enabled a normal oral intake, but only temporarily in one of the patients. Even with a sigmoidostomy the patients needed supplementary parenteral nutrition because of severe malabsorption with high stomal output.

Endogenous faecal calcium was measured by an isotopic technique in five patients with protein-losing enteropathy due to intestinal lymphangiectasia and in ten patients with chronic malabsorption due to severe Crohn's disease (one patient) or extensive small-bowel resection (nine patients). In most patients absorption of dietary calcium and calcium balance were also determined. Endogenous faecal calcium and digestive juice calcium were highly increased in 3 patients with intestinal lymphangiectasia and normal or subnormal in the remaining 12 patients. Absorption of dietary calcium was normal in patients with intestinal lymphangiectasia but extremely low in most patients with chronic malabsorption syndromes. It is concluded that a net loss of calcium in stools in patients with intestinal lymphangiectasia is due to increased endogenous faecal calcium. In contrast, a net loss of calcium in stools in patients with extensive small-bowel resection is due to decreased absorption of dietary calcium with normal or almost normal endogenous faecal calcium.

Seventy patients, 37 females and 33 males, median age 46 years, have been treated with long-term parenteral nutrition for 816 patient-months, or 68 patient-years. Short-bowel syndrome was the commonest indication for parenteral nutrition (582 patient-months). Twenty-four patients were receiving home parenteral nutrition. Most had severe short-bowel syndrome following intestinal resection for Crohn's disease or mesenteric infarction. Metabolic complications included zinc deficiency syndrome in four patients before routine zinc administration and progressive halisteresis in five patients. The mortality for 26 patients with short-bowel syndrome was 23%, for 15 patients with intestinocutaneous fistulas 40%, and for 15 patients with severe emaciation for various causes 27%. Parenteral nutrition was withdrawn in 6 (23%) of the 26 patients with short-bowel syndrome, who subsequently were able to maintain body weight with oral feeding. Fifteen patients are still (February 1980) receiving home parenteral nutrition.

Catheter-related complications were investigated in 70 patients receiving long-term parenteral nutrition (LTPN) for 1 to 63 months (median, 4.5 months) with a total observation period of 816 patient-months. Two hundred and three central venous catheters were used: 52 Broviac silicone rubber catheters and 151 Intracaths or Argyle baby feeding tubes made from polyvinyl chloride with plasticizers. The median duration was longer for Broviac catheters (5.0 months) than for the other catheters (1.1 months). Pneumothorax and/or subcutaneous emphysema occurred in 14 of 113 subclavian vein punctures (12%). Forty-eight episodes of catheter sepsis occurred in 27 patients. The incidence of sepsis was lower for Broviac catheters (0.3 per catheter-year) than for the other catheter types (0.9 per catheter-year). Catheter-induced thrombosis of a central vein was shown by phlebography 35 times among 25 (52%) of te 48 patients investigated, corresponding to an overall incidence of 1 in 22 patient-months. Total occlusion of a central vein occurred in 14 cases. The incidence of thrombosis was lower for Broviac catheters (0.5 per catheter-year) than for the other catheters (1.6 per catheter-year). Partial venous occlusions usually resolved after heparin therapy and/or catheter exchange, whereas total occlusions usually persisted for years. No correlation was found between incidence of complications and catheter lifetime. Seventeen patients died while receiving LTPN. In three patients death was related to LTPN: catheter sepsis, subdural haematoma possibly due to anticoagulant therapy, and respiratory failure caused by pulmonary infection after iatrogenic pneumothorax. For LTPN we recommend Broviac catheters, which showed longer duration, lower complication rate, and higher patient compliance. Catheter sepsis should be treated with both catheter exchange and antibiotics. Because of the high incidence of thrombosis we recommend that all patients on LTPN receive anticoagulant therapy. However, the value of anticoagulant therapy is not proved in a prospective, controlled study.

A cobalamin absorption test, the stool spot test (SST), which makes use of radioactive cobalamin and a nonabsorbable isotope, 51Cr-trichloride, has been shown to produce reliable results in patients with pernicious anemia and in healthy controls. The reliability of the SST in patients with bowel disorders and in patients with decreased renal function was investigated by comparing with both whole-body counting and the Schilling test. Fourteen patients with bowel disorders and eight patients with uremia joined the trial. The SST correlated highly significantly with the whole-body counting method. However, the precision of the SST was poor in patients with decreased bowel transit time and inferior to that in the uremic patients. In one of two patients with decreased bowel transit time the two isotopes were shown to have different transit times, thus invalidating the test. In patients with uremia the SST was significantly more reliable than the Schilling test. It is concluded that the SST is reliable also in patients with uremia but may not be reliable in patients with intestinal disorders and decreased bowel transit time. In these patients collection of larger stool samples is recommended.

The importance of the colon for the absorption of calcium, fat, and fluid was studied in 118 patients with small-bowel resections of various lengths. The patients fell into two groups: 38 with ileostomy and 80 with part of or the whole colon in function. In patients with ileostomy, but not in patients with the colon preserved, the absorption of 47Ca and fluid was inversely correlated to the length of the resected small intestine. In patients with extreme small-bowel resection (greater than or equal to 150 cm) the 47Ca absorption was significantly higher when colon was preserved. In groups of equal small-bowel resections stool mass was significantly higher in patients with ileostomy, but faecal fat was not. However, in both groups faecal fat was correlated to the length of the resected small bowel. The study shows that colon plays an important role for the absorption of calcium after small-intestinal resection and confirms the importance of colon for fluid absorption.

In eight patients who had received long-term parenteral nutrition because of short-bowel syndrome the need for parenteral supply of fluid, sodium, and potassium was estimated by balance studies. Six patients had jejunostomies. In two, most of the colon was preserved. Jejunostomy patients had a huge stool mass (1710--5270 g, median 2530 g/day) with fixed concentrations of sodium (92 +/- 10 mmol/l) and potassium (15 +/- 4 mmol/l). In contrast, two patients with massive small-bowel resection but with more than half of the colon intact showed almost normal sodium absorption and considerably smaller stool mass (170--510 g/day). Despite apparently good health and normal plasma electrolytes, urea, and haematocrit, four of six jejunostomy patients were sodium-depleted with low plasma volume, low sodium excretion in the urine, and increased plasma renin activity and, in the three most severe cases, increased aldosterone. Even in case of sodium depletion the sodium loss from jejunostomy effluents remained high and presumably unaffected by salt-retaining hormones. The study confirms the importance of preservation of part of the colon for maintenance of fluid and electrolyte balance in patients with extensive bowel resection. Jejunostomy patients who are eating normally may need large parenteral saline supply. Assessment of water and electrolyte homeostasis in these patients requires determination of the urinary sodium excretion and is supported by measurements of plasma renin activity and plasma aldosterone concentration.

The response to 5-aminosalicylic acid (5-ASA) in mild and moderately active Crohn's disease localized in the small bowel was studied in a randomized, double-blind, placebo-controlled trial in four centres. Sixty-seven patients were included, of whom 30 were treated with 1500 mg slow-release 5-ASA/day (Pentasa) for a scheduled period of 16 weeks. In the 5-ASA group 40% of the patients improved, versus 30% of the placebo-treated group ('intent to treat' basis; p greater than 0.1). Four of the patients treated with 5-ASA left the study owing to disease deterioration, versus 10 of the placebo-treated patients (p greater than 0.2). Seventeen patients were secondarily excluded, and the remaining 50 patients (23 receiving 5-ASA) were reevaluated in greater detail. No statistically significant differences in outcome were shown. Three patients (one given 5-ASA) were withdrawn from the study because of presumed side effects, but no serious adverse reactions were recorded. The present results indicate that 5-ASA, at least in the dosage used, is not superior to placebo. Nevertheless, trends towards a beneficial effect in Crohn's disease in the small bowel justify further clinical trials with a larger dosage of 5-ASA.

The effect of the H2-receptor blocking agent cimetidine on jejunal effluent was examined in eight short-bowel patients with high-output jejunostomies. Stool mass and faecal excretion of sodium and potassium were significantly reduced by intravenous injection of 400 mg cimetidine four times a day. The amount of calcium, magnesium, phosphate, zinc, and fat in jejunostomy effluent did not change significantly. Cimetidine may be considered an antidiarrhoeal drug in extensively small-bowel-resected patients with a jejunostomy and may reduce the need for parenteral saline supply in these patients.