Search

Objective: Selenium is a fundamental nutrient to human health that might have anticarcinogenic effects. Previous studies have assessed the possible relationship of selenium status to colorectal adenomas with controversial results. We primarily aimed to assess the relationship of serum selenium status with the presence of large size colorectal adenomas in subjects living in a poor selenium region. The serum selenium status in colorectal cancer was also evaluated., Methods: Serum selenium levels were measured in 28 patients with large size sporadic adenomatous polyps, 24 patients with colorectal adenocarcinomas, and 35 age-matched healthy individuals. A logistic regression analysis was performed to assess the relationship of serum selenium to colorectal adenomatous polyps after adjusting for confounding variables (age, sex, smoking habit, and alcohol drinking)., Results: Among subjects aged < or = 60 yr, mean serum selenium levels were significantly lower in both patient groups (adenoma, 57.9 +/- 4.3 microg/L; cancer, 43.7 +/- 6.6 microg/L) than in healthy controls (88.9 +/- 8 microg/L) (p = 0.0001). There were no difference among subjects > 60 yr old. A significant inverse association between selenium status and the diagnosis of large size adenomatous polyps after adjusting for confounding variables was found (adjusted p = 0.029). Subjects with higher selenium status (> or = 75th percentile value of 82.11 microg/L) had a lower probability (OR = 0.17, 95% CI = 0.03-0.84) to be in the adenoma group than subjects with lower selenium status (< 82.11 microg/L). This association was more marked in subjects aged < or = 60 yr (adjusted p value = 0.04, OR = 0.08, 95% CI = 0.007-0.91), and was not significant in older subjects., Conclusions: Results suggest that high selenium status may decrease the risk of large size adenomas in a low selenium region, and that this preventive effect seems to be exclusive to subjects < or = 60 yr. These results will need to be confirmed in additional epidemiological studies before recommending selenium supplementation in patients with colon adenomas.

Objective: It has been suggested that, in inflammatory bowel disease, cytomegalovirus behaves in the intestine as a nonpathogenic bystander, and even its finding in intestinal mucosa has unclear clinical relevance. We report our experience with a small series of patients with refractory inflammatory bowel disease and cytomegalovirus infection and their clinical outcome., Methods and Results: Nine patients with moderate-severe attacks of inflammatory bowel disease did not respond to i.v. prednisone (1 mg/kg/day) for a mean of 24 days. Four of these patients were further treated with i.v. cyclosporine A (4 mg/kg/day). Cytomegalovirus infection was diagnosed in two patients after resection for treatment failure. In the remaining patients, cytomegalovirus infection was diagnosed in endoscopic mucosal biopsies and i.v. ganciclovir was then administered at a dose of 10 mg/kg/day for 2-3 wk. Five of these patients went into clinical remission, allowing corticosteroid and cyclosporine A discontinuation. Follow-up biopsies were performed and in all cases cytomegalovirus could not be detected in the colonic tissue. Two patients needed to be treated with intravenous cyclosporine A after antiviral therapy because of persistence of clinical symptoms despite the elimination of cytomegalovirus infection., Conclusions: Cytomegalovirus infection may play a role in the natural history of refractory inflammatory bowel disease and in some of its complications. The clearance of cytomegalovirus in colonic mucosa may lead some of these patients to remission.

Objective: Butyrate enemas may be effective in the treatment of active distal ulcerative colitis. Because colonic fermentation of Plantago ovata seeds (dietary fiber) yields butyrate, the aim of this study was to assess the efficacy and safety of Plantago ovata seeds as compared with mesalamine in maintaining remission in ulcerative colitis., Methods: An open label, parallel-group, multicenter, randomized clinical trial was conducted. A total of 105 patients with ulcerative colitis who were in remission were randomized into groups to receive oral treatment with Plantago ovata seeds (10 g b.i.d.), mesalamine (500 mg t.i.d.), and Plantago ovata seeds plus mesalamine at the same doses. The primary efficacy outcome was maintenance of remission for 12 months., Results: Of the 105 patients, 102 were included in the final analysis. After 12 months, treatment failure rate was 40% (14 of 35 patients) in the Plantago ovata seed group, 35% (13 of 37) in the mesalamine group, and 30% (nine of 30) in the Plantago ovata plus mesalamine group. Probability of continued remission was similar (Mantel-Cox test, p = 0.67; intent-to-treat analysis). Therapy effects remained unchanged after adjusting for potential confounding variables with a Cox's proportional hazards survival analysis. Three patients were withdrawn because of the development of adverse events consisting of constipation and/or flatulence (Plantago ovata seed group = 1 and Plantago ovata seed plus mesalamine group = 2). A significant increase in fecal butyrate levels (p = 0.018) was observed after Plantago ovata seed administration., Conclusions: Plantago ovata seeds (dietary fiber) might be as effective as mesalamine to maintain remission in ulcerative colitis.

Objectives: Few studies have assessed the IgA antineutrophil cytoplasmic antibody (ANCA) positivity in ulcerative colitis patients and there is no information about factors related to its synthesis and its status after colectomy. The aims of the study were to assess the serum IgA ANCA prevalence in ulcerative colitis patients, both nonoperated and operated, and to determine the clinical factors related to this positivity., Methods: Fifty-four ulcerative colitis patients, 63 ulcerative colitis colectomized patients (32 with Brooke's ileostomy and 31 with ileal pouch anal anastomosis), and 24 controls were studied. Antineutrophil cytoplasmic antibodies were detected by specific indirect immunofluorescent assays., Results: The percentage of IgA ANCA was significantly higher in patients with ileal pouch anal anastomosis (45%) than in patients with Brooke's ileostomy (22%). There were no differences related to the presence of pouchitis in ileal pouch anal anastomosis patients. Patients with nonoperated extensive colitis (47%) had a significantly higher percentage of IgA ANCA than patients with proctitis (19%). Total percentage of ANCA (IgA and/or IgG) tended to be higher in ulcerative colitis and in patients with ileal pouch anal anastomosis than in patients with Brooke's ileostomy. However, in ileal pouch anal anastomosis patients, ANCA positivity was mainly due to exclusive IgA production., Conclusions: A substantial percentage of ulcerative colitis patients, and especially colectomized patients with ileal pouch anal anastomosis, had IgA ANCA, suggesting that ANCA production in ulcerative colitis might be stimulated by an immune reaction in the intestinal mucosa.

Background/aim: Therapeutic regimens with intravenous (i.v.) cyclosporine followed by oral cyclosporine maintenance therapy reduce the need for immediate surgery in steroid-refractory severe ulcerative colitis, but the short-term colectomy rate is still as high as 70%. We report our experience with long-term azathioprine maintenance therapy in a small series of ulcerative colitis patients with i.v. cyclosporine-induced remission., Methods and Results: Twelve of thirteen patients with severe ulcerative colitis refractory to i.v. prednisone (1 mg/kg/day for at least 10 days) went into remission after adding i.v. cyclosporine (4 mg/kg/day) and are the subjects of this report. After a discouraging initial experience with oral cyclosporine plus mesalazine as maintenance therapy in the first four patients, we treated the following patients with azathioprine plus mesalazine starting immediately after response to i.v. cyclosporine was obtained. Overall, only 1 of 10 patients treated with azathioprine relapsed after a mean follow-up of 16.3 months (range: 6-48). Moreover, this relapse probably occurred when the drug was still not therapeutically active because, after reinducing remission with oral prednisone, the patient remained symptomless on azathioprine. Steroids could be discontinued in all patients., Conclusions: The relapse rate on maintenance therapy with azathioprine (10%) is a figure considerably lower than that previously reported with oral cyclosporine. This promising experience should be confirmed in randomized controlled trials.

Objective: To investigate the relationship of sugar malabsorption to the development of clinical symptoms in functional bowel disease., Methods: Twenty-five consecutive outpatients [five men, 20 women; mean age 38.7 +/- 2.6 (SEM) yr] with functional bowel disease and symptoms suggestive of carbohydrate malabsorption were studied. Twelve healthy subjects [six men, six women; mean age 35.7 +/- 3.7 (SEM) yr] acted as the control group. Sugar malabsorption was assessed by breath-hydrogen test after an oral load of various solutions containing lactose (50 g), fructose (25 g), sorbitol (5 g), fructose plus sorbitol (25 + 5 g), and sucrose (50 g). The severity of symptoms developing after sugar challenge was studied. In addition, the effect on clinical symptoms of a diet free of the offending sugars, compared to a low-fat diet, was assessed., Results: Frequency of sugar malabsorption was high in both patients and controls, with malabsorption of at least one sugar in more than 90% of the subjects. Median symptom scores after both lactose [median 6; interquartile (IQ) range 3-7] and fructose plus sorbitol (median 2; IQ range 0-4) malabsorption were significantly higher than after sucrose load (median 1; IQ range 0-1.5) in functional bowel disease patients (p = 0.001 and p = 0.007, respectively). However, there were no differences in healthy controls. In addition, symptoms score after both lactose and fructose plus sorbitol malabsorption was significantly higher in patients than in control subjects (p = 0.02 and p = 0.008, respectively). On the other hand, H2 production capacity, as measured following lactulose load, was significantly higher in patients than in controls. The clinical symptoms improved in 40% of the evaluated patients after restriction of the offending sugars., Conclusions: These results suggest that sugar malabsorption may be implicated in the development of abdominal distress in at least a subset of patients with functional bowel disease.

The LeVeen peritoneovenous shunt has been used for nearly 20 yr in the treatment of refractory ascites due to liver cirrhosis. However, the technique encompasses a high incidence of serious complications. We report the case of a 59-yr-old man presenting with right pulmonary artery embolization caused by ruptured venous segment of a LeVeen shunt. After localizing it arteriographically, we were able to satisfactorily remove the segment by tying it up with a catheter introduced through the femoral vein.

In an attempt to improve the prognostic capacity of Child-Pugh score in nonbleeding cirrhotics, 110 consecutive in-patients without gastrointestinal hemorrhage at admission were studied and followed up for 24 months or until death. Fifty-five of the 110 patients (50%) died during this period. Mean survival time was 18.8 +/- 1.4 months (mean +/- SEM). In addition to Child-Pugh score, eight variables, including anthropometric nutritional parameters, routine renal function tests, and alcoholism markers, were recorded at admission. The ability of these variables to improve the prognostic capacity of the Child-Pugh score was assessed with the proportional hazard Cox's regression procedure, using a stepwise method for covariate selection, after including the Child-Pugh score at the first step. Thus, in addition to Child-Pugh score (beta = 0.302), three variables were included in the final model: serum urea (beta = 0.113), MCV (beta = 0.027), and mid-arm muscle circumference (beta = -0.025). According to the contribution of each of these factors to the model, a prognostic index was obtained to estimate survival in the individual patient. An assessment of the predictive power of the model was made by means of a split-sample technique. The prognostic index described in this study may contribute to improve the selection of nonbleeding patients with advanced cirrhosis to receive specific therapies such as transplantation. However, its true clinical relevance will be established only by prospectively comparing its prognostic value with that of the Child-Pugh score in a new sample of patients.

Portacaval anastomosis has proved to be effective in avoiding active and recurrent hemorrhage from gastroesophageal varices in liver cirrhosis. However, hepatic encephalopathy is the most common and serious complication of this procedure. The aim of this study was to investigate by multivariate analysis the predictive factors of development of hepatic encephalopathy in 50 Child's A and B cirrhotic patients whose variceal bleeding was treated with emergency (n = 17) or elective (n = 33) portacaval anastomosis. The etiology of the cirrhosis was alcoholic in 74% of cases. The mean follow-up was 22.7 +/- 16.6 months (range 1-60 months). The 2-yr probability of suffering from at least one episode of hepatic encephalopathy in the overall group was 43%. The multivariate analyses (Cox's regression method) of 37 variables based upon clinical history, physical examination, and laboratory data disclosed that only five of these variables had independent predictive value: need for diuretic treatment in the days prior to surgery, absence of hepatomegaly, and serum levels of total bilirubin, gamma-globulin, and hemoglobin. According to the contribution of each one of these factors to the final model, a prognostic index was obtained which allowed the division of patients in two different groups of risk for developing hepatic encephalopathy (20% and 74%, respectively, after 2 yr of surgery; p = 0.0002). This index may help to better choose those candidates for portacaval anastomosis.

Twenty-five patients with abdominopelvic malignant tumors receiving irradiation were studied. The following items were assessed before, during, and at the end of the radiation period: 1) clinical symptoms, scored on the basis of their severity; 2) orocecal transit time (lactulose-H2 breath test); and 3) absorption of lactose and bile salts. Ninety-two percent of the patients showed clinical symptoms suggestive of acute radiation enteropathy, mainly diarrhea. A significant acceleration of the orocecal transit was observed during the study: 70 +/- 6.9 min vs 63.3 +/- 6.3 min vs 44.3 +/- 5.1 min (F = 5.49, p = 0.008), being faster in patients with severe diarrhea (F = 3.25, p = 0.05). Forty-four percent and 57% of the patients developed lactose and bile salt malabsorption, respectively. A decrease in the transit time was observed, independent of the absorption or malabsorption of such substances. However, the orocecal transit was faster in those lactose malabsorbers with severe diarrhea, than in those with mild diarrhea (F = 4.2, p = 0.03). The results suggest that acceleration of orocecal transit may be a major factor in the pathophysiology of radiation-induced diarrhea, whereas lactose malabsorption may contribute to the severity of the diarrhea.

Serum levels of zinc, copper, and selenium, and alkaline phosphatase activity were prospectively studied in 29 patients with inflammatory bowel disease. Fifteen patients had extensive active colitis (active colitis group). Seven patients had active, and seven cases inactive small bowel or ileocecal Crohn's disease (small bowel disease group). Ninety-three healthy subjects acted as controls. Serum trace element levels were considered in relation to vitamin A and E levels, nutritional parameters, the activity of the disease, and the recent intake of steroids. The effect of total enteral nutrition on serum trace elements was studied in seven cases. Serum zinc levels were lower and serum copper levels higher in the active colitis group than in controls (p = 0.0007, and p = 0.02, respectively). More than 50% of patients with active colonic or small bowel disease showed zinc levels below the 15th percentile of the control group. Serum zinc levels correlated with plasma vitamin A in acute colitis (r = 0.67; p = 0.006), and with both serum albumin concentration (r = 0.76; p = 0.002) and disease activity score (r = -0.67, p = 0.009) in patients with small bowel disease. The copper:zinc ratio was higher in the active colitis group than in controls (p = 0.002). In spite of the increase in serum albumin levels and the decrease in disease activity, serum zinc levels remained low after total enteral nutrition. The implications of the abnormal trace element status in patients with inflammatory bowel disease are discussed.

A 64-yr-old woman developed acute hepatitis after 3 wk of treatment with 40 mg/day of piroxicam (Feldene). Jaundice was preceded by a skin rash associated with eosinophilia. Despite withdrawal of the drug, she developed severe hepatocellular failure and died 53 days after the onset. Hepatitis was attributed to piroxicam because of the absence of other etiological factors.

Plasma fatty acids (FA) from C14:0 to C22:6 omega 3 were measured in five healthy subjects and in 27 patients with liver cirrhosis. According to the assessment of triceps skinfold, mid-arm muscle circumference, and serum albumin concentration, patients were prospectively included in three groups: group A (n = 7) with acceptable nutritional status (including good nutrition and mild malnutrition), group B (n = 10) with moderate malnutrition, and group C (n = 10) with severe malnutrition. Plasma levels of total FA, saturated FA, linoleic acid, and omega 6 greater than 18C and omega 3 greater than 18 polyunsaturated fatty acids (PUFA) were lower in cirrhotics than in controls. Linoleic:arachidonic ratio was increased and delta 5-desaturation precursors:products ratio did not change, suggesting a reduction in delta 6-desaturase and/or C18-C20 elongase activities. In addition, a stepwise fall in plasma levels of all but saturated FA was found as the nutritional status worsened, suggesting that, in cirrhosis, impairment in PUFA biosynthesis is related to the severity of associated malnutrition. Since PUFA have important biological functions as components of cell membranes and precursors of eicosanoids, the results reported here may open new perspectives in the understanding of the cirrhosis-malnutrition relationship.

The status of water- and fat-soluble vitamins was prospectively evaluated in 23 patients (13 men, 10 women, mean age 33 +/- 3 yr) admitted to the hospital with acute or subacute attacks of inflammatory bowel disease. Protein-energy status was also assessed by means of simultaneous measurement of triceps skinfold thickness, mid-arm muscle circumference, and serum albumin. Fifteen patients (group A) had extensive acute colitis (ulcerative or Crohn's colitis), and eight cases (group B) had small bowel or ileocecal Crohn's disease. Eighty-nine healthy subjects (36 men, 53 women, mean age 34 +/- 2 yr) acted as controls. In both groups of patients, the levels of biotin, folate, beta-carotene, and vitamins A, C, and B1 were significantly lower than in controls (p less than 0.01). Plasma levels of vitamin B12 were decreased only in group B (p less than 0.01), whereas riboflavin was lower in group A (p less than 0.01). The percentage of patients at risk of developing hypovitaminosis was 40% or higher for vitamin A, beta-carotene, folate, biotin, vitamin C, and thiamin in both groups of patients. Although some subjects had extremely low vitamin values, in no case were clinical symptoms of vitamin deficiency observed. Only a weak correlation was found between protein-energy nutritional parameters and vitamin values, probably due to the small size of the sample studied. The pathophysiological and clinical implications of the suboptimal vitamin status observed in acute inflammatory bowel disease are unknown. Further studies on long-term vitamin status and clinical outcome in these patients are necessary.