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Background and Aims: The incidence of inflammatory bowel disease (IBD) is increasing in Eastern Europe possibly due to changes in environmental factors towards a more "westernised" standard of living. The aim of this study was to investigate differences in exposure to environmental factors prior to diagnosis in Eastern and Western European IBD patients. Methods: The EpiCom cohort is a population-based, prospective inception cohort of 1560 unselected IBD patients from 31 European countries covering a background population of 10.1. million. At the time of diagnosis patients were asked to complete an 87-item questionnaire concerning environmental factors. Results: A total of 1182 patients (76%) answered the questionnaire, 444 (38%) had Crohn's disease (CD), 627 (53%) ulcerative colitis (UC), and 111 (9%) IBD unclassified. No geographic differences regarding smoking status, caffeine intake, use of oral contraceptives, or number of first-degree relatives with IBD were found. Sugar intake was higher in CD and UC patients from Eastern Europe than in Western Europe while fibre intake was lower (p.

BACKGROUND: No direct comparison of health care cost in patients with inflammatory bowel disease across the European continent exists. The aim of this study was to assess the costs of investigations and treatment for diagnostics and during the first year after diagnosis in Europe.METHODS: The EpiCom cohort is a prospective population-based inception cohort of unselected inflammatory bowel disease patients from 31 Western and Eastern European centers. Patients were followed every third month from diagnosis, and clinical data regarding treatment and investigations were collected. Costs were calculated in euros (€) using the Danish Health Costs Register.RESULTS: One thousand three hundred sixty-seven patients were followed, 710 with ulcerative colitis, 509 with Crohn's disease, and 148 with inflammatory bowel disease unclassified. Total expenditure for the cohort was €5,408,174 (investigations: €2,042,990 [38%], surgery: €1,427,648 [26%], biologicals: €781,089 [14%], and standard treatment: €1,156,520 [22%)]). Mean crude expenditure per patient in Western Europe (Eastern Europe) with Crohn's disease: investigations €1803 (€2160) (P = 0.44), surgery €11,489 (€13,973) (P = 0.14), standard treatment €1027 (€824) (P = 0.51), and biologicals €7376 (€8307) (P = 0.31). Mean crude expenditure per patient in Western Europe (Eastern Europe) with ulcerative colitis: investigations €1189 ( €1518) (P < 0.01), surgery €18,414 ( €12,395) (P = 0.18), standard treatment €896 ( €798) (P < 0.05), and biologicals €5681 ( €72) (P = 0.51).CONCLUSIONS: In this population-based unselected cohort, costs during the first year of disease were mainly incurred by investigative procedures and surgeries. However, biologicals accounted for >15% of costs. Long-term follow-up of the cohort is needed to assess the cost-effectiveness of biological agents.

Frequency of anaemia and anaemia subtypes in east-west European inception cohort : an ECCO-EpiCom cohort study

BACKGROUND & AIMS: Health-related quality of life (HRQoL) is impaired in patients with Inflammatory Bowel Disease (IBD). The aim was prospectively to assess and validate the pattern of HRQoL in an unselected, population-based inception cohort of IBD patients from Eastern and Western Europe.METHODS: The EpiCom inception cohort consists of 1560 IBD patients from 31 European centres covering a background population of approximately 10.1million. Patients answered the disease specific Short Inflammatory Bowel Disease Questionnaire (SIBDQ) and generic Short Form 12 (SF-12) questionnaire at diagnosis and after one year of follow-up.RESULTS: In total, 1079 patients were included in this study. Crohn's disease (CD) patients mean SIBDQ scores improved from 45.3 to 55.3 in Eastern Europe and from 44.9 to 53.6 in Western Europe. SIBDQ scores for ulcerative colitis (UC) patients improved from 44.9 to 57.4 and from 48.8 to 55.7, respectively. UC patients needing surgery or biologicals had lower SIBDQ scores before and after compared to the rest, while biological therapy improved SIBDQ scores in CD. CD and UC patients in both regions improved all SF-12 scores. Only Eastern European UC patients achieved SF-12 summary scores equal to or above the normal population.CONCLUSION: Medical and surgical treatment improved HRQoL during the first year of disease. The majority of IBD patients in both Eastern and Western Europe reported a positive perception of disease-specific but not generic HRQoL. Biological therapy improved HRQoL in CD patients, while UC patients in need of surgery or biological therapy experienced lower perceptions of HRQoL than the rest.

BACKGROUND AND AIMS: The EpiCom study and inception cohort was initiated in 2010 in 31 centers from 14 Western and 8 Eastern European countries, covering a 10.1million person background population. Our aim was to investigate whether there is a difference between Eastern and Western Europe in health care and education of patients with inflammatory bowel disease (IBD).METHODS: A quality of care (QoC) questionnaire was developed in the EpiCom group consisting of 16 questions covering 5 items: time interval between the onset of symptoms and diagnosis, information, education, empathy and access to health care providers.RESULTS: Of 1,515 patients, 947 (217 east/730 west) answered the QoC questionnaire. Only 23% of all patients had knowledge about IBD before diagnosis. In Eastern Europe, significantly more patients searched out information about IBD themselves (77% vs. 68%, pCONCLUSION: Health care differed significantly between Eastern and Western Europe in all items, but satisfaction rates were high in both geographic regions. Because of the low awareness and the rising incidence of IBD, general information should be the focus of patient organizations and medical societies. In Western Europe IBD nurses play a very important role in reducing the burden of patient management.

Objective: The incidence of inflammatory bowel disease (IBD) is increasing in Eastern Europe. The reasons for these changes remain unknown. The aim of this study was to investigate whether an East-West gradient in the incidence of IBD in Europe exists. Design: A prospective, uniformly diagnosed, population based inception cohort of IBD patients in 31 centres from 14 Western and eight Eastern European countries covering a total background population of approximately 10.1 million people was created. One-third of the centres had previous experience with inception cohorts. Patients were entered into a low cost, web based epidemiological database, making participation possible regardless of socioeconomic status and prior experience. Results: 1515 patients aged 15 years or older were included, of whom 535 (35%) were diagnosed with Crohn's disease (CD), 813 (54%) with ulcerative colitis (UC) and 167 (11%) with IBD unclassified (IBDU). The overall incidence rate ratios in all Western European centres were 1.9 (95% CI 1.5 to 2.4) for CD and 2.1 (95% CI 1.8 to 2.6) for UC compared with Eastern European centres. The median crude annual incidence rates per 100 000 in 2010 for CD were 6.5 (range 0-10.7) in Western European centres and 3.1 (range 0.4-11.5) in Eastern European centres, for UC 10.8 (range 2.9-31.5) and 4.1 (range 2.4-10.3), respectively, and for IBDU 1.9 (range 0-39.4) and 0 (range 0-1.2), respectively. In Western Europe, 92% of CD, 78% of UC and 74% of IBDU patients had a colonoscopy performed as the diagnostic procedure compared with 90%, 100% and 96%, respectively, in Eastern Europe. 8% of CD and 1% of UC patients in both regions underwent surgery within the first 3 months of the onset of disease. 7% of CD patients and 3% of UC patients from Western Europe received biological treatment as rescue therapy. Of all European CD patients, 20% received only 5-aminosalicylates as induction therapy. Conclusions: An East-West gradient in IBD incidence exists in Europe. Among this inception cohort-including indolent and aggressive cases-international guidelines for diagnosis and initial treatment are not being followed uniformly by physicians.

The EpiCom cohort is a prospective, population-based, inception cohort of inflammatory bowel disease (IBD) patients from 31 European centers covering a background population of 10.1 million. The aim of this study was to assess the 1-year outcome in the EpiCom cohort. Patients were followed-up every third month during the first 12 (±3) months, and clinical data, demographics, disease activity, medical therapy, surgery, cancers, and deaths were collected and entered in a Web-based database (www.epicom- ecco.eu). In total, 1367 patients were included in the 1- year follow-up. In western Europe, 65 Crohn's disease (CD) (16%), 20 ulcerative colitis (UC) (4%), and 4 IBD unclassified (4%) patients underwent surgery, and in eastern Europe, 12 CD (12%) and 2 UC (1%) patients underwent surgery. Eighty-one CD (20%), 80 UC (14%), and 13 (9%) IBD unclassified patients were hospitalized in western Europe compared with 17 CD (16%) and 12 UC (8%) patients in eastern Europe. The cumulative probability of receiving immunomodulators was 57% for CD in western (median time to treatment 2 months) and 44% (1 month) in eastern Europe, and 21% (5 months) and 5% (6 months) for biological therapy, respectively. For UC patients, the cumulative probability was 22% (4 months) and 15% (3 months) for immunomodulators and 6% (3 months) and 1% (12 months) for biological therapy, respectively in the western and eastern Europe. In this cohort, immunological therapy was initiated within the first months of disease. Surgery and hospitalization rates did not differ between patients from eastern and western Europe, although more western European patients received biological agents and were comparable to previous population- based inception cohorts.

Specific nutrition standards are now developed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in order to improve the nutritional status in hospitalized patients. We investigated the use of clinical nutrition in Danish hospitals and compared it with the standards of JCAHO by doing a questionnaire-based investigation among doctors and nurses randomly selected in 40 hospitals including internal medicine, gastroenterology, oncology, orthopedic departments and intensive care units (ICU).Overall, 857 (43.4%) responded to the questionnaire (doctors: 395, nurses: 462). Seventy-seven percent stated that nutritional assessment ought to be performed on admission, but only 24% stated that it was a routine procedure. Forty percent found it difficult to identify risk-patients, and 52% needed specific screening tools. Twenty-two percent registered body weight in all patients, and 18% registered nutrient intake routinely. Eighty-four percent found that a nutrition plan should be described in the patient record, but 39% found it difficult to set up an individual plan, and 79% expressed a need for specific guidelines. Eighty-four percent would only accept a patient being on isotonic glucose and/or electrolyte infusion for5 days (42% for2 days), and 33% would only accept a weight loss of 5% before active nutrition was initiated. About 50% would be restrictive in supplying enteral or parenteral nutrition to patients with impaired liver or kidney function. Twenty-seven percent did not use active nutritional therapy at all. Seventy-six percent found that nutritional assessment should be performed during hospital stays, but only 23% monitored the nutritional status. Sixty-eight percent stated that responsibility should be assigned to one or more persons, but this was the case in only 20%The use of clinical nutrition in Danish hospitals did not fulfill the standards for nutrition support according to the criteria established by JCAHO. Special efforts should be aimed at education, specific screening tools and introduction of guidelines in clinical nutrition.

The cost of investigations and medical treatment including biological therapy in a European inception cohort from the biological era : An ECCO-EpiCom study

In a Danish multicentre trial we compared the relapse preventing effects of olsalazine and sulphasalazine in patients with ulcerative colitis over a 12 month treatment period. Two hundred and twenty seven patients (118 men) with at least two previous attacks of ulcerative colitis were randomly allocated according to a prearranged treatment schedule to olsalazine 500 mg bd or sulphasalazine 1 g bd in a double blind, double dummy fashion. One hundred and ninety seven patients completed the trial. The relapse rate after 12 month in the olsalazine group was 46.9% v 42.4% in the sulphasalazine group with a 95% confidence interval for the difference in proportions of -9% to 18%. Seven per cent of the patients were withdrawn from the trial because of adverse drug reactions and these were equally distributed between the two groups.

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.

Summary Background Undernutrition in hospitals is a common problem associated with increased morbidity and mortality, prolonged convalescence and duration of hospital stay and increased health care costs. During recent years several initiatives have brought hospital undernutrition into focus and guidelines and standards have been published. In 1997, a questionnaire-based survey among Danish hospital doctors and nurses in selected departments concluded that clinical nutrition did not fulfil accepted standards. Aims We wished to determine if improvements had occurred in the intervening period. Method Thus, in 2004 a similar questionnaire was sent to 4000 randomly selected Danish hospital doctors and nurses and responses were compared to those from 1997. The questionnaire dealt with attitudes and practice in the areas of nutritional screening, treatment plan, monitoring as well as with knowledge, education, tools and guidelines, organisation and possible barriers to implementation of nutritional screening and therapy. Results The overall response rate was 38%. We observed a marked improvement especially in screening procedures, calculation of energy intake in at-risk patients and local availability of guidelines. Many departments had appointed staff members with special interest and knowledge in clinical nutrition. Conclusion Although significant positive changes had thus occurred, the main barriers against implementation of good nutrition care continued to be lack of knowledge, interest and responsibility, in combination with difficulties in making a nutrition plan. This will be the focus of future activities.

Many barriers make implementation of nutritional therapy difficult in hospitals. In this study we investigated whether, a targeted plan made by the staff in different departments could improve nutritional treatment within selected quality goals based on the ESPEN screening guidelines.The project was carried out as a continuous quality improvement project. Four different specialities participated in the study with a nutrition team of both doctors, nurses, and a dietician, and included the following methods: (1) Pre-measurement: assessment of quality goals prior to study including the use of screening of nutritional risk (NRS-2002), whether a nutrition plan was made, and monitoring was documented in the records. (2) INTERVENTION: multidisciplinary meeting for the ward staff using a PC-based meeting system for detecting barriers in the department concerning nutrition, elaboration of an action plan and implementation of the plan. (3) Re-measurement: as in (1) based on information from records and patient interviews, and an evaluation based on focus group interview with the staff. Patients who gave informed consent to participate in the study (14 years) were included consecutively. Mann-Whitney and Kruskal-Wallis test was used for ordinal data, and Pearson chi(2) test for nominative data. P values0.05 were considered significant. The study was performed in accordance with the Research Ethics Committee.In this study 141/122 patients were included before/after the implementation period with a mean weight loss within the last 3 months of 6.2 and 5.2 kg, respectively. Before the study we found that BMI was not measured. More than half of the patients had a weight loss within the last 3 months, and 40% had a weight loss during hospitalization, and this was not documented in the records. About 75% had a food intake less than normal within the last week, and nearly one-third were at a severe nutritional risk, and only 33% of these had a nutrition plan, and 18% a plan for monitoring. Barriers concerning nutrition included low priority, no focus, no routine or established procedures, and insufficient knowledge, lack of quality and choice of menus, and lack of support from general manager of the hospital. The staff introduced individually targeted procedures including assigning of responsibility, a nutrition record, electronic calculator of energy intake, upgrading of the dieticians and special diets, communication, and educational programs. A great consistency existed between barriers for targeted nutrition effort and ideas for improvement of the quality goals between the different departments. Quality assessment after study showed an overall significant improvement of the selected quality goals.The introduction of a new method for implementation of nutritional therapy according to ESPEN screening guidelines seems to improve nutritional therapy in hospitals. The method included assessment of quality goals, identification of barriers and individual targeted plans for each department followed by an evaluation process. The model has to be refined further with relevant clinical endpoints.

Sa1114 The Cost of Medical Management, Surgery and Clinical Investigations in a European Population-Based Inception Cohort From the Biological Era : An ECCO-Epicom Study

Specific nutrition standards have now been developed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). We investigated the use of clinical nutrition in Danish hospitals and compared it with the standards of JCAHO by doing a questionnaire-based investigation among doctors and nurses randomly selected in 40 hospitals. Overall, 857 (43.4%) responded to the questionnaire (doctors: 395, nurses: 462). Forty percent found it difficult to identify risk-patients, and 52% needed specific screening tools. Eighty-four percent found that a nutrition plan should be described in the patient record, but 39% found it difficult to set up an individual plan, and 79% expressed a need for specific guidelines. The use of clinical nutrition in Danish hospitals did not fulfill the standards for nutrition support according to the criteria established by JCAHO. Special efforts should be aimed at education, specific screening tools and introduction of guidelines in clinical nutrition.

Laparoscopic intestinal surgery has theoretical advantages compared with conventional intestinal surgery by minimizing the surgical trauma. The aim of the study was to examine the operative and postoperative course as well as the time for recovery after laparoscopic-assisted ileocoecal resection for Crohn's disease. Seventeen 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. Median operation time was 145 min. Two operations (12%) were converted to open procedure. Complications occurred in three patients (18%). Median postoperative time to discharge was five days. Median time to return to work was 26 days. In conclusion laparoscopic-assisted ileocoecal resection seems suited to Crohn's disease, but the benefit of the method needs confirmation in controlled, randomized studies.

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.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.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 (P0.0001). 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.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.

The purpose of the study was to evaluate the effect and side-effects of once daily (OD) administration of gentamicin. The study was a retrospective analysis of patients treated with gentamicin OD for at least two days for proven or suspected infection. Of the 101 patients included, 60 were female, and the median age was 64 years (range: 20-90 years). Median duration of treatment was six days (2-63 days). All patients received combination therapy with two (36 patients), three (64 patients) or four (one patient) antibiotics, apart from gentamicin usually ampicillin, cefuroxime and/or metronidazole. Gentamicin doses were usually 240 mg on a fixed basis, but reduced in patients with pre-treatment impairment of serum-creatinine. Bacteriological cultures were taken in 90% of the patients, of which 59% were positive, most often with Enterobacteriaceae (57%) or other Gram-negative rods (11%). Effect of antibiotic treatment was seen in 82% of the patients. Nephrotoxicity defined as a 44 umol/l increase in serum-creatinine during treatment was found in five patients (5%). Ototoxicity, i.e. clinical signs of tinnitus, dizziness and/or impaired hearing, was reported in two patients. In conclusion, gentamicin OD with 240 mg is easy to administer, appears to be sufficient with regard to effect and has a low frequency of side-effects.

Background: Patients on home parenteral nutrition (HPN) require significantly higher amounts of selenium compared with controls. The purpose of the present study was to investigate if selenium deficiency of patients with short bowel syndrome is caused by selenium malabsorption or by excessive intestinal or renal loss. Methods: The metabolism of [ 75 Se]selenite was investigated in eight selenium-depleted short bowel patients on HPN and in six control subjects. The isotope was given orally, and in a subsequent study as bolus injection or as 12-hour IV infusion. Results: The fractional intestinal absorption of selenium was significantly reduced in the patients (2% to 58%, median 20%) when compared with the reference group (79% to 91%, median 82%) (p

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.

Short-bowel syndrome is a state of severe malabsorption secondary to extensive bowel resection. The most common reasons for extensive bowel resection are Crohn's disease and mesenteric infarction. The pathophysiological consequences depend on extent and site of resection, integrity and adaptation of the remaining bowel, and secondary effects on other organs. Most extensively bowel resected patients can be adequately nourished by mouth, especially since they develop compensatory hyperphagia. For patients with colon in function a high-carbohydrate low-fat diet is beneficial compared to a diet with a normal fat content, because it results in decreased diarrhoea, decreased faecal mineral losses, and increased energy assimilation. The relative amount of dietary fat does not influence stool mass or energy assimilation in jejunostomy patients. Patients with jejunostomy have a high faecal output of water, sodium, and divalent cations, and they often need permanent parenteral supply of saline as well as calcium and magnesium if their small intestinal remnant is200 cm and parenteral nutritional support if they retain100 cm small bowel. In contrast, 50 cm of the jejunum often suffices for adequate oral nutrition if most of the colon is preserved. The majority of patients needing long-term intravenous supply are trained to administer parenteral nutrition at home (HPN). Most patients on HPN obtain a good or fair quality of life with hospital readmissions corresponding to an average of 10% of the HPN duration and an overall HPN related mortality of about 4%.

A retrospective survey was performed in 1994, involving 496 adult home parenteral nutrition (HPN) cases, newly enrolled in the year 1993 from 13 European countries from 75 centres. From the 8 countries having registered more than 80% of cases (423 patients), incidence and prevalence ranged from 0.2 to 4.6 and 0.3 to 12.2 patients/106 population/year. In the patients studied, the diagnosis was cancer (42%), Crohn's disease (15%), vascular diseases (13%), radiation enteritis (8%), AIDS (4%) and other nonmalignant non-AIDS diseases (18%). Short bowel syndrome and intestinal obstruction were the two major indications for HPN in 31% and 22%, respectively. Seventy-three percent of the centres had a nutrition team. HPN was administered through a tunnelled venous central catheter in 73%, cyclical nocturnal infusions were used in 90% of patients, and intravenous feeding was the sole source of nutrition in 33%. Only 44% undertook HPN unaided. The present report indicates that cancer has now become the main indication for HPN in Europe; there was, however, a heterogeneous distribution of diseases amongst the reporting countries. The observed 9 (6–12)-month probability of survival was poor in AIDS (n = 8; 12%) and cancer patients (n = 78; 29%) but better for the other HPN indications (n = 115; 92%).

Is there an east-west gradient in the incidence of IBD in Europe? : and further far east in China? First results from the epicom study

In the period 1968-1989 50 patients, 38 women and 12 men, aged 30-76 years, median 58 years, were referred to the Department of Gastroenterology, Rigshospitalet for severe chronic radiation enteropathy. Most women had received radiation for gynaecological cancer, and most men for urogenital cancer. The initial symptoms of the enteropathy were diarrhoea in 74%, abdominal pain in 62% and weight loss in 52%. Twelve per cent had visible blood in the stools. Ten per cent had fistulas. The symptoms occurred 0-37 years, median ten months after the radiation. The radiation enteropathy had necessitated one or more laparotomies in 35 patients, most often because of subileus/ileus, including resection of the small bowel or the colon in 25 patients, and establishment of an ileostomy or a colostomy in 11. Seven patients developed new fistulas postoperatively. In 32 patients one or more tests for malabsorption were performed as a guidance for therapy: stool mass (26 patients), faecal fat excretion (26 patients), Schilling test (22 patients), lactose absorption (11 patients) and bile acid breath test (seven patients). Half of the patients had diarrhoea, including one third of the patients without intestinal resection. Two thirds had steatorrhoea, including half of the patients without small bowel resection. Three fourths showed decreased absorption of vitamin B12, including half of the patients without ileal resection. All patients studied had abnormal deconjugation of bile acids and more than half of them had bile acid malabsorption. Malabsorption of lactose was found in only one patient. There was no correlation between the radiological and functional abnormalities of the small intestine.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of Whipple's disease (WD) initially presenting with migrating arthralgia and later with weight loss, malaise, fever and abdominal discomfort is reported. On examination the patient showed signs of malnutrition, was anaemic and pyrexial (37.6-38.8) and had mild abdominal distention. Retroperitoneal lymph node enlargement was demonstrated by CT-scanning. Gastroduodenoscopy demonstrated white plaques and erosions in the 2nd and 3rd part of the duodenum. Repeated small bowed biopsies revealed pathological changes typical of WD. The patient was treated with parenteral penicillin 2 MIE t.i.d. for 14 days followed by sulfamethoxazole 800 mg and trimethoprim 160 mg b.i.d for a year. Response to treatment was satisfactory. Serum alkaline phosphatase levels were raised: 324-649 U/l (80-275) on admission and remained so following treatment.

The diagnosis of immediate adverse reactions to food (food allergy) depends exclusively on the outcome of double-blind, placebo-controlled food challenges (DBPCFC) [1, 2, 4, 5 (to be published), 9]. The diagnostic value of a skin prick test (SPT), radio-allergosorbent test (RAST) and histamine release from basophils (HR) has not yet been fully elucidated and cannot replace DBPCFC [3, 6, 10]. This also applies to a new technique, the intragastric provocation under endoscopic control (IPEC), developed by Reimann and Ring [7, 8], although the authors reported a very close correlation between the results of IPEC and DBPCFC. As this new technique might prove to be more valuable than SPT, RAST, or HR in the diagnosis of food allergy, we therefore compared the outcome of IPEC with that of DBPCFC in our adult patients.

Long term parenteral nutrition is lifesaving in a few patients with severe gastrointestinal failure. Such therapy is often carried out at home (Home parenteral nutrition, HPN) and based on a high degree of self-care. The risk of complications is high, and it requires a considerable skill and experience from the hospital staff to manage HPN and educate patients. The prevalence of such patients in the Nordic countries is 3-4 per million. In some Nordic countries it is impossible to centralize this treatment only to one or two hospitals. With such a small number of patients scattered all over the country it is therefore important to establish a national co-operation and registration regarding HPN-patients. This will increase experience with HPN and make it possible to standardize the therapy with regards to indications, catheter technique, nutritional supply, management of complications, education etc. Furthermore it is a wish to expand this co-operation and registration to include all Nordic countries. Such multinational co-operation might be of value in cases of rare and difficult patients on HPN and in children and will further increase our experience with HPN. Results from a meeting on Nordic co-operation concerning HPN is presented.

Background & aims: Undernutrition is associated with increased morbidity and mortality and is common in patients admitted to hospital. We examined (1) the prevalence of patients at nutritional risk, (2) whether these patients were identified by the staff, and (3) whether a nutritional plan and monitoring was made for patients at nutritional risk. Methods: A cross-sectional study in 15 randomly selected departments (>200 beds, departments of internal medicine, gastro- and orthopedic surgery) in Danish hospitals. The patients were characterized by scoring the components ‘undernutrition’ and ‘severity of disease’ in 4 categories (absent, mild, moderate or severe). The patient could have a score of 0–3 for each component (undernutrition and severity of disease), and any patient with a total score ⩾3 was considered at nutritional risk. Undernutrition was evaluated by 3 variables (BMI, recent weight loss, recent food intake). Results: Out of 590 patients, 39.9% were nutritionally at risk, with the highest prevalence in departments of gastro-surgery (57%). BMI was

A comparison was made between isocaloric amounts of 24% glucose and 24% Triofusin® (composed of 120 g fructose, 60 g glucose and 60 g xylitol per liter) during the course of a 6-day, 3-phase crossover study of 15 patients undergoing total parenteral nutrition. The patients received a total of 0.5 g carbohydrate per kilogram body weight per hour and 6 g carbohydrate per kg per day. Plasma glucose was significantly higher during glucose infusion (7–22 mmol/l, median: 9 mmol/l) than during Triofusin® infusion (5–16 mmol/l, median: 6 mmol/l). A moderate to severe glucosuria was detected in three patients during infusion of 24% glucose, and this declined considerably during the Triofusin® period. The total renal carbohydrate loss during the glucose period was 0–143 g, median: 6 g per day, and during the Triofusin® period was 6–68 g, median: 10 g per day. The nitrogen balance and carbamide production rate were the same in the two infusion regimes. Changes in biochemical liver parameters were observed in most of the patients, but these could not be attributed to parenteral nutrition. None of the patients developed symptoms of metabolic acidosis. There was a slightly but significantly higher urinary excretion of oxalate in the Triofusin® period (0.1–1.1 mmol per day, median: 0.5 mmol per day) than in the glucose period (0.1–1.0 mmol per day, median: 0.4 mmol per day). Most of the patients exhibited a slightly increased urinary excretion of urate, irrespective of the infusion regimen. Serum urate remained normal. It was concluded that Triofusin® infused in the described dosage is a suitable calorie source for parenteral nutrition, but that it does not present a distinct advantage over the use of pure glucose solution. In patients suffering from reduced glucose tolerance, however, Triofusin® represents a more easily manageable calorie source.

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.

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.

Net absorption of calcium, calcium balance and bone mineral content were studied in 83 patients with small-bowel resections of various lengths, mainly owing to CIBD, while they were receiving a standardized diet supplying 70 g fat and 800 mg calcium. Median duration of disease was 9 years (range, 5 months to 53 years) and median length of time from resection 3 years (range, 2 months to 18 years). In the whole case material net absorption of calcium ranged from +573 to −268 mg/day; median, +65 mg/day (+56% to −26% of dietary calcium; median, +6%). A weak inverse correlation was found between net absorption of calcium and length of resected small bowel, both in patients with ileostomy (no. = 32, r = −0.43, p < 0.01) and in patients with part of or the whole colon in function (no. = 51, r=−0.34, p < 0.01). Net absorption of calcium and urinary calcium correlated only weakly (no. = 78, r = 0.39, p < 0.001). In all patients studied the median calcium balance was −49 mg/day (range. +447 to −339 mg/day). No diff...

The effect of a long acting somatostatin analogue SMS 201-995 on stomal effluents in patients with severe short bowel syndrome was investigated in a double blind placebo controlled balance study. Six patients, five with Crohn's disease and one with radiation enteropathy were studied. Five patients had a jejunostomy and one an ileostomy. The patients had a normal food intake, but because of severe malabsorption had received home parenteral nutrition for several years. Faecal mass was reduced (p less than 0.005) and intestinal net sodium absorption was increased (p less than 0.005) by intravenous infusion of SMS 25 micrograms/h. Net absorption of potassium, calcium, magnesium phosphate, zinc, nitrogen and fat was not influenced. Subcutaneous injections of 50 micrograms SMS every 12 hours had a similar effect on net intestinal absorption of sodium and water. Four patients continued with a five to six months open follow up study when subcutaneous SMS in the same dose was administered by the patients at home. The effect on faecal sodium loss persisted, but in one patient faecal mass gradually increased and finally exceeded pretreatment values. SMS may decrease net absorption of water and sodium following reduced secretion of digestive juices rather than by increasing absorptive capacity. SMS may be useful as an antidiarrhoeal drug in patients with high output jejuno- or ileostomies, but in patients who need permanent parenteral nutrition the effect is too small to significantly alter management.

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.