Nongastrointestinal symptoms of irritable bowel syndrome: an office-based clinical survey.

Irritable bowel syndrome (IBS) is the most prevalent gastrointestinal problem faced by practicing gastroenterologists. For many years, nongastrointestinal symptoms have been documented in IBS patients, but the medical literature does not emphasize them. The present study explored how IBS and inflammatory bowel disease patients differ in their reporting of nongastrointestinal symptoms. Information from 200 consecutive patients with IBS and a similar number of patients with Crohn's disease (in a single gastroenterology practice) was obtained at the initial visit using a simple questionnaire. Comparison of the data revealed that IBS patients describe certain nongastrointestinal symptoms far more frequently than do those with inflammatory bowel disease. It is recommended that these symptoms be considered along with the generally accepted criteria for making a positive diagnosis of IBS.

Disappearance of Crohn's ulcers in the terminal ileum after thalidomide therapy.

A case of intractable Crohn's disease unresponsive to all forms of therapy, including multiple operations and medication, is reported. The patient responded to thalidomide and this has resulted in the disappearance of the disease in the neoterminal ileum. Thalidomide may be a valuable treatment in intractable cases of Crohn's disease. The case is presented in a chronological fashion and endoscopic photographs documenting the disappearance of the disease are presented.

Intestinal permeability is increased in a proportion of spouses of patients with Crohn's disease.

OBJECTIVE: Increased small intestinal permeability has been found in patients with Crohn's disease and in a proportion of their healthy relatives. This may reflect a shared environment or shared genes. The finding of abnormal permeability in the healthy spouses of patients would favor an environmental cause for this observation. METHODS: The healthy spouses of patients with Crohn's disease attending three gastroenterology clinics were invited to participate. Eligible subjects consumed a 350-ml solution containing lactulose, mannitol, and sucrose before bedtime. All overnight urine was collected, assayed by high performance liquid chromatography, and the ratio of fractional excretion of lactulose to mannitol was calculated as an index of permeability. The results were compared with those of a previously determined control group. RESULTS: Sixty spouses completed the study. Increased permeability was present in eight (13.3%, 95% CI = 6.0-24.6%). The presence of increased permeability was not related to age, gender, duration of cohabitation, alcohol use, nonsteroidal anti-inflammatory drug use or to disease activity in the patient with Crohn's disease. There was a nonsignificant trend for abnormal permeability to occur in those spouses cohabiting with the patient with Crohn's disease at the time of disease diagnosis (p = 0.128). CONCLUSIONS: Small intestinal permeability is increased in a proportion of healthy spouses of patients with Crohn's disease. The presence of abnormal permeability studies in patients with Crohn's disease and a proportion of their healthy close contacts suggests that this phenomenon is caused by environmental factors.

Anticipation in an Indo-Canadian family with Crohn's disease.

Genetic anticipation, associated elsewhere with monogenic neurological disorders, has been hypothesized to be present in familial forms of Crohn's disease. Usually, with studies of parent-child pairs, the parent who is initially diagnosed is older at the onset of disease than the child. With each successive generation, an apparent increase in disease severity or behaviour occurs. This phenomenon is believed to have a molecular basis. In the present report, an Indo-Canadian family with Crohn's disease is described. In all members of the family, disease was diagnosed only after prolonged residence in Canada, supporting the view that Crohn's disease arises in individuals with a genetic predisposition following exposure to some, as yet unknown, common environmental factor. Three siblings with Crohn's disease, first diagnosed between ages 15 and 27 years, or six to 11 years after arrival in Canada, had phenotypically concordant disease localized in the ileum and colon, with fistulizing complications, including perianal sepsis. Crohn's disease was only diagnosed in the father at the age of 76 years, almost three decades after his arrival in Canada. His disease was localized to the ileum and had a fibrostenosing behaviour. This is the first reported instance of familial Crohn's disease in an immigrant population, illustrating potential biases in genetically based studies of Crohn's disease that rely solely on phenotypic expression.

The abdominal wall. A frequently overlooked source of abdominal pain.

Here, I review various conditions from my practice as a consultant gastroenterologist that present with abdominal pain in which the cause of the pain is the result of abdominal wall conditions, or disorders that affect the nerves to the abdominal wall. The diagnosis of abdominal wall pain can be made by careful history and physical examination, thus eliminating numerous unnecessary and sometimes dangerous invasive procedures and tests.

Predictors of hospitalization early in the course of Crohn's disease. A pilot study.

A historical cohort was used to assess the ability of clinical features and laboratory values recorded at the time of initial diagnostic investigations to predict nondiagnostic hospital admissions in the first 3 months following the diagnosis of Crohn's disease. Data were abstracted from the medical records of 225 eligible patients at primary and secondary care level whose disease was diagnosed between 1977 and 1985. The total study group was randomly divided into two groups (group 1, n = 112; group 2, n = 113). Discriminant analysis was performed on data of patients in group 1. The resulting predictive model was then cross-validated on data of patients in group 2. The variables entered into the predictive model were identified using bivariate analysis. Results show that presence of abdominal mass, body temperature, absolute basophil and lymphocyte counts, aspartate aminotransferase and blood urea nitrogen serum levels, and place of residence (urban, rural, or out of province) were the most useful variables for predicting hospitalization in the first 3 months (P for model = 0.0010; accuracy = 88%). Cross-validation on group 2 showed an accuracy of 80%, a positive predictive value of 62%, and a negative predictive value of 84%. This predictive model could be useful for counseling purposes on the primary or secondary care levels.

Chronic right upper quadrant pain without gallstones: does HIDA scan predict outcome after cholecystectomy?

Patients with chronic right upper quadrant pain who do not have gallstones on ultrasound or cholecystography are often referred for surgery for presumed acalculous chronic cholecystitis. We followed 26 patients who had cholecystokinin (CCK) cholescintigraphy for evaluation of chronic right upper quadrant pain without demonstrable gallstones on ultrasound who underwent cholecystectomy so that it could be determined whether there was any relation between a low ejection fraction (EF), morphological features of chronic cholecystitis, and clinical outcome. Eighteen patients (69%) were considered therapeutic successes, whereas eight (31%) were failures after an average 2-yr follow-up. Both patient groups had significantly reduced EF: the successful group at 0.39 and the failures at 0.25. Thus, a low EF did not predict clinical outcome, since the failure group had an even lower EF than the success group. Seven gallbladders demonstrated chronic acalculous cholecystitis; the average EF of this group was 0.35. The remaining 19 gallbladders were normal, yet also had an EF of 0.35. Thus, decreased EF does not predict the histologic features of chronic cholecystitis without gallstones. The diagnostic value of cholescintigraphy in patients with acalculous right upper quadrant pain is low, probably because this entity represents a variety of processes, including inflammation, gallbladder dysmotility, and the irritable bowel syndrome.

Biliary obstruction after cholecystectomy: diagnosis with quantitative cholescintigraphy.

Fifty patients with recurrent post-cholecystectomy pain underwent hepatobiliary scintigraphy. Time-activity curves were generated from regions of interest over the liver, bile duct, duodenum, and bowel. Patients were divided into obstructed and unobstructed groups with endoscopic retrograde cholangiopancreatography criteria. Measurements from the liver, duodenum, and bowel curves contributed little to the analysis. The washout phase of the bile duct curve showed intermittent emptying in both obstructed and unobstructed groups. Less than one-third of peak activity remained in both groups at 90 minutes. Retention fell more rapidly in the later portion of the sequence in patients with obstruction. Quantification was essential, since differences were subtle and could not be appreciated visually. In the absence of hepatocellular disease, the most reliable criterion was the time at which maximal bile duct activity occurred. A cutoff level of 29 minutes or more was used in the diagnosis of obstruction. A sensitivity of 93% with an adequate specificity of 64% and an overall accuracy of 80% was achieved in the prediction of obstruction.

Pilot study of cyclosporin A in patients with symptomatic primary biliary cirrhosis.

The purpose of this pilot study was to determine whether daily administration of cyclosporin A to symptomatic patients with primary biliary cirrhosis for 1 yr would lead to a significant and sustained improvement in liver enzyme abnormalities. Twelve adult patients (11 female, 1 male; aged 52.6 +/- 8.9 yr, mean +/- SD) with serologic and histologically defined primary biliary cirrhosis were randomized to receive either oral cyclosporin A or vehicle placebo. Cyclosporin A was administered at sufficient dosages to maintain serum radioimmunoassay trough levels between 100 and 200 ng/ml (starting dosage, 2.5 mg/kg.day). After 1 yr of therapy, significant changes from pretreatment values were seen only in recipients of cyclosporin A. These included a 37% decrease in mean serum alkaline phosphatase and a 43% decrease in gamma-glutamyltransferase (controls +3% and -14%, respectively). Mean serum bilirubin and albumin levels and prothrombin times remained unaltered in the two groups, as did the extent of inflammation and fibrosis and the histologic staging of liver biopsy specimens. Although mean serum creatinine levels increased by 51% in recipients of cyclosporin A (+2% in controls), there were no associated changes in diastolic blood pressure or creatinine clearance values. Other side effects including thrombocytopenia, hirsutism, headaches, tremor, and parasthesiae were common in the treated group but not of sufficient severity to warrant adjustment in the dosage or discontinuation of therapy. The observed changes in hepatic, renal, and hematologic tests tended to return to baseline after discontinuation of therapy. Two patients, both placebo recipients, died of liver failure during the study period. The results of this study indicate that in symptomatic primary biliary cirrhosis, cyclosporin A administration is associated with a significant improvement in cholestatic liver enzyme abnormalities that persists for the duration of therapy. A progressive rise in serum creatinine levels and a high incidence of side effects raise concerns regarding the long-term safety of this agent in primary biliary cirrhosis.