Use of risedronate to prevent bone loss following a single course of glucocorticoids: findings from a proof-of-concept study in inflammatory bowel disease.

SUMMARY: We performed a randomised controlled trial (RCT) to determine whether risedronate 35 mg once weekly prevents bone loss following an 8-week reducing course of prednisolone given for an exacerbation of inflammatory bowel disease (IBD). The greatest change in bone mineral density (BMD) was at Ward's triangle (WT), which fell by 2.2% in the placebo group, compared with a reduction of 0.8% in the risedronate group. INTRODUCTION: Whether bisphosphonates can prevent bone loss associated with intermittent glucocorticoid (GC) therapy is unknown, reflecting the difficulty in performing RCTs in this context. METHOD: To explore the feasibility of RCTs to examine this question, lumbar spine (LS; L2-4) and hip dual X-ray absorptiometry (DXA) scans were performed in 78 patients commencing a GC therapy course for a relapse of IBD. They were then randomised to receive placebo or risedronate 35 mg weekly for 8 weeks, after which the DXA scan was repeated. RESULTS: For LS BMD, there was no change in the placebo group (0.1 +/- 0.4, p = 0.9), but there was an increase after risedronate (0.8 +/- 0.4, p = 0.04; mean% +/- SEM by paired Student's t test). There were small decreases in both groups at the total hip (-0.5 +/- 0.3, p = 0.04; -0.5 +/- 0.3, p < 0.05, placebo and risedronate, respectively). At WT, BMD fell after placebo (-2.2 +/- 0.5, p = 0.001) but not risedronate (-0.8 +/- 0.5, p = 0.09; p = 0.05 for between-group comparison). CONCLUSION: RCTs can be used to examine whether bisphosphonates prevent bone loss associated with intermittent GC therapy, providing metabolically active sites such as WT are employed as the primary outcome.

Multicentre randomized-controlled clinical trial of Ipocol, a new enteric-coated form of mesalazine, in comparison with Asacol in the treatment of ulcerative colitis.

BACKGROUND: 5-Aminosalicylates remain important in the treatment of ulcerative colitis, but it is uncertain if the various preparations currently available are equivalent given the different delivery systems that exist. Generic prescription of mesalazine (mesalamine) is therefore inappropriate. Ipocol has recently become available as an alternative to Asacol-MR. AIM: To compare the two agents in a controlled trial using a non-inferiority design. METHODS: Eighty-eight ulcerative colitis patients with a mild to moderate clinical relapse were randomized to one of the two drugs at a daily dose of 2.4 g for 8 weeks. Safety was the key concern; the primary measured end-point was efficacy as judged from a colitis activity index. RESULTS: There were no unexpected adverse events of clinical consequence. The colitis score improved similarly in both patient groups (by 2.3 with Ipocol and by 1.5 with Asacol: not significant), and a similar proportion was in clinical remission at the end of the study (26.1% for Ipocol and 28.6% for Asacol: not significant). Systemic steroids were needed in 11.9% of the Asacol-treated patients compared with 6.5% with Ipocol (not significant). CONCLUSION: It appears appropriate to conclude that, while not identical to Asacol-MR, Ipocol offers a safe and similarly effective alternative.

The effects of a preassessment clinic on nonattendance rates for day-case colonoscopy.

BACKGROUND AND STUDY AIMS: Nonattendance for colonoscopy contributes to an increase in the waiting lists for this procedure. Preassessment clinics routinely run for a number of day-patient surgical procedures have been shown to reduce nonattendance rates by enhancing patient understanding. This study aimed to determine prospectively whether preassessing patients booked for colonoscopy would lead to a reduction in the nonattendance rate. PATIENTS AND METHODS: Nonattendance rates for colonoscopy were assessed in consecutive 9-month periods. During the first period all patients were mailed appointments for colonoscopy with dietary and purgative bowel preparation instructions. During the second period, patients who had never previously undergone a colonoscopic examination were invited to attend a preassessment clinic, while patients who had attended for colonoscopy in the past were sent appointments and purgative instructions in the post. RESULTS: 344 colonoscopies were booked in the first 9-month period and 350 in the second, of which 195 were preassessed. Overall, 60 patients did not attend for colonoscopy during the first 9-month period (17.4%), and 40 (11.4%; P<0.05) did not attend during the second period of study. During the second 9 months only six (3.1%) of the 195 preassessed patients did not attend for colonoscopy, in comparison with 34 (22%; P<0.0001) of the 155 patients not preassessed. CONCLUSIONS: By running a limited preassessment clinic for patients due for colonoscopy, we have shown a significant reduction in the nonattendance rate. If all patients were to attend for preassessment, nonattendance rates for colonoscopy might be reduced to that seen in our preassessment group (3.1%).

Thrombin is effective in arresting bleeding from gastric variceal hemorrhage.

Gastric variceal hemorrhage is associated with a high morbidity and mortality. We report the efficacy and safety of bovine thrombin in the treatment of bleeding gastric varices. At endoscopy 52 patients with hematemesis were diagnosed with bleeding gastric varices. Patients were treated by intravariceal injection with bovine thrombin and underwent further endoscopy at 72 hr and then at two-week intervals. Initial hemostasis was achieved in 49/52 patients (94%). Bleeding-related mortality at 72 hr after the index bleed was 3/52 (6%). The mean amount of thrombin used to achieve initial hemostasis was 1070 IU (range 400-2000 IU) and no adverse drug effects were observed. The median number of treatment sessions required to achieve gastric variceal ablation was 2 (range 1-3). At six weeks, 9 of 49 surviving patients (18%) rebled and one further patient died. The six-week mortality in patients treated with thrombin was 4/52 (8%). In conclusion, safe and effective hemostasis of bleeding gastric varices can be achieved by intravariceal injection with thrombin.

The effect of benign and malignant liver disease on the tumour markers CA19-9 and CEA.

The serum concentrations of CA19-9 and carcinoembryonic antigen (CEA) were measured in 150 consecutive patients with histologically proven liver disease admitted to a liver unit for transplant assessment. A significant proportion of the cases studied had a CA19-9 above the upper limit of the reference range (35 kU/L): alcoholic liver disease (73%), primary sclerosing cholangitis (61%), primary biliary cirrhosis (60%), chronic hepatitis B (71%), chronic hepatitis C (84%), autoimmune hepatitis (36%) and hepatocellular carcinoma (54%). CEA was only elevated in a small proportion of the patients with benign liver disease and the degree of elevation was small (15-37 micrograms/L). Significantly raised CEA was observed in two patients (15%) with hepatocellular carcinoma. Statistically significant correlations were observed between the serum CA19-9 concentration and standard parameters of liver dysfunction: positive correlations with aspartate aminotransferase, alkaline phosphatase and bilirubin and negative correlations with albumin and gamma-glutamyltransferase. Positive relationships were also observed between CA19-9 and both CEA and creatinine. Both increased production of CA19-9 from biliary epithelial cells and decreased clearance due to cholestasis may be contributing to the elevation of CA19-9 in the bloodstream. Our data indicate that caution is needed in the interpretation of CA19-9 results in the presence of liver dysfunction.

Carbohydrate deficient transferrin in alcoholic and non-alcoholic liver disease: a comparison of two assay methods.

Carbohydrate-deficient transferrin (CDT) was assayed in 105 patients with non-alcohol-related liver diseases, 50 patients with alcohol-induced liver disease and 40 alcohol misusers with minimal hepatic dysfunction. The patients with liver disease were hospitalized for assessment of suitability for orthotopic liver transplantation. CDT was measured by two commercially available micro anion exchange methods; CDTect (Pharmacia) and %CDT (AXIS). Additionally, total transferrin was measured to allow expression of the CDTect results as 'relative' measurements. Overall, 41/105 (39%) of patients with non-alcohol-related liver diseases had a raised CDTect result, 13/105 (12%) had a raised %CDT result and 26/105 (25%) an abnormal CDTect/total transferrin ratio. In general, patients with cholestatic liver disease, primary biliary cirrhosis or primary sclerosing cholangitis had more 'false positive' results by CDTect than did those with viral or autoimmune hepatitis. The sensitivity of the two methods for the detection of alcohol misuse was similar; CDTect 77%, %CDT 65% and CDTect/total transferrin ratio 70%. This was, however, lower than the sensitivity of the conventional marker GGT (82%). In patients with severe liver disease, where up to 30% of the serum total transferrin concentrations fall outside the reference range, 'relative' CDT methods have greater specificity than 'absolute' measurements.

Analysis of interleukin-4 and interleukin-10 and their association with the lymphocytic infiltrate in the small intestine of patients with coeliac disease.

BACKGROUND: Concentrations of pro-inflammatory cytokines are raised in the small intestine of patients with coeliac disease after ingestion of gluten but there are equivalent data on interleukin-4 (IL-4) and interleukin-10 (IL-10) producing cells. These cytokines are known to exert important regulatory effects on pro-inflammatory cytokine production from lymphocytes and macrophages. AIMS: To investigate whether there is a primary deficiency of IL-4 and IL-10 producing cells and their site of production in the small intestine of patients with coeliac disease in relation to the changes in inflammatory cell infiltrate. PATIENTS: Jejunal biopsy specimens from patients with coeliac disease (11 untreated, 10 treated) and nine disease controls were studied. METHODS: Immunohistochemical staining of sections for IL-4 and IL-10 cytokines and the cell phenotypic markers CD3 (T lymphocytes) and CD45 (total inflammatory cell infiltrate) was carried out using monoclonal antibodies. Expression of IL-4 and IL-10 messenger RNA was detected by in situ hybridisation with oligonucleotide probe cocktails for each cytokine. RESULTS: IL-4 and IL-10 mRNA and protein were detected in the lamina propria of treated and untreated coeliac patients and disease controls but not in the epithelium. A significant increase in the number of CD45 (p < 0.005) and CD3 (p < 0.05) positive cells was found in the lamina propria of patients with untreated coeliac disease compared with treated coeliac patients and disease controls but there were no differences in IL-4 or IL-10 between these groups with either method. CONCLUSIONS: There is no primary deficiency of IL-4 and IL-10 producing cells in the small intestine of patients with coeliac disease. Detectable concentrations of IL-4 and IL-10 were found in control patients which suggests that these cytokines are involved in normal mucosal immunoregulation. The increased number of T lymphocytes but not IL-4 or IL-10 producing cells in the lamina propria of patients with untreated than in those with treated disease suggests not only that the lamina propria is the major mucosal compartment for cytokine production but that newly recruited mucosal T lymphocytes are directed to a predominant Th1 and not a Th2 cytokine response in coeliac patients on a diet containing gluten.

Cognitive impairments of alcoholic cirrhotic patients: correlation with endogenous benzodiazepine receptor ligands and increased affinity of platelet receptors.

OBJECTIVES: To determine whether differences in cognitive function between alcoholic and non-alcoholic cirrhotic patients relate to differences in endogenous ligands for the benzodiazepine receptor and/or benzodiazepine binding. METHODS: Seventeen grade-I hepatic encephalopathic patients (nine alcoholic, eight non-alcoholic) were compared with 10 matched controls on plasma concentrations of endogenous ligands for the neuronal benzodiazepine receptor, benzodiazepine binding in platelets, and performance on tests of cognitive function. RESULTS: Both groups of patients were impaired on verbal recall and on reaction time tasks compared with controls; alcoholic patients were also impaired on Reitan's trails test and digit cancellation. Four of the 17 patients had detectable concentrations of endogenous benzodiazepine ligands and they were more impaired than other patients on trails and cancellation tests. The groups did not differ in the density of benzodiazepine platelet receptors, but receptor affinity was higher in alcoholic patients than in controls; furthermore, receptor affinity correlated with the time to complete the cancellation task and with reaction time. CONCLUSION: Alcoholic cirrhotic patients may have enhanced concentrations of ligands for neuronal and peripheral benzodiazepine receptors and these may contribute to cognitive impairments in these patients.

A duodenal mucosal abnormality in the reduction of Fe(III) in patients with genetic haemochromatosis.

BACKGROUND: Previous in vitro studies have shown that the uptake of Fe(III) by freshly isolated duodenal mucosal biopsy specimens is increased in patients with genetic haemochromatosis. Moreover, in the mouse it has recently been found that reduction of Fe(III) to Fe(II) is a prerequisite for iron uptake by the proximal intestine. AIMS/METHODS: This study used the in vitro technique to investigate the rates of reduction and uptake of 59Fe(III) by duodenal mucosal biopsy specimens obtained at endoscopy from treated and untreated patients with genetic haemochromatosis. RESULTS: The rate of reduction of iron in the medium was proportional to the incubation time and was not caused by the release of reducing factors from the tissue fragments. Ferrozine, a specific Fe(II) chelator and ferricyanide, a non-permeable oxidising agent, inhibited uptake of 59Fe showing that reduction of Fe(III) precedes uptake. The rates (all values given as pmol/mg/min) of reduction (152 (49) v 92 (23)) and uptake (8.3 (4.0) v 3.6 (1.3), mean (SD)), were significantly increased in biopsy specimens from the untreated group (n = 6) compared with those from 10 control subjects (p < 0.04). Furthermore, the reduction and uptake rates were still increased in five patients in whom iron stores were normal after venesection treatment. CONCLUSIONS: These results show that there is a persistent abnormality in the reduction and uptake of iron by the intestine in genetic haemochromatosis.

Cytokines and gastrointestinal disease mechanisms.

Cytokines mediate immune responses and are detectable in the normal gastrointestinal mucosa. It is unclear how cytokines are physiologically regulated but in inflammatory enteropathies their expression is often greatly increased and may account for the tissue damage observed. T-cells may be sub-divided according to the pattern of cytokines which they secrete. TH1 cytokine expression is increased in delayed type IV cell mediate immune responses whereas TH2 cytokines are raised in diseases in which humoral mechanisms are more important. Cytokines are secreted by macrophages in relatively greater amounts than from T-cells. They are non-specific products of inflammation and may account for the majority of tissue damage seen in mucosal disease. The pattern of cytokine secretion may determine the immunopathogenesis of an inflammatory disorder. The ultimate goal of cytokine research is the development of therapeutic measures based on a better understanding of their actions which may be achieved with a better understanding of the molecular immune-microenvironment in inflammatory enteropathies. Studies with transgenic mice and gene targeted mice have important implications to the understanding of the immune system and its role in intestinal diseases.

In vitro toxicity of gluten peptides in coeliac disease assessed by organ culture.

BACKGROUND: We have used organ culture to investigate the in vitro toxicity of three oligopeptides corresponding to amino acids 31-49 (peptide A), 202-220 (peptide B), and 3-21 (peptide C) of A-gliadin, Frazer's fraction III (FFIII), and ovalbumin. METHODS: Eight to 14 jejunal biopsy specimens were obtained from each of 8 treated and 7 untreated coeliac patients and 5 normal controls and cultured for 18 h in organ culture with test peptide (1 mg/ml) or medium alone. Mean enterocyte cell heights (ECH) were compared with paired values for specimens grown in medium alone. RESULTS: A significant reduction in the mean of the ECH values for each of the patient groups was observed with peptide A and FFIII in both treated (p = 0.01 and 0.02, respectively) and untreated (p = 0.03 and 0.01) coeliac patients when compared with tissue incubated with medium alone. No significant changes in the mean ECH value were noted in any of the patient groups in tissue incubated with peptide B, peptide C, or ovalbumin as compared with those with medium alone. CONCLUSIONS: These results suggest that peptide A is toxic in vitro to the jejunal mucosa of both treated and untreated coeliac patients, correlating with recent findings that this peptide exacerbates coeliac disease in vivo.

Cytokine mRNA expression in the mucosa of treated coeliac patients after wheat peptide challenge.

This study investigated the presence of mRNA coding for interferon gamma (IFN gamma), tumour necrosis factor alpha (TNF alpha), and interleukins 2 (IL2) and 6 (IL6), in the mucosa of four coeliac patients in remission who had been challenged with either gliadin or synthetic gliadin oligopeptides. Jejunal biopsy specimens from these patients, taken before and at two, four, and six hours after challenge, were hybridised with specific 35S-labelled DNA oligonucleotide probes. The lamina propria of all the patients contained significantly increased numbers of cytokine mRNA expressing cells four hours after challenge with gliadin or an oligopeptide corresponding to amino acids 31-49 of A-gliadin (peptide A). No significant changes were seen with the peptides corresponding to aminoacids 202-220 (peptide B) or 3-21 (peptide C) of A-gliadin, with the exception of one patient who showed a significant increase in the number of TNF alpha mRNA expressing cells four hours after challenge with peptide B. In vivo studies in coeliac disease have shown that significant histological changes occur in the mucosa of treated coeliac patients four hours after challenge with either gliadin or peptide A. These findings suggest that the histological changes seen previously in the mucosa of coeliac patients after wheat peptide challenge may be caused by increased expression of cytokines within the mucosa.

Histological changes in small bowel mucosa induced by gliadin sensitive T lymphocytes can be blocked by anti-interferon gamma antibody.

The isolation of gliadin specific HLA-DQ2 restricted T lymphocyte clones from the intestinal mucosa of patients with coeliac disease supports a role for cell mediated immunity in the pathogenesis of this condition. Whether supernatants from immune activated T cell clones could produce histological damage to duodenal mucosa in vitro was studied. Biopsy specimens were obtained from 18 patients without coeliac disease or any other demonstrable abnormality. The tissue was maintained in organ culture for 24 hours with organ culture medium alone, with supernatant from gliadin sensitive T cell clones that had (B) or had not (A) been stimulated with gluten, and compared with the effects caused by the addition of interferon gamma to the organ culture medium. Both the (B) supernatants (1:100) and interferon gamma (100 IU/ml) produced a significant reduction in the enterocyte height (21:5 (3.4) microns and 21.0 (3.2) microns respectively, each p < 0.001) compared with specimens grown in organ culture medium alone (27.3 (2.8) microns). The toxic effects of (B) supernatants could be blocked by pre-incubating them with anti-interferon gamma antibody. These findings support the role of gliadin sensitive T lymphocytes in the immune pathogenesis of coeliac disease and their secretion of interferon gamma may cause the damage to enterocytes observed in this condition.

Expression of tumour necrosis factor-alpha, interleukin-6, and interleukin-2 mRNA in the jejunum of patients with coeliac disease.

BACKGROUND: A T-cell-mediated immune response may be responsible for the enteropathy seen in coeliac disease (CD), but it is unclear whether this is initiated in the epithelium or the lamina propria. We studied the site and number of cells expressing mRNA encoding the cytokines interleukin-2 (IL-2), IL-6, and tumour necrosis factor-alpha in jejunal biopsy specimens from patients with untreated or treated CD and normal controls. METHODS: Tissue sections were hybridized with 35S-labelled DNA oligonucleotide probes specific for each cytokine RNA sequence. Positive cells were counted in the lamina propria and epithelial compartments. RESULTS: For each cytokine significantly greater numbers of positive cells were found in the lamina propria of untreated CD patients. Few positive cells were detected in the epithelium of all three groups. CONCLUSIONS: This study shows that the immune response to gliadin appears to occur in the lamina propria and supports cell-mediated immunity in the pathogenesis of coeliac disease.

Analysis of crypt cell proliferation in coeliac disease using MI-B1 antibody shows an increase in growth fraction.

This study aimed to investigate the pattern of cellular proliferation and to calculate the growth fraction of small intestinal crypts in 24 patients--eight with untreated coeliac disease (CD), six with treated CD, and 10 controls with normal villous architecture. Duodenal biopsy specimens were stained with MI-B1 antibody using an immunoperoxidase method. Positive stained crypt cells were counted and their position within each intact crypt column was noted. These were used to construct proliferation index distribution curves for each cell position from which the crypt growth fraction for each group of patients was calculated. The crypt growth fraction was found to be higher in the untreated CD group (0.57) than in the treated patients (0.39) and the controls (0.44). The mean (SEM) proliferative index for each crypt was significantly higher in the untreated group (42.3 (10.8)%; p < 0.05) than in the treated CD (21.7 (8.5)%) and control (19.7 (7.5)%) groups and correlated closely with the surface:volume index and enterocyte cell height measurements in all three groups. An increased growth fraction may contribute to other changes in crypt cell kinetics to produce the histological changes seen in untreated CD.