Altered immunoregulatory profile during anti-tumour necrosis factor treatment of patients with inflammatory bowel disease.

Inflammatory bowel disease (IBD) can be treated effectively by anti-tumour necrosis factor (TNF) therapy. We set out to investigate the unclear immunoregulatory mechanisms of the treatment. Thirty-four patients with IBD treated with anti-TNF were included. Lymphocytes from peripheral blood and intestinal biopsies were analysed by flow cytometry. Regulation of antigen-stimulated proliferation was analysed by blocking of interleukin (IL)-10, transforming growth factor (TGF)-ß or depletion of CD25(+) cells in peripheral blood mononuclear cell cultures. No changes in CD4(+)CD25(+), CD25(+)TNF-RII(+) or CD4(+)CD25(+) forkhead box protein 3 (FoxP3(+)) T cells could be observed in peripheral blood after, in comparison to before, 6 weeks of treatment. The suppressive ability of CD4(+)CD25(+) cells did not change. There was an initial decrease of CD4(+)CD25(+) cells in intestinal mucosa after 2 weeks of treatment, followed by an increase of these cells from weeks 2 to 6 of treatment (P < 0·05). This was accompanied by an increased percentage of CD69(+) cells among these cells after 6 weeks of treatment compared to before treatment (P < 0·01). There was also an increase of mucosal T helper type1 cells from weeks 2 to 6 (P < 0·05). In addition, CD25(+)TNF-RII(+) cells in the mucosa were decreased after 6 weeks of treatment compared to before treatment (P < 0·05). Before treatment, peripheral blood mononuclear cell baseline proliferation was increased when IL-10 was blocked (P < 0·01), but not after. In CD25(+) cell-depleted cultures proliferation increased after treatment (P < 0·05). Our data indicate that anti-TNF treatment leads to an induction of effector T cells. Anti-TNF therapy has no significant impact on regulatory T cells in IBD, although the composition of regulatory T cell subsets may change during treatment.

Comparison of the performance of serological kits for Helicobacter pylori infection with European and Asian study populations.

Most commercial kits for the detection of Helicobacter pylori were developed and validated with Western populations, and some have been found to perform less well with Asian populations. This study compared the performances of three serological kits with Swedish and Vietnamese peptic ulcer patients and asymptomatic individuals. The Pyloriset EIA-GIII and HM-CAP ELISA kits indicated that Asian populations had lower antibody titres to H. pylori than European populations. Despite the difference, the Pyloriset EIA-GIII kit performed well with Vietnamese peptic ulcer patients and population controls. The HM-CAP ELISA kit had a significantly lower performance with Asian populations that could not be improved by adjustments to the cut-off level. The Helicoblot 2.1 immunoblot kit performed equally well with Vietnamese and Swedish populations, although the response rate to the 35-kDa band was significantly lower with Vietnamese individuals.

Daily treatment with esomeprazole is superior to that taken on-demand for maintenance of healed erosive oesophagitis.

BACKGROUND: On-demand therapy with esomeprazole is effective for long-term treatment of non-erosive gastro-oesophageal reflux disease, but it has not been evaluated in erosive gastro-oesophageal reflux disease. AIMS: To compare endoscopic and symptomatic remission over a 6-month period when patients with healed erosive gastro-oesophageal reflux disease are treated with esomeprazole 20 mg, either once daily or on-demand. METHODS: Patients with verified erosive reflux oesophagitis of Los Angeles grades A-D were enrolled. Following 4-8 weeks treatment with esomeprazole 40 mg daily, those who were endoscopically healed and had symptom control during the last week were randomized to maintenance therapy for 6 months with esomeprazole 20 mg, taken either once daily or on-demand. RESULTS: Of 539 enrolled patients, 494 (91%) were healed at 8 weeks and 477 were randomized to maintenance therapy with esomeprazole 20 mg, 243 once daily and 234 on-demand. After once daily treatment, 81% of patients were still in remission at 6 months, compared with only 58% who took on-demand treatment (P < 0.0001). A difference in remission was found irrespective of baseline grade of oesophagitis, but it was more pronounced for the more severe grades. There was no difference in overall symptomatic remission between the two treatments, although heartburn was significantly more prevalent in the on-demand group. CONCLUSIONS: Once daily esomeprazole 20 mg was better than that taken on-demand for maintaining healed erosive oesophagitis, regardless of baseline Los Angeles grade.

Colorectal cancer in colonic Crohn's disease--high frequency of DNA-aneuploidy.

BACKGROUND: The risk of colorectal cancer (CRC) in colonic Crohn's disease (CCD) seems to be of the same magnitude as in extensive, longstanding ulcerative colitis (UC) and colonoscopic surveillance has been advocated. Mucosal dysplasia and DNA-aneuploidy are early warning markers of malignant transformation in UC. Data concerning the occurrence of such premalignant lesions in CCD are scarce. AIMS: The objective of this study was to investigate the DNA ploidy pattern in CCD-patients with manifest CRC, both in the tumour, as well as in the adjacent and distant colorectal mucosa. The results from DNA-flow cytometry analyses (FCM) prior to the development of a CRC in CCD were also investigated. MATERIALS AND METHODS: Biopsies obtained at colonoscopy and surgical specimens from 43 patients with colonic or ileocolonic CD developing CRC between 1988 and 1998 were reviewed. The CRC histological phenotype, and the occurrence of dysplasia were registered. CRC-tissue and tissue from areas with dysplasia adjacent to and/or distant from the tumour were obtained from paraffin-embedded blocks and were analysed by FCM after preparation. RESULTS: Twenty-four CRCs in 21 patients (14 men) were suitable for FCM-analyses. The median age at CRC-diagnosis was 53 years (21-73) and the median CCD-duration was 14.5 years (1-50). A predominance of CRC was found either in the cecum (9124) or in the rectum (7/24). DNA-aneuploidy was found in 62.5% (15/24) of the tumours, in 25% (2/8) in adjacent and/or distant mucosa, and in 50% (2/4) of the patients that had been subjected to colonoscopic surveillance prior to the CRC-diagnosis. In 7patients (29%), definite dysplasia was detected adjacent to andlor distant from the tumour. Of the 6 patients undergoing colonoscopic surveillance, 3 (50%) displayed definite dysplasia prior to the colectomy. CONCLUSION: Since DNA- aneuploidy is a' common feature in CRCs in CCD and precede the development of invasive carcinoma, inclusion of FCM-analyses of colorectal biopsies may enhance the sensitivity of identifying high-risk CCD-patients prone to develop CRC within the frame of colonoscopic surveillance programs.

The characteristics of mitotic figures in jejunal mucosa of patients with celiac disease.

The morphologic characteristics of the mitotic figures present in the jejunal mucosa of 23 pediatric patients having gluten enteropathy were recorded. Of the 851 mitoses found, 4.9% were in prophase, 39.9% in prometaphase, 29.5% in metaphase, 22.3% in anaphase, and 3.3% in telophase. Of the 851 mitoses found, 98.8% were considered to be morphologically normal and the remaining 1.2% were considered atypical. The occurrence of atypical mitoses in the jejunal mucosa of pediatric patients was unexpected. However, because jejunal adenocarcinomas in celiac patients are known to be rare, the plausible explanation for the present findings is that the occurrence of atypical mitoses may mirror morphologic variations from the normal mitotic pattern occurring in a rapidly proliferating mucosa, such as that of patients with gluten enteropathy.

Blood and tissue dehydroepiandrosterone sulphate levels and their relationship to chronic inflammatory bowel disease.

OBJECTIVE: To evaluate the levels of dehydroepiandrosterone sulphate (DHEAS) in the blood and tissues of patients with inflammatory bowel disease (IBD). METHODS: DHEAS levels were measured by radioimmunoassay in blood from 112 patients with IBD: 46 with ulcerative colitis (UC) and 66 with Crohn's disease. The levels were compared with those in 80 healthy controls. In addition, DHEAS concentrations were measured in gut tissue from 40 patients (28 patients with IBD and 12 with other bowel disorders) who had undergone gut surgery. Correlation analyses were carried out between the blood and tissue levels of DHEAS. RESULTS: The mean levels of DHEAS in the blood were markedly lower in the two patient groups (1350 nmol/l in UC and 1850 nmol/l in Crohn's disease vs. 3300 nmol/l in controls; p < 0.001 and p < 0.01 respectively). A diminution below the confidence limits of the controls (< 2500 nmol/l) was found in 37 (79%) of the patients with UC and in 49 (74%) of those with Crohn's disease. The remainder had DHEAS levels within the normal range (> 2500 nmol/l). The overall mean DHEAS concentration in gut tissue was 226 nmol/kg. A significant correlation was found between levels in the blood and those in tissues (correlation coefficient = 0.469; p < 0.002). CONCLUSION: These data indicate that low blood DHEAS is a feature in a majority of patients with UC or Crohn's disease. The possibility that there is a functional relationship between low DHEAS levels and some of the pathophysiologic features of IBD needs to be investigated.

Atypical mitoses in colectomy specimens from patients with long standing ulcerative colitis.

About 1% of dividing epithelial cells in esophageal, gastric and duodenal mucosas with chronic inflammation have been found to be atypical. In the present work, the characteristics of the mitotic figures in the colorectal mucosa with ulcerative colitis (UC)--a disease characterized by chronic mucosal inflammation--were investigated. Feulgen-stained histologic sections (having > 30 mitoses in 3 large tissue sections) from 59 colectomy specimens with long standing total UC were scrutinized at high power microscopy (1000 x). A total of 2,104 mitoses were recorded in the 59 specimens with UC: 591 (28.1%) were atypical. Atypical mitoses were present in 19.2% (SE 4.7) of the 26 specimens having chronic active inflammation, in 16.9% (SE 5.6) of the 9 with UC in remission, in 34.6% (SE 7.7) in mucosas with dysplasia (n = 8) and in 49.1% (SE 10.2) in carcinoma (n = 16). Atypical mitoses were also found in 17.0% (SE 5.4) in the non-dysplastic mucosa from colitic patients having dysplasia or carcinoma elsewhere as well as in 0.96% (SE 0.3) in 14 "noncolitic" controls with chronic inflammation. The percentage of atypical mitoses was influenced-except in areas with dysplasia or carcinoma-by the duration of the disease (< 15 or > 16 years), but not by the age or the gender of the patients. Since the frequency of atypical mitoses in "noncolitic" controls with chronic inflammation was low, it is evident that factors other than chronic inflammation may be involved in the induction of atypical mitoses in colitics. Acquired nuclear aberrations detected during the mitotic phase, but not at interphase do occur in colorectal epithelial cells from long-standing UC patients, not only in areas with dysplasia or carcinoma but also in areas without those neoplastic changes.

Villous and serrated adenomatous growth bordering carcinomas in inflammatory bowel disease.

The histologic phenotype of the dysplastic lesion juxtaposing colorectal carcinomas was assessed in 100 consecutive colectomy specimens: in 50 patients with inflammatory bowel disease (IBD) and in 50 controls (non-IBD patients). Adenomatous growths (AG) were regarded both Dysplasia Associated Lesion or Mass (DALM) and sporadic adenomas. AGs juxtaposing carcinomas were found in 76% (n = 38) of the IBD cases: 52.3% (20 out of 38) were villous, 28.9% (11 out of 38) serrated, 5.3% (2 out of 38) tubular and the remaining 13.2% (5 out of 38) were mixed AGs. Juxtaposing AGs (sporadic adenomas) were also found in 58% (n = 29) of the control cases: 51.7% (15 out of 29) were villous, 6.9% (2 out of 29) tubular, 3.4% (1 out of 9) serrated and the remaining 37.9% (11 out of 29) were mixed. The majority or 81.2% (31 out of 38) of the dysplastic lesions juxtaposing IBD carcinomas were villous or serrated AGs, but only 55.1% (16 out of 29) in control cases. Serrated AGs in particular accounted for nearly 29% of the non-invasive dysplastic lesions abutting IBD carcinomas but only for 3% in control specimens. It would appear that villous and serrated AGs are the most common non-invasive neoplastic lesions from which IBD carcinomas originate.

Colorectal carcinoma in ulcerative colitis is decreasing in Scandinavian countries.

A total of 31 cases with Ulcerative Colitis (UC) and colorectal carcinoma were retrieved from the files of the Karolinska Hospital, Stockholm between 1951 and 1998. Sections from 16 colectomy specimens (operable cases) and 15 biopsies obtained at laparotomy (inoperable cases), were available for the study. Of the 31 patients reported here, 22 (71%) were 49 years of age or younger at the time of surgery for carcinoma. In comparison only 47 (5.5 %) of the 855 colorectal carcinomas without UC reported in the Stockholm area in 1990 were 49years of age oryounger. When this hospital was a referral Center (1951 through 1969) 18 cases of carcinoma in UC were operated between 1951 and 1960 (1.8 patients/year), but only 4 between 1961 and 1969 (0.44 patients/year). During the surveillance period of 29 years (1970 to March 1998) only 9 patients (0.31 cases/year) were found to have carcinoma complicating UC. Notably, 8 of the 9 patients were operated on between 1970 and December 1989 (0.42 patients/year), but only one case between January 1990 and March 1998 (0.11 patients/year). The data presented indicate that the frequency of carcinoma cases in pancolitics has decreased at this hospital, not only during the referral period, from 1.8 patients/year during the 50's to 0.40 patients/year during the 60's, but also during the surveillance period (from 0.44 patients/year/during the 70's and 80's to 0.11 patients/year between 1990 and March 1998). This, despite the incidence of UC in the Stockholm County remained stable for the past 40 years (4.2 to 5 patients/10(5) inhabitants) and that the population in the Stockholm County has steady increased since 1950. A review of the present literature indicated that the ris for colorectal carcinoma in pancolitics is presently decreasing, not only in Sweden but also in other Scandinavian countries.

[Certain immune-genes may affect Crohn disease. Advances in diagnosis, pathogenesis and treatment]. / Vissa immungener kan påverka Crohns sjukdom. Nyheter inom diagnostik, patogenes och behandling.

Despite extensive research, the cause of Crohn's disease remains unknown. No specific infectious agent has been identified, though interest has been focused on the possible involvement of mycobacteria, and recently on child hood measles as a possible aetiological factor. Both hereditary and environmental factors seem to contribute to development of the disease. The clinical picture may be dependent upon individual HLA subtypes, as they appear to differ from each other regarding the secretion of inflammatory cytokines. Non-invasive scintigraphy and computerised tomography are used to determine the extent of disease, and to localise such complications as abscesses and fistulas. Endoscopic ultrasonography and magnetic resonance imaging have proved particularly valuable in diagnosing rectal and rectovaginal fistulas. New 5-ASA (5-aminosalicylic acid) preparations, steroids with fewer systemic side effects, and azathioprine-induced immunosuppression constitute the cornerstones of medical treatment, further developments in pharmacological immunoregulation being a future treatment possibility.

Protection of the gastroduodenal mucosa by prostaglandins.

Like other nucleated cell populations in the body, the cells of the gastroduodenal mucosa are capable to metabolise arachidonic acid into prostaglandins, with prostaglandin E2 as the probable major metabolite. The production increases on demand and can be followed in the gastric lumen, where the output of prostaglandin E2 increases two to fourfold after exposure of the mucosa to hydrochloric acid. Exogenous prostaglandins, in particular of the E series, stimulate several identified mucosal defense factors in the upper gastrointestinal tract. Prostaglandins of the E series stimulate the transport of bicarbonate and the production and release of mucus glycoproteins from the gastroduodenal mucosa. They have trophic effects on gastrointestinal epithelia by increasing the survival time of mucosal cells and have cytoprotective properties. In addition, E2 prostaglandins suppress the gastric acid secretion and accelerate peptic ulcer healing. Non steroidal antiinflammatory drugs, which block the biosynthesis of prostaglandins, suppress the bicarbonate secretion, the production of mucus glycoproteins and cytoprotective properties. They interfere with the inhibitory feedback regulation of the gastric acid secretion and are ulcerogenic in experimental and clinical situations. These actions of PG biosynthesis blockers provide indirect information on the importance of local prostaglandin formation for maintenance of gastrointestinal mucosal integrity. It is hypothesised that biosynthesis of prostaglandins in the gastroduodenal mucosa is of importance and may be a key event in triggering the different components of the mucosal defense.

Fatigue in out-patients with inflammatory bowel disease is common and multifactorial.

BACKGROUND: Patients with inflammatory bowel disease (IBD) often complain of fatigue. AIM: To investigate the prevalence and characteristics of fatigue among IBD out-patients in Scandinavia and to provide normative values for fatigue in IBD patients. METHODS: A cross-sectional study was conducted on 425 IBD patients from six out-patient centres in Denmark, Norway and Sweden. Fatigue was measured using the Multidimensional Fatigue Inventory. The patients were also screened for anaemia and iron deficiency. Each centre included approximately 5% of their IBD cohort. The patients were enrolled consecutively from the out-patient clinics, regardless of disease activity and whether the visit was scheduled. The fatigue analysis was stratified for age and gender. RESULTS: Using the 95th percentile of the score of the general population as a cut-off, approximately 44% of the patients were fatigued. When comparing the IBD patients with disease activity to the IBD patients in remission, all dimensions of fatigue were statistically significant (P < 0.05). Being anaemic or iron deficient was not associated with increased fatigue. Being a male patient with ulcerative colitis treated with corticosteroids was a strong determinant for increased fatigue. The normative ranges for IBD fatigue were calculated. CONCLUSIONS: Fatigue in IBD is common regardless of anaemia or iron deficiency. Fatigue in IBD is most marked for patients < 60 years of age. Stratifying for gender and age is necessary when analysing fatigue, as fatigue is expressed differently between groups.

Clinical trial: the safety and short-term efficacy of recombinant cholera toxin B subunit in the treatment of active Crohn's disease.

BACKGROUND: The cholera toxin B subunit ameliorates experimentally induced colitis in mice. In humans, cholera toxin B subunit has never been tested in the treatment of Crohn's disease (CD). AIM: To evaluate the safety and efficacy of treatment with recombinant cholera toxin B subunit of patients with CD. METHODS: An open-label, multicentre, nonrandomized trial including 15 patients with mild/moderate CD. Patients received an oral solution of 5 mg recombinant cholera toxin B subunit three times weekly for 2 weeks. Reduction in CD Activity Index (CDAI) with >100 between baseline and days 15, 29, 42 and 70 defined clinical response. Patients with CDAI score < or = 150 were defined as being in remission. RESULTS: A significant decrease in CDAI score was observed. Response rates were 40% in the full analysis set and 42% in the per protocol analysis. Two patients receiving adjuvant treatment after day 29 were excluded, after which 40% were in remission at 4 weeks and 30% at 8 weeks post-treatment. Mild side effects (arthralgia, headache and pruritus) were seen in 33% of patients. CONCLUSIONS: Treatment with recombinant cholera toxin B subunit was safe. Approximately 40% of patients with active CD responded to treatment. Randomized studies are needed to establish the clinical efficacy of recombinant cholera toxin B subunit.

Combined oral and enema treatment with Pentasa (mesalazine) is superior to oral therapy alone in patients with extensive mild/moderate active ulcerative colitis: a randomised, double blind, placebo controlled study.

BACKGROUND AND AIMS: Oral aminosalicylates are well established in the treatment of active mild/moderate ulcerative colitis (UC) when the disease is extensive (that is, beyond the splenic flexure). The majority of clinical symptoms relate to disease activity in the distal part of the colon and therefore this study was designed to investigate if adding a mesalazine enema to oral mesalazine has additional benefit for patients with extensive mild/moderate active UC. METHODS: A randomised double blind study was performed in 127 ambulatory patients. All received 4 g/day (twice daily dosing) oral mesalazine for eight weeks. During the initial four weeks, they additionally received an enema at bedtime containing 1 g of mesalazine or placebo. Disease activity was assessed using the ulcerative colitis disease activity index, with clinical and endoscopic signs at four and eight weeks. RESULTS: Remission was obtained in 44% (95% confidence interval (CI) 31%, 58%) of the mesalazine enema group (Me) and in 34% (95% CI 21%, 49%) of the placebo enema group (Pl) at four weeks (p = 0.31) and in 64% (95% CI 50%, 76%) of the Me group versus 43% (95% CI 28%, 58%) of the Pl group at eight weeks (p = 0.03). Improvement was obtained in 89% (95% CI 78%, 96%) of the Me group versus 62% (95% CI 46%, 75%) of the Pl group at four weeks (p = 0.0008) and in 86% (95% CI 75%, 94%) of the Me group versus 68% (95% CI 53%, 81%) of the Pl group at eight weeks (p = 0.026). CONCLUSION: In patients with extensive mild/moderate active UC, the combination therapy is superior to oral therapy. It is safe, well accepted, and may be regarded as firstline treatment.

Oral PGE2 inhibits gastric acid secretion in man.

The effect of oral prostaglandin E2 (PGE2) on gastric acid secretion was examined in healthy subjects. The gastric secretion was stimulated by a modified shamfeeding procedure. Each subject underwent one control test and three tests with intragastrically administered graded doses of PGE2: 0.5, 1.0 and 2.0 mg. Oral PGE2 significantly suppressed the peak and total acid response to vagal stimulation. The total acid output in controls was 27.5 +/- 3.2 mmol/90 min and 20.8 +/- 2.8, 15.8 +/- 2.2 (p less than 0.01) and 15.9 +/- 3.8 (p less than 0.005) mmol/90 min in test series with 0.5, 1.0 and 2.0 mg PGE2 respectively. The two higher doses were equally inhibitory to an average 40%. Gastric outputs of sodium and potassium in response to modified shamfeeding were reduced by PGE2. In controls there was a significant release of plasma-gastrin in response to shamfeeding. Plasma-gastrin was apparently suppressed after the two lower doses of PGE2 but 2.0 mg PGE2 gave an elevation similar to controls. Thus the study demonstrates that oral natural PGE2 suppresses the gastric acid secretion in man. The absence of such an effect in prior studies has been one of the objections against an acid regulatory action of endogenously formed prostaglandins. The present results do not support this argument.