New-onset ulcerative colitis in pregnancy associated to toxic megacolon and sudden fetal decompensation: Case report and literature review.

Ulcerative colitis (UC) is a chronic inflammatory disease rarely arising during gestation. Because the available information is based on case reports or small retrospective studies, diagnosis may be difficult and treatment is still controversial. A case of toxic megacolon developing in late pregnancy associated to a sudden fetal decompensation is described. Diagnostic and clinical topics of acute UC onset in pregnancy are debated.A primipara, 34 years old, 33/0 weeks of gestation, was admitted with a diagnosis of preterm labor, associated to acute bloody diarrhea (up to 10 daily motions) and cramping abdominal pain. A diagnosis of new-onset early-stage UC was made by sigmoidoscopy. An intensive care regimen including hydrocortisone, antibiotics and parenteral nutrition was immediately started. Magnetic resonance imaging of maternal abdomen, fostered by the worsening patient conditions, evidenced dilatation of the entire colon and a severely hampered of fetal muscular tone.Toxic megacolon complicated by superimposed Clostridium difficile infection was associated to a sudden fetal decompensation diagnosed by chance during maternal abdominal magnetic resonance imaging. An emergency cesarean section was mandatory. According to a senior surgeon's decision, total colectomy was not immediately performed following cesarean section with reference to the absence of colonic perforation. We obtained a good short-term maternal outcome and an uncomplicated neonatal course. Counseling of those patients must be focused on timely and multidisciplinary intervention in order to improve the course of maternal disease and to prevent fetal distress.

Early hydrogen excretion peaks during breath tests. Small intestinal bacterial overgrowth or accelerated transit?

BACKGROUND: Small intestinal bacterial overgrowth (SIBO) has been reported with varying prevalence, depending upon the criteria used for diagnosis. Lactulose and glucose breath tests are the most used in clinical settings. Early rises of hydrogen excretion during a lactose breath test suggest SIBO, but the finding could result from accelerated mouth-to-caecum transit time. AIMS: Defining the prevalence of early hydrogen peaks during lactose breath tests and assessing the proportion of patients affected by SIBO. METHODS: An early (≤ 60') hydrogen excretion peak was observed in 120/663 patients with positive lactose hydrogen breath test. Eighty-one of them underwent a 50 g-9sample-glucose hydrogen breath test to diagnose SIBO. RESULTS: The glucose breath test proved positive in 11/81 (13.6%) patients. The positivity rate was 18.2% (2/11) in those with the first peak detected at 30' and 12.8% (9/70) in those with the peak occurring at 60'. CONCLUSIONS: Early hydrogen excretion peaks are rarely associated with SIBO. The low positive predictive value indicates that the finding does not help identifying patients at high risk for this condition. Indirectly, the present data support the opinion that the prevalence of SIBO diagnosed by standard lactulose breath tests is much lower than reported, and the reliability of the test is low.

Factors affecting vitamin D deficiency in active inflammatory bowel diseases.

BACKGROUND: Hypovitaminosis D is prevalent in inflammatory bowel disease (IBD) and may be associated with disease activity. AIM: This study evaluated vitamin D (VitD) status in an Italian cohort of IBD patients, not taking VitD supplementation. We investigated risk factors for VitD deficiency and its correlation with disease activity. METHODS: VitD levels were measured in 300 consecutive outpatients (42% with Crohn's Disease (CD) and 58% with ulcerative colitis (UC), 56% male) from a tertiary referral center. Data from the IBD cohort were compared with those of 234 healthy controls, matched by sex, age, and the month in which VitD levels were measured. RESULTS: The mean VitD level in IBD patients was significantly lower than in controls (18.9 ng/ml vs. 25 ng/ml, p < 0.001) when accounting for gender, age, and season. VitD deficiency was present in 62% of IBD patients. Risk factors for deficiency were: age <40 and ≥60 years, winter, previous surgery, C-reactive protein (CRP) ≥0.5 mg/dl, and erythrocyte sedimentation rate ≥20 mm/h. In multivariate analysis, VitD levels were negatively influenced by disease location and CRP in UC. CONCLUSIONS: Although VitD deficiency was more prevalent than expected in healthy controls living in a Mediterranean country not at high risk of hypovitaminosis D, it was more common and severe in IBD patients. This study also found an association between VitD status and disease activity.

Inadequate sunlight exposure in patients with inflammatory bowel disease.

OBJECTIVE: Inadequate sun exposure impairs vitamin D activity and favors low bone density, especially in patients at increased risk for osteoporosis, such as those affected by inflammatory bowel disease (IBD). In this study, sun exposure was investigated in a large series of patients with IBD in a Mediterranean country, Italy, where this risk is considered less likely to occur than in higher latitudes. METHODS: This is a case-control study of 292 patients with IBD [132 with Crohn's disease (CD) and 160 with ulcerative colitis (UC)], 80 diseased and 540 healthy controls, conducted via a validated questionnaire to quantify sunlight exposure. Data were also compared with controls matched by age and gender. RESULTS: In total 78 of the 292 patients with IBD had low, 169 had moderate and 45 had high exposure to sunlight, significantly differing from controls (P < 0.001). The 132 patients with CD were more likely to have abnormal levels of sunlight exposure (49 low, 72 moderate and 11 high) than those with UC (29 low, 97 moderate and 34 high) (P < 0.001). The controls were significantly more exposed to sunlight than both men and women with IBD (P < 0.001 and 0.004, respectively). CONCLUSIONS: IBD patients are significantly less exposed to sunlight than matched controls in Italy, often to an extent that may impair vitamin D activation. Increasing responsible sunlight exposure, thus promoting adequate vitamin D concentrations, may prove beneficial in IBD, in geographical areas in which this risk factor is not generally taken into consideration.

Diagnosis of lactose intolerance and the "nocebo" effect: the role of negative expectations.

BACKGROUND: Diagnosis of lactose intolerance is based on a "positive" H(2) breath test associated with abdominal symptoms. The present study established to what extent the occurrence of symptoms during a "negative" H(2) breath test may result from a "nocebo effect" instead of lack of sensitivity of the procedure. METHODS: Between 2005 and 2007, 636 outpatients performed a standard 4-h 25g lactose tolerance test. The test was positive in 254, negative in 325, and 57 patients were H(2) "non-producers". Twenty-seven patients reporting symptoms despite a negative H(2) breath test underwent a "sham" breath test following ingestion of 1g of glucose. Fifty-four patients presenting with documented lactose intolerance were used as controls. RESULTS: Twelve out of 27 patients (44.4%), and unexpectedly also 14 (25.9%) controls presented abdominal symptoms during the sham test. The difference between the two groups was not significant (P<0.15) OR 2.28; C.I. 0.77-6.78. CONCLUSION: In most instances, symptoms reported by patients during a negative lactose H(2)BT cannot be attributed to a false-negative test. Instead, a non-organic component, resulting from negative expectations ("nocebo effect") is likely implicated. Moreover, also in patients diagnosed as lactose intolerant, the need for restricting the primary source of dietary calcium should be critically reconsidered.