Therapeutic action of ketogenic enteral nutrition in obese and overweight patients: a retrospective interventional study.

Ketogenic enteral nutrition (KEN™) is a modification of Blackburn's protein-sparing modified fast, using a hypocaloric, ketogenic liquid diet. The study is about ketogenic enteral nutrition (KEN) in overweight and obese patients receiving a short treatment of the nutritional solution as a 24-h infusion. It is a retrospective analysis that examines safety, weight loss and body composition changes after three sequential 10-day cycles of KEN therapy. Anthropometric and bio-impedance data from 629 patients who underwent KEN were collected before and after completing a 10-day cycle. The study focuses on the change in outcomes from the first cycle to the second cycle and from the first cycle to the third cycle. The following outcomes were explored: weight, waist circumference, BMI, fat mass, lean mass, dry lean mass, phase angle, wellness marker, water mass as a percentage of total body weight. Statistical tests were used to test for significant differences between paired cycle 1 and cycle 2 outcomes and also between paired cycle 1 and cycle 3 outcomes. Where changes in outcomes between timepoints were found to be normally distributed, the paired t test was used, whereas where the changes in outcomes had skewed distributions, the Wilcoxon signed-rank test was used. Linear regression was used to examine associations between changes in both phase angle and BMR/weight with percentage weight change. Initially the simple relationship between variables was examined, and subsequently multiple linear regression was used to re-examine the relationships after adjusting for two pre-specified confounding variables. The results suggested significant changes for all analyzed parameters. There were significant decreases in weight, waist circumference, BMI, fat mass, lean mass, dry lean mass and phase angle. Quantitative changes in lean mass and dry lean mass were minor changes with respect to changes in fat mass. When considering the change from cycle 1 to cycle 3, there was a significant association between change in BMR/weight and change in weight, which remained significant after adjusting for changes in phase angle, fat mass and waist circumference. A one-unit increase in BMR/weight was associated with a 2.4% reduction in weight. There was no significant association between change in phase angle from cycle 1 to cycle 3 in the simple analysis. However, after adjustments greater change in phase angle was associated with a greater weight loss. KEN treatment was overall well tolerated. Results might be restricted to a British cohort only and should not be universally applied. Long-term results need to be explored in controlled studies. KEN treatment is safe, well tolerated and results in rapid fat loss without detriment to dry lean mass.

Citrulline in health and disease. Review on human studies.

The amino acid L-citrulline (CIT) is safely used from the neonatal period onwards in those with urea cycle defects and carbamyl phosphate synthetase or ornithine transcarbamylase deficiencies, but several lines of enquiry indicate that it might have a much wider therapeutic role. When protein intake is low and there is a catabolic state, endogenous arginine (ARG) synthesis cannot fully be met and its supplementation can prove challenging, particularly in patients with critical and multisystem illness. Supplementary CIT could constitute a safer but still focused means of delivering ARG to endothelial and immune cells as CIT is efficiently recycled into these cells and as kidneys can convert CIT into ARG. Unlike ARG, CIT is efficiently transported into enterocytes and bypasses liver uptake. It also appears to prevent excessive and uncontrolled nitric oxide (NO) production. Animal studies and early human data indicate positive effects of CIT on protein synthesis, in which its contribution is thought mediated through the mTOR pathway. It appears that CIT is an anabolic pharmaconutrient that can be safely administered even in critically ill patients. Promising results in cardiovascular diseases and in disease-related malnutrition can now be considered sufficient to justify formal clinical exploration in these areas and in sarcopenia in general.

Abnormal thymic stromal lymphopoietin expression in the duodenal mucosa of patients with coeliac disease.

OBJECTIVE: The short isoform of thymic stromal lymphopoietin (TSLP), a cytokine constitutively expressed by epithelial cells, is crucial in preserving immune tolerance in the gut. TSLP deficiency has been implicated in sustaining intestinal damage in Crohn's disease. We explored mucosal TSLP expression and function in refractory and uncomplicated coeliac disease (CD), a T-cell-mediated enteropathy induced by gluten in genetically susceptible individuals. DESIGN: TSLP isoforms-long and short-and receptors-TSLPR and interleukin (IL)-7Rα-were assessed by immunofluorescence, immunoblotting and qRT-PCR in the duodenum of untreated, treated, potential and refractory patients with CD. The ability of the serine protease furin or CD biopsy supernatants to cleave TSLP was evaluated by immunoblotting. The production of interferon (IFN)-γ and IL-8 by untreated CD biopsies cultured ex vivo with TSLP isoforms was also assessed. RESULTS: Mucosal TSLP, but not TSLPR and IL-7Rα, was reduced in untreated CD and refractory CD in comparison to treated CD, potential CD and controls. Transcripts of both TSLP isoforms were decreased in active CD mucosa. Furin, which was overexpressed in active CD biopsies, was able to cleave TSLP in vitro. Accordingly, refractory and untreated CD supernatants showed higher TSLP-degrading capacity in comparison to treated CD and control supernatants. In our ex vivo model, both TSLP isoforms significantly downregulated IFN-γ and IL-8 production by untreated CD biopsies. CONCLUSIONS: Reduced mucosal TSLP expression may contribute to intestinal damage in refractory and untreated CD. Further studies are needed to verify whether restoring TSLP might be therapeutically useful especially in refractory patients with CD.

Diverticular disease and colon cancer: a real association between the two diseases?

BACKGROUND: During the last century the incidence of diverticular disease (DD), as well as the prevalence of colonic adenocarcinoma (ADK), recorded a marked increase in Western populations. In literature has been reported a higher incidence of sigmoid colon carcinoma associated with diverticular disease suggesting a possible sharing of risk factors and pathogens between these two pathologies. MATERIALS AND METHODS: We prospectively examined 165 patients undergoing left colonic resection from May 2010 to December 2012 at the operating unit of General Surgery and Organ Transplantation of University Hospital of Parma , dividing them into three groups: affected by left colon cancer (120 cases), affected by complicated diverticular disease (29 cases) and affected by both diseases (16 cases). In this last group the indication for surgery has always been oncology based. All cases have been subjected to a 6 months minimum follow-up. RESULTS: The average age of patients operated for colonic ADK was 69.91 years. The average age of patients operated for ADK and concomitant DD, compared to that of patients treated for single DD, was statistically higher (73.8 ± 6.89 VS 60.9 ± 13.5, p = 0.004). It was found instead a higher diverticular inflammation degree in patients treated for DD compared with those treated for ADK associated with DD. No patient with ADK associated with DD showed hepatic metastases, whereas among patients with just ADK, peritoneal carcinomatosis was recorded in 2.6% of cases and liver metastases, always synchronous, in 11 .5%. The lymph nodes positivity instead, has presented a prevalence of 33.5% in patients with ADK and of 7% in patients with associated DD. CONCLUSION: In our study and its comparison with literature we found in synthesis multiple clinical evidences of a possible association between the two diseases. The role played by DD would lead to an early diagnosis of colonic ADK. It remains to be analyzed however the possible etiopathogenetic correlation over time between the two clinical entities, which actually still remains maybe under random association.

FOXE1 and SYNE1 genes hypermethylation panel as promising biomarker in colitis-associated colorectal neoplasia.

BACKGROUND: Colitis-associated colorectal cancer affects individuals with inflammatory bowel disease (IBD) more often and earlier than cancer in the general population. Colonoscopy provides the surveillance gold standard. Changes to the surveillance intervals depending on endoscopic activity have been made, given data demonstrating that this is an important predictor of future dysplasia or cancer, but adjuvant, noninvasive clinical tools are still warranted to improve surveillance outcomes and to assist in management and interpretation of dysplasia. Methylation markers may be able to do this. METHODS: SYNE1, FOXE1, NDRG4, and PHACTR3 genes were screened using methylation-specific PCR that permit the methylation status of the genes to be determined directly on biopsies. Ninety-three patients with long-standing IBD undergoing a cancer surveillance program, and 30 healthy controls were studied. These included colorectal adenocarcinomas on a background of IBD of various stages (n = 25), IBD-associated dysplastic lesions (n = 29), adenomas arising on a background of ulcerative colitis (n = 8), samples from patients with no evidence of dysplasia or cancer but long-standing IBD (n = 31), and symptomatic patients found to have normal colonoscopy (controls) (n = 30). RESULTS: Gene promotor hypermethylation of SYNE1 and FOXE1 genes varied significantly between the groups and was increasingly likely with increased disease severity. Neither occurred in controls, whereas promotor hypermethylation was detected in biopsies of 60% of patients with colitis-associated colorectal cancer for FOXE1 and 80% for SYNE1. Promotor hypermethylation of either gene was highly significantly different between the groups overall. CONCLUSIONS: FOXE1 and SYNE1 hypermethylation markers demonstrated significantly increased expression in neoplastic tissue. Promoter methylation analysis of these genes might be a useful marker of neoplasia in long-standing IBD.

Diagnosing small bowel malabsorption: a review.

Malabsorption encompasses dysfunctions occurring during the digestion and absorption of nutrients. A small proportion of patients presents with chronic diarrhoea. A clinical history supportive of malabsorption may guide investigations toward either the small bowel or pancreas. Serological testing for coeliac disease will determine most cases without invasive investigations. In the clinical context of persisting weight loss and malnutrition, small bowel enteropathy may be investigated with small intestinal biopsies. Small bowel absorptive capacity and permeability might be measured by oral sugar-mix ingestion. Further, approaches to the investigation of malabsorption might also involve the detection in faeces of a substance that has not been absorbed. A variation of the latter is the use of breath testing which relies on the breakdown of the malabsorbed test substance by colonic flora. Measurement of protein absorption is difficult and unreliable; it is, therefore, rarely advocated in clinical settings. No single biological marker confirming a diagnosis of small bowel malabsorption or small bowel integrity is presently available in clinical practice. Plasma citrulline concentration, an amino acid not incorporated into endogenous or exogenous proteins, has been extensively used in research studies and supportive results are establishing its concentration as a reliable quantitative biomarker of enterocyte absorptive capacity.

Sensitivity and specificity of magnetic resonance enterography in the clinical management of fistulizing Crohn's disease.

BACKGROUND: High diagnostic accuracy is reported for magnetic resonance enterography (MRE) in Crohn's disease (CD), but few studies have evaluated its role in abdominal fistulae. The primary aim of this study was to assess the reliability of MRE in the identification of internal fistulae in CD. METHODS: One hundred and eighty-six patients with moderate CD (CD Activity Index : 250-400) were prospectively selected from the inflammatory bowel disease clinic of Parma University Hospital. Eligible patients had already undergone nutritional screening, pancolonoscopy, and computed tomography enterography (CTE) in the month before enrollment. MRE was performed according to the study protocol. Additional fluoroscopic contrast-enhanced studies or surgical evaluation were used for discordance between CTE and MRE results. A consensus committee resolved equivocal findings. Surgical findings and/or fluoroscopic contrast-enhanced studies together with the clinical data were considered the composite "reference standard" to which the results of MRE were compared. RESULTS: MRE identified 22 internal fistulae in 21 patients (11%), of whom 4 (19%) also had perianal fistulae and found 7 abscesses (33%). Forty-one (22%) additional patients with perianal fistulae were identified. Thirteen patients (57%) with internal fistulae required enteral nutrition support. No statistically significant differences were found between MRE and CTE in fistula detection. There was also no significant difference between MRE and the composite diagnosis in those who underwent surgery (n = 8) and/or contrast-enhanced studies (n = 7). CONCLUSIONS: CTE and MRE accurately detect internal fistulae in CD. MRE is preferable because it avoids radiation. Reliable identification of internal fistulae by MRE should permit earlier and improved treatment.

Altered expression of type-1 and type-2 cannabinoid receptors in celiac disease.

Anandamide (AEA) is the prominent member of the endocannabinoid family and its biological action is mediated through the binding to both type-1 (CB1) and type-2 (CB2) cannabinoid receptors (CBR). The presence of AEA and CBR in the gastrointestinal tract highlighted their pathophysiological role in several gut diseases, including celiac disease. Here, we aimed to investigate the expression of CBR at transcriptional and translational levels in the duodenal mucosa of untreated celiac patients, celiac patients on a gluten-free diet for at least 12 months and control subjects. Also biopsies from treated celiac patients cultured ex vivo with peptic-tryptic digest of gliadin were investigated. Our data show higher levels of both CB1 and CB2 receptors during active disease and normal CBR levels in treated celiac patients. In conclusion, we demonstrate an up-regulation of CB1 and CB2 mRNA and protein expression, that points to the therapeutic potential of targeting CBR in patients with celiac disease.

Impact of lymph node ratio in the colorectal cancer staging system.

AIM: Some researchers have proposed the Lymph Node Ratio (LNR) as a prognostic index for post-surgical colorectal cancer follow up. MATERIAL AND METHOD: Two hundred patients with colorectal cancer (ratio F/M of 2:1) were studied. Patients were divided in subgroups according to N-stage and LNR score, subgroups of LNR were made on quartiles. For each subgroup 5 year survival rate was calculated and comparison between groups was carried out. RESULTS: There were 104 patients on N0, 38 on N1 and 58 on N2 stage. Survival rate at 5 years was 61.30% for the NO subgroup, 18.70% for the N1 subgroup, and 12.31% for the N2 subgroup (Fig. 1). The most significant p value, was reported between N0 and N1 as well as between N0 and N2 subgroup (p=0.001). Nodes positive were 44 a LNR ranging from 1% to 25% (1% < LNR < 25%); 24 patients from 26% to 50% (26% < LNR < 50%). In 6 patients LNR was ranging from 51% to 75% (51% < LNR 75%) and in 8 patients from 76% to 100% (76% < LNR 100%); overall survival rate in different quartiles was respectively 27.12%, 9.38%, 16.67% and 1.56%. CONCLUSION: LNR is a reliable prognostic index in post surgical colorectal cancer staging.

Abnormal anandamide metabolism in celiac disease.

The endocannabinoid system has been extensively investigated in experimental colitis and inflammatory bowel disease, but not in celiac disease, where only a single study showed increased levels of the major endocannabinoid anandamide in the atrophic mucosa. On this basis, we aimed to investigate anandamide metabolism in celiac disease by analyzing transcript levels (through quantitative real-time reverse transcriptase-polymerase chain reaction), protein concentration (through immunoblotting) and activity (through radioassays) of enzymes responsible for anandamide synthesis (N-acylphosphatidyl-ethanolamine specific phospholipase D, NAPE-PLD) and degradation (fatty acid amide hydrolase, FAAH) in the duodenal mucosa of untreated celiac patients, celiac patients on a gluten-free diet for at least 12 months and control subjects. Also, treated celiac biopsies cultured ex vivo with peptic-tryptic digest of gliadin were investigated. Our in vivo experiments showed that mucosal NAPE-PLD expression and activity are higher in untreated celiac patients than treated celiac patients and controls, with no significant difference between the latter two groups. In keeping with the in vivo data, the ex vivo activity of NAPE-PLD was significantly enhanced by incubation of peptic-tryptic digest of gliadin with treated celiac biopsies. On the contrary, in vivo mucosal FAAH expression and activity did not change in the three groups of patients, and accordingly, mucosal FAAH activity was not influenced by treatment with peptic-tryptic digest of gliadin. In conclusion, our findings provide a possible pathophysiological explanation for the increased anandamide concentration previously shown in active celiac mucosa.

Is CD10 a reliable marker of invasive colorectal cancer?

AIM: Previous studies reported that CD10 positive Colorectal Cancer Cells (CRC) characterized by deeply invasive neoplasia. MATERIALS AND METHODS: We have examined 50 pts surgically treated for colorectal cancer on at least 5 years follow up. TNM, grading score and survival have been compared to CD10 expression. RESULTS: Thirty-four out of fifty cases have been analyzed (18 males and 16 female) of whom nineteen were CD10 positive and fifteen were CD10 negative. The remaining 16 cases were droping out. No difference in survival rate between CD10 positive and negative in N0, N1, N2. No difference on survival rate and grading 1, 2, 3. We have then analyzed CD10 positive and CD10 negative cases, according to neoplasia grading, in patients with positive linphonodes N1 and N2. We showed a statistical difference between the CD10 positive/N2 (grading 1.66 +/- 0.5) and the CD10 negative/N2 (grading 3) (p < 0.005). CONCLUSIONS: We can hypothesize that CD10 positive neoplasia display a more invasive behaviour, independently from the N score and the G score, compared to CD10 negative neoplasia.

Laparoscopic proctocolectomy: analysis of long term complications. Case report.

Surgery can be a curative treatment for ulcerative colitis. The correct surgical procedure is a total proctocolectomy and ileo anal J pouch anastomosis (IPAA). This procedure is feasible also in laparoscopic approach after a correct learning curve. Pouchitis, pouch complications, intestinal occlusion, infertility are the most common long term complications. We present a case of a 37-year-old man treated with laparoscopic proctocolectomy and followed at 18 months.

Evaluation of CD10 positivity in colorectal polyps in neoplastic transformation.

BACKGROUND: CD10 is a metalloprotein that is potentially associated with greater tumour growth. MATERIALS AND METHOD: We have correlated CD10 positive in carcinomatous polyps with tumour size, grade, patient age and sex, postoperative TNM staging and Asler-Coller classification. We have matched these cases with a control group that showed presence of polypoid adenomatous tissue with mild to moderate dysplasia. RESULTS: We have divided these in a group of 39 cases, characterised by the presence of carcinoma arising in adenomatous polyps, and a control group of 16 cases, characterised by the presence of colorectal polyps with mild to moderate dysplasia. In the first group, we have discarded three cases for incomplete data. In the remaining 36 cases we have identified 28 patients testing positive for CD10 with positivity values and 8 cases negative for CD10. In CD10 positive cases, we have confirmed the presence of increased incidence of lymph node involvement compared to CD10 negative cases, with high specificity and high predictive value and a higher incidence of cases attributable to group C (Asler-Coller) and grading 3. CONCLUSIONS: CD10 positivity should be assessed in terms of increased progression.

Analysis of risk factors for complications in 262 cases of laparoscopic colectomy.

BACKGROUND: The aim of the study was to critically review the experience of our unit to identify all the risk factors that can predict the intra-operative and post-operative complications, early and late, that are related to the procedure. MATERIALS AND METHODS: We retrospectively reviewed 293 patients who had undergone laparoscopic colectomy at the General Surgery and Organ Transplantation Unit of the University Hospital of Parma between January 2001 and September 2009. Preoperative tumour staging was performed for all patients by pancolonoscopic examination, performed preferably by the operating surgeon, thoracic-abdominal-pelvic CT, and, for rectal neoplasia, with further input from endoscopic ultrasound and/or pelvic magnetic resonance (MR) imaging. The parameters evaluated for each patient included age, sex, body mass index (BMI), ASA score, preoperative blood tests, associated comorbidities, cancer, others surgical procedures, operative time, laparotomy conversion rate, intra- and post-operative complications, any returns to the operating theatre, length of hospital stay and mortality. RESULTS: A total of 293 laparoscopic colectomy procedures were performed in our unit between January 2001 and September 2009; we analysed 262 of the 293 cases treated, since the data were incomplete and not correctly stored for 31 cases. The overall rate of intra- and post-operative complications was 22.9% (60/262). In 40 cases (40/262, 15.26%), the complications were surgical, and in the other 20 cases (7.63%) they were medical; mortality rate of 0.38% (1/262). CONCLUSIONS: Rectal resection is significantly associated with a greater number of intra- and post-operative complications than the other surgical procedures examined. The laparoscopic approach maintains its benefits even in patients with known preoperative comorbidities and constitutes a feasible procedure even in patients who are obese and/or with ASA status > or = III.

Plasma citrulline as a quantitative biomarker of HIV-associated villous atrophy in a tropical enteropathy population.

BACKGROUND & AIMS: Studies have shown that the circulating citrulline concentration is decreased in patients with proximal small bowel villous atrophy from coeliac disease and more so in patients with extensive damage to the intestinal mucosa, but there have been few data on HIV enteritis and tropical enteropathy (TE). Our primary aim was to correlate serum citrulline with the degree of reduction of the enterocyte mass in HIV-infected patients with TE. METHODS: Postabsorptive fasting serum citrulline was measured in 150 TE pts, 44 of whom had HIV infection, using reverse phase, high performance liquid chromatography. Absorptive capacity and permeability were measured after intrajejunal instillation of 4 sugars (5 g lactulose, 1 g L-rhamnose, 0.5 g D-xylose, 0.2 g 3-O methyl D glucose) with assay by thin-layer chromatography. Morphometric analysis was carried out on jejunal biopsies. RESULTS: In HIV positive patients, the median serum citrulline was significantly lower (median 19, interquartile range (IQR) 17-24 µmol/L) than in HIV negative patients (median 27, IQR 23-33 µmol/L; p < 0.001). There were statistically significant correlations (p < 0.005) between citrulline and: crypt depth; villous height/crypt depth ratio; Shenk-Klipstein score; and xylose absoption, only in the HIV positive. CONCLUSIONS: Serum citrulline concentration appears to be a quantitative biomarker of small bowel mass integrity in HIV positive enteropathy and deserves assessment as a surrogate for monitoring anti-retroviral therapy.

Plasma citrulline concentration: a reliable marker of small bowel absorptive capacity independent of intestinal inflammation.

OBJECTIVES: Postabsorptive plasma citrulline concentration has been proposed as a reliable marker of small bowel absorptive capacity in short bowel patients. The aim of this study was to address the potentially confounding impact of intestinal inflammation. METHODS: Fifty-five patients were selected according to diagnosis, small bowel length, and degree of bowel inflammation. (a) Crohn's disease (CD) with massive small bowel resection leaving 220) (N = 7), (d) CD without resection or active inflammation (normal CRP and CDAI <150) (N = 9), (e) mesenteric infarction (MI) with resection leaving