Absence of skin sensitivity to oxides of aluminium, silicon, titanium or zirconium in patients with Crohn's disease.

BACKGROUND: Some metallic compounds, especially of zirconium, can cause cell mediated granulomatous inflammation of the skin. Pigment granules containing compounds of aluminium, silicon, and titanium have been observed within macrophages in the wall of the small intestine in health and in Crohn's disease. Zirconium compounds can be ingested in toothpaste. AIM: To determine in a pilot study if granulomatous sensitivity can be detected to compounds of these metals or silicon after injection into the skin of patients with Crohn's disease. SUBJECTS: Eight patients with Crohn's disease known to have had granulomata in the intestine and not currently treated with corticosteroids, and two healthy controls. METHOD: Two intradermal injections each of 0.1 ml of a 0.02% suspension of one of the compounds made in the abdominal wall of each subject. The site was marked and full thickness skin biopsy performed six weeks later. RESULT: A foreign body granuloma was observed on histological examination of two biopsy specimens but no evidence of a cell mediated response in any subject. CONCLUSION: No support was found for the hypothesis that Crohn's disease is due to a specific sensitivity to ingested metallic or silicon compounds.

Controlled randomised trial of visual biofeedback versus muscle training without a visual display for intractable constipation.

Training to contract the abdominal muscles effectively and to relax the pelvic floor during defecation straining helps some patients with severe constipation. Hitherto all such training has used a visible or audible signal of sphincter muscle activity as a biofeedback method to assist in relaxation. A randomised controlled trial comparing the outcome of muscular training without any biofeedback device with the same training supplemented by an electromyographic (EMG) record visible to the patient is reported. Significant symptomatic improvement was noted and electromyographic measurements confirmed a decrease in pelvic floor muscle activity during defecation straining after treatment in both groups. The outcome was similar in the two treatment groups. Muscular coordination training using personal instruction and encouragement without a visual display is thus a potentially successful treatment suitable for outpatient use by paramedical personnel.

Review article: practical management of the short bowel.

A shortened small intestine may end at a stoma or be anastomosed to the colon. Patients with a jejunostomy, but not those with a colon, lose large amounts of sodium. The intake and absorption of sodium can be increased by sipping a sodium-glucose solution; stomal loss can be reduced by restricting water or low-sodium drinks. If a stoma is situated less than 100 cm along the jejunum, a constant negative sodium balance may necessitate parenteral saline supplements. Gastric anti-secretory drugs or a somatostatin analogue reduce jejunostomy losses in such patients but do not restore a positive sodium balance. Loperamide or codeine phosphate benefit some patients. Magnesium deficiency can usually be corrected by oral magnesium oxide supplements. An elemental or hydrolysed diet is not beneficial. Patients with a jejunostomy can maintain a normal diet without fat reduction. When the colon is present, unabsorbed carbohydrate is fermented to absorbable short chain fatty acids. Unabsorbed long chain fatty acids and bile salts cause watery diarrhoea and increased colonic oxalate absorption with hyperoxaluria. Such patients benefit from a high carbohydrate, low-fat and low-oxalate diet. Parenteral nutrition is needed only by the few patients unable to maintain health or avoid socially disabling diarrhoea despite these measures.

Clinical management of constipation.

First, it is important to find out whether the patient is complaining of infrequent defaecation, excessive straining at defaecation, abdominal pain or bloating, a general sense of malaise attributed to constipation, soiling, or a combination of more than one symptom. Second, one must decide if there is a definable abnormality as a cause of the symptom(s). Is the colon apparently normal or is its lumen widened (megacolon)? Is the upper gut normal or is there evidence of neuropathy or myopathy? Is the ano-rectum normal or is there evidence of a weak pelvic floor, mucosal prolapse, major rectocele, an internal intussusception or solitary rectal ulcer? Is there any systemic component such as hypothyroidism, hypercalcaemia, neurological or psychiatric disorder or relevant drug therapy? Choice of treatment will depend on this clinical evaluation. The range of treatments available is: Reassurance and stop current treatment: Patients with a bowel obsession may take laxatives or rectal preparations regularly without need. Increase dietary fibre: Most cases of 'simple' constipation respond to increased dietary fibre, possibly with an added supplement of natural bran. Toilet training and altered routine of life: Young people particularly may need to recognise the call to stool and alter their daily routine to permit and encourage regular defaecation. Medicinal bulking agent: Ispaghula, methyl cellulose, concentrated wheat germ or bran, and similar preparations are useful when patients with a normal colon find it difficult to take adequate dietary fibre. These preparations increase the bulk of stool and soften its consistency. They may be useful for those patients with the constipated form of irritable bowel syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)

The short bowel syndrome: what's new and old?

Conditions which resulted in colonic preservation such as strangulated hernia, intestinal volvulus, and mesenteric infarction were once the main reasons for a major intestinal resection leading to the short bowel syndrome. Now Crohn's disease is the most common underlying diagnosis; such patients often have a jejunostomy. A measurement of the residual jejunal length from the duodenojejunal flexure makes possible predictions of patient outcome. Patients with a jejunostomy and less than 100 cm jejunum usually need long-term parenteral support, whereas 50 cm or more of jejunum usually suffices for adequate oral nutrition if the colon is preserved. While patients with and without a colon have problems with nutrient absorption, those with a jejunostomy also have problems of water, sodium and magnesium losses. Stomal losses may exceed oral intake and all such patients ('secretors') need parenteral supplements. Fluid and sodium losses can be reduced by octreotide, omeprazole or H2 blockers but not sufficiently to avoid the need for intravenous supplements. Colonic preservation increases the incidence of calcium oxalate renal stones (20%). Patients with and without a colon have a high prevalence of gallstones (40%). Clinically important intestinal adaptation occurs in those with a colon but not in those with a jejunostomy. Many surgical techniques, including small bowel transplantation, have been suggested to improve absorption, but as the quality of life of most patients with a short bowel is good with current treatments, they are not at present recommended.

Colonic preservation reduces need for parenteral therapy, increases incidence of renal stones, but does not change high prevalence of gall stones in patients with a short bowel.

Forty six patients with less than 200 cm of normal jejunum and no functioning colon were compared with 38 patients with similar jejunal lengths in continuity with a functioning colon. Women predominated (67%), and the most common diagnosis in each group was Crohn's disease (33 of 46 no colon, 16 of 38 with colon). All patients without a colon and less than 85 cm of jejunum and all those with a colon and less than 45 cm jejunum needed long term parenteral nutrition. Six months after the last resection 12 of 17 patients with less than 100 cm jejunum and no colon needed intravenous supplements compared with 7 of 21 with a colon. Between 6 months and 2 years, little change occurred in the nutritional/fluid requirements in either group, though there was weight gain. Of 71 patients assessed clinically at a median of 5 years, none with more than 50 cm of jejunum and a colon needed parenteral supplements. Most (25 of 27) of those without a colon who did not need parenteral supplements required oral electrolyte replacement compared with few (4 of 27) with a colon. None of the patients without a colon developed symptomatic renal stones compared with 9 of 38 (24%) with a colon (p < 0.001). Stone analysis in three patients showed calcium oxalate. Gall stone prevalence was high but equal in the two groups--43% of those without and 44% of those with a colon.

Double blind, controlled trial of 4-aminosalicylic acid and prednisolone enemas in distal ulcerative colitis.

Corticosteroid or 5-aminosalicylic acid enemas are the treatment of choice for distal ulcerative colitis but up to one third of patients may be unresponsive. As an alternative therapy might be advantageous, the efficacy of six weeks' treatment with 2 g 4-aminosalicylic acid (4-ASA) (n = 24) and 20 mg prednisolone enemas (n = 21) were compared in a double blind, randomised trial in patients with acute distal (less than 30 cm from the anus) ulcerative colitis. Baseline demography and clinical severity were similar in both groups. Five of 24 patients receiving 4-ASA and 4 of 21 receiving prednisolone did not complete the trial because of deteriorating symptoms, failure to improve, or side effects. At the time of leaving the trial, 24 hour stool frequency, the presence of blood in the stools, and histological and sigmoidoscopic appearances were similar in both groups. Symptomatic improvement occurred in 17 of 24 patients receiving 4-ASA compared with 11 of 21 receiving prednisolone (chi 2 = 1.62, NS). Complete symptomatic improvement occurred in 9 of 24 patients receiving 4-ASA compared with 5 of 21 receiving prednisolone (chi 2 = 0.98, NS). Histological improvement was seen in 9 of 24 patients on 4-ASA compared with 7 of 21 on prednisolone (chi 2 = 0.08, NS). One patient receiving 4-ASA was considered to have an idiosyncratic reaction to the drug but other side effects were not considered to be drug related. Thus, 4-ASA, previously used in the treatment of tuberculosis (para-aminosalicyclic acid), is as good as prednisolone in the treatment of distal ulcerative colitis and should be considered in patients unresponsive to steroids or in whom steroid treatment is undesirable.

Oral rehydration solutions in short bowel syndrome.

Patients with a reduced length of small intestine ending in a stoma experience loss of water and sodium, even when they take nothing by mouth. After food or drink, the loss from the stoma increases. Secretors are patients who lose more from the stoma than they take in by mouth. Absorbers are those whose output is less than their intake. In both groups, the sodium concentration of the effluent is about 90 mmol/L. The secretors are in constant negative sodium balance of up to 400 mmol/day and can only maintain balance with self-administered parenteral water and sodium. The absorbers may lose 200 mmol of sodium daily and need to take an oral sodium supplement to maintain balance. The optimal oral replacement solution has a concentration of at least 90 mmol/L of sodium. Lower sodium concentrations, or drinking water without sodium, lead to increased sodium losses and negative balance. The role of glucose, glucose polymers, or bicarbonate in promoting sodium absorption in the short bowel is unclear. Potassium losses from a small intestinal stoma are small. A modified glucose electrolyte solution, without potassium or bicarbonate and with a sodium concentration of 90 to 120 mmol/L, is appropriate for patients with an intestinal stomal output of 1 to 2 L daily. Once the output rises above 2 L daily, it is difficult to maintain sodium balance with an oral supplement.

The effects of octreotide, soy polysaccharide, codeine and loperamide on nutrient, fluid and electrolyte absorption in the short-bowel syndrome.

Four agents, which could delay intestinal transit, were tested in six short-bowel patients (jejunal length 30-120 cm) on long-term nutritional/electrolyte replacement therapy. Intestinal transit time of a liquid test meal and nutrient, water and sodium absorption were measured during a control study and with each test agent on separate days. Soy polysaccharide tended to increase transit time, but decreased the absorption of water, sodium and nutrients. Codeine phosphate and loperamide caused inconsistent and clinically unimportant changes. Octreotide, a long-acting analogue of somatostatin, delayed transit and increased water, sodium and calorie absorption from the meal. Octreotide appears to have the potential to reduce the need for electrolyte and nutritional supplements in patients with the short-bowel syndrome.

Successful resolution of severe perianal ulceration with photochemotherapy (PUVA).

We report a case of recurrent perianal ulceration associated with gastrointestinal symptoms, but without evidence of underlying disease, that responded to a course of photochemotherapy (PUVA).

Ulcerative colitis with relative sparing of the rectum. Clinical features, histology, and prognosis.

A series of 12 patients with relative sparing of the rectum in ulcerative colitis is analyzed. Half were recorded as having normal sigmoidoscopic appearance and, in every case, double-contrast barium enema showed an apparently normal rectum but an abnormal colon. Rectal biopsy showed changes compatible with ulcerative colitis in all cases, though in four, changes were slight. Thus, complete histologic sparing of the rectum was not observed. In four of six patients treated by colectomy and ileorectal anastomosis, inflammation of the retained rectum required medical or surgical treatment.

Patients with a high jejunostomy do not need a special diet.

Absorption from a chemically defined liquid feed consisting of small peptides, oligosaccharides, and little fat (half medium-chain triglycerides) was compared with that from a feed of whole protein, polysaccharides, and long-chain triglycerides in 7 patients with less than 150 cm of jejunum ending in a stoma. Comparisons of absorption from three solid food diets varying in their fiber and fat content but containing equal amounts of nitrogen and minerals were also made in 4 of the patients. There were no consistent differences between the two liquid or three solid-food diets in percentage of calorie, nitrogen, or fat absorption. The absolute loss of fat depended on the fat intake, but larger losses did not appear detrimental. A liquid diet consisting of peptides, oligosaccharides, and medium-chain triglycerides is not more beneficial than a polymeric diet in patients with a high jejunostomy. A liberal attitude is appropriate toward the fat and fiber content of the diet. Electrolyte supplements, especially sodium and magnesium, are often needed.

Failure of rectal expulsion as a cause of constipation: why fibre and laxatives sometimes fail.

High-fibre diet and laxatives are not always successful in the treatment of severe constipation. In a group of thirteen women with intractable constipation three experimental models of rectal evacuation showed that all had a disorder of defaecation. None could expel 120 ml barium paste as fast or as completely as could ten normal women; six could expel hardly any barium. Only three of the thirteen could expel a balloon containing 50 ml water from the rectum, whereas all of six normal subjects could do so easily. Four of the patients with repeated straining efforts could expel no more than 10% of a 500 ml saline enema, whereas six normal subjects rapidly passed 40-80%. It is postulated that dietary and drug treatment designed to soften and increase the bulk of the stools fails to help some patients because they find it difficult to expel even semi-solid or liquid stool. Electromyography showed that these patients tend to contract rather than relax the striated muscle of the pelvic floor on attempted defaecation. Their failure to defaecate is due to incoordination of the pelvic floor rather than an abnormality of the stool or a disorder of the colon.

Severe chronic constipation of young women: 'idiopathic slow transit constipation'.

A series of 64 women complaining of severe constipation is described, in each of whom delayed elimination of markers from the colon was demonstrated but a barium enema was normal. All completed a detailed questionnaire and the responses are compared with those obtained in an age-matched series of healthy women with no bowel complaint. In each group 40 women also recorded in a manner suitable for analysis all food eaten over a period of seven days. The patients passed about one stool weekly with the aid of laxatives, and were greatly troubled by abdominal pain, bloating, malaise and nausea, to the extent that the symptoms were a major social disability and many lost time from work. Decreased bowel frequency and other symptoms were often first noticed around the age of puberty and slowly became worse until they were severe by the third decade. In a few, the symptoms began suddenly after an abdominal operation c-accident. Comparison with the control group showed no evidence that the patients had been underweight at any time or that they took less fibre; treatment with a bran supplement did not usually help them. The patients experienced rectal sensation before defaecation less often than the control subjects and they used digital pressure to assist defaecation more frequently. The women with constipation tended to have more painful and irregular menstrual periods, and there was an increased incidence of ovarian cystectomy and hysterectomy. Hesitancy in starting to pass urine was more common, as were some somatic symptoms such as cold hands or blackouts. Attention is drawn to this distinctive combination in young women of slow total gut transit time and a colon of normal width on barium enema, associated with abdominal, anorectal, gynaecological and somatic symptoms, as a disorder which can be disabling and particularly difficult to treat.

Balloon expulsion from the rectum in constipation of different types.

The defaecatory mechanism using a balloon model with simultaneous measurement of intrarectal pressure has been studied in 15 control subjects with normal bowel habit and in 39 patients with chronic constipation; 31 with a normal barium enema and eight with idiopathic megarectum. Fourteen of those with a normal barium enema had prolonged whole gut transit times as measured by radio-opaque shapes. The ability of the patient to expel a rectal balloon containing 50, 100, and 150 ml of water, lying on their side in the left lateral position was tested and if unsuccessful, in the sitting position with the knees raised. All but one of the control subjects could expel balloons in the left lateral position. Only five of 17 constipated patients with normal barium enemas and transit times could expel balloons lying on their side although a further three could do so when sitting. None of 14 patients with slow transit and normal barium enemas could expel balloons in left lateral position although three could do so when sitting. Patients with megarectum could not expel balloons in either position. Levels of intrarectal pressure with straining were not significantly different between controls, who were able to expel balloons, and constipated patients with a normal barium enema, but were greater (p less than 0.01) in patients with megacolon than in control subjects. Using the balloon model a disorder of the defaecatory mechanism is present in patients with constipation of different types, but this is not because of an inability to raise intrarectal pressure.

Therapeutic benefits from a poorly absorbed prednisolone enema in distal colitis.

A double blind controlled trial has been conducted in 40 patients to compare the therapeutic effects of prednisolone metasulphobenzoate enemas with those of prednisolone-21-phosphate enemas. Both enemas brought about improvement in symptoms and sigmoidoscopic appearances in more than 70% of patients treated. The absorption of prednisolone from the metasulphobenzoate enema in three patients was less than from the 21-phosphate enema. In view of the low plasma prednisolone concentrations obtained, there are theoretical advantages in using a poorly absorbed enema to avoid the possibility of systemic steroid effects in patients requiring long term steroid treatment.

Anismus in chronic constipation.

Among patients complaining of constipation, a group can be defined in which there is slow whole gut transit shown by retention of radiopaque markers but a rectum and colon of normal width judged by measurements of barium enema radiographs compared with control observations. It is not known whether their symptoms are due to an abnormality of colonic motility or to a failure of the defecatory mechanism. Defecation was simulated experimentally in a group of these patients by asking them to expel a water-filled rectal balloon. The constipated patients were not able to expel the balloon, whereas normal subjects could do so. Electromyography of the striated pelvic floor muscles during attempts at expulsion of the balloon in the constipated patients showed failure of the normal inhibition of resting activity. Failure of external and sphincter relaxation on attempted defecation may contribute to the symptoms of some patients who complain of constipation.

Towards a radiologic definition of idiopathic megacolon.

Measurements of bowel width and rectal area were used to define normal limits of size in 50 double-contrast barium enema films. Two types of patient with constipation were defined by comparison with these results. In 18 women with prolonged whole-gut transit time, the measurements were within the normal range. Of 11 men and 9 women with a previous radiologic diagnosis of idiopathic megacolon, all had an enlarged rectum and the abnormal width extended proximally to involve the colon for a variable distance. A width of 6.5 cm at the pelvic brim provides a convenient and discriminating separation of normal from abnormal.