Is colonoscopic cancer surveillance in ulcerative colitis essential for every patient?

Surveillance aims to diagnose precancer or cancer at a surgically curable stage. Cancer complicating ulcerative colitis affects only 1-2 per million of the general population annually. The risk is low within 10 years of disease onset, and in proctitis or left-sided colitis. It is approximately one in 120 per year for those with extensive disease after 10 years from onset. Results of surveillance programmes from regional hospitals among 423 patients led to surgery for precancer or cancer once every 123 colonoscopies; there were no cancer deaths during surveillance and all 4 cancers were Dukes' stage A or B. At referral centres, many patients have dysplasia at the first colonoscopy. Two-thirds of cancers in colitis develop in the recto-sigmoid; flexible sigmoidoscopy has a role in surveillance which is untested. Colonoscopic surveillance is not appropriate for most patients with colitis; it is worthwhile but not essential for those with long-standing extensive disease.

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.

Effect of omeprazole on intestinal output in the short bowel syndrome.

Ten patients with an end jejunostomy and one with a jejuno-rectal anastomosis (jejunal length 30-140 cm) ate a constant chosen diet for 2 control days, and 2 test days when 40 mg omeprazole orally was taken each morning. In the 7 patients with a net secretory output of fluid, there was a mean reduction in wet weight of 0.66 kg/24 h (range -0.16 to 1.45 kg/24 h; P less than 0.05) and sodium 46 mmol/24 h (-51 to 135 mmol/24 h; N.S.); the four patients with net absorption of fluid showed no reduction in intestinal output. One patient with 30 cm jejunum responded little to oral but did so to intravenous 40 mg omeprazole twice a day with a reduction in wet weight of 3.00 kg/24 h and sodium 157 mmol/24 h. In one patient oral 40 mg omeprazole daily gave equivalent results to oral 300 mg ranitidine twice daily; in 2 others it was equivalent to intravenous 50 micrograms octreotide twice daily. Omeprazole reduces the intestinal output in patients with the short bowel syndrome and a net secretory output, but not enough to prevent the need for parenteral fluid and electrolyte replacement.

Verapamil inhibits in-vitro leucotriene B4 release by rectal mucosa in active ulcerative colitis.

Increased mucosal eicosanoid synthesis occurs in active ulcerative colitis; suppression of the synthesis of pro-inflammatory leucotrienes could be therapeutically useful. Neutrophil 5-lipoxygenase is calcium-dependent. In this study, the effect of the calcium channel antagonist, verapamil, on the release of eicosanoids by colitic rectal mucosal biopsies has been examined. Verapamil in therapeutic concentration (5 micrograms/ml, 10(-5) M) reduced leucotriene B4 release from actively inflamed rectal mucosa by 30% (from 60 (5.0 S.E.M.) ng/g wet weight/20 min without, to 42 (5.7 S.E.M.) with verapamil, P less than 0.05), but had no effect on leucotriene B4 release by rectal biopsies taken from patients with quiescent ulcerative colitis (39 (2.8 S.E.M.) ng/g wet weight/20 min without, and 43 (5.0 S.E.M.) with verapamil). Verapamil did not affect mucosal prostaglandin E2 release. The results suggest that, in active ulcerative colitis, verapamil inhibits mucosal 5-lipoxygenase activity and warrants therapeutic evaluation.

Octreotide (a somatostatin analogue) improves the quality of life in some patients with a short intestine.

Six patients with short intestine (jejunal length 25-70 cm) on long-term parenteral nutrition, needing 4-5 L of intravenous fluid daily, were given octreotide (a somatostatin analogue, SMS 201-995) to investigate whether it would reduce beneficially their secretory diarrhoea (3.6-6.9 kg/day). They consumed the same diet for 2 control days, followed by 2 test days. Octreotide was given intravenously, initially in a dose of 50 micrograms b.d. through the central feeding line. There was a significant reduction of daily stomal output (0.5-5.0 kg) and daily sodium and potassium output; however there was no significant change in energy absorption. The response to octreotide was greatest in those patients who absorbed least nutrients. A dose increase to 100 micrograms t.d.s. gave no further measurable benefit though the patients found it smoothed-out the post-prandial rise in stomal output. Two patients were continued on long-term octreotide therapy, which allowed for a daily reduction in intravenous fluid of 1 and 1.5 L. Octreotide's anti-secretory effect was found to have been maintained when it was retested in one patient after a year of continuous therapy.

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.

Prednisolone absorption in inflammatory bowel disease: correlation with anatomical site and extent.

Prednisolone absorption was studied in 13 normal subjects, eight patients with ulcerative colitis and 21 patients with Crohn's disease, by measuring plasma levels after a single oral dose. Absorption of the drug was delayed in all patient groups. The peak plasma level of the drug was lower in patients with extensive small bowel Crohn's disease. Patients in this category may need higher doses of oral prednisolone than other patients with inflammatory bowel disease.

Balsalazide in the maintenance treatment of patients with ulcerative colitis, a double-blind comparison with sulphasalazine.

Balsalazide (BSZ) is a pro-drug which releases 5-aminosalicylic acid (5ASA) and 4-aminobenzoyl-beta-alanine (an inert carrier) in the colon of various species including man. BSZ was compared with sulphasalazine (SASP) (both 1 g b.d. orally) in the maintenance of remission in patients with ulcerative colitis (UC). Seventy-nine patients (53 male, 26 female), mean age 49 years (range 19-79 years), with UC were randomly allocated to either treatment (41 BSZ, 38 SASP) for 6 months. The groups were similar in respect of age, sex, duration and extent of disease. Seven patients defaulted (3 BSZ, 4 SASP) leaving 38 on BSZ and 34 on SASP. Two male patients, both receiving SASP, were withdrawn because of severe side-effects. One of these patients, with an exfoliative rash, was maintained satisfactorily on open BSZ. Remission rates at 6 months (51% BSZ, 63% SASP) were not significantly different (life-table analysis P less than 0.1). Twelve patients (15%) reported troublesome side-effects (2 BSZ 5%, 10 SASP 26%, P = 0.017 Fisher Exact Test). Mean haemoglobin concentrations, similar on entry, increased after 6 months with BSZ (0.2 g/dl) but decreased with SASP (0.5 g/dl) (P less than 0.0002). BSZ was not significantly different from SASP in maintaining remission in patients with UC but had fewer side-effects.

Improved maintenance of remission in ulcerative colitis by balsalazide 4 g/day compared with 2 g/day.

The efficacy of two doses of balsalazide for the maintenance of remission in patients with ulcerative colitis was compared in a double-blind multicentre trial. Sixty-five patients received a 2 g daily dose, and 68 a 4 g dose. The patient groups were similar at entry for sex, age, and disease distribution. Clinical assessment was carried out at 3-monthly intervals, with sigmoidoscopy, rectal biopsy, and blood tests on entry and at 26 and 52 weeks. Clinical relapse over twelve months was significantly less common on the 4 g dose (36%), than on the 2 g dose (55%), P less than 0.01. There were eight withdrawals on 2 g daily and 13 on 4 g daily, six and nine respectively being mainly due to gastrointestinal intolerance. It is concluded that balsalazide is a well-tolerated drug, and is effective for the maintenance of remission in patients with ulcerative colitis, the optimal dose being greater than 2 g daily.

Observer study of the grading of dysplasia in ulcerative colitis: comparison with clinical outcome.

Patients with extensive ulcerative colitis are entered into surveillance programs that aim to detect premalignant changes. Biopsy specimens have been collected in the St Mark's Hospital (London) surveillance program over a 22-year-period. Specimens from patients reported as having dysplasia were reexamined. A total of 207 biopsy specimens from 86 patients were graded by five experienced pathologists according to the severity of the dysplasia. The overall agreement between the pathologists grading the specimens was poor; each pair agreed on between 42% and 65% of the slides. The best agreement was for slides that were said to show no dysplasia. Comparison with clinical outcome indicated that the pathologists most likely to diagnose dysplasia in patients with carcinoma were also likely to diagnose dysplasia in patients who did not go on to develop carcinoma. Calculating an average grade of dysplasia did not significantly improve diagnostic accuracy. Despite the findings of this interobserver study, dysplasia has been a successful marker in clinical practice. Pathologists should ensure that they have access to previous slides from the same patient and adequate clinical information before reporting biopsies as positive for dysplasia. An additional biopsy should usually be undertaken before surgery is considered.

Intravenous feeding in a gastroenterological unit: a prospective study of infective complications.

We have assessed the bacteriological safety of a system of intravenous feeding by culturing catheters on removal, swabs taken from the catheter's skin entry sites, and samples of infusion fluid. Among 38 treatment periods using 51 catheters over 1551 patient days, septicaemia due to Staphylococcus aureus was observed in one treatment period and bacteraemias due to Staphylococcus albus and Diphtheroid species in two others. The Staph. aureus and the diphtheroids probably gained access via the skin entry site along the outside of the catheter. The origin of the Staph. albus was uncertain. Parenteral nutrition over extended periods can be a safe procedure if aseptic precautions are taken. The importance of the catheter's skin entry site as a source of contaiminating organisms is emphasised.

Brush cytology of the colon and rectum in ulcerative colitis: an aid to cancer diagnosis.

In a prospective study of 100 patients with ulcerative colitis, 82 of whom had extensive colitis, carcinoma and dysplasia were distinguished cytologically from reactive hyperplasia. Six patients had carcinoma complicating colitis and satisfactory samples were obtained from five; the cytological appearances were interpreted as carcinoma in three and as dysplasia in two. Seventy eight patients had not developed carcinoma or dysplasia; the cytological appearances were interpreted as negative for dysplasia in 75 and indefinite for dysplasia in three. In patients who had developed dysplasia the changes seemed to be more widespread on cytological rather than on histological examination. Brush cytology may complement histological assessment in patients with ulcerative colitis who have developed strictures or in whom there is a high suspicion of neoplastic change.

The microbial flora of the rectal mucosa and faeces of patients with Crohn's disease before and during antimicrobial chemotherapy.

The faecal flora and mucosa-associated flora (MAF) of rectal biopsy material from 12 patients with active Crohn's disease were studied before and during treatment with a combination of metronidazole and cotrimoxazole given orally for at least 2 weeks. The total faecal flora was greater than the MAF although the proportions of bacterial groups were similar. The changes observed during treatment were: obligate anaerobes such as Bacteroides spp. decreased in faeces (p less than 0.05) and in MAF (p less than 0.02); the total count of facultative bacteria increased in the faeces (p less than 0.002) but not in the MAF. Streptococci, predominantly enterococci, increased significantly in faeces (p less than 0.001) and in MAF (p less than 0.02) such that they became predominant components of these florae. Facultative gram-negative bacilli were unaltered in faeces but significantly reduced in the MAF (p less than 0.05). Sporing clostridia were infrequently isolated from the MAF but were significantly reduced in the faeces (p less than 0.01). During the treatment period, eight of the 12 patients showed clinical improvement, but this could not be related to the site or extent of disease or to specific changes in faecal flora or MAF. This combination of antibacterial agents causes profound alterations to the bacterial flora of mucosa and faeces and these changes may help to define the role of bacteria in the pathogenesis of Crohn's disease.

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.

A patient with jejunostomy liberated from home intravenous therapy after 14 years; contribution of balance studies.

A patient with a jejunostomy 100 cm from the duodeno-jejunal flexure, following surgery for Crohn's disease, had needed parenteral fluids at home for 14 years because of a negative intestinal balance of sodium. Measurements were made of her oral intake and intestinal output during study periods each of 2 days. Loperamide 4 mg QDS, codeine phosphate 60 mg QDS and both together put her into positive intestinal fluid balance but sodium balance remained negative. Both drugs used together were more effective than either used alone. Ranitidine 300 mg BD made no significant difference to her intestinal output. 1 litre of a glucose-electrolyte solution (120 mmol sodium) sipped during the day resulted in sodium balance, but only with the addition of loperamide and codeine phosphate was positive sodium balance achieved (mean 44 mmol/day). This therapy allowed her to dispense with parenteral fluids which have been stopped for the last year.

Screening by nurses and junior doctors to detect malnutrition when patients are first assessed in hospital.

Four hundred and fifty four ward nurses and 319 junior doctors in 70 hospitals were interviewed about the last patient they had admitted, using a brief questionnaire. The availability of weighing scales and height measuring equipment was assessed by observers who visited the wards of 107 hospitals. Two thirds of nurses and doctors asked patients about recent food intake; half of the nurses and three quarters of the doctors asked about unintentional weight loss. Answers to the questions were recorded in the notes on 52-80 per cent of occasions. Two thirds of nurses weighed the patient, but only 11 per cent (%) measured height; approximately 80% of results were recorded. Most nurses and doctors who asked no questions about nutrition and made no measurements failed to do so because they regarded them as unimportant. Weighing scales were adequately provided, but height measuring equipment was available in only 17% of wards.

A radiological study after parenteral nutrition through silicone rubber catheters: fibrin sleeves without thrombosis.

Injection of contrast material through 38 central silicone rubber catheters at the time of withdrawal after a mean catheter life of 55 days (range 5-369) has shown no evidence of occult venous thrombosis despite the presence of a fibrin sleeve around the whole length of the intravascular portion in 37 cases. The presence of this fibrin sleeve appears to have been harmless. The absence of thrombosis suggests that silicone rubber is the material of choice for central venous feeding catheters and that the addition of heparin to the infusion fluid is unnecessary.

Clinical uniformity of inflammatory bowel disease a presentation and during the first year of disease in the north and south of Europe. EC-IBD Study Group.

OBJECTIVE: To compare the methods used for diagnosis and the clinical features of non-specific inflammatory bowel disease (IBD) in the north and south of Europe. DESIGN: A prospective study over 2 years in 1991-3 at eight centres in the north and 12 in the south of Europe using the same criteria for disease definition and same protocol for recording data. SETTING: Specialist gastroenterological centres with good diagnostic facilities at which every effort was made to ascertain all new cases of IBD seen in other departments and primary care in a defined geographical area of known population. PARTICIPANTS: A total of 2201 patients newly diagnosed as suffering from IBD, 1397 with ulcerative colitis (UC), 706 with Crohn's disease (CD) and 116 with indeterminate colitis (IND). RESULTS: Diagnostic methods used were similar in north and south, a biopsy or resection specimen was available for examination in 94 and 95%, of cases of UC and 92 and 87% of CD in north and south, respectively. The type, clinical presentation, site and extent of disease were similar in north and south. Treatment followed a common pattern and mortality from IBD was low in the first year after diagnosis. In both areas, age of onset of UC tended to be later than CD. CONCLUSION: The standard of diagnosis and clinical features of IBD are similar in specialist centres throughout Europe so providing a valid basis for this aspect of collaborative epidemiological or other studies.

Adult patients with a short bowel due to Crohn's disease often start with a short normal bowel.

OBJECTIVE: The normal adult human small intestinal length, measured surgically or at autopsy from the duodeno-jejunal flexure, ranges from 275 to 850 cm. The length is generally shorter in women than in men. Patients with a short bowel have often had relatively little bowel resected and the majority of patients are women. We aimed to determine whether patients with a short bowel had a short small intestinal length before any resections. PATIENTS AND METHODS: In 11 patients (six men and five women) with Crohn's disease and less than 200 cm residual small intestine, both the residual length of small intestine and the amount resected were measured. RESULTS: Patients had a median of four resections (range 1-5). The median length of small bowel resected was 120 cm (range 60-165 cm) and the medium length of small bowel remaining was 125 cm (range 90-185 cm). Thus, the calculated median original small intestinal length was 240 cm (range 205-315 cm). CONCLUSION: Although there may have been some bowel shortening as a result of Crohn's disease, the original small intestinal length before any resections was short. It is therefore more important, after performing a bowel resection, to measure the remaining than the resected bowel length. Patients with Crohn's disease and a short bowel may have had a short but 'normal' small intestinal length before any bowel was resected.

Nutritional support in intensive care units in England and Wales: a survey.

OBJECTIVE: To assess current practice in nutritional support in intensive care units (ICUs) in England and Wales. DESIGN: A three-section questionnaire about feeding practice was sent to all adult ICUs in England and Wales; this requested information on nutritional support provided for all patients during a single designated 24-h study period. RESULTS: 66% of the questionnaires were completed and returned. 43% of patients received nutritional support. Of these, 46% received only parenteral nutrition, 34% only enteral nutrition, 4% received sip feeds and the remaining 16% received more than one form of feeding. 81% of patients fed by the nasogastric route had a large-bore tube in place. More than 40% of patients were fed parenterally via the central route, of these 54% had a dedicated feeding line. CONCLUSIONS: Despite the complications of central venous feeding and the advantages of and developments in enteral feeding these findings suggest there could be further improvement in our provision of nutrition for the critically ill patient.