European evidence based consensus on the diagnosis and management of Crohn's disease: current management.

This second section of the European Crohn's and Colitis Organisation (ECCO) Consensus on the management of Crohn's disease concerns treatment of active disease, maintenance of medically induced remission, and surgery. The first section on definitions and diagnosis includes the aims and methods of the consensus, as well as sections on diagnosis, pathology, and classification of Crohn's disease. The third section on special situations in Crohn's disease includes postoperative recurrence, fistulating disease, paediatrics, pregnancy, psychosomatics, extraintestinal manifestations, and alternative therapy for Crohn's disease.

Evaluation of the barostat for recordings of gastrointestinal motility.

BACKGROUND: The barostat has been used to investigate gastrointestinal motility. No detailed technical evaluation to characterize the properties of this device for motility recordings has been reported. We, therefore, aimed to test the barostat in vitro under standardized conditions. METHODS: Barostat and manometry recordings were performed using a combined catheter in a pressure chamber. Some of the experiments were made in pig sigmoid colon in order to mimic recordings in a hollow organ. Data are mean +/- SD. RESULTS: Baseline changes of the bag volume under constant conditions were 3.9 +/- 2.0%. The bag volume increased by 4.5 +/- 1.1% with a temperature increase from 22 to 37 degrees C (p < 0.05). At external pressures above the bag operating pressure, the barostat bag collapsed, while only minimal volume reductions occurred at external pressures below the bag pressure. Barostat recordings of pressure events were delayed when compared with manometry and not linearly related to the pressure increases. CONCLUSION: The influence of temperature changes on barostat recordings is small. The volume decrease in the barostat bag is not linearly related to the external pressure increase and influenced by the operating pressure in the bag. This experimental study provides insight and caveats for those planning to use the barostat device for motility recordings of the gastrointestinal tract.

Neurotransmitter coding of enteric neurones in the submucous plexus is changed in non-inflamed rectum of patients with Crohn's disease.

Knowledge of the neurochemical coding of submucosal neurones in the human gut is important to assess neuronal changes under pathological conditions. We therefore investigated transmitter colocalization patterns in rectal submucosal neurones in normal tissue (n=11) and in noninflamed tissue of Crohn's disease (CD) patients (n=17). Neurone-specific enolase (NSE), choline acetyltransferase (ChAT), vasoactive intestinal polypeptide (VIP), substance P (SP), nitric oxide synthase (NOS) and calcitonin gene-related peptide (CGRP) were detected immunohistochemically in whole-mount preparations from rectal biopsies. The neuronal marker NSE revealed no differences in the number of cells per ganglion (controls 5.0; CD 5.1). Four cell populations with distinct neurochemical codes were identified. The sizes of the populations ChAT/VIP (58% vs. 55%), ChAT/SP (8% vs. 8%), and ChAT/- (22% vs. 22%) were similar in control and CD. The population VIP/- was significantly increased in CD (12% vs. 2% in controls). Unlike in controls, all NOS neurones colocalized ChAT in CD. Thickened CGRP-fibres occurred in CD. We identified neurochemically distinct populations in the human submucous plexus. The increase in the VIP/- population, extensive colocalization of ChAT and NOS and hypertrophied CGRP fibres indicated adaptive changes in the enteric nervous system in noninflamed rectum of CD patients.

Postoperative colonic motility and tone in patients after colorectal surgery.

PURPOSE: Colonic motility is crucial for the resolution of postoperative ileus. However, few data are available on postoperative colonic motility and no data on postoperative colonic tone. We aimed to characterize postoperative colonic tone and motility in patients. METHODS: Nineteen patients were investigated with combined barostat and manometry recordings after left colonic surgery. During surgery a combined recording catheter was placed in the colon with two barostat bags and four manometry channels cephalad to the anastomosis. Recordings were performed twice daily from Day 1 to Day 3 after surgery. RESULTS: Manometry showed an increasing colonic motility index, which was a mean (+/- standard error of the mean) of 37 +/- 5 mmHg/minute on Day 1, 87 +/- 19 mmHg/minute on Day 2, and 102 +/- 13 mmHg/minute on Day 3 (P < 0.05 for Day 1 vs. Day 2 and Day 2 vs. Day 3). Low barostat bag volumes indicating a high colonic tone were observed on Day 1 after surgery and increased subsequently (barostat bag I was 19 +/- 4, 32 +/- 6, and 32 +/- 6 ml; barostat bag II was 13 +/- 1, 19 +/- 3, and 22 +/- 5 ml on Days 1, 2, and 3, respectively; for both barostat bags P < 0.05 for Day 1 vs. Day 2 but not Day 2 vs. Day 3). CONCLUSIONS: Colonic motility increased during the postoperative course. The low barostat bag volumes indicated a high colonic tone postoperatively which would correspond to a contracted rather than to a distended colon. High colonic tone postoperatively may be relevant for pharmacologic treatment of postoperative ileus.

Lymphoscintigraphy and gamma probe-guided surgery in papillary thyroid carcinoma: the sentinel lymph node concept in thyroid carcinoma

The authors report the use of lymphoscintigraphy and gamma probe-guided resection of the sentinel lymph node in a 65-year-old woman with clinically and cytologically indicated metastasizing papillary thyroid carcinoma. The results of the preoperative lymphoscintigraphy corresponded well with FDG PET and histologic findings, which gives promise of its validity in thyroid carcinoma. With experience in ultrasound-guided fine-needle aspiration biopsy, this method can be performed without any serious side effects for the patient. The validity of the sentinel lymph node concept in thyroid carcinoma and a possible improvement of nodal staging and local recurrence rate must still be proved.

C-fos protein expression in the nucleus of the solitary tract correlates with cholecystokinin dose injected and food intake in rats.

C-fos protein expression was investigated in the nucleus of the solitary tract (NTS) in response to increasing cholecystokinin (CCK) doses and food intake in rats by counting the number of c-fos protein positive cells in the NTS. C-fos protein expression in the NTS dose-dependently increased in response to CCK, the lowest effective dose being 0.1 microg/kg. The ED(50) for c-fos protein expression in the NTS in response to CCK was calculated to be 0.5 to 1.8 microg/kg, depending on the anatomical level of the NTS investigated. Food intake increased c-fos protein expression in the NTS, the maximum number of c-fos protein positive cells being reached at 90 min after the start of food intake. Regression analysis identified a positive correlation between c-fos protein expression and the amount of food intake. Our data indicate that subpopulations of the NTS that are activated by CCK or food intake are involved into the short-term regulation of food intake and the neural control of feeding by the caudal brainstem.

Comparison of different tracers in the follow up of differentiated thyroid carcinoma.

In the follow up of differentiated thyroid carcinoma (DTC) several scintigraphic methods are used in addition to the serum thyroglobulin and ultrasonography of the neck. Iodine-131 whole body scintigraphy (WBS), which is performed since many years, is able to detect iodine positive recurrence, lymph node metastases and distant metastases in a very specific way. However, the problem of I-131 WBS is the fact that only 67% of metastases from DTC accumulate iodine. Therefore non specific radionuclides like TI-201 or tracers such as Tc-99m Sestamibi or Tc-99m Tetrofosmin and new metabolic tracers like F-18 FDG were introduced in the diagnostic work up to detect iodine negative metastases as well. This study describes the comparison of different tracers in 35 patients with elevated thyroglobulin and suspicion of metastatic disease or already known metastases from DTC.

Simultaneous detection of cell volume and intracellular pH in isolated rat duodenal cells by confocal microscopy and BCECF.

The combination of confocal laser scan microscopy and the pH-sensitive fluorescent dye BCECF allowed us to record simultaneously intracellular pH, cell viability and relative cell volume. pH was measured by using the pH-sensitive excitation wavelength at 488 nm and the pH-independent excitation wavelength at 442 nm to obtain ratio images. Cell volume was traced by measuring fluorescence dye concentration at 442 nm. Isolated villus tip rat duodenal enterocytes were exposed to 20 mM NH4Cl, sodium free, or 1 mM amiloride buffer. Sodium free buffer and amiloride buffer acidified the cells. Cell volume did not change in sodium free buffer, or NH4Cl exposure, but amiloride led to an increase in cell volume of 20%. After acidification of the duodenal cells, amiloride buffer increased cell volume by almost 50%. These studies revealed that cell volume regulation during pH changes in short-living cells could easily be detected by confocal microscopy and BCECF.

Long-term follow-up after resectional surgery in patients with Crohn's disease involving the colon.

BACKGROUND: The majority of patients with Crohn's disease will eventually have colonic involvement, and more than 50% of these patients undergo resectional colonic surgery. The extent of colonic resection is discussed controversially. AIMS: We evaluated prognostic factors influencing the long-term outcome after resectional surgery including the colon. METHODS: We analyzed the postoperative course in 170 patients (mean follow-up 7.4 years) after first colonic surgery. Lifetable and multivariate factor analysis were performed to assess the influence of various factors on the postoperative long-term outcome. 85% of the patients had concomitant ileal disease, 40% had rectal disease, 48% percent of the patients had extensive colonic disease at the time of primary surgery. RESULTS: In 17% of the initial operations a colectomy was performed, the remaining 83% operations consisted in segmental colonic resections. The cumulative risks of clinical recurrence/reoperation were 63%/33% after ten years and increased by the presence of anal fistulas (relative risk 1.7/3.0) and after colocolonic type of anastomosis (relative risk 1.9/2.8). Ileal disease, rectal disease, extent of resection and pattern of colitis did not influence the recurrence rates. The risk to undergo completion colectomy was 11% ten years after segmental resection and not higher in the presence of extensive colonic disease. The risk of a definitive stoma was 11% after ten years and higher after ileorectal anastomosis (25% versus 8% after segmental resection: p < 0.003). CONCLUSION: Colocolonic type of anastomosis and the presence of anal fistulas are risk factors for recurrence after initial colonic resection. Segmental resections were not followed by increased recurrence rates or a higher stoma rate. To maintain colonic length and intestinal continuity segmental colonic resection is the treatment of choice in patients undergoing surgery for local complications, even in the presence of extensive colonic disease.

[Gastroduodenal involvement and circumscribed intestinal stricture in Crohn disease]. / Gastroduodenaler Befall und umschriebene Darmstriktur bei M. Crohn.

Symptomatic gastroduodenal Crohn's disease (CD) is rare although new endoscopic/histologic data indicate a typical focally enhanced gastritis in up to half of all patients with CD. One third of the patients with symptomatic gastroduodenal CD undergo surgery, most of them for (gastro-) duodenal obstruction. Gastroenterostomy with vagotomy is the surgical treatment of choice. Resection, strictureplasty or balloon dilatation can be performed in selected patients. Enterogastric and enteroduodenal fistulas are rare, frequently missed during routine examination and often detected only during laparotomy. Treatment of those fistulas consists of resection of distal bowel (fistula origin) with suture closure of the fistula opening in the stomach/duodenum. Recurrence rate after surgery for gastroduodenal CD is lower than in ileal and/or colonic disease, and only a minority of the patients requires further surgical intervention. Bowel obstruction is a frequent indication for surgery in CD. Interventional or surgical therapy should be performed in chronic-recurrent obstruction, progressive stenosis and stenosis refractory to medical treatment. In short fibrous stenosis of the small bowel or ileocecal anastomosis without acute inflammation or perforating complications balloon dilatation or, if endoscopic access is not possible, strictureplasty should be performed. In all other cases, especially in colonic strictures with their increased risk of malignancy, resection is the treatment of choice. The results of balloon dilatation, strictureplasty or resection are comparable with five year reoperation rates reported between 20% and 38%.

A model to investigate postoperative ileus with strain gauge transducers in awake rats.

BACKGROUND: Postoperative ileus influences patients well-being, hospital stay, and health cost, and postoperative inhibition of colonic motility is a major contributor to postoperative ileus. Experimental models for investigating postoperative ileus are needed. In particular, recording of postoperative colonic motility in awake rats has not been described yet. MATERIAL AND METHODS: Gastric, small intestinal, and colonic motility were recorded with strain gauge transducers in awake rats, and the effects of anesthesia and abdominal surgery on gastrointestinal motility were investigated. RESULTS: Ether anesthesia increased gastric motility and inhibited small intestinal motility, while enflurane anesthesia had only minor effects on gastrointestinal motility. Abdominal surgery inhibited gastric, small intestinal, and colonic motility, and a detailed analysis of gastrointestinal motility in our postoperative ileus model is given. CONCLUSIONS: We established a model to record gastric, small intestinal, and colonic motility in awake rats postoperatively. We could demonstrate that enflurane anesthesia had little effect on gastrointestinal motility, while laparotomy and short manipulation of the cecum produced a prolonged inhibition of gastrointestinal motility. Our model could be used to investigate postoperative ileus, particularly of the colon, in awake rats.

Functional results after transanal rectal advancement flap repair of trans-sphincteric fistula.

BACKGROUND: Transanal rectal advancement flap repair is an operation to treat trans-sphincteric fistula which leaves the external sphincter muscle essentially untouched. Anal sphincter function was evaluated prospectively before and after this procedure. METHODS: Anorectal manometry was performed in 24 patients before operation and 3 months after surgery. A detailed standardized questionnaire on faecal continence was answered before surgery, then at 3 and 48 months after surgery. RESULTS: No significant differences were seen between mean(s.e.m.) preoperative and postoperative values for maximum squeeze pressure (100.0(9.7) versus 118.0(12.7) mmHg), maximum resting pressure (56.6(4.3) versus 52.8(4.1) mmHg), rectal compliance (4.4(0.6) versus 3.5(0.5) ml/mmHg) or any other parameter of anorectal manometry. The questionnaire revealed the occurrence of minor incontinence in two patients following surgery, which remained unchanged for 4 years. Three other patients had continence disturbances 4 years after surgery which were probably unrelated to the procedure. CONCLUSION: In addition to high success rates, transanal rectal advancement flap repair also yields excellent functional results. This procedure should be performed for trans-sphincteric fistula in place of alternative treatments whenever feasible.

[Postoperative colon tonus after partial resection of the large intestine]. / Postoperativer Kolontonus nach Dickdarmteilresektion.

Only limited data are available on postoperative colonic motility in patients. We investigated colonic tone and motility after large bowel resection in 20 patients. A combined barostat/manometry catheter was placed intraoperatively. Postoperative colonic motility increased day by day. Barostat bag volumes were reduced on postoperative day 1 compared to postoperative day 2 and 3 indicating increased colonic tone on the 1st postoperative day. The use of morphine-like analgesics was highest right after surgery but might not explain increased colonic tone on postoperative day 1 since morphine has been shown to decrease colonic tone. Possibly, increased postoperative sympathetic activity which caused reduced splanchnic blood flow may be responsible for the apparent increase in postoperative colonic tone. The recording of colonic motility in the early postoperative period is feasible with a combined manometry/barostat catheter. These investigations may improve the understanding of the pathophysiology of postoperative colonic ileus.

Recombinant human transforming growth factor beta 3 accelerates gastric ulcer healing in rats.

BACKGROUND: Gastric ulcer healing is mediated by various endogenous growth factors. In this experimental study effect of locally and systemically applied recombinant human transforming growth factor beta 3 (rhTGF-beta 3) on gastric ulcer healing was investigated in the rat. METHODS AND RESULTS: Gastric ulcers were induced with a cryoprobe, and ulcer healing was evaluated 7 days after local infiltration (0.5 micrograms, 1.0 microgram, 2.5 micrograms, and 50 micrograms) or systemic (intravenous) application of TGF-beta 3 (500 micrograms/kg body weight). Compared with controls, a dose-dependent stimulation of ulcer healing (as evidenced by a reduction in ulcer size) was observed 7 days after local infiltration of TGF-beta 3 (1.0 microgram, 2.5 micrograms, and 50 micrograms). Corresponding increases in the levels of proliferating cell nuclear antigen (PCNA) and intracellular TGF-beta 3 expression and a downregulation of the TGF-beta type-II receptor expression were also observed in the granulation tissue of the ulcer margins. Systemic application of TGF-beta 3 produced effects similar to those observed after local treatment with 50 micrograms of the compound. CONCLUSION: Local and systemic TGF-beta 3 treatment accelerates gastric ulcer healing in rats.

High prevalence of bone disorders after gastrectomy.

BACKGROUND: Studies indicate that gastrectomy might alter calcium and bone metabolism, resulting in bone disorders. No data are currently available on the prevalence of bone disorders after gastrectomy. METHODS: Sixty gastrectomy patients were investigated for serum parameters of calcium and bone metabolism 5 to 20 years postoperatively and compared to an age- and sex-matched healthy control population. Forty patients agreed to a radiological investigation of the spine by anterior-posterior and lateral radiographs of the thoracic and lumbar spine and by computed tomography (CT) osteodensitometry. RESULTS: Serum calcium and 25-(OH)-vitamin D were decreased in gastrectomized patients, while parathyroid hormone and 1,25-(OH)2-vitamin D were increased. Serum parameters of calcium metabolism were altered in as many as 68% of patients. We found 31 vertebral fractures in 13 patients, 30 grade 2 vertebral deformities in 18 patients, and osteopenia in 15 patients, corresponding to a prevalence of 33%, 45%, and 37% in gastrectomized patients, respectively. The overall rate of gastrectomy patients having vertebral fractures and/or osteopenia was 55%. The risk of having a vertebral deformity was increased by more than sixfold after gastrectomy. Our study is the first report evaluating vertebral deformities in gastrectomized patients, and the largest series of gastrectomized patients investigated by CT osteodensitometry. CONCLUSION: We found a high prevalence of bone disorders in gastrectomized patients, possibly resulting from disorders in calcium metabolism. Postgastrectomy bone disease might derive from a calcium deficit, which increases calcium release from bone and impairs calcification of newly build bone matrix.

The Favre system for anorectal manometry: comparison with other manometry systems in vitro and in healthy volunteers.

BACKGROUND: The Favre system operates with airflow in a semi-closed circuit to transmit pressure. We aimed to evaluate the Favre system in comparison with other commonly used manometry systems. METHODS: The Favre, Arndorfer, Arhan, and Synectics systems were evaluated in vitro and in 14 volunteers. RESULTS: In vitro testing showed no relevant differences for latency, precision, or retest stability. In vivo, maximum resting pressure differed among all probes (P < 0.01) except for Arhan versus Arndorfer (NS). Maximum squeeze pressures differed among all probes (P < 0.01). Decrease of resting pressure during rectoanal inhibitory reflex was similar for Favre versus Arndorfer and Arhan versus Synectics (NS). Retest stability was higher with Favre than with Arndorfer (P < 0.05) and Synectics (P < 0.05) with regard to maximum resting pressure; it was higher with Favre than with Arhan (P < 0.01) and Arndorfer (P < 0.05) with regard to maximum squeeze pressure. Favre caused less discomfort than Synectics (P < 0.05) or Arndorfer (P < 0.05). CONCLUSION: The Favre probe is an excellent and cost-efficient system for routine anorectal manometry.

[Calcium and bone metabolism after gastrectomy]. / Calcium- und Knochenstoffwechsel nach Gastrektomie.

Disturbances in calcium and bone metabolism after gastrectomy have long been recognized. It has been suggested that due to impaired calcium absorption after gastrectomy, serum calcium is decreased, being counter-regulated by parathyroid hormone release and 1,25-(OH)2-vitamin D formation. Both parathyroid hormone and 1,25-(OH)2-vitamin D are known to release calcium from bone, resulting in bone mass loss and increased fracture risk in some of the gastrectomized patients. No therapy is currently generally agreed on, although supplementation of vitamin D and calcium has been suggested repeatedly. A review on the current understanding of calcium and bone metabolism after gastrectomy is given.

Perianal complications of Crohn disease: MR imaging findings.

The aim of this study was to revisit anal anatomy, to explain surgical terminology in perianal complications of Crohn disease, and to show the MR imaging findings of perianal fistulas and abscesses. To this end more than 200 patients were studied using surface coils (Helmholtz; phased array) at 1.0 and 1.5 T. Transverse and coronal T1- and T2-weighted images were obtained. Parks' classification was used to describe perianal abscesses and fistulas. This pictorial essay shows the normal anal anatomy and pathologic findings such as subcutaneous, para-anal, ischiorectal, intersphincteric, and supralevatoric abscesses and fistulas. MR imaging with surface coils is well suited to showing the anal anatomy and to reliably describing perianal abscesses and fistulas according to surgical terminology.