Low prevalence of gastroesophageal reflux symptoms in vegetarians.

BACKGROUND: Dietary modification could reduce the risk of gastroesophageal reflux disease. Circumstantial evidence suggests that gastroesophageal reflux is less prevalent in people adhering to a vegetarian diet. We aimed to study the relationship between vegetarianism and the occurrence of gastroesophageal reflux symptoms (GERS). METHODS: This study compares the prevalence of GERS in vegetarians with non-vegetarian controls from the general population. Frequency and severity of GERS (heartburn and/or acid regurgitation) were assessed with a self-administrated questionnaire. RESULTS: Within 1 year, any GERS were experienced by 19 of 100 (19%) vegetarians and by 98 of 250 (39.2%) non-vegetarian controls (p < 0.001). Frequent GERS, defined as GERS on at least 1 day per week, were noted in 3% of vegetarians and in 12.8% of controls (p = 0.006). Reflux symptoms were significantly less severe in vegetarians than in non-vegetarians (p < 0.001). According to multivariable analysis, independent predictors of GERS included male sex, current smoking, BMI ≥ 25 (odds ratio [OR] = 1.94; 95% confidence interval [CI], 1.14-3.31), and a non-vegetarian diet (OR = 2.19; 95% CI, 1.20-3.97); non-vegetarian diet independently predicted frequent GERS (OR 4.03; 95% CI, 1.17-13.9). An increased risk of GERS (OR = 2.17; 95% CI, 1.09-4.29) and frequent GERS (OR 4.00; 95% CI, 1.13-14.18) in non-vegetarians were also demonstrated by logistic regression of matched data. In non-vegetarians, the risk of reflux symptoms was not significantly related to meat intake. CONCLUSIONS: The prevalence and severity of GERS are lower in vegetarians than in non-vegetarians from the general population. The results are in line with a mitigating effect of vegetarianism on GERS. Data must be interpreted with caution given the retrospective study design and the small sample size.

Withdrawal of long-term maintenance treatment with azathioprine tends to increase relapse risk in patients with Crohn's disease.

BACKGROUND AND AIM: Many patients with quiescent Crohn's disease are maintained on long-term treatment with azathioprine (AZA), but controlled data are limited. We aimed to evaluate the efficacy of AZA therapy for more than 4 years to maintain clinical remission. METHODS: We performed a randomized double-blind placebo-controlled AZA withdrawal trial with a follow-up period of 24 months. Patients had to have continuous AZA therapy ≥ 4 years without exacerbation of disease during the 12 months before enrollment, and a Crohn's disease activity index < 150 at baseline. Patients were randomized to continue on AZA or switch to placebo. The primary endpoint was time to clinical relapse during follow-up. RESULTS: After inclusion of 52 patients, the trial was stopped prematurely due to slow recruitment. During the 2-year follow-up, clinical relapse occurred in 4 of 26 (15 %) patients on continued AZA and in 8 of 26 (31 %) patients on placebo. Time to clinical relapse averaged 22.3 months (95 % CI 20.6-24.0) on AZA and 19.2 months (95 % CI 16.4-22.1) on placebo (p = 0.20). According to life-table analysis, the proportion of patients in remission after 12 and 24 months was 96 ± 4 and 86 ± 7 % in patients receiving AZA versus 76 ± 8 and 68 ± 9 % in patients receiving placebo (month 12, p = 0.035; month 24, p = 0.30). A higher AZA dose at enrollment was an independent predictor for relapse (p < 0.05). CONCLUSIONS: AZA withdrawal resulted in a significantly increased relapse risk after 1 year and a nonstatistically significant trend for relapse after 2 years. Our results are in line with previous observations.

Alteration of intestinal dysbiosis by fecal microbiota transplantation does not induce remission in patients with chronic active ulcerative colitis.

BACKGROUND: In patients with ulcerative colitis (UC), alterations of the intestinal microbiota, termed dysbiosis, have been postulated to contribute to intestinal inflammation. Fecal microbiota transplantation (FMT) has been used as effective therapy for recurrent Clostridium difficile colitis also caused by dysbiosis. The aims of the present study were to investigate if patients with UC benefit from FMT and if dysbiosis can be reversed. METHODS: Six patients with chronic active UC nonresponsive to standard medical therapy were treated with FMT by colonoscopic administration. Changes in the colonic microbiota were assessed by 16S rDNA-based microbial community profiling using high-throughput pyrosequencing from mucosal and stool samples. RESULTS: All patients experienced short-term clinical improvement within the first 2 weeks after FMT. However, none of the patients achieved clinical remission. Microbiota profiling showed differences in the modification of the intestinal microbiota between individual patients after FMT. In 3 patients, the colonic microbiota changed toward the donor microbiota; however, this did not correlate with clinical response. On phylum level, there was a significant reduction of Proteobacteria and an increase in Bacteroidetes after FMT. CONCLUSIONS: FMT by a single colonoscopic donor stool application is not effective in inducing remission in chronic active therapy-refractory UC. Changes in the composition of the intestinal microbiota were significant and resulted in a partial improvement of UC-associated dysbiosis. The results suggest that dysbiosis in UC is at least in part a secondary phenomenon induced by inflammation and diarrhea rather than being causative for inflammation in this disease.

A case of opportunistic skin infection with Mycobacterium marinum during adalimumab treatment in a patient with Crohn's disease.

Opportunistic infections, especially reactivation with M. tuberculosis, are major complications during treatment with anti-TNF agents. Infections with atypical mycobacteria like Mycobacterium marinum are rare and tend to turn into a difficult and prolonged course due to delayed diagnosis. This is the first case of M. marinum infection during adalimumab therapy in a patient with Crohn's disease. The most important diagnostic step was a detailed medical history as PCR tested for M. tuberculosis and for atypical subspecies was false negative. Up to now a discontinuation of anti-TNF therapy has been recommended, however, there is no consensus about the reintroduction of biologicals after sufficient anti-infective therapy. In this patient anti-TNF therapy had to be reintroduced because of increasing activity with no relapse of M. marinum after a follow-up of 12 months.

Diarrhea in chronic inflammatory bowel diseases.

Diarrhea is a common clinical feature of inflammatory bowel diseases and may be accompanied by abdominal pain, urgency, and fecal incontinence. The pathophysiology of diarrhea in these diseases is complex, but defective absorption of salt and water by the inflamed bowel is the most important mechanism involved. In addition to inflammation secondary to the disease, diarrhea may arise from a variety of other conditions. It is important to differentiate the pathophysiologic mechanisms involved in the diarrhea in the individual patient to provide the appropriate therapy. This article reviews microscopic colitis, ulcerative colitis, and Crohn's disease, focusing on diarrhea.

Austrian infliximab experience in Crohn's disease: a nationwide cooperative study with long-term follow-up.

OBJECTIVE: To determine the nationwide experience with infliximab for the treatment of Crohn's disease in Austria. DESIGN: National multicentre retrospective postal questionnaire survey. SETTING AND PARTICIPANTS: All institutions using infliximab for Crohn's disease in the years 1999 and 2000 were identified by the registry of the local provider of this drug. OUTCOME MEASURES: Response after first treatment course according to physician global assessment, number of subsequent infliximab infusions, disease activity at end of follow-up, avoidance of steroids, frequency of surgery for Crohn's disease, and adverse events. RESULTS: Questionnaires were returned by 32/35 (91%) centres approached. A total of 748 infusions were administered to 153 patients. After the first treatment course an excellent or good response occurred in 48/58 (83%) patients with luminal disease, and in 67/95 (71%) patients with fistulous disease (P < 0.05). After the first treatment course 108 (71%) patients received further infliximab therapy. At a mean follow-up of 29 months, 50% of patients had improved since baseline without requiring surgery for Crohn's disease. Steroid withdrawal was achieved in 25% of patients. Surgery had been performed in one-third of patients and was associated with lacking response to the first treatment course (P < 0.001) and with fistulous disease (P = 0.012). Co-medication with azathioprine favoured the initial response and steroid withdrawal (P < 0.05). One patient died from myocarditis; other adverse events were consistent with that seen in other studies of infliximab. CONCLUSIONS: The Austrian experience with infliximab for Crohn's disease is in general accordance with results from clinical trials and post-marketing studies from single centres. A substantial subgroup of patients appear to have a prolonged benefit from infliximab therapy.

Effect of prenatal cortisone on spontaneous bacterial translocation from gastrointestinal tract in neonatal rat.

The immature host is prone to the passage of bacteria across the gut mucosal barrier. Corticosteroids accelerate the maturation of the intestinal mucosa and alter the composition of the gut bacterial flora. The present study was performed to assess the effect of prenatal cortisone on bacterial translocation in the neonatal rat. Time-pregnant Sprague Dawley rats were randomized on the 19th day of gestation for intraperitoneal injection of either 20 mg/100 g body weight of hydrocortisone or saline. Rats delivered spontaneously and the offspring were suckled ad libitum by the dam. Rat pups (N = 82) were killed 1 or 9 days after delivery. Mesenteric lymph nodes, liver, heart blood, and the terminal ileal loop were excised and quantitatively analyzed for bacteria. After one day, the proportion of rats with positive translocation was not significantly different between the two treatment groups (saline 62%, cortisone 80%, P = NS). By day 9, translocation had increased in the saline group (P = 0.03 vs day 1), did not significantly change in the cortisone group, and was significantly lower in rats treated with cortisone compared with the saline control (saline 90%, cortisone 60%, P = 0.02). The decrease in bacterial translocation after treatment with cortisone was associated with significantly lower total bacterial counts in the ileum (P < 0.05). Cortisone did not reduce bacterial counts in extraintestinal organs with positive translocation. In conclusion, prenatal treatment with cortisone reduces the incidence of spontaneous bacterial translocation from the intestine but not the concentration of translocated bacteria in extraintestinal organs of 9-day-old rats. Cortisone-induced changes of the intestinal microflora may have contributed to the reduction in translocation frequency.