Treatment of refractory distal ulcerative colitis with short chain fatty acid enemas.

OBJECTIVES: To determine the efficacy and safety of short chain fatty acids (SCFA) in the treatment of refractory distal ulcerative colitis (UC). METHODS: Ten patients with distal UC who had failed to respond to rectal and oral therapy with 5-ASA and corticosteroids were treated with twice daily enemas containing sodium acetate 60 mM, sodium propionate 30 mM, and sodium butyrate 40 mM titrated to a pH of 7. Patients were assessed clinically (rectal bleeding, tenesmus, bowel motions), endoscopically, and histologically before and after 6 wk of therapy. In addition, patients gave a self-assessment of the efficacy of treatment. RESULTS: Five of the 10 patients responded clinically, and four of these had a clinical remission as reflected by a decrease in degree of bleeding (2.2 vs. 1.2, p < 0.05) and tenesmus (1.6 vs. 0.3, p < 0.05) and by global self-assessment. Endoscopic improvement occurred in five (6.78 +/- 0.83 vs. 4.44 +/- 2.7, p < 0.05). Histologically, no improvement was noted. No side effects were noted, and no patient's condition deteriorated. CONCLUSIONS: In this open-labeled study in patients with highly refractory distal UC, 50% had an overall clinical and endoscopic response. Forty percent of the patients assessed the treatment to be superior to previous treatments and expressed a desire to continue. This trial confirms other studies as to the efficacy of this treatment and further confirms the need for controlled trials of this promising therapy.

Is duodenal ulcer a seasonal disease? A retrospective endoscopic study of 3105 patients.

The monthly pattern of distribution of endoscopically diagnosed duodenal ulcer disease was evaluated for the years 1975-1989. A retrospective review of 3105 endoscopies performed for peptic disease was recorded and analyzed. Among them, 2020 endoscopies revealed duodenal bulb deformity, and 1035 revealed the presence of acute duodenal ulcer. Chi-square analysis of the data for goodness of fit revealed statistical differences for certain months. Slightly more patients with chronic deformity presented in June and November, whereas more patients with acute duodenal ulcer presented in July, November, and December (p < 0.001). The ratio of acute to chronic disease was nearly constant throughout the year. The Edwards chi 2 test for seasonal trends did not reveal any seasonality (p > 0.75). The differences observed in June-July and November-December, as compared with the rest of the year, were so small that they should not be relied upon for the clinical management of peptic disease.

Effect of clonidine on gallbladder contraction and small bowel transit time in insulin-treated diabetics.

Cholelithiasis is more prevalent in diabetics than in nondiabetics. Gallbladder dysmotility is supposed to be one of the causative factors. Reduced alpha-adrenergic tone has been demonstrated in the enterocytes of diabetic rats, and its correction by clonidine might explain the beneficial effect that the drug has on diabetic diarrhea. We therefore surmised that diabetic cholecystoparesis could also be due to alpha-adrenergic alterations. To test this hypothesis, we studied gallbladder contractions by real time ultrasonography, and small bowel transit time by lactulose hydrogen breath test, in 13 insulin-requiring diabetics before and after administration of the alpha-adrenergic stimulant clonidine (0.3 mg orally). That plasma levels were sufficient was evidenced indirectly by a fall in blood pressure. Clonidine significantly improved the rate of emptying (0.0193 +/- 0.00057/min vs. 0.0318 +/- 0.0027/min; p less than 0.005), but not the fasting and residual gallbladder volumes. Small bowel transit time was significantly prolonged after clonidine (169 +/- 17 min vs. 208 +/- 17; p less than 0.05). These results suggest that 1) reduced alpha-adrenergic tone corrected by clonidine may be present in the diabetic gallbladder, and 2) clonidine's antidiarrheal effect might be explained, at least in part, by a prolongation of the small bowel transit time.

Successful treatment of pancreatic pseudocyst with a somatostatin analogue and catheter drainage.

We report a patient with bile duct stone-induced pancreatitis who subsequently developed a large pseudocyst that became infected after endoscopic retrograde cholangiopancreatography (ERCP) was done for extraction of the stones. Percutaneous external drainage allowed control of the infection, but failed to seal the pseudocyst. We then treated the patient with a long-acting somatostatin analogue which shrunk the cyst within a week. Patients with pancreatic pseudocyst resistant to drainage should be offered a course of somatostatin before surgery is contemplated.

Campylobacter pylori in Israel: prospective study of prevalence and epidemiology.

Antral biopsy samples were taken from 147 patients undergoing gastroscopy. Campylobacter pylori was cultivated from 100 of these patients. C. pylori was isolated from 76% of the specimens showing any degree of histologic gastritis, but from only 11% of specimens with completely normal histology. A questionnaire was completed on all patients and included demographic, epidemiologic and clinical information. Sephardic origin, smoking, and a bad taste in the mouth were more prevalent in the campylobacter-positive group. Previous use of antibiotics was negatively associated with the presence of C. pylori. Histologically confirmed gastritis was highly associated with the presence of C. pylori, especially in the moderate or severe grades in which 84% of biopsy specimens were positive. C. pylori was also cultivated from 50% of patients with mild gastritis, in 88% of patients with duodenal ulcer and in 71% of patients with gastric ulcer. The presence of C. pylori in 11% of normal specimens and the absence of C. pylori in 24% of specimens with gastritis further raises the question of the exact role played by C. pylori in the etiology of gastritis.

Ornithine decarboxylase: an unreliable marker for the identification of population groups at risk for colonic neoplasia.

Ornithine decarboxylase (ODC) is the first and rate-limiting enzyme in the polyamine biosynthetic pathway. Polyamines have been studied as potential markers of neoplastic diseases, including colonic cancer. Previous studies have pointed out the possible value of this enzyme as a biochemical marker of colonic neoplasia, we studied 100 patients undergoing diagnostic total colonoscopy. There were 40 normal controls and 20 patients in each of the following groups: 1) family members of patients diagnosed as having colonic tumors, 2) patients with adenomas, and 3) patients with colonic adenocarcinoma. Six forceps biopsies were obtained from the normal-appearing sigmoid mucosa for the analysis of ODC. No difference was found among the four groups studied. We therefore conclude that ODC is unreliable for clinical use as a biochemical marker for the identification of population groups at risk for colonic neoplasia.

Postpartum restoration of pregnancy-induced cholecystoparesis and prolonged intestinal transit time.

Pregnancy-induced cholecystoparesis and prolonged intestinal transit are well known, but their duration after delivery and any relation to the rapid decline of serum progesterone have not been studied in the early postpartum period. We studied gallbladder and small intestinal motor function in 10 women during the third trimester of pregnancy and in the second and fourth days postpartum, comparing the results to a control group of 8 women during the follicular phase of the menstrual cycle. Gallbladder motor function was evaluated by real-time ultrasonography and intestinal transit time was measured by the lactulose hydrogen breath test. Postpartum correction of gallbladder and intestinal motor function is early and is initially related to the fall of serum progesterone. Other as yet unknown mechanisms operate later to achieve normalization of gallbladder motor function.

Alteration in aminotransferase levels in rats after acute hepatic injury.

Measurement of serial aspartate aminotransferase (AST) and alanine aminotransferase (ALT)--formerly GOT and GPT--in both serum and urine, were carried out in rats with hepatocellular injury induced by ingestion of carbon tetrachloride. Contrary to the accepted clinical observations, the AST was initially higher than the serum ALT. Also, the clearance of AST from blood to urine was more rapid than that of ALT. This difference in enzyme excretion resulted in a more persistent elevation of ALT than of AST in the serum after hepatic injury. The persistent elevation of serum ALT correlates well with the timing of the clinical observation of higher ALT in patients with hepatitis.

Incidence and prevalence of ulcerative colitis in the Jewish population of Jerusalem.

It has been generally accepted that ulcerative colitis is more common among Jews than among non-Jews. This has been challenged by a study performed in Tel Aviv. Since further investigation was indicated, we performed a survey of the incidence and prevalence of ulcerative colitis in the Jewish population of Jerusalem for the 6-year period, 1973-78. The prevalence on 31 December 1978 was 56.9/100,000, and the average annual incidence was 6.3/100,000. This prevalence is considerably higher than the 44.1/100,000 found in a similar 6-year study of the general population of Copenhagen. Compared with the previously mentioned study, which reported a prevalence of 37.3/100,000 and an incidence of 3.6/100,000 in the presumably corresponding Jewish population of Tel Aviv, we found both the prevalence and incidence to be considerably greater. When the European- and American-born Jews in the Jerusalem population were considered separately, the prevalence rose to 92.9/100,000 and the incidence to 11.2/100,000--much higher results than in previously reported studies of similar duration. The prevalence in Asian-born Jews was 31.3/100,000 and in African-born 6.5/100,000. Peak incidence was in the 20- to 25-year-old range. Of the patients with ulcerative colitis who had immigrated to Israel from Western countries, 38% had in fact been symptomatic prior to their immigration. Only 5% of patients immigrating from Eastern countries experienced symptoms prior to immigration.

Lymphocyte response to a bovine milk protein in ulcerative colitis.

A recently described in vitro test for cow's milk protein hypersensitivity was applied to adult patients with ulcerative colitis. The test system involved the culture of their peripheral blood lymphocytes with and without beta-lactoglobulin, and the results were expressed as a stimulation index. Stimulation with beta-lactoglobulin was significantly higher (P less than 0.02) in patients with active disease than in those with inactive disease or in healthy controls. beta-Lactoglobulin was the only one of four cow's milk proteins that showed this effect. It is concluded that the cow's milk protein beta-lactoglobulin has a specific blastogenic effect on the lymphocytes of patients with active ulcerative colitis, and, therefore, may serve as a marker of disease activity.

Colonoscopic perforation: its emergency treatment.

One of the accepted complications of colonoscopy is perforation. This is known to occur in greater frequency in patients having undergone previous pelvic or colonic surgery, as well as patients suffering from diverticulosis. A case is presented of colonic perforation during diagnostic examination in an area of adhesions secondary to pelvic surgery. Immediately after the perforation, the patient entered into vascular collapse and respiratory distress, with a distended abdomen. The introduction of a large bore intravenous catheter into the abdominal cavity with the release of the pneumoperitoneum resulted in an instantaneous return of vital signs and the patient subsequently underwent surgery and recovered. It is felt that this method of emergency treatment can be life-saving in a patient perforating during colonoscopy.