Fat composition may be a clue to explain the primary therapeutic effect of enteral nutrition in Crohn's disease: results of a double blind randomised multicentre European trial.

BACKGROUND: Dietary fat has been suggested to determine the therapeutic effect of enteral diets in Crohn's disease. AIM: To assess the efficacy of two whole protein based diets with different fat compositions (n6 polyunsaturated fatty acids v monounsaturated fatty acids) in inducing clinical remission in active Crohn's disease compared with steroids. METHODS: Sixty two patients with active Crohn's disease were randomised to receive, for not more than 4 weeks: (a) a polymeric enteral diet containing 35 g of lipids per 1000 kcal, high in oleate (79%) and low in linoleate (6.5%) (PEN1), (b) an identical enteral diet except for the type of fat which was high in linoleate (45%) and low in oleate (28%) (PEN2), or (c) oral prednisone (1 mg/kg/day). Diets were double blindly administered. The steroid group received a conventional ward diet. Treatment failure was considered when remission was not achieved at week 4. Clinical activity and biological and nutritional parameters were monitored. Independent predictors of remission were identified by stepwise logistic regression analysis. RESULTS: Overall remission rates (by intention to treat) were 20% (4/20) for PEN1, 52% (12/23) for PEN2, and 79% (15/19) for steroids (overall p=0.001; p<0.0005 steroids v PEN1, and p=0.056 PEN2 v PEN1). After excluding those patients who were non-compliant during the first week (per protocol analysis), remission rates were 27%, 63%, and 79%, respectively (p=0.008, steroids and PEN2 v PEN1). After adjusting for confounding variables, PEN1 remained significantly associated with a poor response. CONCLUSION: The type of dietary fat may be of importance for the primary therapeutic effect of enteral nutrition in active Crohn's disease.

Short- and long-term outcome of severe alcohol-induced hepatitis treated with steroids or enteral nutrition: a multicenter randomized trial.

Steroids are recommended in severe alcohol-induced hepatitis, but some data suggest that artificial nutrition could also be effective. We conducted a randomized trial comparing the short- and long-term effects of total enteral nutrition or steroids in these patients. A total of 71 patients (80% cirrhotic) were randomized to receive 40 mg/d prednisolone (n = 36) or enteral tube feeding (2,000 kcal/d) for 28 days (n = 35), and were followed for 1 year or until death. Side effects of treatment occurred in 5 patients on steroids and 10 on enteral nutrition (not significant). Eight enterally fed patients were prematurely withdrawn from the trial. Mortality during treatment was similar in both groups (9 of 36 vs. 11 of 35, intention-to-treat) but occurred earlier with enteral feeding (median 7 vs. 23 days; P =.025). Mortality during follow-up was higher with steroids (10 of 27 vs. 2 of 24 intention-to-treat; P =. 04). Seven steroid patients died within the first 1.5 months of follow-up. In contrast to total enteral nutrition (TEN), infections accounted for 9 of 10 follow-up deaths in the steroid group. In conclusion, enteral feeding does not seem to be worse than steroids in the short-term treatment of severe alcohol-induced hepatitis, although death occurs earlier with enteral nutrition. However, steroid therapy is associated with a higher mortality rate in the immediate weeks after treatment, mainly because of infections. A possible synergistic effect of both treatments should be investigated.

[Persistent leucocytosis as initial manifestation of Whipple's disease and development of gastric cancer in the follow up]. / Leucocitosis persistente como debut de la enfermedad de Whipple con desarrollo de cáncer gástrico en el seguimiento.

We report the case of a 57 year old male with Whipple's disease. The patient was asymptomatic and an unexplained peripheral leucocytosis was found in a routine examination. It persisted as the only abnormality for one year and then he developed articular symptoms, diarrhoea and weight loss. The diagnosis was confirmed by duodenal biopsy five years later. The leucocyte count ranged between 14,000 and 22,000 leuc/mm3. Response to cotrimoxazole was favourable with disappearance of all signs and symptoms, including leucocytosis. In the last endoscopic control, eight years after initial manifestations, an intramucosal gastric adenocarcinoma was diagnosed.

Randomized clinical trial of Plantago ovata seeds (dietary fiber) as compared with mesalamine in maintaining remission in ulcerative colitis. Spanish Group for the Study of Crohn's Disease and Ulcerative Colitis (GETECCU).

OBJECTIVE: Butyrate enemas may be effective in the treatment of active distal ulcerative colitis. Because colonic fermentation of Plantago ovata seeds (dietary fiber) yields butyrate, the aim of this study was to assess the efficacy and safety of Plantago ovata seeds as compared with mesalamine in maintaining remission in ulcerative colitis. METHODS: An open label, parallel-group, multicenter, randomized clinical trial was conducted. A total of 105 patients with ulcerative colitis who were in remission were randomized into groups to receive oral treatment with Plantago ovata seeds (10 g b.i.d.), mesalamine (500 mg t.i.d.), and Plantago ovata seeds plus mesalamine at the same doses. The primary efficacy outcome was maintenance of remission for 12 months. RESULTS: Of the 105 patients, 102 were included in the final analysis. After 12 months, treatment failure rate was 40% (14 of 35 patients) in the Plantago ovata seed group, 35% (13 of 37) in the mesalamine group, and 30% (nine of 30) in the Plantago ovata plus mesalamine group. Probability of continued remission was similar (Mantel-Cox test, p = 0.67; intent-to-treat analysis). Therapy effects remained unchanged after adjusting for potential confounding variables with a Cox's proportional hazards survival analysis. Three patients were withdrawn because of the development of adverse events consisting of constipation and/or flatulence (Plantago ovata seed group = 1 and Plantago ovata seed plus mesalamine group = 2). A significant increase in fecal butyrate levels (p = 0.018) was observed after Plantago ovata seed administration. CONCLUSIONS: Plantago ovata seeds (dietary fiber) might be as effective as mesalamine to maintain remission in ulcerative colitis.

[Silent axial arthropathy in inflammatory bowel disease. Clinical, radiological and genetic characteristics]. / Artropatía axial silente en la enfermedad inflamatoria intestinal. Características clínicas, radiológicas y genéticas.

OBJECTIVES: To evaluate the prevalence, clinical and radiological characteristics, association with HLA B27 in a subgroup of patients with inflammatory bowel disease (IBD) and subclinical sacroileitis. The sensitivity of the diagnostic criteria for spondyloarthropathy in this group of patients is evaluated. MATERIALS AND METHODS: All patients with inflammatory bowel disease attending an outpatient gastroenterology unit from January 1994 to June 1994 were recruited. A total of 62 patients with IBD and without clinical evidence of axial involvement were included in the study. The demographic, clinical, and radiological characteristics were collected. The radiological examination included PA and lateral views for the dorso-lumbar, and three views (Ferguson, right and left oblique views) for the sacroiliac joints. Films were interpreted by three independent readers. The HLA B27 allele distribution was analyzed in the 62 patients and in 80 healthy controls. The modified New York criteria, Amor criteria, and European Spondyloarthropathy Study Group criteria were evaluated. Patients were prospectively followed for two years with the same initial protocol. The statistical management of data was performed with the information program SPSS/PC. RESULTS: Fifteen cases of silent sacroileitis were detected, and most of them were grade 2 unilateral sacroileitis. There was no correlation between sacroileitis and IBP type, extradigestive symptoms, disease duration, sex, or peripheral arthritis. The frequency of HLA B27 in the sacroileitis group was 20% (p < 0.05). During the two-year follow-up period none of these cases has changed from diagnostic category. The sensitivity of diagnostic the criteria for spondyloarthropathy was low in these patients (40%-53%). CONCLUSIONS: A high frequency of asymptomatic sacroileitis in patients with IBD was detected. We propose the term Silent Axial Arthropathy to define this category of patients and, as with other authors, we consider this is a third form of rheumatic syndrome in IBD, different from the classical forms of peripheral arthritis and ankylosing spondylitis.

[Etiology and epidemiology of 547 episodes of acute viral hepatitis diagnosed in adults in a general hospital (1983-1994)]. / Etiología y epidemiología de 547 episodios de hepatitis viral aguda diagnosticados en adultos en un hospital general (1983-1994).

The etiology and epidemiology of 547 consecutive episodes of acute viral hepatitis in adults and diagnosed in a general hospital over 12 years (1983-1994) were prospectively analyzed as were the changes observed during the two halves of the study period. Of the 547 episodes, 25.4% were of type A, 41.1% type B, 21.9% type C, 6.6% non A, non B, non C, 2.4% type D, 1.1% by cytomegalovirus and 1.4% by the Epstein-Barr virus. The proportion of hepatitis A increased from 21.5% from 1983-1988 to 34.1% from 1989-1994 (p = 0.002), while hepatitis C decreased from 24.9% to 15.3% (p = 0.01) during the same periods. The proportion of hepatitis B observed in intravenous drug addicts fell from 56.1% in the first period to 39.3% in the second period (p = 0.03), while sexually transmitted hepatitis B rose from 7.3% to 22.9% (p = 0.002). A decrease was observed in the cases of hepatitis C in both periods in the intravenous drug addict cases (60.6% vs. 34.6%; p = 0.03) with an increase being observed in the C virus transmitted by unapparent mechanisms (2.1% vs. 23.1%; p = 0.001). These results suggest that modifications may currently be observed in the epidemiology of the viral hepatitis in Spain and that these trends should be taken into account when planning preventive strategies.

Tuberculous peritonitis: diagnostic value of ascitic fluid pH and lactate.

BACKGROUND: The analytical pattern of ascitic fluid in peritoneal tuberculosis is frequently similar to that found in other causes of ascites. The diagnostic value of the ascitic fluid pH and lactate in cases of tuberculous peritonitis has not yet been established. METHODS: Ascitic fluid pH, lactate, total proteins, cell count, lactate dehydrogenase, glucose, and their blood-ascitic gradients were determined in 10 patients with tuberculous peritonitis (group I). These results were compared with those obtained from 40 patients with cirrhotic sterile ascites (group II), 16 patients with spontaneous bacterial peritonitis (group III), and 18 patients with malignant ascites (group IV). RESULTS: A decreased pH and an elevated lactate level in ascitic fluid were found in patients in group I in comparison with those in group II (p < 0.001). No significant differences were found between group I and groups III and IV. The arterial blood-ascitic fluid pH gradient was more than 0.10 (p < 0.001), and the ascitic fluid-serum lactate gradient was greater than 15 mg/dl (p < 0.001) in group I when compared with group II. No significant differences were found between group I and groups III and IV. CONCLUSIONS: Ascitic fluid pH and lactate are useful markers in differentiating tuberculous peritonitis from cirrhotic sterile ascites. However, these variables lack specificity, as they are also decreased and increased, respectively, in cases of malignant ascites and spontaneous bacterial peritonitis.

[Behavioral profile of the patient with Crohn's disease]. / Perfil comportamental del paciente con enfermedad de Crohn.

The present study describe epidemiology, clinics and psychology of 92 patients with Crohn's Disease. The study has been designed in order to assess the psychological repercussion and the way of life secondary to Crohn's Disease; and assess the relationship between environmental factors and behavioral reactions with the symptomatology. The psychological assessment show higher levels of neurosis (66.9% vs 50%), anxiety (55% vs 50%), depression (49.2 vs 35) and stress (13 vs 10) in these patients than in a normal population. The patients describe stresses related to Crohn's Disease: the disease's severity and chronicity, ineffectiveness of the medical treatment and the limited way of life; 83.9% of patients describe concurrent psychosocial stress not directly attributable to Crohn' Disease: conflicts with parents, friends, work. We confirm the utility of psychological treatment in the management of these patients.

[Ulcerative colitis and amyloidosis. Presentation of a case and review of the literature]. / Colitis ulcerosa y amiloidosis. Presentación de un caso y revisión de la literatura.

A case of ulcerative colitis associated with secondary amyloidosis in a 62-year-old man who died from septic shock and pneumonia complicating head injury is reported. Amyloid deposition was incidentally found at autopsy. Proteinuria and hepatomegaly discovered a few days before his death were the only signs of amyloidosis. The postmortem examination showed chronic ulcerative colitis (remitting form) with pseudo-polyps and amyloid deposition in the liver, spleen, pancreas, rectum, adrenals and kidneys. Although secondary amyloidosis complicating with Crohn's disease has been frequently reported, amyloidosis associated with ulcerative colitis has been exceptionally described and only 10 cases have been collected from the literature.

[Crohn's disease and amyloidosis. An association to be considered]. / Enfermedad de Crohn y amiloidosis. Una asociación a considerar.

Two instances of Crohn's disease and amyloidosis are presented. The time elapsed between the diagnosis of Crohn's disease and that of amyloidosis was 2 and 8 years respectively. The first case had hepatosplenomegaly and moderate proteinuria; the other one, severe proteinuria in the nephrotic syndrome range. One patient had ileocolic disease and the other disease limited to the terminal ileum. In both cases renal functional was normal. The diagnosis was made by liver biopsy in one patient and by repeated renal biopsy in the one with nephrotic syndrome. Ileocolic resection was undertaken in one patient without complications. Screening for amyloidosis is important in patients with Crohn's disease.

[Prognosis of patients with irritable intestine syndrome. A prospective study with 1 year follow-up]. / Pronóstico de los pacientes con síndrome del intestino irritable. Estudio prospectivo con seguimiento de un año.

An analysis was made of the prognosis over a one-year follow-up period of a consecutive series of 86 out patients with irritable bowel syndrome (SII) who were treated randomly with an antispasmodic (otilonium) or a tranquilizer (clobazam), and the existence of factors, mainly psychological, that could worsen it was determined with the Zung anxiety test and the Hamilton depression scale. We confirmed that irritable intestine syndrome is a chronic disease, with a mean course of 13 +/- 12.5 years at the time of consultation. A large proportion of patients had permanent problems (58.1%) and did not experience important changes in the intensity of symptoms throughout evolution (68.6%). Although most improved initially with the treatment instated (76.7%), the improvement was rarely complete (11.8%). A year after beginning treatment, 61.6% were the same or worse than before the index consultation. In the group of patients with a good course, the proportion of those that correctly followed medical treatment and of those who had experienced more or less lengthy asymptomatic periods before consultation was significantly larger. In the group of patients with poor evolution, the scores on the Zung anxiety test and Hamilton depression scale were significantly higher than in those who evolved favorably. Neither consultation of a specialist nor the treatment used in this study seem to have contributed to an evident improvement in the prognosis.