Microscopic colitis and small intestinal bacterial overgrowth--diagnosis behind the irritable bowel syndrome?

UNLABELLED: Some patients previously diagnosed with irritable bowel syndrome (IBS) may develop microscopic colitis or small intestinal bacterial overgrowth (SIBO). AIM: To estimate the prevalence of microscopic colitis and SIBO in patients with IBS, to evaluate the symptoms and the efficacy of treatment. MATERIAL AND METHODS: We examined patients with IBS admitted in our clinic during a three-year period. We identified patients with microscopic colitis by performing total colonoscopy with multiple biopsies from normal intestinal mucosa and those with SIBO by performing a H2-breath test with glucose. We compared the symptoms and the effectiveness of the treatment. RESULTS: Out of the 132 patients initially diagnosed with IBS 3% (n=4) had microscopic colitis and 43.9% (n=58) had SIBO. Diarrhea was the main symptom in patients with microscopic colitis and SIBO (p=0.041), while abdominal pain, abdominal bloating and flatulence were prominent in IBS patients (p=0.042; p=0.039; p=0.048). Specific treatment with rifaximin in SIBO patients negativated H2-breath test in 70.9% cases. CONCLUSIONS: Patients suspected to have irritable bowel syndrome should be evaluated for microscopic colitis and SIBO. The proper diagnosis and the specific treatment may cure some difficult cases of the so called "irritable bowel syndrome".

[Periampullary carcinoma or tumor of the ampulla of Vater?]. / Carcinom periampular sau ampulom vaterian?

The term periampullary carcinoma is widespread in the medical literature. This is a consequence of the difficulty to establish the histogenesis of the tumor. The question is open if the tissular origin of the mass can be established after an accurate pathological examination and if the effort to distinguish between the so called "periampullary tumors" originating in the pancreatic tissue and those of a biliary, ampullary, duodenal or papillary origin can be useful; if there are significant differences among clinical signs, surgical approach and prognosis of these two sub-classes of "periampullary carcinomas". Between 1990 and 1998 54 patients were operated with the operative diagnosis of periampullary carcinoma in our department. In 35 cases a resection was performed. This 35 operative specimens were retrospectively analysed (operative protocols, macroscopical description of the resected specimens, reevaluation of the slides and new sections from the parafin blocks). Same macroscopic pathological features of the tumors were taken into consideration as suggestive for the pancreatic origin as the concentric development. On the contrary, the infiltrative and exofitic aspects were considered signs for a biliary respectively duodenal origin. The microscopic examination showed 32 adenocarcinoma and 3 undifferentiated carcinomas. In 9 cases a squamous metaplasia, in 22 cases the microscopic invasion of the duodenal wall and in 8 the invasion of the pancreas tissue were present. In 6 cases we found lymph nodes metastasis. The ductal pattern and the squamous metaplasia are suggestive for a pancreatic histogenesis. The papillary proliferation is more characteristic for a biliary or a duodenal origin. After this retrospective analysis we were able to establish the histologic origin of the tumor as follows: 11 with biliary origin, 10 with pancreatic origin and in 14 cases the diagnosis remains "periampullary carcinoma". The term periampullary carcinoma is not a well defined pathological entity. It seems to be an expression of the impossibility to define more accurate the origin of these tumors. Until now, the term remains still useful. However it is reasonable and useful to make the effort to limit such an imprecise diagnosis and to specify the pancreatic, biliary or duodenal histogenesis of the tumor. According to our data as well as to other authors, this accuracy is beneficial for the therapeutic strategy.

Correlation of some cytomorphological and ultrastructural modifications of synovial fluid in juvenile chronic arthritis.

Experiments have been performed on 25 synovial fluid samples from patients with juvenile chronic arthritis (mono- and polyarticular forms) and with hydroarthrosis, the latter considered as controls. By cytomorphologic studies, we determined the cellularity, ragocytosis and synoviocytogram of the synovial fluid cellular pellet and found out that the synovial fluid from cases of juvenile chronic arthritis is characterised by cytosis (11.270/mm3; 15.275/mm3), polynucleosis (67.3%, 72.2%) and ragocytosis (12.8%, 17.5%) whereas hydroarthrosis synovial fluid is characterised by lymphocytosis (47.8%). Ultrastructurally, ragocyte-like polymorphonuclear cells are characterised by: a) segmentation of the nucleus and preferential concentration of chromatime on the periphery of the nuclear membrane: b) frequent intracytoplasmic inclusions and phagolysosomes. Phagocyte-like mononuclear cells present numerous inclusions and phagolysosomes, certainly indicating an endocytic activity. Lymphocytes are characterised by a narrow cytoplasmic rim, presenting relatively few cellular organelles. They coexist with immunely activated lymphocytes rich in cytoplasm, mitochondria and endoplasmic reticle. Corroboration of cytomorphological and ultrastructural date enables us to explain the morphological modifications and emphasize their importance in juvenile chronic arthritis pathogenesis and diagnosis.

Histopathological and histoenzimological investigations of the rheumatoid articular cartilage.

Twenty seven biopsies of articular cartilage taken intraoperatively from patients with Rheumatoid arthritis (RA) and from control patients with traumas were examined using histopathological techniques (HE, VG, PAS-Alcian, Gömöri, Safranine 0) and histoenzymological techniques (Acid phosphatase-lysomal marker, Chondroitinsulphatase, Peroxidase). Histopathologically, the rheumatoid articular cartilage appears with superficial and deep cartilaginous fissures, frequent perichondrocytic gaps associated with modification of the tinctorial activity. At the pannus synovia-cartilage junction we found invasive and destructive synovial inflammatory infiltrates penetrating and eroding the cartilage. Histoenzymologically, the rheumatoid chondrocytes have a high lysosomal potential (phosphatasic, chondroitinsulphatasic) and highly oxidative potential (peroxidasic) specific for lesion modifications.

Aspects of ankylosing spondylarthritis immunopathogenesis correlated with some immunoseric- and synovial parameters in the investigation of histopathological and electronmicroscopic alterations of the articular cartilage correlated with some immunoseric and synovial parameters.

Eighteen biopsies of articular cartilage taken intraoperatory from patients with Ankylosing Spondylarthritis (AS) and from others with traumatisms (controls) were investigated using histopathological (HE, VG, PAS-Alcian, Gömöri, Safranin 0), electronmicroscopic and histoenzymamologic techniques. Histopathologically, the synovitis in AS is characterized by abundant synovia lymphoplasmocytic infiltrates associated with aspects of vascular hyperplasia and fibrosis. At the pannus synovia-cartilage junction we found the invasive synovia lymphoplasmocytic infiltrates. The proteoglycan (PG) depletion is confirmed histopathologically by diminishing the Safranin 0 staining, then ultrastructurally by the existence of collagen revealing areas, whereas biochemically, by the presence of glycosaminoglycans (GAG) in serum and synovial fluid (SF). The morphological data were related to some immunological parameters involved in pathogenesis. In this way, we found pathological values of the immune circulating complexes (ICC) (serum, mean = 73.5 U; SF mean = 81.80 U) and of anti Collagen II antibodies (serum mean = 410 U; SF mean = 436 U). The reactive protein C acting in the phase (CRP) showed high pathological values both in serum (mean = 5.01 mg%) and in SF (mean = 3.6 mg%) of the patients with AS, emphasizing the inflammatory characteristics of the rheumatic disease. The presence of ICC, anticollagen II antibodies and GAS as well in synovia suggests that the inflammatory articulation in AS is a local potential antigen of collagen and proteoglycan nature.

Aspects of immunopathogenesis of rheumatoid arthritis correlated with some immunological parameters in histopathological and electronmicroscopical investigations of the articular cartilage.

The histopathological (H. E., V. G., PAS-Alcian, Safranine 0, Gömöri) and electron-microscopical investigations were carried out on twenty samples of articular cartilage taken during operations from patients with Rheumatoid Arthritis (R. A.) and from others with traumatism, as controls. Histopathologically, the rheumatoid synovial membrane is characterized by synovitis with abundant perivascular lymphoplasmocytic infiltrates. At the pannus synovia-cartilage junction we found the invasive and destructive inflammatory infiltrates penetrating and eroding the cartilage. The histopathological characteristics of the rheumatoid articular cartilage lie in alteration of tinctorial activity, affection of reticuline collagen network and the presence of superficial and deep cartilaginous fissures. The histopathological alterations were confirmed ultrastructurally. Immunologically we found pathological serum values regarding the immune circulating complexes (I. C. C.) (mean = 104 +/- 1.04 U), anticollagen II antibodies (mean = 538 +/- 5 U), reactive Protein C (mean = 16.75 +/- 1.95 mg%) and orosomucoid (mean = 151.1 +/- 4.91 mg%), in seropositive R. A. The corroboration of histopathological, electronmicroscopical and immunological data show the inflammatory and autoimmune feature of this rheumatic disease.

Cytomorphological, ultrastructural and immunological characteristics of the ovialsyn fluid in seropositive rheumatoid arthritis.

Experiments have been performed on 15 samples of synovial fluid (SF) from patients with seropositive rheumatoid arthritis (RA) (Latex 1/280 and Waaler Rose 1/1024) versus 10 SF samples from patients with hydroarthrosis, used as control. By cytomorphologic studies, we determined the cellularity, ragocytosis and synoviocytogram of the SF cellular pellet and found out that rheumatoid SF is characterized by cytosis (9953/mm3), ragocytosis (70%) and polynucleosis (73%) whereas hydroarthrotic SF is characterized by lymphocytosis (54.6%). Ultrastructurally, rheumatoid SF ragocytes present numerous intracytoplasmic inclusions and phagolysosomes, a fact that certainly evidences an endocytotic activity. At the level degenerative of PMN cells, (6%), the experiments evidenced the presence of some lysis cytoplasmic plateau associated with the absence of cellular organelles, as well as an alteration of the granulofibrillar structure of the nucleus. We also noticed cellular debris consisting of partially destroyed cellular organelles. By immunologic studies we obtained seric pathologic values for CIC (mean = 108.05 U), IgM (mean = 420 Ul/ml), IgG (mean = 355 Ul/ml), anti DNA antibodies (mean = 405 U) and anti collagen II antibodies (mean = 558 U). As regards the seric complement activity of C1q and C3 fractions, it was higher (mean = 18.87 mg% and mean = 109.94 mg%, respectively) than in the SF (mean = 5.78mg% and mean = 30.83 mg%, respectively). Corroborating the cytomorphological, ultrastructural and immunological data, we could better explain the lesional types examined and emphasize the importance of the immunomorphological changes in RA diagnosis.

Some humoral immunological aspects of the rheumatoid arthritis correlated with the ultrastructural changes of the rheumatoid synovial fluid.

We performed serologic and synovial investigations in rheumatoid (Latex 1/1280, 1/640, negative and Waaler Rose 1/1024, 1/512, negative), non-rheumatoid and control lots. The immunological results were correlated with ultrastructural changes found in the synovial fluid (SF) at the same titres of rheumatoid factor (RF). The pathologic values of the circulating immune complexes (CIC) (mean = 108.05 U), IgM (mean = 420 UI/ml), IgG (mean = 355.36 UI/ml), and anti-collagen II antibodies (mean = 558.6 U) were present at high titres of RF (Latex 1/1280, Waaler Rose 1/1024). These cases had also major ultrastructural changes of the nucleus and cytoplasm. We inferred from this the implication of the immune factors in the etiology and pathology of the Rheumatoid Arthritis (RA). The high, titres of RF were correlated with pathologic values of the C-reactive-protein (CRP) (mean = 13.31 mg%) and alpha-1-acid glycoprotein (A-1-GA) (mean = 158.3 mg%). The decline of the complement fraction C3 from the synovial fluid in RA confirms the immune character of the rheumatoid synovitis and may be useful in the diagnosis process. The significantly lower concentrations of the protease inhibitors alpha-1-anti-trypsin (A-1-AT) (mean = 165.1 mg%) and alpha-2-macroglobulin (A-2-M) (mean = 129.6 mg%) in synovial fluid suggest a diminution of the anti-proteasic activity due to local immune conflict.

Cytomorphological, ultrastructural and immunological particularities of the synovial fluid in seronegative rheumatoid arthritis.

Our studies on the cytomorphological and ultrastructural analysis of 15 Synovial Fluid (SF) samples from patients diagnosed with seronegative Rheumatoid Arthritis (RA) and 10 SF from patients with Hydroarthrosis considered as controls were carried out. By cytomorphological studies we determined the cellularity, ragocytosis and synoviocytogram. SF in seronegative RA is characterized by leucocytosis (7,656/mm3) with polynucleosis (65.38%) and ragocytosis (59.27%) versus hydroarthrosis SF defined morphologically by lymphocytosis (47%). Degenerative forms of ragocyte-like polymorphonuclears (PMN) cells, individualized by an ultrastructural alteration less evident than recorded in seropositive Rheumatoid Arthritis (RA), associated with a remarkable capacity of endocytosis. The ultrastructural alterations, immune complexes (CIC), the immunoglobulins (MG) and the anticollagen II antibodies, suggest the early implication of these immune parameters in etiopathogenesis. The corroboration of the cytomorphological, ultrastructural and immunological data allows the profound study of the etiopathogenic mechanism and may represent a paraclinical criterion for differentiated seronegative RA field.

An ultrastructural study of the synovial fluid (S.F.) in rheumatoid arthritis versus ankylotic spondylarthritis.

Our studies focused on the cytomorphological and ultrastructural analysis of ten synovial fluid (S.F.) samples from patients with serum positive rheumatoid arthritis (R.A.) (latex 1/1280, 1/640 and Waaler-Rose 1/1024, 1/1512) as compared to five S.F. sampes from patients with peripheral ankylotic spondylarthritis (A.S.). The cytomorphological investigation aimed at defining the cellularity, ragocytosis and synoviocytogram. We found out that the average number of cells (R.A. = 8060/mm3; A.S. = 6100/mm3), percentage of ragocytes (R.A. = 75%; A.S. = 25%), polymorphonuclear cells (R.A. = 70%; A.S. = 58%), degradative polymorphonuclear cells (R.A. = 7%, A.S. = 3%) and phagocytic mononuclear cells (R.A. = 16%; A.S. = 13%) are by far larger in R.A. than in A.S., whereas the lymphocyte percentage is much more reduced (R.A. = 13%; A.S. = 26%). Ultrastructurally, the rheumatoid S.F. ragocytes present specific intracytoplasmic inclusions and phagolysosomes pointing to an endocytotic activity. At the level of the degradative polymorphonuclear cells (7% cytomorphologically confirmed), the alteration of the granular-fibrillar structure of the nucleus and the presence of some cytoplasmic lysis areas were associated with the absence of cellular organelles. We also noticed cellular and collagen detritus. In A.S. the ultrastructural effect on the polymorphonuclear cells is much more reduced (3%) as compared to R.A. and resides in the dilatation of both mitochondrial cristae and granularendoreticular cisternae as well as in a slight concentration of the fibrogranular nuclear matter. The cells are considerably active in endocytosis. The phagocytotic mononuclear cells of the rheumatoid S.F. and A.S. are morphologically identical to the immunologically activated macrophages.(ABSTRACT TRUNCATED AT 250 WORDS)

Epstein-Barr virus (EBV). VII. Established lymphoid cell line (IVPat-88) obtained from synovial fluid of a patient with aseptic arthritis.

Attempts have been made to culture mononuclear cells from synovial fluid of 8 patients with arthropathy, and have led to the development of the lymphoid cell line IVPat-88. Cell line has been propagated by serial passages for more than 14 weeks in continuous culture. The cells grew as single, free-floating individuals, or in dense clumps without adherence to glass or plastic surface. All these cells were identified as altered lymphoblasts because of their growth pattern and uniform morphology, and the presence of Epstein-Barr Viral Capsid Antigen (VCA) in 5 to 10% of the cells. The cell concentration varied during the period of culture from about 300,000 to 1,700,000 cells per ml, and mean doubling time during phases of active growth was 42 and 60 hours in MEM and RPMI 1640 tissue culture media, respectively. The methods used and the characteristics of the cell line are described.

Advances in the physicochemical, immunologic and cytologic investigation of the synovial fluid.

Investigations of the pathologic synovial fluid (SF), carried out by numerous research teams, have attempted to elucidate certain pathogenic mechanisms suggestive for diagnosis and treatment. Recent studies have tried to draw some biorheologic patterns of the SF, useful for diagnosis and for the evaluation of certain therapies (synoviorthesis). A systematization of the microcrystalline arthropathies has been possible by microscopic examinations of the SF. Enzymologic studies have demonstrated the properties of enzymatic inhibitors of some classical antirheumatic drugs, suggesting the introduction of new antienzymatic products, and have supported the indication for synoviorthesis. Studies of the SF oligoelements have established new criteria for differential diagnosis, have suggested new treatments (by zinc compounds) and have offered explanations for the good effects of some drugs, such as D-penicillamine. Knowing the role of the toxic oxygen radicals in the pathogeny of the rheumatoid synovial inflammation, drugs with a protective action against the effects of free radicals have been introduced in the antirheumatic therapy. Analyses of the various SF cellular populations, including complex immunologic, cytoenzymatic, optic and ultrastructural cytologic investigations, are opening new prospects of clinical application. The general review of the above-mentioned problems is based on the personal experience of the authors and on the latest data in the specialty literature.