Compensatory enteral hyperalimentation for management of patients with severe short bowel syndrome.

In order to evaluate the effects of an unrestricted, compensatory, enteral hyperalimentation in patients with short bowel syndrome, we retrospectively selected from 128 consecutive patients with extensive small bowel resection a group of 25 who developed under this regimen a massive protracted diarrhea (fecal weight 2005-6188 g/day). All the patients but one were weaned from parenteral nutrition by the eighth day after admission. Although fecal weight increased in relation to the increase of the enteral intake, there was a significant gain of body weight, serum-albumin, and creatinine-height index and an improved fluid and electrolyte balance through the period of hospitalization. By contrast, 18 of the 25 patients developed hypocalcemia and/or hypomagnesemia. After discharge (median follow-up, three years), most patients resumed normal social activity. It is concluded that exclusively enteral hyperalimentation can stabilize most patients with severe short bowel syndrome even in the case of massive fecal losses.

Isotonic high-sodium oral rehydration solution for increasing sodium absorption in patients with short-bowel syndrome.

We compared the effect of a standard oral rehydration solution and a high-sodium polymeric-glucose solution on sodium absorption in short-bowel syndrome. Six patients with high jejunostomy were tested in a random order with the standard solution or a solution containing maltodextrins (18 g Glucidex 12/L) enriched with 2.5 g NaCl/L. Solutions were administered via a nasogastric tube at a rate of 2 mL/min. Jejunal effluent was collected during an 8-h period. The net 8-h fluid absorption was not significantly different in the two periods. Glucose absorption was greater than 90% of the administered amount for both solutions. Net sodium absorption was greater for the maltodextrin solution than for the standard solution (56 +/- 12 vs 24 +/- 20 mmol, P less than 0.05). We conclude that replacement of glucose with maltodextrins and addition of sodium in the standard oral rehydration solution results in improved sodium absorption in short-bowel syndrome.

Intestinal histoplasmosis in AIDS patients: report of three cases observed in France and review of the literature.

We report three cases of colonic histoplasmosis observed in a non-endemic area in patients with AIDS. The patients presented with fever, abdominal pain and an abdominal mass in the right lower quadrant. Diagnosis was obtained using Gomori-Crocott staining of endoscopic or surgical biopsies. One patient died without specific treatment and two patients had a complete remission when treated with intravenous amphotericin B but suffered a relapse when given oral itraconazole. Thus, physicians in areas where intestinal histoplasmosis is not endemic should be aware of the condition. Diagnosis can easily be obtained using Gomori-Crocott staining of colonoscopic biopsies; this should avoid unnecessary laparotomies and allow specific treatment to be instituted rapidly.

Treatment of refractory diarrhoea in AIDS with acetorphan and octreotide: a randomized crossover study.

OBJECTIVE: To compare the efficacy and tolerance of acetorphan, an orally active enkephalinase inhibitor whose antidiarrhoeal properties derive from a purely antisecretory activity, to that of octreotide, a subcutaneously administered somatostatin analogue, in the treatment of refractory diarrhoea in AIDS patients. DESIGN: An open randomized crossover trial. SETTING: The inpatient medical units of three hospitals. PATIENTS: Thirteen adult inpatients with AIDS and refractory diarrhoea that lasted for 35 +/- 8 weeks despite use of traditional antidiarrhoeal agents and was characterized by 7.0 +/- 1.2 stools/day, weighing 1033 +/- 174 g/day with a lipid output of 18.8 +/- 3.5 g/day. INTERVENTIONS: Acetorphan (100-300 mg thrice daily) and octreotide (50-150 micrograms thrice daily) were given in random order during two 1-week periods. MAIN OUTCOME MEASURES: Response was defined as a reduction by at least one-third of both daily stool number and weight. RESULTS: The mean daily stool number was reduced to 4.6 +/- 1.1 with acetorphan (P < or = 0.05) but was 5.6 +/- 1.2 with octreotide (NS). Whereas two patients responded to both treatments, two responded to acetorphan alone and one to octreotide alone. Daily lipid output in faeces was reduced non-significantly with acetorphan (11.5 +/- 2.3 g) but was nearly doubled with octreotide (33.7 +/- 12.0 g). Acetorphan was very well tolerated. CONCLUSION: Enkephalinase inhibitors may be a useful alternative to somatostatin analogues in the management of refractory diarrhoea in AIDS.

Improvement in protein absorption with a small-peptide-based diet in patients with high jejunostomy.

We compared urinary and fecal excretions of fluid, electrolytes, and nutrients in six patients with a high jejunostomy during three randomized consecutive 3-day periods of total enteral nutrition with three diets differing only by the degree of hydrolysis of the protein moiety: whole proteins, their hydrolysate (63% nitrogen as small peptides with < 1000 M), and the two mixed together. Daily nitrogen absorption was significantly enhanced with the small-peptide and mixed diets (14.3 +/- 3.4 and 13.1 +/- 2 g, respectively) compared with the whole protein diet (10.9 +/- 2.4 g, p = 0.012). Concomitantly, blood urea nitrogen and urinary urea excretion increased with the small-peptide diet. Apparent absorption of fat and calories, fecal weight, and urinary and fecal excretions of sodium, potassium, calcium, and magnesium remained unchanged. We conclude that a small-peptide-based diet may be beneficial in patients with short-bowel syndrome.

The role of anatomic factors in nutritional autonomy after extensive small bowel resection.

BACKGROUND: It is difficult to predict which patients with a postsurgical short bowel will require long-term parenteral nutrition. METHODS: We performed a retrospective prognostic study for the time to home parenteral nutrition or death from malnutrition (nonautonomy), on the basis of 103 patients with a residual short bowel of 17 to 150 cm. The influence of anatomic variables was summarized through the use of Cox regression model. RESULTS: Of the 103 patients included, 24 lost nutritional autonomy. Three anatomic variables were identified as having independent predictive information; remaining small bowel length (measured on small bowel x-rays; p = .0001), and jejunoileal anastomosis (p = .01) promoted autonomy, whereas end jejunostomy (p = .002) increased the risk of losing nutritional autonomy. CONCLUSIONS: On the basis of these results and on the relative weight of these variables, high-risk patients for loss of nutritional autonomy were defined as those with jejunoileal anastomosis and a remaining small bowel length < 35 cm, patients with jejunocolic anastomosis and remaining small bowel length < 60 cm, and patients with an end jejunostomy and remaining small bowel length < 115 cm. This classification was thereafter validated on a prospective series of 32 patients.

[Chronic radiation enteritis. I. Intestinal malabsorption. Anatomo-functional correlates]. / L'entérite radique chronique. I. La malabsorption intestinale. Corrélations anatomo-fonctionnelles.

Intestinal malabsorption was studied in 51 cases (46 patients) with radiological and/or operative evidence of small bowel radiation injury. At the time of the study, 23 patients had not been operated on (MED patients), and 28 had undergone previous small-intestinal by-pass or resection (BP/R patients). Fecal analysis data (n = 51), and results of alpha-1-antitrypsin clearance (n = 24), and of D-xylose (n = 37), folic acid (n = 20) and Schilling (n = 27) absorption tests were compared to the extent and severity of small-intestinal damage assessed radiologically and/or operatively. Mean fecal weight was 311 g/24 h in MED patients and 1,190 g/24 h in BP/R patients. Sixty-five, 43, 86, and 82 p. 100 of MED patients, and 93, 77, 93, and 85 p. 100 of BP/R patients, respectively presented increased fecal weight, sodium, lipid, and nitrogen. In MED patients, there was a significant relationship between the extent and severity of small-intestinal damage and fecal weight, lipid, and nitrogen. In BP/R patients, fecal data were related to those calculated from the site and the extent of the intestinal resection. Fecal losses tended to be more abundant when the residual intestine was severely damaged. Alpha-1-antitrypsin clearance (mean 37 ml/24 h) was increased in 8 out of 9 MED patients and in 11 out of 15 BP/R patients. Its value was not related to the extent and severity of small-intestinal damage.(ABSTRACT TRUNCATED AT 250 WORDS)

[Chronic radiation enteritis. II. General consequences and prognostic factors]. / L'entérite radique chronique. II. Conséquences générales et éléments du pronostic.

We have studied 54 patients (age 19-83 years) with radiological and/or operative evidence of small bowel radiation injury, in order to assess clinical and biological features, final outcome, and prognostic factors of late radiation enteropathy; 23 of them had undergone previous small-intestinal by-pass or resection. During initial treatment (first 6 months), the patients received symptomatic medical treatment and 17 had a 3-6 week continuous enteral alimentation; 15 were operated on. At entry, 51 out of 54 complained of diarrhea, 32 had repeated vomiting and abdominal pain, 43 were undernourished (36 had lost more than 20 p. 100 of their normal weight, 27 had profound anorexia, 29 had hypo-albuminemia of less than 30 milligrams). Anemia was present in 30 patients. Seventy six and 88 p. 100, respectively, had hypocalcemia and hypomagnesemia, with clinical symptoms in 14 cases. Fourteen patients, 12 of whom had undergone intestinal by-pass or resection, had biological hepatic abnormalities. Six patients died during initial treatment and 5 during follow-up; the actuarial survival rate was 72 p. 100 at four years (65 p. 100 for the unoperated patients, and 79 p. 100 for those previously operated on). Carcinoma was the cause of death in 5 cases. Social activity and state of nutrition were satisfactory in 22 out of the 32 patients seen in 1982 with 6-96 months (mean 29 months) follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

[The overwhelmed intestine syndrome]. / Le syndrome de l'intestin dépassé.

We studied 54 patients who, after small intestinal resection, developed a massive protracted diarrhea with a daily fecal loss greater than 2 kg, status we defined as the "overwhelmed intestine syndrome" (OIS). Median length of residual small bowel was 120 cm, 19 patients had a definitive stoma (jejunostomy, n = 9; colostomy, n = 10), 26 patients had a provisional jejunostomy. Fecal weight greater than 2 kg was related to enteral hyperalimentation (greater than 3,500 Kcal) in 19 patients (induced OIS) and was clearly independent in 16 others who had fecal weight over 3 kg while receiving approximately 2,000 Kcal (obligatory OIS); the last 19 patients had fecal weight between 2 and 3 kg during normoalimentation. Hypocalcemia and hypomagnesemia were common in the three groups. The other complications were seen mostly in patients with obligatory OIS: in those patients, parenteral nutrition was maintained in 9 cases out of 16 (vs. 0 in other groups), nutritional gain was scanty, sodium equilibrium was difficult to obtain in spite of a large sodium intake (380 mmol/day), hospitalization lasted several months and autonomy via the enteral route could not be achieved in 7 out of the 9 patients with definitive short bowel (vs. 0 in other groups). This study shows that the OIS is an unique functional entity. Complications and prognosis are dependent on the obligatory or induced pattern of the syndrome. Only patients with obligatory OIS require definitive home parenteral nutrition.

[Role of the prevalvular terminal ileum in fecal losses in ileostomized patients]. / Rôle de l'iléon terminal prévalvulaire dans les pertes fécales des iléostomisés.

Fecal losses of water, electrolytes, fat and nitrogen were studied retrospectively in 42 cases (40 patients). To assess the role of the terminal ileum, patients were classified into 2 groups according to the length of resected and/or excluded ileum before the ileocecal junction; group I (n = 17; length less than or equal to 15 cm) and group II (n = 25; length ranging from 15 to 50 cm). In group I, fecal weight and fecal output of sodium, fat and nitrogen were (mean for 24 h) 544 g, 63 mmol, 6.5 g (6.4 p. 100 of ingesta), 2.94 respectively. In group II, fecal outputs were higher; (mean for 24 h) 862 g, 112 mmol, 10.9 g (14.2 p. 100 of ingesta), 4.2 respectively. These differences were statistically significant for fecal weight and fecal output of sodium (p less than 0.001) and for fecal output of fat when expressed as percentage of ingesta (p less than 0.02). These results show that the length of terminal ileum is a major determinant in fecal losses after ileostomy; therefore, it appears to be of major importance to preserve this segment of ileum as much as possible during ileocolic surgery.

[Ultrasonic study of gallbladder motility during exclusive continuous enteral feeding]. / Etude échographique de la motricité vésiculaire au cours de l'alimentation entérale continue exclusive.

Total parenteral nutrition may be responsible for gallbladder sludge and lithiasis which might possibly be related to gallbladder bile stasis. Gallbladder motility has not yet been studied during constant-rate enteral nutrition. We performed serial ultrasonographic studies of gallbladder volume and contents in ten patients receiving constant-rate enteral nutrition during 35 +/- 17 days. Each patient had two weekly examinations at 9 AM and 2 PM on the same day. None of the patients developed gallbladder sludge or lithiasis. The gallbladder was frequently seen to be contracted. Mean gallbladder volume during constant-rate enteral nutrition was not significantly different from mean gallbladder volume after Bladex. Individual gallbladder volume changed significantly from one measurement to another. This study showed that gallbladder motility is preserved during constant-rate enteral nutrition. The persistence of gallbladder contractions may prevent the development of biliary sludge ad lithiasis.

[Functional diarrheas are not, in most cases, minor clinical forms of lymphocytic or collagenous colitis]. / Les diarrhées fonctionnelles ne sont pas, pour la plupart, des formes cliniques mineures de colite lymphocytaire ou collagène.

AIM: The aim of the study was to test the hypothesis that some patients with functional diarrhea could actually suffer from a mild clinical pattern of collagenous or lymphocytic colitis. PATIENTS AND METHODS: Twenty consecutive patients with chronic diarrhea were included in the study if the colonic mucosa appeared normal during colonoscopy. From multiple colonic biopsies were established a conventional histological diagnosis and a quantitative histological diagnosis. This latter diagnosis was based on the semiquantitative evaluation of epithelial morphological alterations and lamina propria monocellular infiltration, and on the determination of both intraepithelial lymphocyte count and subepithelial collagen layer thickness. Multiple colonic biopsies from 12 control patients without diarrhea were analyzed according to the same protocol. RESULTS: Among the 20 patients with diarrhea, the quantitative diagnosis of collagenous colitis was made in 3 patients (thickness of the collagen band between 11 and 26 microns) and the diagnosis of lymphocytic colitis in one (21% of intraepithelial lymphocytes). The percentage of intraepithelial lymphocytes did not differ between the 16 remaining patients and the controls (12 +/- 5% and 9 +/- 4%, respectively). Similarly, the score of surface epithelial damage and the score of lamina propria infiltration in patients with diarrhea (1.2 +/- 1.0 et 1.7 +/- 1.5) were not different from the values in the control group (1.3 +/- 1.3 et 1.5 +/- 1.2). The mean fecal weight in patients with diarrhea but without colitis was 161 +/- 130 g/d. All the values of fecal weight were below 300 g/d, except in one patient with a past history of truncular vagotomy. CONCLUSIONS: These results suggest that most of the patients with functional diarrhea do not suffer from mild clinical patterns of collagenous or lymphocytic colitis.

[Evaluation of pindolol absorption in malabsorption syndromes]. / Evaluation de l'absorption du pindolol dans les syndromes de malabsorption.

Reports on drug absorption in intestinal diseases are scarce. To investigate pindolol absorption, a drug particularly well absorbed and with low hepatic extraction, plasma concentrations and 54-h urinary excretion (after both oral and intravenous dose) were studied in 6 healthy volunteers and 13 patients with intestinal malabsorption (coeliac disease 5 cases, short bowel syndrome 8 cases) after an overnight fasting. Pindolol plasma concentrations were almost identical after a single intravenous dose in both patients and controls. Again mean blood levels after an unique oral dose were not significantly different between the two groups. However, absorption was slow and/or delayed in eight out of thirteen patients and overall absorption was decreased in two of them. These abnormalities might be related to the diseased intestine, since plasma concentrations and urinary excretion following intravenous administration were quite similar to those observed in volunteers. Nevertheless, results were not related to the extent of the intestinal disease nor the degree of impairment of small intestinal function.

[Aid to decision for nutritional support in chronic digestive diseases]. / Aide à la décision d'assistance nutritionnelle au cours des affections digestives chroniques.

In patients with chronic gastro-intestinal disease, deciding whether or not to provide nutritional support is difficult. The aim of the present study was to develop an objective index to help clinicians to decide which patients should be treated with nutritional support. Two hundred and two patients were studied prospectively. Seventy-one had an inflammatory bowel disease, 51, a malabsorption syndrome, 59, an esophagogastric disorder, and 21, a pancreatic disease. On admission, nutritional status was assessed by anthropometric and biological measurements, and spontaneous oral caloric intake. Clinical assessment of the nutritional condition was performed by an independent observer. Using discriminant analysis, collected data were correlated to the therapeutic outcome of the patient during the 15 days after admission, i. e. whether or not they received nutritional support. Clinical global assessment proved to be the most discriminant variable: 83 p. 100 of the patients were correctly classified. This variable was deleted from further analysis to obtain an objective index, calculated with four variables: mid-arm muscle circumference, body weight, serum albumin, and caloric oral intake expressed as kcal X IBW kg-1 X day-1. The index classified correctly 84 p. 100 of the patients. This study demonstrates that subjective clinical assessment is the best variable to decide whether or not a gastrointestinal patient should receive nutritional support. We suggest that this index might be of help in these situations.

[Effects of preoperative artificial nutrition in intestinal resections for Crohn disease]. / Effets de la nutrition artificielle préopératoire dans les résections intestinales pour maladie de Crohn.

UNLABELLED: Artificial nutrition prior to bowel resection has not been evaluated fully. The aim of the present study was to assess the effects of preoperative artificial nutrition upon postoperative complications, length of resected bowel and relapses of Crohn disease. RESULTS: Between 1990 and 1994, 108 consecutive patients underwent bowel resection for Crohn disease. Thirty nine patients had received exclusive enteral nutrition (n = 14) or parenteral nutrition (n = 25) for 19 +/- 10 days. Patients who had received artificial nutrition were more malnourished and had complicated Crohn disease (fistulae, abscesses) more often than patients operated without artificial nutrition. After 19 days of artificial nutrition, the nutritional state of patients was not significantly improved. Postoperative complication rate was higher in patients operated after artificial nutrition (33 vs. 16%; P = 0.03). Using multivariate prognosis analysis, the extent of colic resection was significantly associated with postoperative complications (P = 0.0003). Length of resected bowel and relapse rates were similar in patients with or without preoperative nutrition. CONCLUSION: Artificial nutrition prior to bowel resection for Crohn's disease is indicated in patients with the most severe form of the disease. A preoperative nutrition of 19 days does not seem to reduce postoperative complications nor the length of resected bowel.

[Prognosis in pancolonic forms of hemorrhagic rectocolitis]. / Pronostic des formes pancoliques de rectocolite hémorragique.

OBJECTIVE: To assess the prognosis of pancolitis in ulcerative colitis including survival, colectomy rate, colon cancer risk, activity of disease, functional and socioprofessional impact. METHODS: Retrospective study of 130 cases of ulcerative pancolitis referred consecutively to Rothschild Hospital from 1962 to 1993. They were 58 men and 72 women. The mean age at onset of ulcerative colitis was 30 years (range: 5-77). The extension to the right colon was secondary in 68% of patients. The period of observation ranged from 0.8 year to 46 years from the onset, with a median of 10.6 years. Three patients were lost to follow up. RESULTS: Eight patients died, the survival rate being 93% at 10 years. Surgical treatment was performed in 85 patients. The cumulative colectomy rates were 61% and 77% at 10 and 20 years respectively. Colonic cancer developed in three patients, corresponding to a cumulative risk after 25 years of 6% in unoperated patients and 1.9% in the whole series. No cancer occurred after colectomy and ileorectal anastomosis. In the group of unoperated patients there was a decrease of activity of the disease during the first fifteen years. The quality of life of colectomized patients with reestablishment of intestinal continuity and of those treated conservatively did not differ significantly. CONCLUSION: In this series, long term prognosis of ulcerative pancolitis was favourable. The high colectomy rate was balanced by a very low risk of colorectal cancer.

[Does continuous enteral nutritional deficiencies in digestive system diseases? Results of a longitudinal study of 92 consecutive patients treated for 3 to 7 weeks]. / L'alimentation entérale continue corrige-t-elle la dénutrition des affections digestives? Résultats de l'étude longitudinale de 92 malades consécutifs traités pendant trois à sept semaines.

In order to assess the effectiveness and potential limitations of continuous enteral nutrition (CEN) to correct denutrition related to underlying digestive diseases, 10 nutritional criteria were measured weekly in 92 under-nourished patients fed with CEN for a 3-7 week period. All the patients received a standard non-elemental diet providing a mean daily energy intake of 52.8 kcal/kg BW (36.5 kcal/kg BW by tube feeding and 16.3 kcal/kg BW orally). The influence of preexisting intestinal malabsorption, hypercatabolic status, and post-radiation or inflammatory bowel disease was studied by an a posteriori classification of patients in one of the six following groups: I (no limiting factor), II (malabsorption), III (catabolic disease), IV (catabolic disease and malabsorption), V (colitis), VI (enteritis). During CEN, 8 patients had transient and one had persistent vomiting while 3 developed bronchopneumonia. Gains in body weight, triceps skinfold, midarm muscle circumference, creatinine-height index, urinary sodium and serum transferrin were significant as early as the 2nd week of CEN. Serum albumin and cholesterol, hemoglobin, and total count of lymphocytes were not significantly affected. Sixty-five patients (71 per cent) had an objective nutritional improvement and mean spontaneous oral intake increased from 17.8 to 28.7 kcal/kg BW per day. Significant increase of oral intake and objective nutritional improvement were observed in each group, but a longer period of CEN was necessary to achieve this result in groups II, IV and VI.(ABSTRACT TRUNCATED AT 250 WORDS)

[Exclusive elemental enteral diet in cortico-resistant and cortico-dependent forms of Crohn's disease]. / L'alimentation entérale élémentaire exclusive dans les formes corticorésistantes et corticodépendantes de la maladie de Crohn.

The aim of this study was to investigate the value of elemental diet in steroid-resistant and steroid-dependent Crohn's disease. Elemental diet (Vivonex HN, 39.4 +/- 9.2 kcal/kg/d) was delivered through a nasogastric tube at a constant rate. Twenty therapeutic periods lasting from 20 to 74 days (median, 32 days) were undertaken in 18 patients. Elemental diet was well tolerated. Mean values of hemoglobin, serum albumin, and serum transferrin increased significantly through the therapeutic period; body weight and anthropometric data did not change significantly. The short-term response to elemental diet was excellent in 11 cases, demonstrated by achievement of clinical remission and steroid withdrawal; six patients had an incomplete remission and remained slightly active or had to be maintained under low dose steroids; three patients did not respond to therapy and had to be operated upon. During the follow-up (6-30 months), 8 patients out of 17 had a relapse. Relapse was controlled by medical therapy in 5 cases and led to surgery in the 3 other cases. We conclude that elemental diet, as total parenteral nutrition, is an effective therapy of steroid-resistant and steroid-dependent Crohn's disease. However, elemental diet does not prevent relapse.

[Elemental feeding into the distal segment of a temporary small bowel]. / L'alimentation élémentaire dans le segment d'aval des grêles courts temporaires.

Patients who have an interruption of the small bowel with a high enterostomy usually need parenteral supply or reinfusion of chyme to maintain nutritional and electrolytic balances before restoring intestinal continuity. Ten patients (aged 28-76 years) with a terminal jejunostomy located within the first meter of jejunum were treated by infusion of an elemental diet into the distal small bowel (IEDDSB). In addition, five of these patients had an extensive small bowel resection. IEDDSB was started 32 days after operation and lasted 4 to 8 weeks. Mean daily caloric infusion was 1,732 +/- 666 kcal diluted in 2,860 +/- 808 ml; mean associated oral intake was 1,187 +/- 480 kcal/24 hr, and jejunal fecal losses averaged 3 kg per day. IEDDSB was well tolerated in 4 patients; 5 experienced transient abdominal pain or diarrhea; 1 developed severe and protracted diarrhea. Biological cholestasis was seen before IEDDSB and persisted in most patients; 1 patient developed biliary sludge. Through IEDDSB, nutritional status improved or remained satisfactory in 9 patients, and worsened in 1 patient with sepsis and a short lower intestine. Mean body weight, triceps skin fold, muscle circumference, serum albumin, serum transferrin did not change significantly. Digestive nitrogen balance performed in 6 patients showed a net absorption between 5 and 15 g/24 hr. Fluid and electrolyte balance was maintained in 9 patients and 1 received iterative intravenous saline. Digestive sodium balance showed a net absorption rate greater than 60 mmol/24 hr. in all patients, except the one who required intravenous supply. Postoperative recovery was uneventful in all patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Testing for course patterns in Crohn's disease using clustering analysis.

Using clustering analysis, we sought to identify groups of patients on the basis of the disease course among a population of 177 patients with Crohn's disease and followed for 3 years or more, starting from the first frank exacerbation of the disease. The first 36 values of a monthly clinical score represented the active variables of the clustering analysis. This method yielded 2 course groups, A and B, of 95 and 82 patients respectively. The unfavorable course in group A was characterized by the persistence of the clinically active disease at 3 years, whereas group B individuals achieved complete clinical remission within 2 years of onset on the average. Among the initially known clinical data which could explain the course, only the incidence of an occlusive syndrome was higher in group B, which showed a more favorable course. Although we applied clustering analysis to a patient sample over a period of only 3 years, our results do suggest the existence or 2 primary course groups within the population of patients with Crohn's disease. It would appear that the disease course cannot be predicted from the clinical parameters present at the time of onset, but rather becomes apparent during the course of the first 2 years.