Hypolactasia and Crohn''s Disease: A Myth

A retrospective analysis was made of jejunal biopsies performed on 62 patients with Crohn's disease for disaccharidase levels and routine histology. Thirteen patients with irritable bowel syndrome acted as a control group. Two patients with Crohn's disease had hypolactasia. Two patients had marginally low sucrase levels, but all patients had normal maltase levels. Only one patient with irritable bowel syndrome had hypolactasia with normal histology. There were no significant differences between the two groups. Four patients with Crohn's disease had abnormal jejunal histology. The prevalence of hypolactasia in patients with Crohn's disease is not increased. Ideally lactase deficiency in patients with Crohn's disease should be confirmed before starting a lactose-free diet which can produce further restrictions on dietary intake.     

Granulomatous cheilitis and Crohn's disease.

Granulomatous cheilitis is characterized by recurrent swelling of the labial tissues and granulomatous histology. Granulomatous cheilitis has been recognized as an early manifestation of Crohn's disease. It may follow, coincide with or precede the onset of Crohn's disease. The first case presented involved an extraintestinal manifestation of Crohn's disease, and the second case presented is of development of granulomatous cheilitis a year before the onset of symptomatic Crohn's disease. Although chronic granulomatous cheilitis is a very rare disorder, once it is diagnosed, the patient should be followed up carefully. These patients should be investigated for asymptomatic Crohn's disease either when the diagnosis of granulomatous cheilitis is confirmed or when gastrointestinal symptoms develop.     

Endoscopy and magnetic resonance imaging in patients with Crohn's disease: a retrospective single-centre comparative study

OBJECTIVE: There is ongoing debate about which imaging modality is best for patients with inflammatory bowel diseases. Magnetic resonance imaging (MRI) has been successfully used to evaluate the jejunum and the ileum. Because virtual colonoscopy by MRI requires bowel cleansing and/or rectal filling, endoscopy is preferred for assessment of the colon. However, hydro-MRI without special bowel preparation may be sufficient as a diagnostic tool if specifically targeted in the course of a known disease. The aim of this study was retrospectively to assess the correlation of endoscopy, histology and MRI findings for the terminal ileum and the colon in a cohort of patients with Crohn's disease. MATERIAL AND METHODS: In all, 60 patients with a confirmed diagnosis of Crohn's disease were included in the study. Here, 412 anatomical segments of the colon were analysed by MRI, 401 by endoscopy and 374 by histology. RESULTS: Presence or absence of inflammation was concordantly diagnosed in 310 segments (77.3%). The highest concordance was found for the terminal ileum and, in patients with previous surgery, the anastomosis. Sensitivity and specificity for MRI versus endoscopy, MRI versus histology and endoscopy versus histology were 64.4%/81.1%, 62.1%/86.2% and 78.2%/80.3%, respectively. CONCLUSIONS: In a retrospective analysis of patients with Crohn's disease, hydro-MRI assessment of inflammation in anatomical segments of the colon reaches acceptable concordance rates with endoscopy and histology without prior preparation of the bowel. The data justify a prospective controlled trial.     

Crohn's disease of the ileal pouch: reality, diagnosis, and management

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical treatment of choice for patients with ulcerative colitis or indeterminate colitis who require surgery. A subset of patients with ileal pouches may develop Crohn's disease or a Crohn's disease-like condition of the pouch after the surgery. Diagnosis, differential diagnosis, and management can be challenging. A combined assessment of endoscopy, histology, radiography, and examination under anesthesia is often necessary for an accurate diagnosis. A multidisciplinary approach by a medical and surgical team is advocated. It is advisable to inform ulcerative colitis patients before the surgery of the potential risk for Crohn's disease along with other inflammatory and noninflammatory complications.     

The role of antibiotics in Crohn's disease.

Antibiotics have been commonly used in Crohn's disease despite a lack of controlled data to support their use. Review of the histology and histopathology favor an infectious origin and increased infectious complications are witnessed in Crohn's patients. Enhanced permeability may play a role in providing access of enteric organisms or their cell wall derivatives to the intestinal mucosa. Through an understanding of the pathophysiology and the important role of the fecal stream along with a critical review of the literature, we may gain a better understanding of the role of antibiotics in Crohn's disease.     

111Indium autologous granulocytes in the detection of inflammatory bowel disease.

Indium leucocyte scanning and measurement of faecal Indium leucocyte excretion are techniques which have recently been introduced for assessing patients with inflammatory bowel disease. The methodology has recently been made more specific for acute inflammation by labelling pure granulocytes rather than the mixed leucocyte preparation. To determine the accuracy of this modified technique in detecting inflammatory bowel disease, we have prospectively compared Indium granulocyte scanning and faecal In granulocyte excretion with rectal histology and contrast bowel radiology as screening procedures in 100 patients with suspected inflammatory bowel disease. Thirty three patients were shown to have inflammatory bowel disease - 24 with Crohn's disease and nine with ulcerative colitis or indeterminate colitis. Overall the respective sensitivities for detecting inflammatory bowel disease were 97% for faecal Indium granulocyte excretion, 94% for Indium granulocyte scanning, 79% for radiology and 70% for rectal histology. The superiority of In granulocytes over radiology and rectal histology in detecting inflammatory bowel disease was, in the main, due to the difficulty in diagnosing Crohn's with conventional techniques. Although three of the patients with ulcerative colitis and indeterminate colitis had normal sigmoidoscopic appearances - all had abnormal rectal histology. No patient with a non-inflammatory bowel disorder had a positive In granulocyte scan or a raised faecal excretion. These results show that investigations using In granulocytes are accurate in identifying inflammatory bowel disease and offer important advantages over conventional procedures for detecting Crohn's disease.     

Impaired lymphocyte reactivity against tumour cells in patients with Crohn's disease

Evidence is presented which indicates a possible reduction in recognition capacity for tumour cell antigens (EB₂ Burkitt lymphoma cell line) by lymphocytes from some patients with longstanding but inactive Crohn's disease. Three out of seven patients tested also showed diminished or absent lymphocytotoxicity when their cells were grown in mixed culture with chromium-labelled lymphoma cells and absent response has never been observed in a large series of controls similarly tested. In both test systems impaired reactivity appeared to be partly caused by a factor present in Crohn's disease serum.

Increased tumour incidence in Crohn's disease may in part be attributable to defective immune surveillance and the histology of Crohn's disease could reflect an imbalance between the proliferative and the cytotoxic responses of lymphocytes to various antigens in the bowel lumen in this disease.

     

克罗恩病和肠结核的组织病理学研究

目的：明确克罗恩病和肠结核的组织病理学特征，找出异同点。方法：利用手术切除的肠结核和克罗恩病理标本，观察其组织病理学特征并比较。结果：克罗恩病的特征为裂隙性溃疡、非干酪样坏死性肉芽肿、肿膜下层增宽；肠结核的特征为干酪样坏死、粘膜下层闭锁，肉芽肿融合，组织切片有许多相似之处，如微肉芽肿，全层炎症等，结论：典型的肠结核和克罗恩病易于鉴别，但二者组织病理学的相似性，给部分病例的鉴别诊断带来困难。     

Histological response and antigen transmission in the lymph nodes of athymic nu/nu mice inoculated with Crohn's disease tissue filtrates.

Lymph node histology and antigen transmission in the nu/nu mouse in response to animal inoculation with Crohn's disease tissue filtrates were re-evaluated. We found that a hyperplastic lymph node response in nu/nu mice occurred with Crohn's disease (CD), ulcerative colitis (UC), or other intestinal disease (OID) tissue inoculations. In addition, antigen transmission to lymph nodes as detected by indirect immunofluorescence using CD sera was observed in all inoculation groups. The immunofluorescent reaction also occurred independently of lymph node histology. Thus, we confirm that CD sera recognize an antigen(s) expressed in lymph nodes of athymic mice inoculated with CD tissue filtrates. The antibody (or antibodies) in CD sera was not specific for this 'CD antigen or antigens', however, as tested in the nu/nu mouse system, because the CD sera antibodies also recognised antigens in UC inoculated and OID inoculated animals.     

Is histology useful for the assessment of the efficacy of immunosuppressive agents in IBD and if so, how should it be applied ?

Crohn's disease and ulcerative colitis are two chronic relapsing inflammatory bowel diseases of unknown etiology. Both conditions are characterized by a considerable morbidity and have an impact upon the social and economic aspects of the patients life. At present, medical treatment is mainly aiming at the control of the inflammation. Drugs used for ulcerative colitis can induce microscopic healing of the mucosa. Similar results have been obtained recently with immunomodulatory drugs in Crohn's disease. The cost of these drugs is however high and the use of these drugs can be associated with side effects. Furthermore, many of the drugs need to be given for a long period. Therefore it is appropriate to assess the efficacy of the drugs before commercial use and even when used in routine practice. For both ulcerative colitis and Crohn's disease, clinical parameters combined in indices and endoscopy are commonly used together with some laboratory tests for the assessment of disease activity. In ulcerative colitis, histology has been used along with the other instruments for the measurement of disease activity because it was shown that the mucosal lesions could improve. More recently, histology has also been used for Crohn's disease. Routinely, disease activity when assessed with microscopy, should be divided into mild, moderate and severe. For drug trials and study purposes, more objective scoring systems should be used. Preferentially, a generally accepted score is used. This allows comparisons between different studies. Different scoring systems have been designed for ulcerative colitis and Crohn's disease. For the latter, multiple biopsies should be analysed. Most scoring systems still need validation.     

Selective IgA deficiency and Crohn's disease: report of two cases.

Two patients are described with Crohn's disease and selective IgA deficiency. Serum IgA was undetectable in each case, and immunoperoxidase studies of the lamina propria showed a gross diminution of IgA-bearing plasma cells. Peripheral blood lymphocytes, however, showed normal numbers of IgA-bearing lymphocytes. The typical clinical course and histology in these two patients suggest that IgA-mediated responses in the mucosa are not involved in the pathogenesis of Crohn's disease.     

Crohn's disease of the esophagus

Crohn's disease only rarely affects the esophagus, usually producing strictures and fistulas. Superficial lesions such as erosive esophagitis are infrequent. Histological proof of esophageal Crohn's disease is only exceptionally obtained with endoscopic biopsies. In a 4-year period we have followed 500 patients with Crohn's disease. Esophageal involvement was recognized in nine patients, usually because of painful dysphagia. Esophagoscopy revealed large aphthoid lesions. The clinical picture was characterized by: (a) involvement of multiple segments of the gastrointestinal tract, (b) extraintestinal manifestations, and (c) critical illness of the patients. Esophageal lesions and symptoms disappeared quickly with therapy. Routine histology of esophagoscopic biopsies revealed granulomas in only two patients, but additional sections showed granulomas in another five.     

Esophagitis in an adolescent patient with Crohn's disease after changing treatment from prednisolone to budesonide

Studies have demonstrated that budesonide is effective in the treatment of active Crohn's disease. Due to its extensive hepatic metabolism, budesonide has much lower adverse events compared to prednisolone. Consequently, the low systemic availability restricts its application to Crohn's disease of the terminal ileum and the colon. Esophageal ulceration is a rare complication of Crohn's disease. This article describes the case of a young lady who presented at the age of 16 with active Crohn's disease of the terminal ileum and the colon without dysphagia or pain in the chest. Her disease was successfully treated with prednisolone for almost two years. Because of weight gain, acne, and moon face she was switched to budesonide. A few days later she presented with intractable pain of the esophagus, dysphagia, and inability to eat. Endoscopy demonstrated aphthous ulcerations of the esophagus and the histology was compatible with Crohn's disease. After two weeks of treatment with prednisolone all symptoms resolved and at follow-up gastroscopy ulcers had disappeared.     

Eosinophilic ileocolitis

Summary This report describes the radiographic, colonoscopic, and histologic features in a patient with eosinophilic ileocolitis. To assess the relative meaning of the infiltration of eosinophils noted in the colonoscopic biopsy material from this patient, the histology of colonoscopic biopsy material obtained from 12 patients with Crohn's involvement of the colon was reveiwed. This paper suggests that eosinophilic ileocolitis may be more common than originally thought and the counting of high-power microscopic fields for eosinophils may be a useful way of distinguishing eosinophilic ileocolitis from Crohn's ileocolitis.     

The size and histological appearances of mesenteric lymph nodes in Crohn's disease

The size of the related lymph nodes and their histology has been correlated in 34 specimens of Crohn's disease.Granulomata were shown not to affect the maximum diameter of the lymph nodes nor to be more frequent in large nodes. The enlargement of lymph nodes appeared to be due to simple, non-specific, reactive changes.Granulomatous lymph nodes were found in 38% of all our cases of Crohn's disease and in 63% of those cases with granulomata in the bowel wall. One case was found with granulomata in the lymph nodes which were not seen in the bowel wall.The mesenteric lymph nodes of 22 cases of ulcerative colitis were shown to be not significantly different in size from those of Crohn's disease.The diameter of the lymph nodes on the histological section was shown to underestimate the diameter of nodes in the fresh state by a factor of 1.5.     

Crohn's disease mimicking sarcoidosis in bronchoalveolar lavage.

Granulomatous disorders like sarcoidosis or Crohn's disease are commonly associated with extrapulmonary or extraintestinal manifestations which occasionally may represent the only symptoms. We describe a 28-year-old female patient suffering from atypical erythema nodosum and arthritis. Although the chest x-ray was unremarkable bronchoalveolar lavage revealed lymphocytic alveolitis with an elevated CD4/CD8 ratio of 8 and 11.4 at repeated examinations suggesting a diagnosis of sarcoidosis. Further diagnostic workup included endoscopy of the bowel. The macroscopic aspect and histology of the terminal small bowel and colon ascendens indicated Crohn's disease. The patient recovered on steroids and sulfasalazine. Six months later she developed a perianal abscess for which she needed surgery supporting the diagnosis of Crohn's disease. This is the first case of a significantly (>6) elevated CD4/CD8 ratio in Crohn's disease previously regarded as highly specific for sarcoidosis.     

Infliximab heals intestinal inflammatory lesions and restores growth in children with Crohn’s disease

BACKGROUND: Infliximab has recently emerged as an efficacious agent for patients with severe Crohn's disease. There are only few studies on the use of infliximab in children with Crohn's disease: most of them are retrospective and deal only with the clinical response to the drug. AIM: We aimed at assessing the efficacy of infliximab in children and adolescents with severe Crohn's disease recruited consecutively and followed up prospectively at a single centre. Clinical response, intestinal inflammation and growth pattern were evaluated. PATIENTS: Eighteen patients entered into the trial (median age: 13 years, range: 6-18). They were referred because of severe symptoms with unsatisfactory response to conventional drugs. METHODS: All patients received a baseline schedule of three intravenous infusions of infliximab (0, 2 and 6 weeks), 5 mg/kg. Paediatric Crohn's Disease Activity Index, nutritional and activity serum variables, and ileocolonoscopy (with histology) were evaluated before and 8 weeks after beginning the therapy. All patients had long-term administration of azathioprine (2 mg/kg per day). After the baseline schedule, eight patients had a retreatment infusion of infliximab (5 mg/kg) every 8 weeks. Weight and height Z scores were measured before starting the baseline infusion programme and after 6 months. RESULTS: After 8 weeks of therapy, there was a dramatic improvement in Paediatric Crohn's Disease Activity Index, in nutritional and activity blood parameters, as well as in endoscopic and histological scores; 10 patients had a clinical remission (Paediatric Crohn's Disease Activity Index < or = 10), 12 patients had an inflammatory remission (decrease in both endoscopic and histological scores for > or = 50% as compared to baseline values). In all patients corticosteroids were stopped within 4 weeks after beginning infliximab therapy. After 6 months of therapy, Paediatric Crohn's Disease Activity Index was markedly lower than the pre-treatment value; however, it was significantly lower in patients on retreatment than in those who received only three infusions of infliximab. Furthermore, a significant increase in both weight and height Z scores was observed 6 months after beginning of the baseline infusion programme. Moreover, weight and height gain was significantly higher in patients on retreatment rather than in those treated only with three baseline infusions of infliximab. Mild infusion reactions controlled by slowing infusion rate were observed in four patients. No delayed hypersensitivity-like reactions were seen. CONCLUSIONS: In children with severe Crohn's disease, infliximab is a safe and valuable treatment in inducing remission, in healing inflammatory lesions of the gut, as documented by endoscopy and histology, and in promoting growth. Retreatment infusions of infliximab may be suggested in childhood-onset Crohn's disease to maintain remission and reverse growth failure.     

Anti-mycobacterial therapy in Crohn''s disease heals mucosa with longitudinal scars

BACKGROUND: A possible causative link between Crohn's disease and Mycobacterium avium ss paratuberculosis has been suggested. AIM: To report unique scarring in Crohn's disease patients treated with anti-Mycobacterium avium ss paratuberculosis therapy. PATIENTS: A retrospective review of 52 patients with severe Crohn's disease was conducted. Thirty-nine patients who had at least one follow-up colonoscopy during treatment were included. METHODS: Patients received rifabutin (up to 600 mg/day), clofazimine (up to 100 mg/day) and clarithromycin (up to 1 g/day) - anti-Mycobacterium avium ss paratuberculosis therapy - for 6 months to 9 years. Ramp-up dosing was used. Colonoscopies and histological analyses monitored progress. RESULTS: Twenty-two patients (56.4%, 22/39) healed with unusual scarring, which appeared as branched, ribbon-like, elevated lines. In 2/6 patients (33.3%) who had > 3 years of treatment after scarring occurred, scars receded, becoming imperceptible as full healing occurred. Histologically, a marked reduction in inflammation occurred in 15/39 patients (38.5%). Of these, 6/15 patients (40%) displayed restoration of normal mucosa. Longitudinal scarring occurred in 12/15 patients (80%) with improved histology. CONCLUSIONS: The presence of scarring fading to normal mucosa on anti-MAP therapy implies a more profound healing not seen with standard anti-inflammatory and immunosuppressant drugs. Longitudinal scarring and consequent healing with normal histology should become a standard treatment goal for Crohn's disease.     

Portal hypertension in the presence of minimal liver damage in Crohn's disease on long-term azathioprine: possible endothelial cell injury

Azathioprine is a useful agent for the treatment of Crohn's disease but side effects occur in 10% of patients. Hepatic toxicity is well recognized and is usually associated with abnormalities of liver function tests. We describe a female patient who was on azathioprine for the treatment of Crohn's disease for a total of 216 months. She developed portal hypertension complicated by variceal haemorrhage. This required the insertion of a trans-jugular intra-hepatic porto-systemic shunt to control the bleeding. Subsequent histology has shown mild nodular regenerative hyperplasia, and other causes of liver disease have been excluded. The only liver function abnormalities were mild elevation of bilirubin and a low albumin in the later stages.     

Diagnosis and management of Crohn's disease of the ileal pouch

Approximately 20-30% of patients with ulcerative colitis would eventually require surgery despite recent advances in medical therapy. Ileal pouch-anal anastomosis has become the surgical treatment of choice after total proctocolectomy. A subset of patients who had a preoperative diagnosis of ulcerative colitis may develop Crohn's disease or a Crohn's disease-like condition of the ileal pouch after surgery. Diagnosis, differential diagnosis, and management of Crohn's disease of the ileal pouch have been challenging. A combined approach with the assessment of clinical history, endoscopy, histology, abdominal/pelvic imaging, and examination under anesthesia is necessary for an accurate diagnosis, disease classification, management and improvement in outcome. A multidisciplinary approach with gastroenterologists, colorectal surgeons, gastrointestinal pathologists and radiologists for proper medical, endoscopic, and surgical treatment is advocated.