Serum antibodies to Escherichia coli in subjects with ulcerative colitis.

It has been proposed that in ulcerative colitis the intestinal flora stimulates autoimmune reactions to colonic epithelium through shared specificities exposed in a `common antigen'' found in most Enterobacteriaceae. The present experiments aimed to resolve conflicting data as to whether patients with ulcerative colitis have selectively increased serum antibody titres to enterobacterial common antigen or E. coli 014, which is rich in enterobacterial common antigen. Antibody titres to enterobacterial common antigen and lipopolysaccharides of E. coli 014 and of five serotypes of E. coli which occur frequently in human faeces were measured by passive haemagglutination. Sera were obtained from patients with ulcerative colitis, age- and sex-matched controls and subjects with other gastrointestinal disorders. Serum titres to enterobacterial common antigen and E. coli 014 lipopolysaccharide were not increased significantly in subjects with ulcerative colitis but significant increases were observed in subjects with chronic liver disease without colitis. Patients with active ulcerative colitis, patients with chronic liver disease and subjects convalescent from Salmonella or Shigella infections all had significantly increased serum titres to the antigens as a group. Class-specific enhancement of passive haemagglutination indicated that the class distribution of serum antibodies was similar in subjects with ulcerative colitis and controls.     

Serum and salivary immunoglobulin A and free secretory component in ulcerative colitis

Patients with ulcerative colitis have been investigated for evidence of defects in secretory immunity. Total serum IgA concentration, serum IgA antibody titres to Candida albicans, salivary IgA and free secretory component concentrations have been measured in thirty-six patients with ulcerative colitis and thirty-six normal controls. None of the parameters was significantly different between patients with proctitis and patients with extensive colitis or between the colitis patients and normal controls.     

Circulating antibodies to heat-shock protein 60 in Crohn''s disease and ulcerative colitis.

Heat-shock proteins (HSPs) are highly conserved immunogenic intracellular molecules that are induced by inflammatory mediators and may induce autoimmune phenomena in vivo. We have recently demonstrated the increased expression of HSP-60 in the colonocytes of patients with ulcerative colitis. To study further the role of HSP-60 in inflammatory bowel disease, we have now measured antibodies to recombinant mycobacterial HSP-65 (a member of the HSP-60 family) in patients with Crohn's disease, ulcerative colitis, healthy volunteers and, as disease controls, patients with confirmed bacterial diarrhoea. In comparison with healthy controls (n = 20; median level of 89 ELISA units; range 24-292), serum IgA HSP-60 antibodies were elevated in Crohn's disease (n = 21; 157; 57-364; P < 0.05) and active ulcerative colitis (n = 16; 188; 58-373; P < 0.01) but not bacterial diarrhoea (n = 10; 106; 51-285). Increased IgA HSP-60 antibody levels in patients with inflammatory bowel disease may occur as the result of HSP release from injured gut epithelium; alternatively, increased intestinal permeability could facilitate mucosal access of luminal antigens and the generation of cross-reactive anti-bacterial HSP antibodies.     

Anti-neutrophil nuclear antibody in ulcerative colitis, Crohn''s disease and primary sclerosing cholangitis.

We have previously described circulating autoantibodies to a portal tract antigen in patients with primary sclerosing cholangitis. In this study the antigen has been shown by double-labelling studies to be specifically located in the nuclei of tissue neutrophils. Using isolated peripheral blood neutrophils and an immunoperoxidase technique, anti-neutrophil nuclear antibody (ANNA) was found in the serum of 84% of patients with primary sclerosing cholangitis (PSC: n = 32) with a median titre of 1/1000 and a peak titre of 1/500,000. ANNA was also detected in 86% of patients with inflammatory bowel disease alone (IBD: n = 76) with a median titre of 1/10 and a peak titre of 1/10,000. In contrast, only 12% of controls had ANNA, and in none was the titre greater than 1/10. In PSC the ANNA titre correlated with the serum aspartate transaminase concentration, suggesting that it is related to disease activity. In IBD the titre of ANNA was significantly higher in patients with recently active disease. There was no significant difference between the titres seen in ulcerative colitis and Crohn's disease. ANNA was not associated with neutropaenia. The results provide further evidence of involvement of autoimmune mechanisms in inflammatory bowel disease and primary sclerosing cholangitis.     

Effect of proctocolectomy on serum antineutrophil cytoplasmic antibodies in patients with chronic ulcerative colitis.

AIMS--To study the effect of proctocolectomy on the antineutrophil cytoplasmic antibody (ANCA) titres in association with ulcerative colitis. METHODS--Serum samples were taken from 15 patients with ulcerative colitis immediately before and at a mean of 24 months after proctocolectomy. Indirect immunofluorescence for ANCA and enzyme immunoassays for myeloperoxidase and proteinase-3 antibodies were employed. A liver biopsy was taken from every patient during the proctocolectomy, and serum liver enzyme activities were also determined. RESULTS--Before proctocolectomy, 13 of the 15 patients had perinuclear antineutrophil cytoplasmic antibodies (p-ANCA). Additionally, one patient had a low tire of classical cytoplasmic ANCA and one had granulocyte specific antinuclear antibodies. After proctocolectomy, the ANCA titres decreased in 10 patients, in two of whom they became negative. The titres remained the same in four patients with positive ANCA and increased twofold in one patient. Only one patient was proteinase-3 antibody positive and all 15 patients were myeloperoxidase antibody negative. The clinical condition improved in all patients, irrespective of the ANCA status after proctocolectomy. Seven patients, all of whom were positive for p-ANCA before proctocolectomy, had histological liver abnormalities. No correlation was observed between serum liver enzyme levels and ANCA staining patterns or titres. CONCLUSIONS--Proctocolectomy decreased the ANCA titres in the majority of our patients, suggesting that reduction of the inflammation or the available antigenic material modifies the immune disturbance related to ulcerative colitis.     

Circulating immune complexes in ulcerative colitis. I. Correlation to disease activity

Twenty-two patients with ulcerative colitis were studied for occurrence of circulating immune complexes (IC) by three independent methods, a complement consumption assay, a Clq-binding assay and a RF-binding assay. All patients had the disease in an active stage when the study was initiated. Positiveness in two or more test systems was considered to indicate the presence of IC in the serum sample examined. By this criterion, circulating complement-fixing IC were detected in eight out of the twenty-two patients (36%; 95% confidence limits: 17–60%). IC were detected most frequently in patients with long-standing disease.

A correlation between the occurrence of circulating IC and disease activity, in terms of visible blood in faeces and number of bowel movements per day, was demonstrated. Cytological examination of the rectal mucus indicated moderate to severe inflammation in all IC-positive patients. Six out of the eight IC-positive patients were subjected to short-term glucocorticosteroid treatment; only one of these patients exhibited circulating IC and high disease activity after treatment —this patient was colectomized. Salazosulphapyridine treatment showed no relation to IC occurrence. Four out of the twenty-two patients (18%; 95% confidence limits 5–40%) were positive for organ non-specific antinuclear factor (ANF), but the presence of ANF did not correlate with circulating IC. Neither was any significant correlation between antibody titres to E. coli O119:B14 antigen and IC occurrence demonstrable.

     

Anti-colon antibody and lymphocytophilic antibody in ulcerative colitis.

The presence of anti-colon antibody in the sera from patients with ulcerative colitis was demonstrated by antibody-dependent cell-mediated cytotoxicity (ADCC) assay. In addition, the high prevalence of lymphocytophilic antibody in the sera from patients with ulcerative colitis was obtained by fluorescence activated cell sorter (FACS) analysis. This lymphocytophilic antibody was absorbed by rat colon epithelial cells. Moreover the lymphocytes from ulcerative colitis showed lower binding capacity to this antibody, but acquired higher binding capacity after 20 hr incubation at 37 degrees C in vitro. These data suggest that ADCC may have some role in the pathogenesis of ulcerative colitis.     

Colonic bicarbonate output as a test of disease activity in ulcerative colitis.

No available test objectively measures impairment of function of the inflamed colonic mucosa in ulcerative colitis. To study function we assessed rectal bicarbonate output by rectal dialysis in the presence of water and bacterial fatty acid (n-butyrate) in 21 controls, 18 patients with acute ulcerative colitis, 12 patients with ulcerative colitis in remission, and 12 patients with other forms of colitis. In acute ulcerative colitis, compared with controls, bicarbonate output and pH was reduced (p less than 0.001); stimulated bicarbonate output with bacterial fatty acid (incremental bicarbonate output) was reduced by 80% in acute ulcerative colitis (p less than 0.01). Results indicate that bicarbonate output is a useful and selective test of mucosal function in acute ulcerative colitis. A diminished incremental bicarbonate output with n-butyrate supports the view of inadequate oxidation of bacterial fatty acids in vivo by the mucosa in ulcerative colitis. Whether the test will prove to be an index of prognosis or will aid choice between medical or surgical therapy requires further study.     

Cold-reactive lymphocytotoxins in Crohn's disease and ulcerative colitis. I. Incidence and characterization.

The incidence of cold-reactive lymphocytotoxins in the serum of patients with Crohn''s disease or ulcerative colitis has been investigated. Twenty-seven percent of patients with Crohn''s disease and twenty-two percent of those with ulcerative colitis had circulating lymphocytotoxins. This is significantly higher than the 4% found in a normal control population. The presence of lymphocytotoxins did not correlate with age or sex of the subjects studied nor with clinical parameters. As in previous studies, the lymphocytotoxin is an antibody of IgM class, is optimally effective at 15 degrees C in the presence of complement and reacts with both T and B lymphocytes. The lymphocytes from patients with active Crohn''s disease or ulcerative colitis are poorly susceptible to lysis by lymphocytotoxins but lymphocytes from patients in remission are as susceptible as normal lymphocytes. This implies that the lymphocyte surface is altered during active disease although the pathogenetic significance of this is unclear.     

Inflammatory bowel disease: The surgical pathology of crohn's disease and ulcerative colitis

Ulcerative colitis and granulomatous colitis are distinct entities, but up to 10 percent of colectoiny specimens remain unclassified. Ulcerative colitis is liriniarily a inucosal disease, and other changes appear to be secondary to this process. By contrast, Crolin's disease, or granulomatous colitis, involves the whole thickness of the bowel wall. About 20 per cent of the cases of Crolin's disease involve the small and large bowel, while another 20 per cent are restricted to the large bowel. Since grantllonlatous colitis is a patchy disease, and many, of the changes are deep within the bowel wall, rectal biopsy may not be as lielpful as in ulcerative colitis. Fully developed granulomas are present in only a small minority of cases, and a diagnostic report of granulomatous colitis may be given in the absence of granulomas. In biopsy material, the differentiation of Inflaninlatory bowel disease from ischenlic colitis and psetidomenlbraliotis colitis may be difficult. In the absence of specific demonstration of an organism it may also be impossible on rectal biopsy to distinguish amebic or bacillary, dysentery from ulcerative colitis. Even by colectomy, 29 of 300 specimens were sufficiently atypical so as not to warrant a label of Crolin's disease or ulcerative colitis. Cancer of the colon, which is comnion in ulcerative colitis, is rare in Crolin's disease, but may also represent a definite complication in the latter. Immunologic studies are still confusing, but it is suggested that patients with ulcerative colitis and Crolin's disease may have a state of altered immunologic reactivity.     

Overexpression of fatty acid synthase in ulcerative colitis

Fatty acid synthase is an enzyme that catalyzes the synthesis of long-chain fatty acids. The enzyme expression is minimal in adult tissues and very high in many cancers. Ulcerative colitis is a chronic inflammatory bowel disease that, when long-standing, is associated with an increased risk of colon cancer. The aim of the present study was to establish whether fatty acid synthase levels in the mucosa without dysplasia of patients with long-standing ulcerative colitis were higher than in control subjects. Three groups of patients were selected: 30 with active ulcerative colitis, 30 with ulcerative colitis in remission, and 30 undergoing colonoscopy for colorectal cancer screening, as healthy control subjects. Fatty acid synthase expression was evaluated with immunohistochemical procedures. The enzyme was detected in all patients with active colitis, in most patients with quiescent disease, in both pathologic and normal mucosa, but in only 3 healthy control subjects. Our results suggest that extension of ulcerative colitis is greater than that revealed by common diagnostic techniques.     

Dynamics of the mucosa-associated flora in ulcerative colitis patients during remission and clinical relapse

The colonic mucosa-associated flora (MAF) in patients with active ulcerative colitis (UC) (n = 13) was investigated by examining 16S rRNA gene signatures during remission and relapse against levels for controls (n = 5). Baseline reduction, temporal instability, and decrease of bacterial richness toward relapse were observed for UC patients, whereas the MAF for controls was stable over time.     

Differences between tissue-associated intestinal microfloras of patients with Crohn's disease and ulcerative colitis

A leading hypothesis for the role of bacteria in inflammatory bowel diseases is that an imbalance in normal gut flora is a prerequisite for inflammation. Testing this hypothesis requires comparisons between the microbiota compositions of ulcerative colitis and Crohn's disease patients and those of healthy individuals. In this study, we obtained biopsy samples from patients with Crohn's disease and ulcerative colitis and from healthy controls. Bacterial DNA was extracted from the tissue samples, amplified using universal bacterial 16S rRNA gene primers, and cloned into a plasmid vector. Insert-containing colonies were picked for high-throughput sequencing, and sequence data were analyzed, yielding species-level phylogenetic data. The clone libraries yielded 3,305 sequenced clones, representing 151 operational taxonomical units. There was no significant difference between floras from inflamed and healthy tissues from within the same individual. Proteobacteria were significantly (P = 0.0007) increased in Crohn's disease patients, as were Bacteroidetes (P < 0.0001), while Clostridia were decreased in that group (P < 0.0001) in comparison with the healthy and ulcerative colitis groups, which displayed no significant differences. Thus, the bacterial flora composition of Crohn's patients appears to be significantly altered from that of healthy controls, unlike that of ulcerative colitis patients. Imbalance in flora in Crohn's disease is probably not sufficient to cause inflammation, since microbiotas from inflamed and noninflamed tissues were of similar compositions within the same individual.     

Mucosal-cell counts in ulcerative and granulomatous colitis.

Epithelial and connective-tissue cells were counted in rectal mucosal biopsies from 215 patients with ulcerative colitis, 98 patients with granulomatous colitis, and 50 controls. The results were analyzed statistically. Significantly decreased mucous goblet cells were found both in sigmoidoscopically abnormal ulcerative colitis and in granulomatous colitis, and they increased during the healing process. More pyknotic and karyorrhectic epithelial cells occurred in active ulcerative colitis than in granulomatous colitis. Inactive ulcerative colitis still manifested histologic evidence of acute and chronic inflammation, while sigmoidoscopically normal granulomatous colitis biopsies after previous gross rectal disease showed significantly increased macrophages in the lamina propria. Cell counts were valuable for differential diagnosis after the sigmoidoscopic appearance became normal. The acute inflammation of ulcerative colitis, as indicated by neutrophils, was decreased most notably following therapy with prednisone or 6-mercaptopurine. Chronic inflammation associated with fewer plasma cells was decreased after salicylazosulfapyridine as well as either of the other two drugs; macrophages, indicators of healing, increased most after 6-mercaptopurine combined with another anti-inflammatory agent.     

Tofacitinib for the treatment of ulcerative colitis

ABSTRACT

Introduction: New generations of small molecules are being developed for the treatment of ulcerative colitis. Among them, tofatinib (a Janus kinase (JAK) inhibitor) has demonstrated efficacy for inducing and maintaining remission and achieving mucosal healing with a reasonable safety profile. Oral administration is attractive for patients and lack of immunogenicity represents an advantage over biologic drugs.

Areas covered: This review discusses the molecular aspects of the JAK-STAT pathway; the mechanism of action of tofacitinib pertinent to ulcerative colitis and the evidence on the efficacy of tofacitinib for achieving clinically relevant outcomes, including clinical remission, mucosal healing, and normalization of quality of life, as well as safety aspects with special attention to adverse events related to the mode of action of the drug.

Expert commentary: Tofacitinib will be the first drug on the class of JAK inhibitors to be available for treatment of ulcerative colitis. The efficacy of the drug, with a rapid onset of action even in cases of severe colitis, oral administration, and possibility to use the drug intermittently without generating immunogenicity, will bring about a redesign of current treatment paradigms for ulcerative colitis.     

Comparison of Bacteroides vulgatus strains in the enhancement of experimental ulcerative colitis

Strains of Bacteroides vulgatus from a variety of sources were tested for their abilities to enhance the inflammatory response in an experimental model for ulcerative colitis. Although there were considerable differences noted in inflammatory responses when guinea pigs were immunized with the various strains, there did not appear to be any correlation between the source of the isolates and the severity of the carrageenan-induced lesions. Strains from patients with ulcerative colitis were no more active in the model system than were strains from patients with antibiotic-associated colitis or strains from a healthy human source. The antibody titer to the strain used for immunization did not correlate with the severity of the cecal ulcerations, as determined by histopathologic evaluation.     

Treatment of the mucosa with local anaesthetics in ulcerative colitis

A new paradigm for the treatment of ulcerative colitis has recently been presented: Treatment of the mucosa with lidocaine (2%) enemas for prolonged periods. This therapy was introduced based on the hypothesis that hyperreactive autonomic nerves may play a pathogenetic role in the disease. One hundred consecutive patients have now been treated and the results presented. Theproctitis patients all responded to the treatment, despite previous therapeutic failures in more than two-thirds of the cases. They were treated for 3–12 weeks, but 68% had a relapse (observation period 20 months). Of the 49 patients withproctosigmoiditis, two-thirds had chronic symptoms resistant to previous therapy. One of these patients did not respond to lidocaine, but developed fulminant total colitis. The other patient had therapeutic failure with lidocaine but responded well to subsequent cortisone enemas. The patients were treated until the subsets of T-lymphocytes ( and ) disappeared from the mucosa. This occurred in parallel with symptomatic relief and eventual healing in 83% of the patients after treatment for 6–34 weeks. Of all the patients with proctosigmoiditis, 42% presented with recurrent symptoms (observation period 16 months). Of the 17 patients withleft-sided colitis, all went primarily into remission within 2–4 months, but 23% had a relapse (observation period 13 months). The 6 patients withtotal colitis had symptomatic relief and improvement of histology when treated over 3–8 months. One patient had recurrence after 12 months. Treatment with a local anaesthetic in ulcerative colitis is a new approach to mucosal inflammation. The beneficial effects may be due to blockade of certain neural effects, such as epithelial proliferation and shedding and congestion of the mucosal vasculature, with actions on cells of the immune system.This work was supported by grants from the Swedish MRC (2207, 5520), the Assar Gabrielsson Foundation, and the Ulf Widengren Foundation.     

A solid-phase radioimmunoassay for measurement of circulating antibody titres to wheat gliadin and its subfractions in patients with adult coeliac disease

A solid-phase radioimmunoassay for the measurement of circulating antibody titres to wheat gliadin is described. Using this assay, we have measured antibody titres to unfractionated gliadin in normal healthy controls, in coeliac patients on a gluten-free or a normal diet, and in patients with ulcerative colitis and Crohn's disease. High titres of antibodies to unfractionated gliadin were observed only in the patients with untreated coeliac disease. Antibody titres to alpha, beta, gamma and omega gliadin subfractions were measured in patients with untreated coeliac disease and compared with titres in normal controls. Patients with untreated coeliac disease had higher antibody titres to the gliadin subfractions. No specific pattern of circulating antibody titres to gliadin subfractions was observed in the untreated coeliac patients which would provide a diagnostic profile. These results suggest shared antigenicity between the gliadin subfractions.     

Malakoplakia in ulcerative colitis.

Classic malakoplakia was found in the colon of a patient with a 30-year history of proven ulcerative colitis. She had undergone total proctocolectomy after failure of medical treatment to control her illness. Immunoperoxidase studies showed immunoglobulins and muramidase within the malakoplakic histiocytes, and electron microscopy showed bacteria resembling Escherichia coli in the same cells. Immunologic studies on the patient showed an unusually high E coli antibody titer (1:512) in her serum and reduced numbers of circulating T-lymphocytes with reduced cytotoxic activity. This case shows the paradoxical rarity of malakoplakia in ulcerative colitis and reaffirms the presence of an immunologic defect that may be pathogenetically significant.     

Immunohistologic demonstration of abnormal colonic crypt cell kinetics in ulcerative colitis

A monoclonal antibody, Ki-67, that reacts with cells in the proliferative phases (G1, G2, S, and M) of the cell cycle was used in an immunohistochemical labeling reaction to examine the colonic crypt epithelium in active ulcerative colitis, inactive ulcerative colitis, and normal mucosa. The proportions of labeled cells in the lower two thirds (proliferative zone) and in the upper quarter of the crypt were determined. The proportions of Ki-67-positive crypt epithelial cells in both the proliferative zone and the upper crypt were higher in biopsy specimens from patients with active ulcerative colitis than from patients with normal mucosa or with inactive ulcerative colitis. In inactive ulcerative colitis the proportion of Ki-67-positive epithelial cells in the proliferative zone of the crypt was higher than in normal mucosa. These results are similar to those obtained in studies using tritiated thymidine to determine the proportion of cells in the DNA-synthesizing thymidine to determine the proportion of cells in the DNA-synthesizing phase of the cell cycle and suggest that immuno-histochemical staining with Ki-67 may be a practical method for measuring the proliferative activity of epithelial cells in patients with ulcerative colitis and other disorders of the gastrointestinal tract.