Macronutrient intake and malabsorption in HIV infection: a comparison with other malabsorptive states

Background—Wasting is a major complication of HIVinfection. The role of malabsorption in wasting is controversial.
Aims—To assess oral intake and malabsorption in acohort of weight losing HIV infected patients, with or without chronic diarrhoea.
Methods—A prospective study using a predefinedprotocol for HIV infected patients was performed in a gastroenterologyand nutrition unit in a university hospital. A retrospective comparison was made with HIV negative patients with malabsorption due either tosmall bowel disease or resection. Body weight and height, serum albumin, oral intake of macronutrients, faecal weight, and faecal fatwere measured.
Results—Seventy nine weight losing HIV infectedpatients were studied. Among the 66 patients with more than 5% lipidmalabsorption, wasting was significantly greater in patients withcryptosporidiosis (n=22) than in patients with microsporidiosis (n=18)who exhibited significantly more wasting than patients with noidentified enteropathogen (n=26) (body mass index 16.8 (14.0-20.7),18.9 (16.5-21.3), 19.7(15.9-23), respectively). When controlling forthe level of lipid malabsorption, HIV infected patients had asignificantly lower energy intake than HIV negative patients withchronic malabsorption. In HIV infected patients, but not in othercategories of malabsorbers, body mass index correlated significantlywith energy intake (r=0.33, 95% confidence intervals 0.12 to 0.51).
Conclusion—In weight losing HIV infectedpatients, reduced energy intake is superimposed on malabsorption andsignificantly contributes to wasting.

     

Biliary lipid composition in idiopathic bile acid malabsorption

Background—Chronic diarrhoea is the clinicalhallmark of patients presenting with idiopathic bile acidmalabsorption. Its pathogenesis is unknown; colonic water secretion canbe induced by dihydroxy bile acids, but it is not known whetherenrichment of the bile acid pool with these bile acids occurs in suchpatients. Furthermore, bile acid malabsorption is known to affectbiliary lipid composition, but no information is available for theidiopathic type.
Aims—To verify: (a) whetherdiarrhoea in patients with idiopathic bile acid malabsorption isassociated with enrichment of the bile acid pool with dihydroxy bileacids; and (b) whether supersaturation with cholesterol ofduodenal bile occurs in such patients as a result of chronic bile acid depletion.
Patients—Thirteen patients with idiopathic bileacid malabsorption diagnosed according to abnormal ⁷⁵SeHCATtest and absence of other organic diseases, and 23 control subjects.
Methods—Bile rich duodenal fluid was collectedduring intravenous ceruletide infusion in the fasting state. Biliarylipids were analysed by enzymatic assays and bile acids by highperformance liquid chromatography.
Results—Patients with idiopathic bile acidmalabsorption had a cholesterol saturation index similar to controls.Bile acid composition showed only a decrease in percentage cholic acid(29(2)% versus 36 (2)%; p<0.05); the dihydroxy:trihydroxy bile acid ratio was similar to controls.
Conclusions—Patients with idiopathic bile acidmalabsorption do not have an increased risk of forming cholesterolgallstones. The mechanism of diarrhoea does not seem to depend on anenrichment of the bile acid pool with dihydroxy bile acids.

Keywords:primary bile acid malabsorption; bile acids; diarrhoea; ⁷⁵SeHCAT; biliary lipids; cholesterol saturationindex

     

Prospective evaluation of protein bound vitamin B12 (cobalamin) malabsorption in the elderly using trout flesh labelled in vivo with 57Co-cobalamin

Background—The frequency of dietary proteinbound vitamin B₁₂ malabsorption in elderly patients remains controversial.
Aims—To evaluate this malabsorption inelderly hospitalised patients using a modified Schilling test.
Patients—Fourteen elderly patients with lowB₁₂ blood levels were prospectively selected from 394 hospitalised patients.
Methods—The modified Schilling test was performedwith trout labelled in vivo.
Results—The test was normal in five healthyelderly subjects, in 7/8 patients with pancreatic insufficiency, and innine non-elderly patients with antral gastritis. The low decision limitwas established at 3.3% (median 4.8%). From the 14 elderly patientswith low B₁₂ prospectively selected from 394 hospitalisedpatients, seven had a real deficiency with anaemia and an increasedhomocysteine and/or methylmalonate serum level. The modified Schillingtest showed malabsorption in five of these patients, including two inwhich the standard Schilling test was normal, and three in which the standard Schilling test was partially corrected by an intrinsic factor.
Conclusions—Protein bound vitamin B₁₂malabsorption was detected in at least 0.5% of elderly hospitalisedpatients, using the labelled trout flesh absorption test.

Keywords:cobalamin deficiency; malabsorption; gastritis; Schilling test

     

No relationship between gastric pH, small bowel bacterial colonisation, and diarrhoea in HIV-1 infected patients

Background/Aims—Conclusivestudies of small bowel bacterial overgrowth in patients with HIV-1infection are limited. The relation was therefore determined betweenthe quantity and species of bacteria in the proximal small intestine ofHIV-1 infected patients and the presence of diarrhoea, gastric acidity,severity of immune deficiency, and clinical outcome.
Methods—Bacteria inthe duodenal fluids obtained endoscopically from 32 HIV-1 infectedpatients, 21 of whom had diarrhoea, and seven control subjects withoutHIV-1 risk factors were quantified and speciated. Gastric pH wasdetermined at the time of endoscopy. Clinical follow up was performedto assess outcome.
Results—OropharyngealGram positive cocci were present in fluids from 28 patients (88%).Gram negative aerobic or facultatively anaerobic bacteria were presentin fluids from 12 patients (38%), and strict anaerobes were detectedin six patients (19%), but for both groups colony counts infrequentlyexceeded 10⁴ colony forming units/ml. The number andspecies of bacteria did not correlate with the presence of diarrhoea,gastric pH, or CD4 lymphocyte count.
Conclusions—Smallbowel bacterial overgrowth is not common in HIV-1 infected patients,regardless of the presence of diarrhoea, and is not associated with hypochlorhydria.

Keywords:bacterial overgrowth; diarrhoea; HIV infection; AIDS

     

Cisplatin impairs fluid and electrolyte absorption in rat small intestine: a role for 5-hydroxytryptamine

Background—Theantineoplastic drug cisplatin has been widely used for the treatment ofcancer in humans but its use has been limited by vomiting anddiarrhoea. Cisplatin releases 5-hydroxytryptamine into the gutwhich is thought to be the major mediator of cisplatin induced vomiting.
Aim—To determinewhether cisplatin affects fluid and electrolyte transport in ratjejunum and whether this change can be modulated by the5-hydroxytryptamine₃ receptor antagonist, ondansetron.
Methods—Jejunalperfusion in rats in vivo was performed one hour after intraperitonealcisplatin (5 and 10 mg/kg) administration. The effect of pretreatmentwith subcutaneous ondansetron 300 µg/kg was investigated.
Results—Median netfluid absorption after cisplatin 10 mg/kg (67 µl/min/g dry intestinalweight (interquartile range 46 to 100); n = 15) was reduced comparedwith controls (120 (107to 151) µl/min/g; n = 13; p<0.001).Ondansetron reversed the impairment of jejunal fluid absorptionproduced by cisplatin to normal (161(130 to 176) µl/min/g; n = 11;p<0.001). Electrolyte movement paralleled fluid movement. Jejunalhistological examination of sections from cisplatin treated animalsshowed villus damage, which was not prevented by pretreatment with ondansetron.
Conclusion—Thesefindings suggest that diarrhoea during cisplatin therapy may be due toaltered fluid transport in the small bowel. The reversal of fluidtransport to normal in the presence of a5-hydroxytryptamine₃ receptor antagonist suggests that5-hydroxytryptamine is a local mediator in the small intestine.

     

Medium term effects of a new 5HT3 antagonist, alosetron, in patients with carcinoid diarrhoea

Background—Carcinoid diarrhoea is associated withrapid small bowel and proximal colonic transit. Intravenousadministration of a serotonin type 3 receptor (5HT₃)antagonist restores postprandial colonic tone towards normal incarcinoid patients.
Aims—To evaluate the medium term effects of anoral 5HT₃ antagonist, alosetron, on symptoms, stool fat,and transit in patients with carcinoid diarrhoea.
Methods—In 27 patients with carcinoid diarrhoea,symptoms were recorded daily and gastrointestinal transit was measuredby scintigraphy in a three dose (0.1, 0.5, 2.0 mg, twice daily), randomised (1:1:1), parallel group, four week study. Placebo was givenduring the first week. Loperamide (2 mg capsules) was used as rescue medication.
Results—There were numerical improvements inmedian diarrhoea score, stool weight, loperamide use, and overallcolonic transit at four hours, but no overall significant drug effectwas shown. Alosetron reduced the proximal colon emptying rate (p<0.05in 20 evaluable comparisons), but did not significantly alter small bowel transit.
Conclusions—Alosetron retardation of proximalcolonic emptying in patients with carcinoid diarrhoea confirms thepotential role of a 5HT₃ mechanism in this disorder. Dosesof alosetron higher than 2.0 mg twice daily will be required forsymptomatic benefit in carcinoid diarrhoea.

Keywords:carcinoid diarrhoea; alosetron; serotoninergicagents; antagonist; colonic transit

     

Enteropathy in Zambians with HIV related diarrhoea: regression modelling of potential determinants of mucosal damage

Background—AIDS is characterised by smallintestinal mucosal damage, but its aetiopathogenesis is poorlyunderstood. Enteric infections in Africa differ from those in northerncountries, where protozoan infections have been associated with severeenteropathy in AIDS patients.
Aims—To characterise enteropathy in ZambianAIDS patients compared with local controls, and to assess relativecontributions of enteric infection, nutritional impairment, and immune dysfunction.
Methods—Computer aided mucosal morphometry ofsmall intestinal biopsy specimens from 56 HIV infected Zambians withpersistent diarrhoea and 26 diarrhoea free controls, followed byregression modelling.
Results—Patients with HIV related diarrhoea hadreduced villous height and increased crypt depth compared withcontrols. There was no difference between HIV positive and negativecontrols. In regression models applied to AIDS mucosal measurements,villous height and crypt depth were related to nutritional parameters and to serum soluble tumour necrosis factor receptor p55 concentration. Crypt depth was also related to lamina propria plasma cell count. Intestinal infection was found in 79%, which consisted predominantly of microsporidia in 34%, Isospora belli in 24%, andCryptosporidium parvum in 21%, but detection of theseenteropathogens was not related to severity of enteropathy.
Conclusions—Nutritional and immune disturbanceswere associated with enteropathy, accounting for over one third of thevariation in mucosal morphometric parameters.

Keywords:small intestine; enteropathy; protozoa; malnutrition; tumour necrosis factor receptors; Africa; AIDS

     

The distal colon provides reserve storage capacity during colonic fluid overload

Background—In addition to its absorptive functionthe capacity of the colon to retain fluid might be relevant incompensating for increased fluid loads and prevention of diarrhoea. Thedistal colon is considered to be mainly a conduit without extensivestorage function.
Aims—To evaluate colonic volume capacity in amodel of pure osmotic diarrhoea.
Methods—A non-absorbable, iso-osmotic solution(OS) containing polyethylene glycol (500 ml) was infused into thecaecum of nine healthy volunteers; the control group (n=5) received anequal amount of an easily absorbable electrolyte solution (ES). Fluids were radiolabelled with technetium-99m and gamma camera images wereobtained for 48 hours. Counts in the proximal and distal colon weremeasured and regional and overall colonic transit and stool output were quantified.
Results—After OS, in contrast to ES, faecal outputwas increased significantly (p<0.05), but colonic transit after OS was not different from transit after ES (p>0.05). This indicates storage of OS in the colon: after OS infusion, counts in the proximal colondecreased linearly while the distal colon stored approximately 30% ofradioactivity for the whole 48 hour study period. After OS, stooloutput correlated with distal (p<0.01), but not with proximal(p>0.05), colonic transit. In constrast, after ES, stool output wasdetermined by proximal colonic transit (p<0.05) but not by transitthrough the distal colon (p>0.05).
Conclusion—The distal colon retainsnon-absorbable fluid volumes extensively. In our model transit throughthe distal colon—but not the proximal colon—determined the time atwhich diarrhoea occurred.

Keywords:osmotic diarrhoea; colonic transit; storagecapacity; colonic scintigraphy

     

Putative analgesic activity of repeated oral doses of vitamin E in the treatment of rheumatoid arthritis. Results of a prospective placebo controlled double blind trial

OBJECTIVE—Vitamin E, the most potent naturally occurring lipid soluble antioxidant has been suggested to possess both anti-inflammatory and analgesic activity in humans. This double blind and randomised study used a broad spectrum of clinical and laboratory parameters to investigate whether there was any additional anti-inflammatory or analgesic effects, or both, of orally administered α-tocopherol in rheumatoid arthritis patients who were already receiving anti-rheumatic drugs.
METHODS—Forty two patients were enrolled and treated with α-tocopherol (n=20) at a dose of 600 mg twice a day (2 × 2 capsules) or with placebo (n=22) for 12 weeks. The following parameters were measured: (1) Three clinical indices of inflammation—the Ritchie articular index, the duration of morning stiffness, and the number of swollen joints; (2) three measures of pain—pain in the morning, pain in the evening, and pain after chosen activity; (3) haematological and biochemical measures of inflammatory activity; (4) assays for the oxidative modification of proteins and lipids.
RESULTS—All laboratory measures of inflammatory activity and oxidative modification were unchanged. Furthermore, the clinical indices of inflammation were not influenced by the treatment. However, the pain parameters were significantly decreased after vitamin E treatment when compared with placebo.
CONCLUSION—The results provide preliminary evidence that vitamin E may exert a small but significant analgesic activity independent of a peripheral anti-inflammatory effect, but which complements standard anti-inflammatory treatment.

     

Prevalence of infection with Cryptosporidium parvum and Cyclospora cayetanensis among international travellers

Background—Cryptosporidium parvumand Cyclospora cayetanensis are recognised aspossible pathogens of traveller's diarrhoea.
Aims—To identify the prevalence of C parvumand Cyc cayetanensis in travellers returning fromdeveloping countries.
Patients—Nine hundred and seventy eight stoolsamples were taken from 795 patients returning from developing countries.
Methods—Microscopy (iron-haematoxylinstain, SAF concentration, modified acid fast stain) and a commerciallyavailable enzyme linked immunosorbent assay (ELISA) kit for thedetection of Cryptosporidium antigen in stool.
Results—Of the 795 patients in the study, 469 suffered from diarrhoea. Infection with Cyc cayetanensiscould be detected in five subjects (1.1%) by acid fast stain, and 13 patients (2.8%) were infected with C parvum. Onevaluation, the antigen capture ELISA turned out to be clearly lesssensitive for detection of C parvum than microscopy. Allpatients with either C parvum or Cyccayetanensis infection suffered from watery diarrhoea.
Conclusions—C parvum and Cyccayetanensis are not major causes of diarrhoea in internationaltravellers. In cases of persistent watery diarrhoea, however, thesepathogens should be taken into account in the differential diagnosis.

Keywords:diarrhoea; Cryptosporidium parvum; Cyclospora cayetanensis

     

Lipids infused into the jejunum accelerate small intestinal transit but delay ileocolonic transit of solids and liquids

Background—Various nutrients areknown to alter small intestinal motility patterns although their effecton transit of fluids and solids in man is not clear.
Aims—To determine small intestinaltransit of solids and liquids during perfusion with lipids, protein,and non-energy solutions.
Methods—Twenty eight healthyvolunteers received a jejunal infusion (1 ml/ minute for 30 minutes) ofone of four solutions: a lipid or a protein solution (4.18 J/ml), anon-absorbable electrolyte solution containing polyethylene glycol, or0.9% sodium chloride. As solid phase marker 1 g of amberlite resinpellets labelled with ¹¹¹InCl₃ was added;^99mTc DTPA was used as a fluid phase marker. Images wereobtained on a gamma camera at 10 minute intervals for four hours oruntil all radiolabel was detected in the colon.
Results—Intestinal transit ofsolids and liquids from the duodenojejunal junction to the caecum wassimultaneous, and independent of the energy content of the solutioninfused. Lipid infusion accelerated transit through the small intestinebut delayed transport of chyme along the ileocolonic junction. Afterprotein small intestinal transit was slowest; ileocolonic transit onthe other hand was fastest with protein. Transit of the non-energysolutions was in between that of the nutrient solutions.
Conclusions—Transit times throughthe small intestine and the ileocolonic junction were influenced by theluminal contents. In the small intestine fat induced significantlyfaster transit compared with proteins, but delayed ileocolonic transit.Once in the small intestine, solids and liquids transit the small bowel together, independent of the luminal content.

Keywords:small intestine; ileocolonic junction; transit; nutrients; lipids; proteins

     

Intractable diarrhoea associated with secondary amyloidosis in rheumatoid arthritis

OBJECTIVE—To examine the clinical characteristics of intractable diarrhoea associated with secondary amyloidosis in rheumatoid arthritis (RA).
METHODS—Of 179 RA patients with biopsy confirmed secondary amyloidosis, 24 cases (23 women and one man) with intractable diarrhoea lasting for more than one month were retrospectively evaluated.
RESULTS—The mean (SD) duration of diarrhoea was 87 (64) days. Prodromal symptoms of gastrointestinal dysfunction (n = 21) and impaired peristalsis (n = 16) were observed. Laboratory data showed hypoproteinaemia (4.7 (0.85) g/dl) caused by malabsorption or protein loss and high values of C reactive protein (17.0 (9.3) mg/dl). Recurrence of intractable diarrhoea (n = 4) and transition from intractable diarrhoea to other gastrointestinal problems of amyloidosis (ischaemic colitis (n = 2) and intestinal pseudo-obstruction (n = 4)) were observed. In 19 patients (25 episodes) the duration of intravenous hyperalimentation at remission (18 episodes) was 68 (52) days. Corticosteroid pulse therapy was administered to 10 patients (11 times) and the time elapsed from the end of corticosteroid pulse therapy to the end of diarrhoea was 18 (14) days. One and five year survival rates after the onset of intractable diarrhoea were 73.4% and 38.9% . Seven of 13 patients (54%) had died as a result of infectious diseases.
CONCLUSION—Intractable diarrhoea associated with secondary amyloidosis in RA is a serious clinical entity and the prognosis is poor. Although it is assumed that intravenous hyperalimentation treatment and corticosteroid pulse therapy are favourable regimens for intractable diarrhoea, the patients should be monitored for possible infectious complications.

     

A randomised, double blind, multicentre trial of octreotide in moderate to severe acute pancreatitis

BACKGROUND—The pharmacological inhibition of exocrine pancreatic secretion with the somatostatin analogue octreotide has been advocated as a specific treatment of acute pancreatitis.
AIM—To investigate the efficacy of octreotide in acute pancreatitis in a randomised, placebo controlled trial.
METHODS—302 patients from 32 hospitals, fulfilling the criteria for moderate to severe acute pancreatitis within 96 hours of the onset of symptoms, were randomly assigned to one of three treatment groups: group P (n=103) received placebo, while groups O1 (n=98) and O2 (n=101) received 100 and 200 µg of octreotide, respectively, by subcutaneous injection three times daily for seven days. The primary outcome variable was a score composed of mortality and 15 typical complications of acute pancreatitis.
RESULTS—The three groups were well matched with respect to pretreatment characteristics. An intent to treat analysis of all 302 patients revealed no significant differences among treatment groups with respect to mortality (P: 16%; O1: 15%; O2: 12%), the rate of newly developed complications, the duration of pain, surgical interventions, or the length of the hospital stay. A valid for efficacy analysis (251 patients) also revealed no significant differences.
CONCLUSIONS—This trial shows no benefit of octreotide in the treatment of acute pancreatitis.


Keywords: acute pancreatitis; somatostatin; octreotide; randomised controlled multicentre trial     

Mucin gene expression in human embryonic and fetal intestine

Background—The intestinal epithelium is coveredby a continuous layer of mucus which is secreted by well differentiatedepithelial cells. Disregulation of the expression of mucins has beenreported to have possible implications in the neoplastic process which affects intestinal mucosae. It is well known that preneoplastic andneoplastic tissues can express fetal phenotypic characteristics.
Aims—To assess whether the expression of mucingenes in the intestinal tract is linked to the stage of cellulardifferentiation and tissue development, by studying the expression ofsix mucin genes in human fetal small intestine and colon, and alsoadult tissues.
Methods—In situ hybridisation was used to studymRNA expression of MUC2, MUC3, MUC4, MUC5B, MUC5AC, and MUC6 in 32 human embryos and fetuses (6.5-27 weeks gestation). Normal adultmucosae were used as controls.
Results—Three mucin genes, MUC2, MUC4, andMUC5AC, were differently expressed in fetal intestine compared withexpression in normal adults.
Conclusion—These differences in mucin geneexpression suggest a possible regulatory role for these products inintestinal epithelial cell differentiation.

Keywords:mucin genes; mucins; intestine; differentiation; human fetus

     

Sex differences in investigation results and treatment in subjects referred for investigation of chest pain

OBJECTIVE—To evaluate differences in investigation results and treatment between men and women referred for diagnostic treadmill exercise testing and coronary arteriography.
DESIGN—Cohort study.
SETTING—Tertiary cardiology centre.
SUBJECTS—1522 subjects referred by primary care physicians to an open access chest pain clinic for initial investigation of chest pain, of whom 485 were subsequently referred for coronary arteriography; and a similar cohort of 107 subjects referred directly by secondary care physicians for diagnostic coronary arteriography.
MAIN OUTCOME MEASURES—Rates of positive exercise tests and rates for referral for arteriography and revascularisation according to sex.
RESULTS—Overall, women were less likely to be referred for arteriography and revascularisation than men. However, men were more likely to have positive exercise tests, and for various exercise test diagnostic end points men were also more likely to have significant coronary artery disease. After taking this into account, there was no sex difference in referral rates for arteriography or revascularisation.
CONCLUSIONS—There was no evidence of a sex bias resulting in inappropriate underinvestigation or undertreatment of women. However, the positive predictive value of treadmill exercise testing is low for women and further research is needed into how best to investigate women with chest pain.


Keywords: sex differences; exercise test; chest pain     

Relation between Helicobacter pylori infection and gastrointestinal symptoms and syndromes

Background—Helicobacter pylori is ahuman pathogen that colonises the gastric mucosa and causes permanentgastric inflammation.
Aims—To assess the symptoms of Hpylori infection in an adult unselected population.
Subjects—A random sample of 3589 adult Danes whowere examined in 1982 and 1987 (n=2987).
Methods—Abdominal symptoms within the precedingyear were recorded at both attendances. Circulating IgG antibodiesagainst H pylori in serum samples drawn in 1982 weremeasured by using in-house indirect enzyme linked immunosorbent assays (ELISA).
Results—People with increased levels of IgGantibodies to H pylori were more likely than uninfectedindividuals to report heartburn (odds ratio (OR) = 1.26, 95%confidence interval (CI) 1.03-1.54) and abdominal pain characterisedby daily length (OR= 1.33, 95% CI 0.92-1.91), nocturnal occurrence(OR = 1.62, 95% CI 1.19-2.19), spring aggravation (OR = 1.68, 95% CI0.70-4.05), and no relation to meals (OR = 0.62, 95% CI 0.43-0.91)or stress (OR = 0.69, 95% CI 0.50-0.95). The inclusion of people withincreased levels of IgG antibodies to H pylori, butwithout upper dyspepsia, at study entry significantly increased thelikelihood of reporting upper dyspepsia at follow up (OR = 1.71, 95%CI 1.24-2.36). People with epigastric pain and increased levels of IgMantibodies to H pylori only indicative of acute Hpylori infection were more likely to report nocturnal pain,heartburn, nausea, and vomiting.
Conclusions—H pylori infection mayprecede the development of dyspepsia and is associated with a varietyof gastrointestinal symptoms in people with no history of peptic ulcer disease.

Keywords:epidemiology; Helicobacter pylori;non-ulcer dyspepsia; symptomatology; upper dyspepsia

     

Lymphocytic colitis: clinical presentation and long term course

Background—Lymphocytic colitis is characterised bychronic watery diarrhoea with normal endoscopic or radiologicalfindings and microscopic evidence of pronounced infiltration of thecolonic mucosa with lymphocytes.
Aim—To investigate the long term clinical andhistological evolution of the disease in a large group of patients withwell characterised lymphocytic colitis.
Methods—Between 1986 and 1995 the histologicaldiagnosis of lymphocytic colitis was obtained in 35 patients; 27 ofthese agreed to a follow up examination. All clinical, endoscopic, andhistopathological records were reviewed at that time and the patientshad a second endoscopic examination with follow up biopsies.
Results—The patients initially presented with thetypical findings of lymphocytic colitis. After a mean (SD) follow up of 37.8 (27.5) months, diarrhoea subsided in 25 (93%) and histological normalisation was observed in 22 (82%) of the 27 patients. Progression from lymphocytic colitis to collagenous colitis was not observed.
Conclusions—Lymphocytic colitis is characterisedby a benign course with resolution of diarrhoea and normalisation ofhistology in over 80% of patients within 38 months. Considering thebenign course of the disease, the potential benefit of any drugtreatment should be carefully weighed against its potential side effects.

Keywords:lymphocytic colitis; colitis; diarrhoea

     

Clinical characteristics of chronic idiopathic intestinal pseudo-obstruction in adults

Background—Chronic idiopathic intestinalpseudo-obstruction, a syndrome of ineffectual motility due to a primarydisorder of enteric nerve or muscle, is rare.
Aims—To determine the clinical spectrum,underlying pathologies, response to treatments, and prognosis in aconsecutive unselected group of patients.
Methods—Cross sectional study of all patientswith clinical and radiological features of intestinal obstruction inthe absence of organic obstruction, associated with dilated smallintestine (with or without dilated large intestine), being activelymanaged in one tertiary referral centre at one time.
Results—Twenty patients (11 men and nine women,median age 43 years, range 22-67) fulfilled the diganostic criteria.Median age at onset of symptoms was 17 years (range two weeks to 59 years). Two patients had an autosomally dominant inherited visceralmyopathy. Major presenting symptoms were pain (80%), vomiting (75%),constipation (40%), and diarrhoea (20%). Eighteen patients requiredabdominal surgery, and a further patient had a full thickness rectalbiopsy. The mean time interval from symptom onset to first operationwas 5.8 years. Histology showed visceral myopathy in 13, visceral neuropathy in three, and was indeterminate in three. In the one otherpatient small bowel motility studies were suggestive of neuropathy. Twopatients died within two years of symptom onset, one from generalisedthrombosis and the other from an inflammatory myopathy. Of theremaining 18 patients, eight were nutritionally independent ofsupplements, two had gastrostomy or jejunostomy feeds, and eight werereceiving home parenteral nutrition. Five patients were opiatedependent, only one patient had benefited from prokinetic drug therapy,and five patients required formal psychological intervention and support.
Conclusions—In a referral setting visceralmyopathy is the most common diagnosis in this heterogeneous syndrome,the course of the illness is usually prolonged, and prokinetic drugtherapies are not usually helpful. Ongoing management problems includepain relief and nutritional support.

Keywords:adult; intestinal; pseudo-obstruction; myopathy; neuropathy

     

Efficacy and safety of the peripheral kappa agonist fedotozine versus placebo in the treatment of functional dyspepsia

Background—Peripheral kappa receptor agonists mayprovide a new therapeutic approach for the treatment of functional dyspepsia.
Aims—To evaluate, in a large multicentre trial,the use of the kappa receptor agonist fedotozine to improve symptomsassociated with functional dyspepsia.
Methods—Two or more of the followingpersistent symptoms were required for inclusion: epigastric pain, earlysatiety, epigastric fullness or distension, nausea, vomiting, and afeeling of slow digestion. On completing a two week placebo washout,271 patients were randomised into two groups to receive 30 mgfedotozine three times daily or placebo for six weeks under doubleblind conditions.
Results—The improvement in the overall intensityof dyspeptic symptoms (main efficacy criterion) was significantly morepronounced in the fedotozine group (p=0.002) compared with placebo, aswas epigastric pain (p=0.004) and nausea (p=0.01); the improvement inpostprandial fullness was nearly significant (p=0.052). Inability tofinish a meal and slow digestion were unaffected. The patient globalscore, the average of the five individual symptoms, was notablyameliorated with fedotozine (p=0.021). The safety of fedotozine was excellent.
Conclusions—Fedotozine at 30 mg three times dailyis safe and more effective than placebo for the relief of key symptomsassociated with functional dyspepsia.

Keywords:fedotozine; functional dyspepsia; kappa receptoragonist

     

Echocardiographic features of Candida species endocarditis: 12 cases and a review of published reports

OBJECTIVE—To describe the specific echocardiographic features of Candida species endocarditis.
DESIGN—Retrospective review of the case records of patients with confirmed candida endocarditis.
SETTING—Cases referred to three French university centres over an eight year period were studied.
DESIGN—12 patients with confirmed Candida species endocarditis infection were identified. The transthoracic (n = 12) and transoesophageal (n = 12) echocardiographic appearances were compared with the surgical findings (n = 10).
RESULTS—Large dense heterogeneous vegetations were found in 11/12 cases. A hyperechogenic heterogeneous myocardial texture, observed in seven of the 12 patients, was associated with extensive myocardial damage at surgery. While it was possible to diagnose candidal cardiac infection in all patients by transthoracic echocardiography, transoesophageal echocardiography was useful for optimal assessment of the valvar and paravalvar structures.
CONCLUSIONS—In the setting of endocarditis, the detection of myocardial involvement, which is characterised by a heterogeneous myocardial texture, is an argument in favour of Candida species endocarditis and may warrant early surgical intervention.


Keywords: echocardiography; Candida species; endocarditis