Collagenous Colitis and Microscopic Colitis: The Watery Diarrhea-Colitis Syndrome

Nine patients (seven females, two males) with chronic watery diarrhea and nonspecific colonic mucosal inflammation followed for 1-5 yr are presented. Eight were diagnosed as having collagenous colitis on the basis of marked thickening of the subepithelial collagen layer in at least one set of biopsies. The thickness of the collagen table varied with time in all eight cases. When thickening was minimal, morphological features were indistinguishable from microscopic colitis, signifying that, in most cases, collagenous colitis and microscopic colitis are part of the same spectrum of colonic mucosal response. One of the eight patients had documented collagenous colitis and gluten-associated enteropathy for 12 yr. The colitis and duodenal histology improved synchronously when a gluten-free diet and corticosteroids were administered. The ninth patient had microscopic colitis and enteropathy which did not respond to gluten withdrawal. This patient never exhibited thickening of subepithelial collagen in repeated biopsies over 5 yr, suggesting that an entity of microscopic colitis may exist independent of collagenous colitis. Duodenal mucosal biopsies showed normal histology in four other patients with collagenous colitis. The histological variability of collagenization and inflammation during the course of collagenous colitis and microscopic colitis and the clinical feature of watery diarrhea suggest that these two entities be grouped together as the watery diarrhea-colitis syndrome.     

Antioxidant Therapy with N-Acetylcysteine Plus Mesalamine Accelerates Mucosal Healing in a Rodent Model of Colitis

The aims of this study were to examine the ability of the antioxidant N-acetylcysteine (NAC) and mesalamine (5-ASA) alone and in combination to affect TNBS-induced colitis in rat. Three days following induction of TNBS colitis rats were randomized to receive daily intracolonic treatment with NAC, 5-ASA, and NAC plus 5-ASA for 5 or 8 days. At the end of the treatment period macroscopic and microscopic colonic injuries were scored. Myeloperoxidase (MPO) activity and cytokine gene expression were measured in colonic tissues. Results indicated that treatment with NAC plus 5-ASA caused a significantly greater reduction in colonic injury than either agent alone. Furthermore, combination therapy inhibited significantly MPO activity and inflammatory cytokine gene expression in the distal colon of TNBS-treated animals. The beneficial effects of NAC plus 5-ASA on reduction of colonic injury and promotion of healing were most evident after 8 days of treatment.     

Colitis ulcerosa: Operationsindikationen und-verfahren

Zusammenfassung  Die Koloproktomukosektomie mit ileoanaler Pouchanlage gilt als der gegenw?rtige „Goldstandard” für die chirurgische Therapie der Colitis ulcerosa. Eine limitierte Resektion gilt als obsolet. Als limitierte Resektion ist bei der chirurgischen Therapie der Colitis ulcerosa lediglich die subtotale Kolektomie vertretbar. Eine limitierte Resektion im Sinne einer linksseitigen Hemikolektomie ist auch bei einer geringgradigen distalen Kolitis wegen der Kolitisexazerbationsgefahr und dem persistierenden Karzinomrisiko obsolet. Die subtotale Kolektomie mit Ileorektostomie stellt ein funktionell zufriedenstellendes Verfahren mit nur geringer Komplikationsrate dar. Wegen des fortdauernden Proktitis- und Rektumkarzinomrisikos (in den angeführten Studien 2,5%) ist diese Operation jedoch nur einer Ausnahmeindikation vorbehalten. Wegen der Impotenzgefahr der ileoanalen Pouchoperation (1,8% Impotenz, 5,8% retrograde Ejakulation) kann die ileorektale Anastomose jungen M?nnern als Alternative angeboten werden. Die subtotale Kolektomie mit Ileostoma und Sigmaschleimfistel ist fester Bestandteil der dreizeitigen ileoanalen Pouchanlage bei Notf?llen, schlechtem Allgemeinzustand und hoher pr?operativer Kortisonmedikation. Wegen der fehlenden Gefahr einer Rektumstumpfinsuffizienz (0% bei Sigmaschleimfistel versus 35% bei Rektumblindverschlu?) und besseren topischen Behandelbarkeit des verbleibenden Rektums ist die subtotale Kolektomie mit Ileostoma und Sigmaschleimfistel dem Rektumblindverschlu? vorzuziehen.      

Comparative Studies of Superoxide Production by Microbial Wall Product-Primed Neutrophils in Ulcerative Colitis

A diminished tolerance to the normal gut bacterial flora has been suggested to be pathogenic in ulcerative colitis (UC) and the aim of this study was to evaluate the priming effect of selected bacterial wall products on UC neutrophil granulocytes. Neutrophils from 10 UC patients and 10 healthy controls were primed with bacterial lipoprotein (BLP) or lipopolysaccharide (LPS) and subsequently activated. Extracellular superoxide production was measured by the cytochrome c reduction assay. Priming neutrophils with BLP or LPS dose dependently increased the superoxide production in both UC and controls (P < 0.01), and BLP was more potent than LPS (P < 0.05). No differences were found between UC and controls. UC neutrophils do not seem to have an intrinsic abnormality with reduced tolerance to bacterial substances. However, bacterial wall products such as BLP modify neutrophil tissue-destruction mechanisms and might be pivotal for perpetuation of chronic colonic inflammation.     

Inhibitory Effects of Fermented Brown Rice on Induction of Acute Colitis by Dextran Sulfate Sodium in Rats

Although the pathogenic mechanisms of inflammatory bowel diseases are not fully understood, colonic microbiota may affect the induction of colonic inflammation, and some probiotics and prebiotics have been reported to suppress colitis. The inhibitory effects of brown rice fermented by Aspergillus oryzae (FBRA), a fiber-rich food, on the induction of acute colitis by dextran sulfate sodium (DSS) were examined. Feeding a 5% and 10% FBRA-containing diet significantly decreased the ulcer and erosion area in the rat colon stained with Alcian blue. In another experiment, 10% FBRA feeding decreased the ulcer index (percentage of the total length of ulcers in the full length of the colon) and colitis score, which were determined by macroscopic observation. It also decreased myeloperoxidase activity in the colonic mucosa. Viable cell numbers of Lactobacillus in the feces decreased after DSS administration and was reversely correlated with severity of colitis, while the cell number of Enterobacteriaceae increased after DSS treatment and was positively correlated with colitis severity. These results indicate that FBRA has a suppressive effect on the induction of colitis by DSS and suggest FBRA-mediated modification of colonic microbiota.     

Outcome After Colectomy for <Emphasis Type="Italic">Clostridium Difficile</Emphasis> Colitis

PURPOSE Clostridium difficile colitis is a relatively common entity, yet large series of patients with fulminant C. difficile colitis are infrequently reported. This study was designed to identify risk factors, clinical characteristics, and outcome of patients who required colectomy for fulminant C. difficile colitis.METHODS A population-based study on all patients in 159 hospitals of the Department of Veterans Affairs from 1997 to 2001 was performed. Data were compiled from several national computerized Department of Veterans Affairs data sets. Supplementary information including demographic information, discharge summaries, operative reports, and pathology reports were obtained from local medical records. Patient variables were entered into a computerized database and analyzed using the Pearson chi-squared and Fishers exact tests. Statistical significance was designated as P < 0.05.RESULTS Sixty-seven patients (mean age, 69 (range, 40–86) years; 99 percent males) were identified. All 67 patients had C. difficile verified in the colectomy specimens. Thirty-six of 67 patients (54 percent) developed C. difficile colitis during a hospitalization for an unrelated illness, and 30 of 36 patients (87 percent) after a surgical procedure. Thirty-one of 67 (46 percent) developed C. difficile colitis at home. There was no history of diarrhea in 25 of 67 patients (37 percent). Thirty of 67 patients (45 percent) presented in shock (blood pressure, <90 mmHg). Forty-three of 67 patients (64 percent) presented with an acute surgical abdomen. Mean white blood cell count was 27.2; mean percent bands was 12. Twelve of 67 patients (18 percent) had a negative C. difficile colitis stool assay. Abdominal computed tomography correctly diagnosed 45 of 46 patients (98 percent) who were imaged. Twenty-six of 67 patients (39 percent) underwent colonoscopy; all 26 were found to have severe inflammation or pseudomembranes. Fifty-three of 67 patients (80 percent) underwent total colectomy; 14 of 67 underwent segmental colonic resection. Perforation and infarction were found in 59 of 67 patients (58 percent) at surgery. Overall mortality was 48 percent (32/67). Mean hospitalization was 36 (range, 2–297) days.CONCLUSIONS Patients with fulminant C. difficile colitis often present with an unexplained abdominal illness with a marked leukocytosis that rapidly progresses to shock and peritonitis. Although frequently developed during a hospitalization and often after a surgical procedure, it may develop outside of a hospital setting. Diarrhea may be absent and stool cytology may be negative for C. difficile toxin. Perforation and infarction are frequently found at surgery. In those patients who survive, a prolonged hospitalization is common. Mortality from fulminant C. difficile colitis remains high despite surgical intervention.Read at the meeting of The American Society of Colorectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.     

Colitis ulcerosa

Background

Ulcerative colitis (UC) is a complex disease in which the interaction of genetic, environmental and microbial factors drives chronic intestinal inflammation that finally leads to extensive tissue fibrosis.

Discussion

The present review discusses the current knowledge on genetic susceptibility, especially of the IL-12/IL-23 pathway, the pathophysiologic role of the involved cytokines (e.g. IL-13, IL-23, TGF-??1) and immune cells (e.g. T cells, epithelial cells, fibroblasts) in UC followed by an overview on actual therapeutic considerations. These future therapies will target selectively the involved cell types by blocking their activation and its downstream signalling, by inhibiting their migration to the inflamed site and by anti-cytokine strategies. This may avoid?Cwhen initiated in time?Cthe perpetuation of the inflammatory mechanisms thus preventing fibrosis. With respect to animal models that have guided the most productive efforts for understanding human inflammatory bowel disease, these will be shortly discussed in the respective context.     

Diversion Colitis

Opinion statement Management of the patient with diversion colitis is dependent upon both patient and disease-related factors. Patients in whom diversion is not permanent, who desire stoma closure, and who have an acceptable surgical risk should undergo re-establishment of intestinal continuity. Asymptomatic, high-risk surgical candidates need only undergo periodic, regular endoscopic surveillance of both the functional and nonfunctional large bowel according to currently accepted screening guidelines. Most symptomatic patients in whom the diversion is permanent can be treated successfully with steroid enemas, 5-aminosalicylic acid enemas or suppositories, or short-chain fatty acid enemas. If diversion is permanent, medical treatment is unsuccessful, and symptoms persist, acceptable surgical candidates should undergo resection of the excluded bowel.