Bioptic microbiology in the differential diagnosis of enterocolitis

Parameters in the differential diagnosis of enterocolitis have been poorly evident for many years. Development and profitable employment of endoscopic instruments were the first step towards advancing the diagnostic facilities in inflammatory bowel disease. The microbiologic examination of mucosal biopsies creates a new diagnostic dimension, and it distinctly seems to increase the diagnostic sensitivity for pathogens. Within fifteen months 152 patients admitted to the gastroenterologic unit with acute, or symptoms of exacerbated, bowel disease were examined for the aetiologic agents. Compared with former reports, idiopathic inflammatory bowel disease (IIBD) such as Crohn's disease (32.2%) and ulcerative colitis (18.4%) were decreased. Infectious colitis (22.3%), mostly Campylobacter or Yersinia infections, was, sometimes exclusively, diagnosed by bioptic microbiology, non-classifiable forms of colitis (21.7%), and rare forms (5.4%) were diagnosed more often. It proved to be important that IIBD was frequently superinfected by Campylobacter, Yersinia and Chlamydia, and the differential diagnosis was complicated, since these microorganisms can mimic IIBD. The results suggest that coloileoscopy combined with bioptic microbiologic investigation additional to faecal samples should include a search for Campylobacter and Yersinia. It appears indispensable that the final diagnosis "Crohn's disease" or "ulcerative colitis" should be confirmed by sequential coloileoscopy and microbiologic examination.     

Inflammatory bowel disease. Part II: Clinical and therapeutic aspects

Once regarded as medical curiosities, ulcerative colitis and Crohn's disease have achieved a remarkable change in status recently and today are among the more compelling of all human illnesses. The cause(s) of inflammatory bowel disease (IBD) are not known. Genetic, environmental, microbial, and immunologic factors are involved, but the precise mechanisms are obscure. The incidence of ulcerative colitis is relatively stable, while Crohn's disease continues to increase in frequency. In 10% to 15% of patients, it is hard to differentiate between ulcerative colitis and Crohn's colitis, however, problems with diagnosis usually resolve with time and repeated examinations. In part I of his two-part monograph on IBD, Dr. Kirsner addressed the nature and pathogenesis of the disease. Increased study of ulcerative colitis and Crohn's disease in recent years has generated new knowledge regarding their etiology. Part I focused on microbial, immunologic, and genetic mechanisms of, and the inflammatory process involved in the disease. In this part, Dr. Kirsner deals with the clinical features, course, and management of IBD, based on the author's 55 years of experience with these problems and supplemented by critical examination of the recent (1988-1990) literature. Particular attention is directed to the symptoms and physical findings of ulcerative colitis and Crohn's disease. The laboratory, radiologic, endoscopic, and pathologic features, and the many systemic complications. IBDs are mimicked by several enterocolonic infections and other conditions making differential diagnosis necessary. Inflammatory bowel disease in children and the elderly conforms to conventional clinical patterns modified by the health circumstances of the respective age groups. Because the cause of IBD has not been established, current medical therapy is facilitative and supportive rather than curative. The principles of medical treatment are approximately the same for ulcerative colitis and Crohn's disease. Treatment emphasizes a program rather than a drug and also considers the individuality of the therapeutic response. A clearer understanding of dietary and nutritional needs, including hyperalimentation and electrolyte and fluid balance, aids treatment. Antidiarrheal and antispasmodal preparation and sedatives are prescribed for symptom relief. The bowel inflammation is controlled with sulfasalazine or the newer 5-amino-salicylic acid (5-ASA) compounds, antibacterial drugs for complications of Crohn's disease and IBD, adrenocortical steroids, and the immunosuppressive compounds 6-mercaptopurine (6MP), azathioprine, and cyclosporine, as determined in each patient. The surgical procedures available for treatment of ulcerative colitis include total proctocolectomy and ileostomy or ileoanal anastomosis.(ABSTRACT TRUNCATED AT 400 WORDS)     

Diagnosis of ulcerative colitis--barium enema examination

Barium enema is useful especially for differential diagnosis of right sided type or segmental type of ulcerative colitis from other inflammatory bowel diseases. Compared with endoscopical examination, it provides more objective informations about the range of affected colon which is necessary for the choice of treatment strategy to the reluctant case. However, as preparation procedures may cause aggravation of ulcerative colitis, an unnecessary barium study should be avoided. Even the case in remission stage, it is advisable to add 40 to 60 mg of water-soluble predonisolone to barium solution. Roentogenographic diagnosis of ulcerative colitis is not difficult, in so far as two major points are properly evaluated. The first is the presence or absence of haustration, and the second is mucosal surface of the colon, namely, multiple ulcers or erosions distributing diffusely and continuously in active stage, or granular mucosa and disarray of network pattern of colonic mucosa in remission stage.     

Inflammatory bowel disease. Part I: Nature and pathogenesis

Once regarded as medical curiosities, ulcerative colitis and Crohn's disease have achieved a remarkable change in status recently and today are among the more compelling of all human illnesses. The cause(s) of inflammatory bowel disease (IBD) are not known. Genetic, environmental, microbial, and immunologic factors are involved, but the precise mechanisms are obscure. The incidence of ulcerative colitis is relatively stable, while Crohn's disease continues to increase in frequency. In 10% to 15% of patients, it is hard to differentiate between ulcerative colitis and Crohn's colitis; however, problems with diagnosis usually resolve with time and repeated examinations. In part I of his two-part monograph on IBD, Dr. Kirsner addresses the nature and pathogenesis of the disease. Increased study of ulcerative colitis and Crohn's disease in recent years has generated new knowledge regarding their etiology. Part I focuses on microbial, immunologic, and genetic mechanisms and the inflammatory processes involved in the disease. In part II, which will be presented in next month's issue of Disease-a-Month, Dr. Kirsner deals with the clinical features, course, and management of IBD, based on the author's 55 years of experience with these problems and supplemented by critical examination of the recent (1988-1990) literature. Particular attention is directed to the symptoms and physical findings of ulcerative colitis and Crohn's disease, the laboratory, radiologic, endoscopic, and pathologic features, and the many systemic complications. The IBDs are mimicked by several enterocolonic infections and other conditions, making differential diagnosis necessary. Inflammatory bowel disease in children and the elderly conforms to conventional clinical patterns modified by the health circumstances of the respective age groups. Because the cause of IBD has not been established, current medical therapy is facilitative and supportive rather than curative. The principles of medical treatment are approximately the same for ulcerative colitis and Crohn's disease. Treatment emphasizes a program rather than a drug and also considers the individuality of the therapeutic response. A clearer understanding of dietary and nutritional needs, including hyperalimentation and electrolyte and fluid balance, aids treatment. Antidiarrheal and antispasmodic preparations and sedatives are prescribed for symptom relief. The bowel inflammation is controlled with sulfasalazine or the newer 5-amino salicylic acid (5-ASA) compounds, antibacterial drugs for complications of Crohn's disease and IBD, adrenocortical steroids, and the immunosuppressive compounds 6-mercaptopurine (6-MP), azathioprine, and cyclosporine, as determined in each patient. The surgical procedures available for treatment of ulcerative colitis include total proctocolectomy and ileostomy or ileoanal anastomosis.(ABSTRACT TRUNCATED AT 400 WORDS)     

Crohn's disease and ulcerative colitis. Evaluation with double-contrast barium examination and endoscopy

Double-contrast barium examination of the colon can demonstrate the changes associated with inflammatory bowel disease more completely and specifically than the single-contrast barium study. However, endoscopy is slightly more sensitive than double-contrast examination for detection of disease. In general, between 18% and 20% of patients with Crohn's disease or ulcerative colitis may be expected to have normal radiographic findings but endoscopically detectable disease. However, most false-negative double-contrast colon studies are associated with mild or minimal findings at proctosigmoidoscopy. Although double-contrast radiography may be less sensitive than endoscopy in detection of inflammatory bowel disease, it has similar accuracy for classification and differentiation. Most studies indicate an accuracy of 95% to 98% in differentiating Crohn's disease and ulcerative colitis, due to the fact that morphologic changes detected by the double-contrast mucosal study rarely overlap in the two diseases. Double-contrast barium examination and endoscopy are complementary studies, and the use of both may provide valuable information for evaluation of patients with suspected inflammatory bowel disease.     

Transrectal ultrasound in the diagnosis and management of inflammatory bowel disease

BACKGROUND AND STUDY AIMS: To aim of the present study was to determine the value of transrectal ultrasonography (TRUS) in the assessment of disease activity in ulcerative colitis patients, and in differentiating between mucosal inflammation and transmural inflammation. PATIENTS AND METHODS: TRUS examinations were used to study 30 control individuals and 76 patients with inflammatory bowel disease, including 50 cases of ulcerative colitis and 26 of Crohn's disease. A rigid linear endorectal probe was used to examine the rectal wall. RESULTS: In the 30 control individuals, the rectal wall showed five layers, with a mean total diameter of 2.6 mm. There were significant differences between patients with quiescent ulcerative colitis, active ulcerative colitis, and control individuals with regard to the total rectal wall thickness (P<0.001), submucosal thickness (P<0.001) and mucosal thickness (P<0.001). Using cut-off values, differentiation between active ulcerative colitis and remission ulcerative colitis was found to be 100% specific and 73 % sensitive for submucosal thicknesses. TRUS revealed a 100% specificity in differentiating between remission ulcerative colitis and control cases based on the total rectal wall thickness, submucosal, and mucosal thicknesses. In the differential diagnosis of active and remission ulcerative colitis, an increase in submucosal wall thickness and the existence of arterial and venous capillary flow in the submucosa were found to be specific and more sensitive than the other parameters. TRUS examination revealed transmural inflammation in 21 of the 26 Crohn's disease patients, and mucosal inflammation in all 50 of the ulcerative colitis patients. CONCLUSION: TRUS is a reliable and easy method of assessing ulcerative colitis activity and differentiating between rectal diseases.     

Radiology in the current assessment of ulcerative colitis

Plain abdominal radiography in acute ulcerative colitis is essential to detect acute colonic complications, such as acute dilatation and free perforation. Sealed perforations may not be detected. Useful information can be gained as to the extent and severity of the mucosal lesions, but can be unreliable so that a contrast examination is required. The double contrast barium enema is more accurate than the single contrast study in revealing the early mucosal lesions of colitis. It is the examination of choice to show the extent and severity of disease, and is of considerable value in the differential diagnosis of colitis. In active colitis, the unprepared double contrast barium enema is recommended. The success of the examination relies on the absence of fecal residue adjacent to an active mucosa. The technique, uses, and limitations of this type of examination are described.In the long-term management of colitis, the role of radiology is to show the presence of extensive disease, which indicates an increased risk of malignancy. Lesions such as strictures or polyps may be found and are more likely to be benign than malignant, but confirmation often requires endoscopic biopsy. In the search for malignancy regular barium enema examination is not recommended, as this can only reveal an overt tumor, whereas premalignancy can be detected histologically from an endoscopic biopsy.     

Evaluation and improvement of QOL among IBD patients

This article provided a short review on the assessment of quality of life (QOL) among patients with ulcerative colitis. Quantitative approach with psychometric measures has empirically showed that psycho-social aspects of patient's QOL are often affected by her clinical, psychological, and social conditions. Although the control of disease activities plays a pivotal role for improving patient's QOL, more holistic approach such as psychoeducational intervention should also be considered to enhance patient's self-efficacy and sense of control. Besides, qualitative research suggests that helping patient's narrative reconstruction through enhanced communication with the physician may be the most powerful tool that the physician can provide for improving patient's QOL.     

Manipulation of cytokines in the management of patients with inflammatory bowel disease

In recent years, new concepts have been formulated for the therapeutic management of the intractable forms of Crohn's disease and ulcerative colitis, the two major forms of inflammatory bowel disease. These advances are based largely on new insights into the immune-inflammatory events occurring in the gut of these patients. Analysis of the types of immune response ongoing in the inflamed intestine has revealed that in Crohn's disease there is predominantly a T-helper cell type 1 response, with exaggerated production of interleukin (IL)-12 and interferon (IFN)-gamma, whereas in ulcerative colitis the lesion seems more of an antibody-mediated hypersensitivity reaction. Despite these differences, downstream inflammatory events are the same in both conditions. In both Crohn's disease and ulcerative colitis mucosa, IL-1gamma, IL-6, IL-8 and tumour necrosis factor (TNF)-alpha are produced in excess, and the production of free radicals accompanying the influx of nonspecific inflammatory cells into the mucosa is above the normal range. Strategies aimed at inhibiting T-cell responses are therefore more relevant in Crohn's disease, whereas, in theory at least, inhibition of downstream inflammatory processes should be therapeutic in both Crohn's disease and ulcerative colitis. This review seeks to summarize studies in which anticytokine antibodies, cytokines or cytokine-modifying agents have been used in the treatment of either Crohn's disease or ulcerative colitis.     

Inflammatory bowel disease: primary health care management of ulcerative colitis and Crohn's disease

Inflammatory bowel disease encompasses both ulcerative colitis and Crohn's disease, two conditions so alike clinically that they are frequently indistinguishable from one another. Inflammatory bowel disease occurs at a rate of approximately five per 100,000 people. It tends to cluster in families and is seen four to five times more often in Jewish Caucasians than in other Caucasians. The etiology is unknown. Increasing attention is being paid to autoimmune factors, genetic factors and food allergies, and the notion that inflammatory bowel disease has its roots in a psychological disorder continues to pale for want of empirically sound evidence. Disease pattern is one of remission and exacerbation. The aim of therapy is to maintain an optimal lifestyle in remission through an individually tailored protocol of medications. Sulfasalazine remains the medication of choice; corticosteroids have short-term utility in exacerbation; and immunosuppressants, though controversial, are thought to have some steroid-sparing benefits during acute flare-ups. Indications for surgery vary, depending on whether or not a clear differential diagnosis has been made between ulcerative colitis and Crohn's disease. There is no cure for inflammatory bowel disease except for total colectomy in clearly diagnosed ulcerative colitis. Current research endeavors seek a cause or causes for inflammatory bowel disease, but the literature does not solidly support any one possibility above other rival etiologies.     

大肠多发溃疡临床研究

目的：对经结肠镜,病理证实的76例大肠多部位溃疡进行回顾性分析,。探讨大肠多部位溃疡的病因诊断及诊断方法,方法：采用Olympus电子结肠镜检查,内镜直视下溃疡边缘取活检,送病理,部分病例结合临床其它检查资料进行综合分析或诊断性治疗。结果：76例中溃疡性结肠炎55例,大肠结核9例,结肠克罗恩（Crohn)病7例,原发性大肠恶性淋巴瘤2例,未能确诊3例,结论：大肠不同部位溃疡以溃疡性结肠炎为最常见的病因,对不典型部位溃疡应警惕大肠结核,结肠Crohn病,原发性大肠恶性淋巴瘤等少见病因。     

Intestinal complications in ulcerative colitis

Although cases of severe intestinal complications such as massive hemorrhaging, perforation, stricture and obstruction occur in some instances of ulcerative colitis, these are relatively infrequent in comparison to Crohn's disease. Many cases with such severe intestinal complications require surgery, sometimes acute surgical emergency, instead of medication as these can be less effective in terms of improvement of the disease. Cytomegalovirus infections, which are at times associated with intractable ulcerative colitis, has recently been considered an etiologic factor in the exacerbation and intractability of ulcerative colitis. Furthermore, colitic cancer, an important complication of ulcerative colitis, may occur at high incidence in patients experiencing long term courses of chronically active or frequently relapsing ulcerative colitis, and thus must be considered and managed appropriately. For the prevention of complications of ulcerative colitis, rapid induction of remission and long-term remission maintenance is essential, in addition to the emphasis in avoiding chronic administration of large doses of steroids.     

Evolution of the concept of proctosigmoiditis: clinical observation

Proctosigmoiditis, or distal colon ulcerative colitis, has been recognized as a clinical entity for over 50 years and considerable information has emerged from the study of the clinical course of patients with distal colon ulcerative colitis who are followed for a period of years. For most patients the condition is benign, although periods of exacerbation can occur between remissions, characterized by rectal bleeding. However, extension of the disease, development of cancer, and the requirement of surgery are all relatively unusual. It has recently been recognized that there are many other causes of proctitis than the idiopathic form, and this has raised important questions in differential diagnosis, particularly in the proctitis occurring in homosexual males. Proctitis, proctosigmoiditis, and distal colon ulceratice colitis and not Crohn's disease; conversely perianal fistulae and abscesses are rare in distal colon ulcerative colitis. Treatment with various forms of topical agents has often been satisfactory.     

Current status of drug therapy for inflammatory bowel disease

Both topical steroids and sulfasalazine are useful for patients with ulcerative proctitis and distal colitis. For patients with more extensive ulcerative colitis with moderate symptoms, prednisone and/or sulfasalazine will result in improvement in about 80% of patients. Parenteral corticosteroids or ACTH should be used in the setting of severe colitis and antibiotics added if the patient appears toxic. Sulfasalazine is of proven efficacy as maintenance therapy in ulcerative colitis. Prednisone and sulfasalazine are useful in Crohn's disease, although the latter is of limited use in patients with ileitis alone. Immunosuppressive agents such as azathioprine and 6-mercaptopurine may be especially helpful in Crohn's patients refractory to other drugs or dependent on high doses of steroids. Azathioprine is of proven usefulness as maintenance treatment of Crohn's disease. Metronidazole is as effective as sulfasalazine in Crohn's disease involving the colon and has an important role in severe perineal disease. New forms of steroid enemas and topical and oral forms of 5-aminosalicylate based on sulfasalazine should be available soon for patients with both ulcerative colitis and Crohn's disease.     

内镜下阑尾孔周围点状糜烂伴左半结肠弥漫性炎症在溃疡性结肠炎中的诊断意义研究

目的研究内镜下阑尾孔周围点状糜烂性改变伴左半结肠弥漫性炎症在溃疡性结肠炎中的意义。方法收集2007年1月-2012年12月内镜下出现阑尾孔周围点状糜烂性改变伴左半弥漫性结肠炎症表现共29例患者,排除阑尾孔周同充血水肿、溃疡、息肉的患者,排除升结肠、横结肠等其他部位出现炎症改变的患者,以及左半结肠为节段性炎症改变患者。结合组织病理结果分析该病变对溃疡性结肠炎诊断的关系。结果29例阑尾孔周同点状糜烂伴左半结肠炎患者中,26例诊断为溃疡性结肠炎,1例为克罗恩病,2例不能确诊。结论内镜下阑尾孔周同点状糜烂伴左半弥漫性结肠炎症改变可能对左半溃疡性结肠炎的诊断有一定的参考价值。     

Newer pharmacologic agents for the therapy of inflammatory bowel disease

Topical 5-ASA Agents. Observations that 5-ASA may be the clinically active component of sulfasalazine have stimulated extensive pharmaceutical efforts to develop a new class of agents for the treatment of the inflammatory bowel diseases. Both oral and rectal forms of 5-ASA have been designed, tested, and released for use in Europe and Canada. Only one rectal 5-ASA formulation is now commercially available in the United States. Studies with topical 5-ASA have demonstrated that this formulation is safe and effective for distal colitis, even in patients with disease refractory to standard therapy. Adverse effects of topical 5-ASA are minimal. However, optimal treatment doses have not been defined, relapse is common after withdrawal of therapy, and issues regarding maintenance regimens are not yet resolved. Other disadvantages include the expense and inconvenience of enema therapy. However, rectally administered 5-ASA is an appropriate initial therapy for the treatment of distal ulcerative colitis, or as a therapeutic option for refractory distal colitis. Data are insufficient to make recommendations regarding the use of topical 5-ASA in Crohn's disease. Whether this class of agents will be of benefit for Crohn's proctitis or for perineal disease must await further clinical trials. Oral 5-ASA Agents. There appears to be a well-substantiated benefit equivalent to that of sulfasalazine achieved by the new oral formulations of 5-ASA when used for the treatment of acute mild to moderate ulcerative colitis, and as maintenance treatment of ulcerative colitis in remission. Adverse reactions to these agents are uncommon, usually mild, and infrequently require withdrawal of therapy. The major problem reported with these agents is watery diarrhea, most commonly associated with olsalazine, but the practical importance of this adverse effect is disputed. Rare occurrences of reversible pericarditis and acute pancreatitis have been encountered during clinical application of these agents. As more experience is obtained, these agents may become the initial therapy of choice for the treatment of mild to moderate ulcerative colitis and for maintenance in inactive disease. Currently available data have defined a role for these agents as an important alternative for the treatment of patients intolerant or allergic to sulfasalazine. As with sulfasalazine, these agents should not be used as the sole treatment for severely active ulcerative colitis. Many unanswered questions remain regarding therapy with these agents for ulcerative colitis. Still undefined are optimal drug dosages, appropriate dosing intervals, and the necessary duration of therapy.(ABSTRACT TRUNCATED AT 400 WORDS)     

Endorectal ultrasound in infectious colitis may predict development of chronic colitis.

BACKGROUND AND STUDY AIMS: In a previous study, we have shown that rectal endoscopic ultrasound (EUS) could be used to differentiate ulcerative colitis from Crohn's disease by demonstrating the presence of pathological lymph nodes around the rectum and sigmoid colon which were characteristic of ulcerative colitis. The aim of the present study was to evaluate the endosonographic features of infectious colitis and their potential clinical relevance. PATIENTS AND METHODS: We carried out rectal endosonography in 17 patients with infectious colitis of various etiologies. Wall features and perirectal lymph nodes were documented systematically. RESULTS: In 15 patients no pathological lymph nodes were seen and the EUS wall features were also normal. In two patients where EUS showed pathological lymph nodes, follow-up confirmed ulcerative colitis several weeks later. CONCLUSIONS: This preliminary study suggests that, in patients with infectious colitis, EUS may be able to suggest the diagnosis of associated ulcerative colitis; further studies with larger patient numbers are necessary.     

Unusual form of ulcerative colitis

Segmental colitis which showed the similar findings of ulcerative colitis and right-sided colitis with back-wash ileitis has been considered as the unusual form of ulcerative colitis. Today, we have few opportunities to come across those cases, because modern diagnosis of colon disease could make differential diagnosis easily with the sense of broad spectrum of IBD. We presented three cases of segmental colitis and one case of so-called indeterminate colitis associated of carcinoma in the cecum and discussed the clinical significance for diagnosis and finding the step of studying the etiology of IBD. Especially, in the third case, thirteen years old man was showing the sign of early stage of Crohn disease with non-caseating granuloma in the biopsy specimen at first, the findings of the segmental ulcerative colitis with crypt abscess were seen after six months in the second examination. To observe the detail changes of the mucosal lesion in this kind of cases will present the new idea for studying the etiology of IBD.     

Differential diagnosis of ulcerative colitis

Important points during differential diagnosis of ulcerative colitis from other inflammatory disorders are endoscopic examination and microbial studies of stools. In acute phase of enterocolitis in which waterly diarrhea with bloody stool and abdominal pain appeared, infectious enterocolitis by Shigella, Salmonella, Campylobacter and Yersinia, which sometimes causes mucosal edema, hyperemia, erosions and ulceration should be distinguished carefully. Microbial studies of stool would bring helpful information in such situation. In chronic phase of inflammatory diseases of bowel, they often showed chronic diarrhea associated with mucobloody stools and abdominal pain. They often revealed mucosal inflammation mimicking ulcerative colitis during endoscopic evaluation. Among them, most important diseases are amebic colitis, ischemic colitis, radiation colitis and antibiotics associated hemorrhagic colitis.     

CT小肠造影影像对结肠型克罗恩病与溃疡性结肠炎的诊断价值

目的 探究CT小肠造影（CTE）对结肠型克罗恩病与溃疡性结肠炎的诊断及鉴别诊断价值。方法 选取蚌埠医学院第一附属医院和南京中医药大学附属江苏省中医院于2019年1月～2022年1月收治的结肠型克罗恩病患者36例和溃疡性结肠炎患者36例行CTE检查,分别观察两组影像特征,结合实验室指标、临床表现对克罗恩病和溃疡性结肠炎患者进行回顾性分析。结果36例克罗恩病患者中,CTE影像示肠壁不均匀增厚21例、肠道狭窄22例、瘘管形成7例及累及升结肠21例,均高于溃疡性结肠炎患者,差异有统计学意义（P<0.05）;36例溃疡性结肠炎患者,粘液便18例及血便22例高于克罗恩病患者（P<0.05）,溃疡性结肠炎患者平均发病年龄较结肠型克罗恩病患者平均发病年龄大（P<0.05）。克罗恩病患者与溃疡性结肠炎患者的C反应蛋白及红细胞沉降率含量均值分别为28.17 mg/L vs 17.67 mg/L、32.25 mm/h vs 22.95 mm/h;C反应蛋白及红细胞沉降率含量的平均值对克罗恩病与溃疡性结肠炎的鉴别无统计学意义（P>0.05）。结论 通过CTE影像特征更直观地对结肠型克罗...