Effectiveness and tolerance of duodenoscopic bowel preparation for colonoscopy]

BACKGROUND/AIMS: Bowel preparation for colonoscopy remains an unpleasant experience because oral solutions have unpleasant tastes and may provoke abdominal pain, nausea, vomiting, and sleep disturbance. Duodenoscopic bowel preparation is an alternative method for patients who are unwilling to take oral preparation solution or for those who are supposed to have both gastroscopic and colonoscopic examination on the same day. We assessed the effectiveness and tolerance of duodenoscopic bowel preparation. METHODS: Patients in group OA (orally administered) ingested 45 mL of sodium phosphate (NaP) in the evening before the day of procedure and in the morning on the day of colonoscopy, whereas patients in group EA (endoscopically administered) were prepared for the procedure by duodenoscopic infusion of 90 mL of NaP diluted with 180 mL of water into the second portion of the duodenum. After 4 hours, we assessed the overall quality of colonic cleansing, using a range of excellent to inadequate. The patients completed a questionnaire on their preparation-associated symptoms, tolerance, and preference. RESULTS: In group EA, sleep disturbance (p0.05) and nausea (p0.05) occurred less frequently than in group OA. Overall, the tolerance rating for preparation was higher in group EA. However, the quality of colonic cleansing and cecum intubation time was not different between the two groups. Patients in group EA who had ingested NaP in the past preferred duodenoscopic bowel preparation. CONCLUSIONS: Duodenoscopic bowel preparation may play a role in colonic cleansing especially for patients who are scheduled to undergo gastroscopic and colonoscopic examination on the same day and for those who are unwilling to ingest NaP.     

Solar radiation is inversely associated with inflammatory bowel disease admissions

Objective: To explore the associations between latitude and solar radiation with inflammatory bowel disease admission rates in Chile, the country with the largest variation in solar radiation in the world.

Patients and methods: This is an ecological study, which included data on all hospital-admitted population for inflammatory bowel disease between 2001 and 2012, according to different latitudes and solar radiation exposures in Chile. The data were acquired from the national hospital discharge database from the Department of Health Statistics and Information of the Chilean Ministry of Health.

Results: Between 2001 and 2012 there were 12,869 admissions due to inflammatory bowel disease (69% ulcerative colitis, 31% Crohn’s disease). Median age was 36 years (IQR: 25–51); 57% were female. The national inflammatory bowel disease admission rate was 6.52 (95% CI: 6.40–6.63) per 100,000 inhabitants with increasing rates over the 12-year period. In terms of latitude, the highest admission rates for pediatric ulcerative colitis and Crohn’s disease, as well as adult ulcerative colitis, were observed in the southernmost region with lowest annual solar radiation. Linear regression analysis showed that regional solar radiation was inversely associated with inflammatory bowel disease admissions in Chile (β: ?.44, p?=?.03).

Conclusions: Regional solar radiation was inversely associated with inflammatory bowel disease admission rates in Chile; inflammatory bowel disease admissions were highest in the southernmost region with lowest solar radiation. Our results support the potential role of vitamin D deficiency on inflammatory bowel disease flares.     

口服耐受与炎症性肠病

口服耐受是机体对口服抗原产生的特异性无应答或低应答状态.低剂量口服抗原主要通过调节性T细胞分泌抑制性细胞因子介导免疫抑制,高剂量口服抗原主要引起T细胞清除或T细胞失能.多次低剂量口服结肠炎提取蛋白或正常结肠提取蛋白均能缓解实验性结肠炎.目前,多次低剂量口服自体结肠提取蛋白已初步应用于临床试验,并证明是安全的治疗方案.充分发挥口服耐受对炎症性肠病的临床疗效仍需深入研究.     

Surveillance colonoscopy for colitic cancer in inflammatory bowel disease

Patients with inflammatory bowel disease are known to be at increased risk for the development of colorectal cancer, especially those with long‐standing extensive ulcerative colitis. Although some recommend prophylactic total proctocolectomy for these high‐risk patients, surveillance colonoscopy to detect ulcerative colitis‐associated colorectal cancer is, instead, generally performed. Dysplasia has been considered to be a useful marker to detect colorectal cancer at surveillance colonoscopy. High‐grade dysplasia is a definite indication for total proctocolectomy, while management of low‐grade dysplasia is still controversial. Patients with Crohn's disease are also considered to be at higher risk for the development of colorectal cancer, although the risk may be lower than in extensive ulcerative colitis. Molecular biology‐based surveillance and chemoprevention for ulcerative colitis‐associated colorectal cancer are also reviewed.     

Better disease specific patient knowledge is associated with greater anxiety in inflammatory bowel disease

BackgroundInflammatory bowel disease (IBD)-related knowledge not only empowers patients, but may also engender anxiety. The study aimed to identify predictors of anxiety in IBD and examine the interplay between anxiety and disease-related patient knowledge. The effect of anxiety on quality of life was also explored.MethodsAmbulatory IBD patients provided data on demographics, their IBD and Crohn's Colitis Association (CCA) membership status. Disease-related knowledge was assessed using the validated Crohn's and Colitis Knowledge score (CCKnow) and disease related QOL using the short IBD questionnaire (SIBDQ). Anxiety and depression were assessed with the Hospital Anxiety and Depression Scores.ResultsOf the 258 patients 19.4% had a potential anxiety and a further 22.4% had a probable anxiety disorder. Females (P = 0.003), tertiary care patients (P = 0.014) and non-Caucasian patients (P = 0.037) had significantly higher anxiety levels. CCA members had marginally higher levels of anxiety (P = 0.07). Anxiety was associated with significantly better patient knowledge (P = 0.016) and increased depression (P < 0.001). Disease related quality of life was significantly lower in patients with anxiety (P < 0.001).ConclusionsThis is the first study to demonstrate that better patient knowledge is associated with higher anxiety levels. The reason for this is unclear: educating patients about their disease might trigger anxiety, but, equally, anxious patients might seek out information and hence have better knowledge. It is thus noteworthy that an educational intervention may not necessarily reduce anxiety. Further work is needed to evaluate the association between anxiety and knowledge and to develop targeted interventions that will improve knowledge and simultaneously reduce anxiety.     

Oral tolerance therapy in inflammatory bowel disease

Oral tolerance is a long-recognized method of inducing immune tolerance or systemic hyporesponsiveness induced by feeding protein. Oral tolerance has been used to prevent and/or treat a variety of T-cell-mediated autoimmune disorders. Feeding colonic extracts prevented colitis in animal model of inflammatory bowel disease (IBD), but the clinical efficacy of oral tolerance in human IBD was unknown. In this issue, the study by Margalit and colleagues suggested that oral administration of autologous colonic extracts to moderately severe Crohn's disease patients might reduce disease activity; however, the study did not employ conventional clinical endpoints. These data provide an important first step to developing "Ag-specific" treatment strategies for IBD in the future. Larger scale studies using variable dosages, modes, and durations of Ag delivery will be required to optimize oral tolerance therapy in IBD.     

Cesarean delivery is associated with celiac disease but not inflammatory bowel disease in children

The postnatal period represents a particularly dynamic phase in the establishment of the host-microbial homeostasis. The sterile protected intestinal mucosa of the fetus becomes exposed to and subsequently colonized by a complex and diverse bacterial community. Both, the exposure to microbial ligands and the bacterial colonization have been described to differ between neonates born vaginally or by cesarean delivery. These differences might influence the development of the mucosal immune system, the establishment of a stable intestinal host-microbial homeostasis, and ultimately contribute to the risk to acquire immune mediated diseases later in life. Indeed, an increased risk for atopic diseases such as allergic rhinitis and asthma was reported in children born by cesarean delivery. Our recent study described an association between cesarean delivery and celiac disease. Here we summarize the available information on postnatal microbial colonization and the influence of the mode of delivery on flora composition and host microbial homeostasis. We discuss possible consequences of the mode of delivery on epithelial barrier function and the establishment of the mucosal immune system and speculate on functional links between flora alterations and the development of inappropriate host immune responses that may contribute to enteric inflammatory diseases.     

Cesarean delivery is associated with celiac disease but not inflammatory bowel disease in children

The postnatal period represents a particularly dynamic phase in the establishment of the host-microbial homeostasis. The sterile protected intestinal mucosa of the fetus becomes exposed to and subsequently colonized by a complex and diverse bacterial community. Both, the exposure to microbial ligands and the bacterial colonization have been described to differ between neonates born vaginally or by cesarean delivery. These differences might influence the development of the mucosal immune system, the establishment of a stable intestinal host-microbial homeostasis, and ultimately contribute to the risk to acquire immune mediated diseases later in life. Indeed, an increased risk for atopic diseases such as allergic rhinitis and asthma was reported in children born by cesarean delivery. Our recent study described an association between cesarean delivery and celiac disease. Here we summarize the available information on postnatal microbial colonization and the influence of the mode of delivery on flora composition and host microbial homeostasis. We discuss possible consequences of the mode of delivery on epithelial barrier function and the establishment of the mucosal immune system and speculate on functional links between flora alterations and the development of inappropriate host immune responses that may contribute to enteric inflammatory diseases.     

Giant inflammatory polyps associated with idiopathic inflammatory bowel disease

Five cases of giant inflammatory polyps associated with idiopathic inflammatory bowel disease are reported. Polyps produced intestinal obstruction in three cases; consequently, surgery was performed. In a further two cases, intestinal bleeding was improved by endoscopic polypectomy. Electron microscopy showed fibroblasts, myofibroblasts, mast cells, lymphocytes, collagen fibers, capillaries, and venules. Remnants of the original mucosal epithelial cells, smooth muscle cells, and hypertrophic autonomous nerve plexuses were noted. Nerve fibers were interwoven with the matrix of the polyps. Mast cells were closely linked with vessels, nerves, and collagen fibers. They may have an important role in the excessive granulation, angiogenesis, and fibrotic process in giant inflammatory polyps.     

Survery of the Use of colonoscopy in inflammatory bowel disease

In a survey of patients with inflammatory bowel disease (IBD), colonoscopy with multiple biopsies has been shown to be superior to either colonoscopy alone or barium studies in assessing disease extent. Thus, of a total of 149 patients, 23 (15%) were considered to have total colitis on barium enema, 51 (34%) on macroscopic colonoscopy appearance compared to 92 (62%) on biopsy. Furthermore, radiological assessment of “skip lesions” was shown to be unreliable. Although it remains to be seen whether the more accurate delineation of disease extent achieved by endoscopy is advantageous in terms of clinical management, it may have implications for our understanding of the disease.     

Arthritis associated with inflammatory bowel disease in children

The records of 102 children with inflammatory bowel disease (44 with ulcerative colitis, 58 with Crohn's disease) were reviewed for evidence of joint disease unassociated with erythema nodosum. Thirteen children had arthritis, four had ulcerative colitis, and nine had Crohn's disease. Arthritis tended to be pauciarticular; ankles, knees, elbows and hips were most commonly affected. In three patients arthritis preceded bowel symptoms, in two the onset of arthritis and bowel disease was concurrent, and in eight arthritis appeared after the onset of bowel symptoms. The relationship between arthritis and specific features reflecting activity and severity of the bowel disease was examined in detail. Twenty-one attacks of arthritis, ranging in duration from two days to 12 weeks (mean, 31 days) were documented. Thirteen attacks occurred when the bowel disease was symptomatic; nine occurred within one month of a flare of the bowel disease. Most exacerbations of bowel disease in patients who had arthritis were unaccompanied by joint complaints. None of the features reflecting activity or severity of the bowel disease was more common in patients with arthritis than in those without arthritis.Supported in part by grant AM 20582 from the National Institute of Arthritis, Metabolism and Digestive Diseases.     

Idiopathic pancreatitis associated with inflammatory bowel disease

The list of extraintestinal manifestations of inflammatory bowel diseases does not classically include pancreatitis and pancreatic insufficiency. We report here six cases of unexplained pancreatitis associated with inflammatory bowel disease (five patients with Crohn's disease, one with indeterminate colitis). None of the classical etiologies for pancreatitis was found in our patients; moreover none of them had duodenal localization of Crohn's disease or sclerosing cholangitis, two conditions in which pancreatitis associated with inflammatory bowel disease has been previously described. Pancreatitis was painless (or was associated with moderate and atypical abdominal pain) in four of our six cases; no pancreatic calcification was found in any case; in three patients a total or subtotal exocrine pancreatic insufficiency was evidenced. Endoscopic retrograde pancreatography performed in four subjects showed normal or minimally altered pancreatic ducts even in those with severe pancreatic insufficiency. These cases emphasize the existence of a probably nonfortuitous association of inflammatory bowel disease with pancreatitis. Its recognition could make a significant contribution in the management of inflammatory bowel disease.     

Vascular complications associated with inflammatory bowel disease

Thromboembolic episode is a well known extraintestinal manifestation of inflammatory bowel disease, but it is a clinical rare complication. Histological and hematological studies suggest that a hypercoagulable state is involved in the pathogenesis of inflammatory bowel disease. However, the exact mechanism of hypercoagulability is still unknown. During the acute recurrences there is an increase of factor VIII, fibrinogen, platelet, factor V and decrease of antithrombin III. Hematologic disorders seem markedly correlated with the activity of the disease. We report on two patients with Inflammatory bowel disease and hypercoagulable state. We review the literature and discuss about the pathogenic mechanisms of such complication.     

Fatigue is not associated with vitamin D deficiency in inflammatory bowel disease patients

AIM To investigate if vitamin D deficiency is associated with fatigue in patients with inflammatory bowel disease(IBD).METHODS IBD patients were recruited from nine hospitals in the southeastern and western regions of Norway to participate in a multicenter cross-sectional study lasting from March 2013 to April 2014. Data were collected by interviews, from medical records and laboratory tests. The Fatigue Questionnaire(FQ) was used to measure fatigue. Linear and logistic regression models were applied to explore the possible association between vitamin D deficiency and total fatigue scores and chronic fatigue, respectively. The analyses were adjusted for age, gender, disease activity, depressive symptoms and sleep disturbance.RESULTS In total, 405 patients were included in the analyses, of which 227(56%) had Crohn's disease(CD) and 178(44%) had ulcerative colitis(UC). Vitamin D deficiency( 50 nmol/L) was present in half(203/405) of the patients. Chronic fatigue was reported by 116(29%) of all included patients with substantial fatigue reported by 194(48%). Vitamin D levels were neither associated with total fatigue nor with chronic fatigue. Higher total fatigue scores and chronic fatigue were both associated with increased disease activity scores in patients with UC and CD, but not with increased CRP or fecal calprotectin. In UC patients, female gender was associated with fatigue in the univariate analysis, but no such difference was found when adjusted for elevated disease activity scores. Sleep disturbance and more depressive symptoms were associated with total fatigue scores in both UC and CD patients, but with chronic fatigue only in CD patients.CONCLUSION In this study, no significant association between fatigue and vitamin D deficiency in IBD patients was revealed.     

Hypoadiponectinemia is associated with impaired glucose tolerance and coronary artery disease in non-diabetic men.

BACKGROUND: Impaired glucose tolerance (IGT) is a significant risk factor for cardiovascular disease, but is not always recognized in the clinical setting. An anti-atherogenic adipocytokine, adiponectin, is decreased in type 2 diabetes mellitus, but its role in non-diabetic subjects has not been clarified. The hypothesis investigated in the present study was that plasma adiponectin levels correlate with IGT and coronary artery disease (CAD) in non-diabetic men. METHODS AND RESULTS: Glucose intolerance was evaluated by an oral glucose tolerance test and plasma adiponectin levels were measured in 232 non-diabetic men who underwent coronary angiography. Patients with IGT (n=102) had significantly lower adiponectin levels than those with normal glucose tolerance (n=130) (4.47 [3.23-6.39] vs 5.85 [3.99-8.65] mug/ml, p=0.003). Plasma adiponectin levels were associated with IGT in multiple logistic regression analysis (odds ratio (OR) 0.623, 95% confidence interval (CI) 0.397-0.980; p=0.041). Non-diabetic patients with CAD (n=122) had lower adiponectin levels than those without CAD (n=110) (4.60 [3.32-6.38] vs 6.08 [4.10-9.88] microg/ml, p<0.001). Multiple logistic regression analysis demonstrated adiponectin independently correlated with the presence of CAD (OR 0.432, 95% CI 0.256-0.728; p=0.002). CONCLUSIONS: Hypoadiponectinemia is associated with IGT and CAD in non-diabetic men, suggesting that the adiponectin level can provide valuable information regarding the risk of CAD even in non-diabetic subjects.     

Chronic fatigue is associated with increased disease-related worries and concerns in inflammatory bowel disease

AIM: To investigate the impact of chronic fatigue on disease-related worries in inflammatory bowel disease (IBD) and the potential multicolinearity between subjective questionnaires.METHODS: Patients in remission or with mild-to-moderate disease activity completed the fatigue questionnaire (FQ), the rating form of IBD patient concerns (RFIPC), the Short-Form 36 (SF-36), and IBD questionnaire (N-IBDQ). In addition, clinical and epidemiological data were obtained.RESULTS: In total, 140 patients were included; of which 92 were diagnosed with ulcerative colitis and 48 with Crohn’s disease. The mean age of patients with chronic fatigue was 44.2 years (SD = 15.8) and for non-fatigued patients was 44.7 years (SD = 16.0). Chronic fatigued patients had clinically significantly increased levels of disease-related worries, as measured by Cohen’s d effect size. Worries about having an ostomy bag, loss of bowel control, and energy levels were most prominent in both chronic fatigued and non-chronic fatigued IBD patients. Variance inflation factor (VIF) and tolerance indicated that there were no problematic multicolinearity among the FQ, RFIPC, SF-36 and N-IBDQ responses (VIF < 5 and tolerance > 2).CONCLUSION: Chronic fatigue is associated with increased levels of disease-related worries and concerns in IBD. Increased levels of worries were also associated with impaired health-related quality of life.