Adaptative changes in terminal ileum after total colectomy, mucosal proctectomy and straight ileo-anal anastomosis in chronic ulcerative colitis.

Total colectomy, mucosal proctectomy and straight ileo-anal anastomosis was performed in four adult patients with chronic ulcerative colitis (three males, one female; mean age 27.4 years). During a follow-up period of one to five years, all patients were continent, had spontaneous bowel evacuation (average 4-5 per day), and had normal bladder and sexual function. Sequential per rectal ileoscopies revealed loss of ileal folds and gradual transformation to a colonic type of mucosa. On barium studies, the anastomosed terminal ileum showed progressive ballooning and assumed a rectosigmoid appearance with complete disappearance of ileal characteristics. The histology showed a progressive transformation from ileal to colonic type of mucosa, with blunting and ultimate disappearance of villi, increasing goblet cell population, and increase in mononuclear cells in the lamina propria. Histochemical studies (high iron diamine and alcian blue stains) revealed a change from small intestinal to colonic mucin, progressing proximally from just above the anastomotic site. Two patients had a single recurrence with ileal histology resembling that of active ulcerative colitis; both responded to short term steroid therapy. The results of straight ileo-anal anastomosis compare well with Western reports of ileal reservoirs. Adaptative changes of 'colonisation' can be consistently demonstrated in the anastomosed ileum on follow-up; these start just above the anastomotic site and ascend proximally. The colonised ileum appears to be susceptible to the ulcerative disease.

Ischemic bowel disease.

Twenty-five cases with ischemic bowel disease seen over a period of 4 years are presented. Of these, 20 cases presented with acute symptoms and five with chronic symptoms. In the majority of patients, the diagnosis was established at operation and on histopathology. Occlusive disease of the superior mesenteric artery was the commonest cause of acute ischemia. Non-occlusive ischemia was not observed in any case. All the patients were treated by resection and anastomosis of the involved bowel. Vascular procedures were not carried out in any. No planned second-look procedures were carried out. Of the 20 acute cases, eight patients died and three developed complications. One chronic case died and there were no other complications in this group. We suggest that ischemic bowel disease should be considered while dealing with cases presenting as acute abdomen or with chronic abdominal pain.

Antipyrine clearance: prognostic marker for obstructive jaundice.

A prospective study was undertaken to determine prognostic markers for patients with obstructive jaundice. Along with routine liver function tests, antipyrine clearance was determined in 20 patients. Four patients died after basal investigations. Five patients underwent definitive surgery. The remaining 11 patients were subjected to percutaneous transhepatic biliary decompression. Four patients died during the drainage period, while surgery was carried out for seven patients within 1-3 weeks of drainage. Of 20 patients, only six patients survived. Basal liver function tests were comparable in survivors and nonsurvivors. Discriminant analysis of the basal data revealed that plasma bilirubin, proteins and antipyrine half-life taken together had a strong association with mortality. A mathematical equation was derived using these variables and a score was computed for each patient. It was observed that a score value greater than or equal to 0.84 indicated survival. Omission of antipyrine half-life from the data, however, resulted in prediction of false security in 55% of patients. This study highlights the importance of addition of antipyrine elimination test to the routine liver function tests for precise identification of high risk patients.

Modulation of immunosuppression in obstructive jaundice by Tinospora cordifolia.

A clinical study was undertaken to determine the immune status of patients with obstructive jaundice. Screening of 16 patients for phagocytic and microbicidal activity of polymorphonuclear cells (PMN) revealed a significant depression (21.2 +/- 3.7% phagocytosis and 20.85 +/- 4.5% intracellular killing) of these functions, as compared to normal values (30.37 +/- 5.1% and 26.41 +/- 4.3% respectively). An animal model of cholestasis was also established, using rats, in which a significant depression of activity of PMN and peritoneal macrophages was observed. These cellular abnormalities were found to precede and predispose to infection. The rats also showed an increased susceptibility to Escherichia coli infection (mortality rate 77.78%). A defect was detected in their serum responsible for depressing the function of phagocytic cells. An attempt was made to improve this immunosuppression by treating the rats with water extract of T. cordifolia 100 mg/kg for 7 days, following development of cholestasis. The extract improved the cellular immune functions. Mortality rate following Esch. coli infection was significantly reduced to 16.67 per cent. This study showed that cholestasis results in immunosuppression and therefore indicates the need for an immunomodulator in management of obstructive jaundice. The plant T. cordifolia seems to meet this need by consolidating host defence mechanism.

Immunotherapeutic modulation of intraperitoneal adhesions by Asparagus racemosus.

The hypothesis that macrophages appear to play a pivotal role in the development of intraperitoneal adhesions and that modulation of macrophage activity, therefore, is likely to provide a tool for prevention of adhesions, was tested in the present study. Effect of Asparagus racemosus, an indigenous agent with immunostimulant properties, was evaluated in an animal model of intraperitoneal adhesions induced by caecal rubbing. Animals were sacrificed 15 days following surgery. The peritoneal macrophages were collected to assess their activity. At the same time, peritoneal cavity was examined for the presence of adhesions, which were graded. A significant decrease was observed in the adhesion scores attained by animals receiving Asparagus racemosus. This was associated with significant increase in the activity of macrophages (70.1 +/- 2.52), compared to that in surgical controls (53.77 +/- 10.8). These findings support our hypothesis and provide a novel approach for the prevention and management of post-operative adhesions.