Nongastrointestinal symptoms of irritable bowel syndrome: an office-based clinical survey.

Irritable bowel syndrome (IBS) is the most prevalent gastrointestinal problem faced by practicing gastroenterologists. For many years, nongastrointestinal symptoms have been documented in IBS patients, but the medical literature does not emphasize them. The present study explored how IBS and inflammatory bowel disease patients differ in their reporting of nongastrointestinal symptoms. Information from 200 consecutive patients with IBS and a similar number of patients with Crohn's disease (in a single gastroenterology practice) was obtained at the initial visit using a simple questionnaire. Comparison of the data revealed that IBS patients describe certain nongastrointestinal symptoms far more frequently than do those with inflammatory bowel disease. It is recommended that these symptoms be considered along with the generally accepted criteria for making a positive diagnosis of IBS.

Disappearance of Crohn's ulcers in the terminal ileum after thalidomide therapy.

A case of intractable Crohn's disease unresponsive to all forms of therapy, including multiple operations and medication, is reported. The patient responded to thalidomide and this has resulted in the disappearance of the disease in the neoterminal ileum. Thalidomide may be a valuable treatment in intractable cases of Crohn's disease. The case is presented in a chronological fashion and endoscopic photographs documenting the disappearance of the disease are presented.

Intestinal permeability is increased in a proportion of spouses of patients with Crohn's disease.

OBJECTIVE: Increased small intestinal permeability has been found in patients with Crohn's disease and in a proportion of their healthy relatives. This may reflect a shared environment or shared genes. The finding of abnormal permeability in the healthy spouses of patients would favor an environmental cause for this observation. METHODS: The healthy spouses of patients with Crohn's disease attending three gastroenterology clinics were invited to participate. Eligible subjects consumed a 350-ml solution containing lactulose, mannitol, and sucrose before bedtime. All overnight urine was collected, assayed by high performance liquid chromatography, and the ratio of fractional excretion of lactulose to mannitol was calculated as an index of permeability. The results were compared with those of a previously determined control group. RESULTS: Sixty spouses completed the study. Increased permeability was present in eight (13.3%, 95% CI = 6.0-24.6%). The presence of increased permeability was not related to age, gender, duration of cohabitation, alcohol use, nonsteroidal anti-inflammatory drug use or to disease activity in the patient with Crohn's disease. There was a nonsignificant trend for abnormal permeability to occur in those spouses cohabiting with the patient with Crohn's disease at the time of disease diagnosis (p = 0.128). CONCLUSIONS: Small intestinal permeability is increased in a proportion of healthy spouses of patients with Crohn's disease. The presence of abnormal permeability studies in patients with Crohn's disease and a proportion of their healthy close contacts suggests that this phenomenon is caused by environmental factors.

Anticipation in an Indo-Canadian family with Crohn's disease.

Genetic anticipation, associated elsewhere with monogenic neurological disorders, has been hypothesized to be present in familial forms of Crohn's disease. Usually, with studies of parent-child pairs, the parent who is initially diagnosed is older at the onset of disease than the child. With each successive generation, an apparent increase in disease severity or behaviour occurs. This phenomenon is believed to have a molecular basis. In the present report, an Indo-Canadian family with Crohn's disease is described. In all members of the family, disease was diagnosed only after prolonged residence in Canada, supporting the view that Crohn's disease arises in individuals with a genetic predisposition following exposure to some, as yet unknown, common environmental factor. Three siblings with Crohn's disease, first diagnosed between ages 15 and 27 years, or six to 11 years after arrival in Canada, had phenotypically concordant disease localized in the ileum and colon, with fistulizing complications, including perianal sepsis. Crohn's disease was only diagnosed in the father at the age of 76 years, almost three decades after his arrival in Canada. His disease was localized to the ileum and had a fibrostenosing behaviour. This is the first reported instance of familial Crohn's disease in an immigrant population, illustrating potential biases in genetically based studies of Crohn's disease that rely solely on phenotypic expression.

Pancreatic polypeptide hyperplasia causing watery diarrhea syndrome: a case report.

Neuroendocrine tumours of the pancreas can secrete numerous peptides, leading to various recognizable clinical syndromes. The secretion of pancreatic polypeptide has been used as a marker for neuroendocrine tumours but is considered to be a biologically inert peptide. A 37-year-old woman had watery diarrhea syndrome from pancreatic polypeptide hyperplasia. Only 2 other reported cases in the literature have described pancreatic polypeptide hyperplasia; however, this is the first reported case in which the patient was successfully treated by surgical resection, with a 2-year follow-up. This report and review of the literature illustrate that pancreatic polypeptide hypersecretion may present as a clinical endocrinopathy.

Expression pattern of metalloproteinases and their inhibitors changes with the progression of human sporadic colorectal neoplasia.

Several studies have implicated the extracellular matrix-degrading metalloproteinases (MMPs) as essential agents in tumor cell invasion and metastasis. In the present study, we have investigated the patterns of expression of a number of MMPs and their specific tissue inhibitors (TIMP-1 and TIMP-2) in human colonic tissue samples that represent various stages of progression from adenomas showing different degrees of dysplasia to adenocarcinomas. We assessed levels of mRNA by Northern blot analysis and the results were measured semiquantitatively by densitometry. In total, we analyzed nine adenomas of varying size and with varying degrees of dysplasia, three adenomas with adenocarcinoma (malignant polyps), and five adenocarcinomas. Although expression of MMP and TIMP mRNA was highly intercorrelated, transcripts for stromelysin 3 and TIMP-2 (high) showed the strongest relation to the neoplastic process. Detection of stromelysin 3 mRNA accompanied a diagnosis of severe dysplasia or malignancy, whereas levels of TIMP-2 (high) mRNA transcripts permitted finer distinctions on the neoplastic continuum. These data indicate changes within extracellular matrix acquired during the process of malignant transformation of human sporadic colorectal neoplasia.

The abdominal wall. A frequently overlooked source of abdominal pain.

Here, I review various conditions from my practice as a consultant gastroenterologist that present with abdominal pain in which the cause of the pain is the result of abdominal wall conditions, or disorders that affect the nerves to the abdominal wall. The diagnosis of abdominal wall pain can be made by careful history and physical examination, thus eliminating numerous unnecessary and sometimes dangerous invasive procedures and tests.

Predictors of hospitalization early in the course of Crohn's disease. A pilot study.

A historical cohort was used to assess the ability of clinical features and laboratory values recorded at the time of initial diagnostic investigations to predict nondiagnostic hospital admissions in the first 3 months following the diagnosis of Crohn's disease. Data were abstracted from the medical records of 225 eligible patients at primary and secondary care level whose disease was diagnosed between 1977 and 1985. The total study group was randomly divided into two groups (group 1, n = 112; group 2, n = 113). Discriminant analysis was performed on data of patients in group 1. The resulting predictive model was then cross-validated on data of patients in group 2. The variables entered into the predictive model were identified using bivariate analysis. Results show that presence of abdominal mass, body temperature, absolute basophil and lymphocyte counts, aspartate aminotransferase and blood urea nitrogen serum levels, and place of residence (urban, rural, or out of province) were the most useful variables for predicting hospitalization in the first 3 months (P for model = 0.0010; accuracy = 88%). Cross-validation on group 2 showed an accuracy of 80%, a positive predictive value of 62%, and a negative predictive value of 84%. This predictive model could be useful for counseling purposes on the primary or secondary care levels.

Chronic right upper quadrant pain without gallstones: does HIDA scan predict outcome after cholecystectomy?

Patients with chronic right upper quadrant pain who do not have gallstones on ultrasound or cholecystography are often referred for surgery for presumed acalculous chronic cholecystitis. We followed 26 patients who had cholecystokinin (CCK) cholescintigraphy for evaluation of chronic right upper quadrant pain without demonstrable gallstones on ultrasound who underwent cholecystectomy so that it could be determined whether there was any relation between a low ejection fraction (EF), morphological features of chronic cholecystitis, and clinical outcome. Eighteen patients (69%) were considered therapeutic successes, whereas eight (31%) were failures after an average 2-yr follow-up. Both patient groups had significantly reduced EF: the successful group at 0.39 and the failures at 0.25. Thus, a low EF did not predict clinical outcome, since the failure group had an even lower EF than the success group. Seven gallbladders demonstrated chronic acalculous cholecystitis; the average EF of this group was 0.35. The remaining 19 gallbladders were normal, yet also had an EF of 0.35. Thus, decreased EF does not predict the histologic features of chronic cholecystitis without gallstones. The diagnostic value of cholescintigraphy in patients with acalculous right upper quadrant pain is low, probably because this entity represents a variety of processes, including inflammation, gallbladder dysmotility, and the irritable bowel syndrome.