Safety, feasibility, and tolerability of ileocolonoscopy in inflammatory bowel disease.

BACKGROUND AND STUDY AIMS: Ileocolonoscopy including biopsies is the first-line investigation in the diagnosis, management, and monitoring of inflammatory bowel disease (IBD). However, data on its safety, feasibility, and tolerability, especially in patients with extensive or severe inflammation, are rare. The aim of this study was to assess prospectively the risks of ileocolonoscopy in relation to various disease patterns and to compare possible burdens of the procedure in the endoscopist's and the patient's perception. PATIENTS AND METHODS: We prospectively analyzed a total of 558 consecutive patients, 482 with a confirmed diagnosis of IBD and 76 with suspected IBD. Data were recorded regarding the indication for ileocolonoscopy, sedation, procedure time, completion rate, feasibility of the procedure, patient tolerance, and procedure-related and postprocedure complications. Endoscopic data included the region involved, the nature of the involvement, activity of the disease, and number of biopsies. RESULTS: In 558 endoscopic procedures performed by 14 gastroenterologists no procedure-related deaths occurred. Major complications, defined as bleeding (n = 1) or perforation (n = 3), occurred in 4/558 patients (0.7 %). Minor complications, which included intense flatulence, tachycardia, allergic reaction to a sedation drug, and autonomic symptoms such as nausea, vomiting, and intense perspiration, occurred in 22/558 patients (3.9 %). There was no relationship between the complication rate and the activity of the disease. Mean procedure time was 21.0 minutes and the completion rate, defined by intubation of the terminal ileum, was 94.6 %. We documented a high tolerability independent of the severity of the disease. CONCLUSIONS: Ileocolonoscopy is a safe and feasible procedure in patients with IBD and is well tolerated by patients when carried out by well-trained endoscopists.

[Recurrent aseptic osteonecrosis in Crohn's disease - extraintestinal manifestation or steroid related complication?]. / Rezidivierende aseptische Knochennekrosen bei Morbus Crohn - Extraintestinale Manifestation oder Steroid-assoziierte Komplikation?

HISTORY: A 57-year-old woman complained about increasing pain and weakness in her hips and legs. 7 months earlier active (Crohn's) ileocolitis had been diagnosed. She had received several bouts of steroids and had been in clinical remission for 12 weeks under a dosage of 40 mg/d prednisone. INVESTIGATIONS: Clinical examination, laboratory work up, x-rays and MRI of the pelvis, bone scan, neurologic examination and muscle biopsy showed unspecific results. THERAPY AN COURSE: Steroides were tapered and replaced by weekly intramuscular methotrexate 20 mg which resulted in long lasting clinical remission. Pain and weakness persisted. 6 months later MRI revealed osteonecrosis of both femoral heads. 4 1/2 years after the initial diagnosis of Crohn's disease the patient complained about pain in her lower legs without evidence of osteonecrosis in MRI. Another 2 years later avascular osteonecrosis was diagnosed by tibial bone biopsy. Now MRI verified patchy osteonecrosis of the tibiae. Further osteonecrosis of the left foot were diagnosed by MRI ten years after initial diagnosis of Crohn's disease in the now 67-year-old patient. She is still in remission on weekly intramuscular 15 mg methotrexate. CONCLUSION: The long interval between steroid treatment and recurrent avascular bone necrosis as well as the unusual pattern of bone involvement indicate that osteonecrosis is an extraintestinal manifestation of Crohn's disease. More reports and comparative studies are necessary to give more evidence that avascular osteonecrosis is an extraintestinal manifestation of inflammatory bowel disease.

Therapy of prednisone-refractory collagenous colitis with budesonide.

Collagenous colitis is a rare cause of chronic watery diarrhea. No effective standard treatment has yet been established. Based upon anecdotal reports some anti-inflammatory and symptomatic drugs seem to have some therapeutic efficacy. Prednisone is widely believed to be the most effective treatment. Here we describe three female patients with histologically confirmed collagenous colitis refractory to therapy with prednisone. Each had received prednisone with a high starting bolus and lower dose maintenance therapy for their disease. However, definite clinical remission could not be achieved. After the administration of 3 x 3 mg/day controlled ileal release (CIR) capsules of budesonide the symptoms resolved immediately. The mean follow-up after beginning budesonide was 11 months (range 7-18). Two patients are still on budesonide. One had had a quick relapse of diarrhea after stopping her treatment. Budesonide therapy was therefore resumed. She has remained symptom-free on a lower daily dose of 2 x 3 mg/day budesonide. One patient has been in remission for more than 1 year after a 3-month course of budesonide. Budesonide is a topically acting steroid with rapid absorption, high receptor affinity, and low systemic bioavailability, thus causing almost no side effects. As yet only few case reports have been published on the use of budesonide for collagenous colitis. We present here the first three cases of prednisone refractory collagenous colitis successfully treated with budesonide.

Quality assurance in clinical bacteriology--a continuous development in Hungary since 1927.

In Hungary, uniform methods and quality assessment date back as early as 1927, when the National Institute of Hygiene and regional public health laboratories were established. The National Microbiology Committee organized in 1984 was replaced in 1992 by the National Clinical Microbiology Board and the Joint Quality Assurance Committee of Clinical Microbiology for which the National Institute of Hygiene acts as an operating centre. A long-range programme of proficiency testing and on-site inspections had a beneficial effect on performance in public health laboratories: in 1989 20 out of 24 of them were scored in the excellent or good degree. Hospital laboratories, which joined this programme only in 1984, exhibited less satisfactory results.

Bacteriological proficiency testing in Hungarian clinical microbiology laboratories.

In course of a proficiency testing programme carried out in 1989, a total of 47 clinical microbiology laboratories of public health stations and of hospitals received freeze-dried cultures for isolation, identification and antimicrobial susceptibility testing. The specimens contained bacteria that occur in everyday work, including those that require improved methods of cultivation and identification. Nine public health laboratories and one hospital laboratory achieved excellent results. Good results were attained by 11 public health and 6 hospital laboratories. Four public health and 10 hospital laboratories were on the medium level and 4 hospital laboratories did not reach even this degree. The main failures were due to an insufficient anaerobic cultivation, unreliable identification and negligation of controls for drug susceptibility tests.

Ferric ammonium citrate decomposition--a taxonomic tool for gram-negative bacteria.

The iron uptake test of Szabó and Vandra has been modified and used for the differentiation of Gram-negative bacteria. Nutrient agar containing 20 g per litre of ferric ammonium citrate was distributed into narrow tubes and solidified so as to form butts and slants. Considering the localization of the rusty-brown coloration produced after seeding and incubation, 2367 strains were classified into four groups. (1) Unchanged medium: Escherichia coli, Shigella spp., Yersinia spp., Hafnia alvei and Morganella morganii 100% each, Klebsiella spp., 50%, Enterobacter cloacae 37%, Proteus vulgaris 59%, Acinetobacter spp. 42%, Pseudomonas fluorescens 19%, some other bacteria 2-12%. (2) Rusty-brown slant, unchanged butt: Salmonella subgenera II, III and IV 98%, Citrobacter freundii 65%, E. cloacae 55%, P. vulgaris 41%, Proteus mirabilis 98%, Providencia rettgeri 100%, urease-negative Providencia 96%, Acinetobacter spp. 58%, Pseudomonas aeruginosa 100%, P. fluorescens 81%, UFP (unclassified fluorescent pseudomonads) 100%, other Pseudomonas spp. 55%. (3) Unchanged slant, brown butt: S. typhi 88%, Salmonella subgenus I 3%, Klebsiella spp. 31%, some other bacteria 2-3%. (4) Rusty-brown slant, brown butt: Salmonella subgenus I 75%, C. freundii 20%, Klebsiella spp. 12%, some other bacteria 1-5%. Colour reactions in ferric ammonium citrate agar are associated with the accumulation of ferric hydroxide: bacteria giving positive reactions on the slant took up as an average, 63 times more iron than those with negative test. The localization of colour reaction correlated partly with aerobic and anaerobic citrate utilization or decomposition in Simmons' minimal and in Kauffmann's peptone water medium.

Characterization of Pseudomonas aeruginosa isolated from drinking water by serogrouping, phage sensitivity and pyocin pattern.

Pseudomonas aeruginosa strains isolated in the years 1977-1981 from drinking water samples fell into a large number of epidemiological units determined on the basis of serogroups, phage sensitivity and pyocin pattern. Strains isolated from water were, as a rule, sensitive to more phages than strains cultured from clinical material. The 427 water isolates fell into 8 serogroups and 31 pyocin patterns; 25.1% were untypable by the pyocin method. The frequency of isolation of different phage patterns varied annually. The most frequent epidemiological unit, comprising 9.1% of the isolates, was (serogroup: phage pattern: pyocin pattern) O1: 2/7/16/21/44/68/73/F7/F8/109/119x/352/1214/M4/C11/C18/C21:12 3567; 73.8% of the strains belonged to epidemiological units each represented by less than 4 strains. The large number of epidemiological units indicated that the distribution system had frequently been polluted with P. aeruginosa at different sites, but the organism was unable to invade the whole water supply system.

Immunoserology of Pseudomonas aeruginosa infections in man. III. Site of infection, duration of the presence of Pseudomonas aeruginosa and antibody response.

In 39 patients of a respiratory intensive care unit the intensity of the serological response to the purified LPS of the causative Pseudomonas aeruginosa was found to change according to the site of infection. The highest titres were found in septic cases, when the antigenic assault reached all the immune-competent cells in the body. Short presence (only one positive bacteriological culture) of P. aeruginosa at the site of inflammation resulted in a low or moderate rise in antibody titre. Ten days were enough for the development of a maximum total antibody (approximately IgM) response, while IgG type antibodies moderately grew further when the presence of P. aeruginosa lasted more than 10 days. Only a 16-fold increase in total antibodies per se or a 4-fold rise in both total (approximately IgM) and IgG antibodies confirmed the pseudomonas infection.

Immunoserology of Pseudomonas aeruginosa infections in man. II. effect of natural and immune anti-LPS antibodies on pseudomonas colonization and infection.

In 39 acute patients of a respiratory unit a comparatively high Pseudomonas aeruginosa anti-lipopolysaccharide antibody level present on admission prevented colonization by the homologous pseudomonas serogroup. At lower natural antibody titres symptomless colonization occurred, and in patients with the lowest initial titres, later P. aeruginosa complications developed. A low antibody level also predisposed to pseudomonas infection in 9 chronic patients. When colonization occurred at high antibody titres, the presence of P. aeruginosa was only transient; however, the titre had no effect on the further duration of harbouring P. aeruginosa. Anti-LPS antibodies may play an important role not only in the outcome of pseudomonas infection, but also in other respects of pseudomonas-man interaction.

Immunoserology of Pseudomonas aeruginosa infections in man. I. Four types of interaction between host and bacterium.

Continuous survey of clinical symptoms, bacteriological findings and anti-LPS antibodies in 39 acute and 9 chronic patients at a respiratory department revealed four interaction-types between Pseudomonas aeruginosa and host: I, clinical complications with a serological response; II, the same without serological answer; III, rise of specific antibodies without clinical symptoms; and IV, no clinical or serological reaction despite the presence of P. aeruginosa. Exogenous factors like massiveness or mode of infection (e.g. instrumental) determined mainly the type of interaction in the absence of immune-antibodies. P. aeruginosa colonization longer than a few days turned generally into manifest or subclinical infection. The lack of antibody production in severe infection was likely a consequence of an immune-paralysis, elicited by a massive infection. Antibody production was lower in subclinical than in manifest infection, yet IgG-type antibodies increased not only in the latter, but always in the former, too.

Incidence of Pseudomonas aeruginosa serogroups in drinking water: use of serotyping in the control of water supplies.

From 26,568 drinking water samples collected in the years 1977-1981 from deep well supplies in Csongrád county, Hungary, 1269 Pseudomonas aeruginosa strains were isolated. The most frequent serogroups (Lányi-Bergan scheme) were O6 (9.5-69.2%), O1 (5.5-35.5%) and O9 (2.2-36.2%). Predominance of a given serogroup varied with, and was characteristic of geographic areas of the county, water plants and distribution systems. Bacteriological monitoring has shown that serotyping of P. aeruginosa may be useful for evaluating the mechanical condition of the water supply.

Rhodanese activity: a simple and reliable taxonomic tool for gram-negative bacteria.

The thiosulphate: cyanide sulphurtransferase (rhodanese) test of Vandenbergh, Bawdon and Berk (1979) has been simplified and 2469 strains from a wide variety of sources representing different biochemical, serological or phage-pattern entities were tested. The percentages of rhondanese-producing strains were: Escherichia coli 98%, Shigella flexneri serovars 1-5%, X and Y 0%, other shigellae 73-100%, Yersinia spp. 0%, Salmonella subgenera I-IV 0%, Citrobacter freundi 16%, Klebsiella 37%, Enterobacter 4%, Hafnia alvei 61%, Proteus spp. 0%, Pseudomonas spp. 98-100%. Rhondanese production by S. flexneri serovar 6 supports the view that this group of bacteria should be removed from S. flexneri and placed in another species of Shigella.

Proticine typing of serologically defined Proteus strains.

Serologically defined Proteus strains including 120 P. vulgaris, 356 P. mirabilis, 47 P. morganii, 36 P. rettgeri and 66 P. inconstans cultures isolated from a wide variety of sources, were classified by proticine (bacteriocine) typing. Using Cradock-Watson's set of indicator and producer strains, the isolates were tested for proticine production (P type) and for proticine sensitivity (S type). P. vulgaris was typable by the P method in 4.1%, by the S method in 41.6%. The respective percentages for P. mirabilis were 60.1 and 48.9. Most strains of P. morganii, P. rettgeri and P. inconstans were untypable by both methods. A correlation has been demonstrated between P/S types and certain serogroups and serotypes of P. mirabilis. It has been concluded that, in combination with the determination of O and H antigens, the P/S method of proticine typing has a high differentiating value in the epidemiological tracing of P. vulgaris and P. mirabilis.

Salmonella and shigella surveillance in Hungary, 1972-1976. II. Shigella surveillance.

Shigellae were isolated from 32 399 persons in the bacteriological laboratories of the Public Health Stations between 1972-1976. The number of isolations ranged between 5325 and 8237 yearly. As S. dysenteriae and S. boydii serotypes occurred only in about 1.5% of all isolations, the epidemiological situation was determined by the incidence of S. flexneri and S. sonnei. Except in 1973, S. sonnei constituted the majority in every year. S. sonnei predominance, observed first in the western regions of the country, showed a gradual eastward spread and became characteristic of all localities in 1975-1976. The July-September peak of shigella isolations was associated with S. sonnei, as S. flexneri was distributed practically evenly in every season. The incidence of shigella isolations per 100 000 inhabitants was the lowest in the middle and the highest in the northern parts of the country. Sporadic cases were somewhat more frequent than epidemic outbreaks. Shigellae were isolated in 64.1% from patients and in 35.9% from asymptomatic excreters. The patient : excreter ratio was higher for S. sonnei (70.2 : 29.8) than for S. flexneri (54.6 : 45.4). In the survey period, 14 692 isolations were made in the course of 3278 epidemics; out of these, 11 171 cases were involved in 574 extensive outbreaks. S. sonnei was responsible mainly for school and nursery outbreaks, whereas S. flexneri dysentery predominated in mental wards and in homes for the aged and for mentally retarded children. The prevalent types of S. flexneri were (serological/phage type): 2a/69, 3a/5, 3a/19, 4a/81, 4a/89d and 6/85. The prevalent epidemiological subunits of S. sonnei were (phage/colicin type): 2/0, 2/6, 2/12, 3/12, 6/0, 7/0, 65/0, 65/6 and 65/12.