The risk of colorectal cancer in ulcerative colitis. An epidemiologic study.

Patients with a definite diagnosis of ulcerative colitis in Stockholm County during the 35-year period 1945-79 were identified and followed up with regard to the development of cancer of the colon. We found 25 patients who had developed 31 cancers. In 24 of 25 cases this occurred in patients with total colitis. The cumulative risk of developing cancer for patients with total colitis at follow-up study was calculated by means of life-table methods. It was 13% at 25 years (SD +/- 4.2%) among patients diagnosed in 1945-79, compared with the 1.9% expected in a population matched for age and sex. Among patients diagnosed in 1955-79 the risk was approximately 5% at 20 years (SD +/- 3.0%), compared with 1.4% for the background population. The cancer risk for all patients with colitis was higher but not significantly higher than that of the general population. The outcome of patients who developed cancer was dependent on histologic staging (Dukes's) at surgery but not on age at cancer diagnosis.

Prevalence of inflammatory bowel disease among relatives of patients with ulcerative colitis.

The familial occurrence of inflammatory bowel disease (IBD) was investigated among 963 patients with ulcerative colitis (UC) diagnosed in 1955-1979 in Stockholm County. For 76 patients who had a relative with IBD a pedigree was drawn. The diagnoses of the diseased relatives were verified. There was a general prevalence of 7.9% for IBD among relatives. In 80% one relative was affected, in most cases a first-degree relative with UC. Sibship was the commonest relationship. No concordance for UC was found among three pairs of monozygotic twins. The prevalence of UC in first-degree relatives was 15 times higher than in non-relatives. The age of onset was significantly lower among patients with a family history for UC; they also had a higher incidence of total colitis. The prevalence of Crohn's disease in first-degree relatives of patients with UC was almost 3.5 times higher than in non-relatives.

Incidence of ulcerative colitis in Stockholm County 1955-1979.

The epidemiology of ulcerative colitis in Stockholm County over a 25-year period, 1955-79, was investigated. Only definite cases in accordance with specified acceptance criteria were included. There were 1274 cases--681 males and 593 females. The proportion of patients with proctitis, left-sided, and total extent of disease of diagnosis remained constant over the study period, as did the time interval between onset of symptoms and definite diagnosis. The peak incidence in relation to age increased slightly but remained in the 3rd and 4th decade through the study period. The incidence in men over 40 years old increased markedly towards the end of the study.

Computerized tomography: a method to study cross-sectional muscle area in nutritional evaluation.

We have compared two ways of determining cross-sectional muscle area in patients undergoing total parenteral nutrition, namely, computerised tomography and anthropometric measurements. There was a poor correlation between the two methods of determining cross-sectional limb area. The cross-sectional area increased in all patients considered on clinical grounds to have improved during the course of treatment.

Nutritional assessment and postoperative morbidity. A prospective study in 286 consecutive surgical patients.

286 consecutive surgical patients went through a nutritional assessment following admission to the hospital. Serum albumin (S-alb), serum transferrin (S-transf), triceps skinfold (TSF) and arm muscle circumference (AMC) were recorded. The frequency of pathological values of TSF and AMC varied greatly depending on the reference population used to set the standard. There was no correlation between TSF or AMC and postoperative morbidity. S-alb less than 36 g/l and S-transf less than 2.0 g/l were associated with a marked increase in postoperative morbidity (29.4% and 20.0% respectively as compared to 7.6% in all operated patients). Thus S-alb and S-transf seemed to be able to predict postoperative morbidity. However, this ability varied depending on the diagnosis. Age was another factor with a marked influence on postoperative morbidity. It is suggested that attempts to make nutritional interpretations from S-alb and S-transf take into account patient age and the diagnosis. TSF and AMC seem to be of less value.

Reduced intestinal permeability to low-molecular-weight polyethyleneglycols (PEG 400) in patients with jejunoileal bypass.

The intestinal permeation and 6-hour urinary recovery of small, multisized tracers, polyethyleneglycol 400 (PEG 400), was used to characterize gut permeability in nine patients after bypass surgery for morbid obesity and in ten healthy volunteers. In the patients, who also had hyperoxaluria, the urinary recovery of ingested PEG 400 was lower than in the healthy persons (10.9 and 24.7%). The patients also showed stronger intestinal exclusion of the larger polymers within the PEG 400.

The effect of clindamycin on the intestinal flora in patients with enteric hyperoxaluria.

Enteric hyperoxaluria is due to increased absorption of oxalate, especially in the colon. However, this mechanism is not fully understood. Little is also known about the composition of the intestinal flora in these patients. Eleven patients with hyperoxaluria (greater than 0.45 mmol/24 h) after jejunoileal bypass were therefore studied under surgical ward conditions for 5 days. The patients were maintained on a constant diet. During days 3, 4, and 5 clindamycin (Dalacina), 1.8 g/24 h, was given parenterally in three divided doses. All patients had hyperoxaluria, with a mean oxalate absorption of 0.94 +/- 0.09 mmol/24 h (+/- SEM). No significant disturbances in the colonic microflora were found. The degree of hyperoxaluria did not change during clindamycin administration, in spite of a significant decrease in the number of anaerobic bacteria. Our patients with enteric hyperoxaluria seem to have a normal colonic microflora. The degree of hyperoxaluria did not seem to be related to changes in the intestinal anaerobic flora.

Urine composition following jejunoileal bypass.

The urinary excretion of oxalate, calcium, citrate, magnesium, urate and creatinine and the inhibition of calcium oxalate crystal growth were determined in 30 patients operated with three different types of jejunoileal bypass. In addition the ion-activity products of calcium oxalate and calcium oxalate saturation were calculated. 15 of the patients had formed urolithiasis postoperatively. The patients were investigated on an out-patient basis with their ordinary diet. All patients had hyperoxaluria. The oxalate excretion did not seem to decrease with time after operation. The patients operated with a biliointestinal shunt had a significantly higher excretion of oxalate than those with the other two types of operation, indicating that variations in the anatomy of the small intestine after jejunoileal bypass might result in different absorption of oxalate or oxalate precursors. Urinary oxalate, calcium oxalate saturation and ion-activity products were higher whereas the excretion of calcium, magnesium and citrate was lower in patients than in controls. The urine volumes, excretion of creatinine and urate and inhibition of calcium oxalate crystal growth were equal in patients and controls. Analogous urine composition was found in patients both with and without urolithiasis with the exception of a higher magnesium excretion observed in stone formers.

Low-oxalate, low-fat dietary regimen in hyperoxaluria following jejunoileal bypass.

Previous studies have shown that the severity of enteric hyperoxaluria can be reduced in hospitalized patients who receive a diet low in oxalate and fat. Little is known of the value of such a diet in the patients' home conditions. Ten patients with hyperoxaluria (greater than 0.45 mmol/24 h) following jejuno-ileal bypass were therefore studied while on their ordinary diet and also on a diet with low-oxalate, low-fat content. The mean urinary excretion of oxalate decreased during the dietary treatment from 1.1 to 0.7 mmol/24 h. The diet was demanding, though not unfeasible for the patients. Careful and regular dietary information, preferably by a dietitian, is recommended in such cases.

Effects of calcium, aluminium, magnesium and cholestyramine on hyperoxaluria in patients with jejunoileal bypass.

The urinary excretion of oxalate, calcium, magnesium and citrate as well as the inhibition of calcium oxalate crystal growth in diluted urine was studied in seven patients with hyperoxaluria following jejunoileal bypass. The study was performed on an outpatient basis before and during daily administration of 38 or 113 mmol calcium, 28 mmol of aluminum, 20 mmol of magnesium or 16 g of cholestyramine. Each substance was administered for seven days with a free interval of at least seven days. The mean urinary oxalate excretion was not reduced with any of these regimens. Administration of 38 mmol of calcium per day resulted in increased oxalate and magnesium excretion. Increased excretion of both calcium and citrate was observed during administration of 113 mmol of calcium per day. Calcium and magnesium excretion was increased with aluminium. An increased magnesium excretion was also observed during administration of magnesium, resulting in a decreased calcium/ magnesium ratio. Cholestyramine resulted in increased oxalate and decreased citrate excretion.

Oxalate metabolism in man studied during total parenteral nutrition.

The mean urinary excretion of oxalate was 325 micromol/24 h in six patients during total parenteral nutrition (TPN). The urinary excretion of oxalate was considered to be equal to the endogenous oxalate production. A 2-day load of the oxalate precursor glycine given to five patients did not influence the oxalate excretion in spite of increased serum glycine concentrations. A 3-day load of the oxalate precursor ascorbic acid given to four patients increased the oxalate excretion in all patients. In one patient TPN was prolonged for 20 days without any change in the amount of oxalate excreted.

Oxalate metabolism after intestinal bypass operations.

Hyperoxaluria and kidney stones are frequent following intestinal bypass operations. The urinary oxalate excretion was studied for 10-13 days during enteral and parenteral nutrition in six patients operated on because of massive obesity with a jejunoileostomy. The oxalate excretion in urine was higher than normal in all patients on normal diet. The excretion decreased on low-oxalate diet. Further decrease was observed during total parenteral nutrition (TPN). The oxalate excretion was stabilized at a low level within 48 h after the start of TPN and was unchanged during the rest of the study. This included a period of 2 days when a load of the oxalate precursor glycine (10 and 20 g) was given parenterally to five patients, resulting in increased serum glycine concentration. A slight decrease in oxalate excretion was found when the amino acid part (Vamin with 10% glucose) of the TPN solution was given enterally instead of parenterally in two patients. This study has indicated that the main reason for hyperoxaluria in patients with intestinal bypass operations is hyperabsorption of dietary oxalate. It seems likely that these patients have a normal endogenous oxalate production.

Difference in kidney stone incidence after three types of intestinal bypass operations.

Jejuno-ileal bypass operations have been used for more than 20 years for the treatment of massive obesity. This treatment results in malabsorption with diarrhoea, especially during the first year after operation. A high incidence of urinary tract calculi was found in these patients (Backman & Hallberg, 1972; Dickstein & Frame, 1973; O'Leary, Thomas & Woodward, 1974; Backman et al., 1975; Gregory et al., 1975). Other known late complications are transient disturbances in liver function and electrolyte balance (Backman et al., 1975). Different types of operations result in different frequencies of kidney stones.