FDG-PET in inflammatory bowel disease.

Accurate, inexpensive, non-invasive studies in evaluation of inflammatory bowel disease (IBD) would represent a significant advancement in identifying and measuring disease activity. There is new evidence that positron emission tomography (PET) scanning can fulfill many of these criteria. The aim of this review is to report the studies pertaining to the use of PET in IBD and provide an evidence-based approach on how to use PET clinically in IBD. Searching Medline and the Cochrane Database of Clinical Trails on July 18, 2008 identified 12 relevant manuscripts for review. Types of studies of PET in IBD include the incidental identification of IBD during studies performed for other indications, the evaluation of suspected IBD and the assessment of known IBD. PET has been studied in both children and adults and has shown excellent sensitivity for detecting active bowel inflammation, but with poor specificity in some studies. PET alone appears sufficient for the evaluation of ulcerative colitis, but PET/computed tomography provides considerably more information over PET alone in the evaluation of Crohn's disease. Current clinical applications for PET in IBD include its use in the early evaluation of IBD, especially in children who may not tolerate an invasive test such as colonoscopy; and its use in differentiating between a flare of IBD versus the onset of a non-inflammatory process causing similar symptoms in patients with known IBD. Many unanswered questions remain, but PET appears to be a promising tool in the non-invasive evaluation of IBD.

Low-attenuation oral GI contrast agents in abdominal-pelvic computed tomography.

BACKGROUND: We designed and evaluated a low-attenuation oral contrast agent for abdominal-pelvic computed tomography (CT). METHODS: In vitro studies, were performed initially to evaluate the imaging characteristics of multiple solutions. These studies resulted in two solutions being compared with the presently accepted oral CT agents of dilute iodinated contrast and water. Ninety-eight consecutive subjects already scheduled for routine outpatient abdominal-pelvic CT were enrolled. Subjects were randomized to water (n = 30), fiber solution (n = 32), polyethylene glycol (PEG; n = 11), or dilute iodinated solution (DI; n = 25). Examinations were then evaluated for gastric distention, small bowel distention, small bowel wall visualization, and colonic transit. A questionnaire was given to the study subjects for feedback concerning taste and potential side effects from these agents. RESULTS: PEG tended to provide better bowel distention, wall visualization, and colonic transit compared with water, fiber solution, and DI. Areas of statistical significance included: (1) average bowel diameter in the left upper quadrant for water was 17.50 mm, whereas that for PEG was 21.88 mm (p < 0.05); (2) average bowel diameter in the pelvis for water was 14.79 mm, that for fiber was 15.67 mm, and that for PEG was 18.48 mm (p < 0.05); (3) wall visualization was better with PEG than with fiber (p < 0.05); (4) successful transit of contrast to the colon occurred in every subject who received PEG compared with only 20% of those received water and 39% of those who received fiber (p < 0.05). Similar trends for the superiority of PEG over DI were noted, although many of these did not reach statistical significance. CONCLUSION: PEG solution has imaging characteristics related to bowel wall visualization, luminal distention, and colonic transit that make it an effective oral agent for abdominal pelvic CT examination.

Results of multiple diagnostic tests for Mycobacterium avium subsp. paratuberculosis in patients with inflammatory bowel disease and in controls.

Mycobacterium avium subsp. paratuberculosis has been incriminated as a cause of Crohn's disease (CD); however, studies to date have been relatively small and generally only used a single diagnostic assay. The objective of the study was to reexamine the association of M. avium subsp. paratuberculosis and CD using multiple diagnostic tests. Five methods were used to detect M. avium subsp. paratuberculosis infections in 439 inflammatory bowel disease (IBD) patients and 324 control subjects in the United States and Denmark. Most assays were adaptations of diagnostic tests for this infection performed routinely on animals. PCR for IS900, a genetic element unique to M. avium subsp. paratuberculosis, was positive significantly more often on resected bowel and lymph node tissues from CD patients (19.0%) and ulcerative colitis (UC) patients (26.2%) than from controls (6. 3%) (P < 0.05). Positive IS900 PCR results occurred more often in U. S. than in Danish IBD patients, 32.0 versus 13.3% (P = 0.025). The majority of Danish patients were bacillus Calmette-Guérin (Mycobacterium bovis BCG) vaccinated (CD, 77.5%; UC, 86.6%; controls, 83.0%) whereas none of the U.S. patients with IBD and only 2% of U. S. controls were vaccinated. Among Danish IBD patients, positive PCR findings were four times more common among subjects who were not BCG vaccinated (33.3%) than among BCG vaccinates (8.8%, P = 0.02). Culture of the same tissues tested by PCR using modified BACTEC 12B medium failed to grow M. avium subsp. paratuberculosis from patients or controls. U.S. CD patients had the highest serological evidence (enzyme-linked immunosorbent assay [ELISA] for serum antibodies) of M. avium subsp. paratuberculosis infection (20.7% of patients positive) which was higher than for all UC patients studied (6.1%) or healthy controls (3.8%, P < 0.005). Among Danish patients alone, however, no significant differences in rates of ELISA-positive results among CD, UC, or control patients were found. For 181 study subjects, both IS900 PCR and ELISA were performed. Although 11 were ELISA positive and 36 were PCR positive, in no instance was a patient positive by both tests, suggesting that these states are mutually exclusive. Evaluation of cytokine-mediated immune responses of IBD patients was complicated by the influence of immunosuppressive therapy given most IBD patients. Gamma interferon (IFN-gamma) release by peripheral blood leukocytes after M. avium purified protein derivative PPD antigen stimulation showed significantly lower responses in CD patients than in UC patients or controls in both U.S. (by ex vivo assay) and Danish (by in vitro assay) populations (P < 0.05). Interleukin-5 responses were not different among CD, UC, or control groups. Collectively, the PCR, ELISA, and IFN-gamma tests for M. avium subsp. paratuberculosis together with the unexpected observation that BCG vaccination influenced M. avium subsp. paratuberculosis detection, lead us to conclude that M. avium subsp. paratuberculosis, or some similarly fastidious mycobacterial species, infects at least a subset of IBD patients. Whether the infection is primary (causal) or secondary, it may contribute to the etiopathogenesis of IBD.

Clinical and humanistic outcomes in patients with gastroesophageal reflux disease converted from omeprazole to lansoprazole.

BACKGROUND: Omeprazole and lansoprazole are 2 proton pump inhibitors (PPIs) currently available in the United States. Both PPIs are approved for the treatment of gastroesophageal reflux disease (GERD) and are commonly converted in therapeutic interchange programs. OBJECTIVE: To measure clinical and humanistic outcomes in patients with GERD converted from treatment with omeprazole to treatment with lansoprazole through a managed care plan policy. METHODS: Patients with heartburn or GERD receiving omeprazole covered by a local health plan were surveyed by telephone. Data collected included symptom frequency, severity, over-the-counter heartburn preparation use, diet, lifestyle, and overall satisfaction. Patients were then converted to therapy with lansoprazole and again interviewed after at least 30-day use of the new PPI. Demographic data were obtained from the health plan database for analysis. RESULTS: A total of 105 patients completed both telephone surveys. After the conversion, 37% of the patients experienced more frequent symptoms while awake. Symptom severity score was significantly higher (more severe) after conversion (mean score of 1.34 vs 2.26). Thirty-three percent of study patients consumed more over-the-counter heartburn preparations, and 13% changed their diet more frequently due to heartburn symptoms after conversion. Overall patient satisfaction score decreased significantly (less satisfied) after conversion (mean score of 9.0 vs 7.2). There were no significant differences in alcohol and tobacco consumption before and after conversion, while patients consumed significantly less caffeine after conversion. CONCLUSIONS: After the PPI therapeutic interchange from omeprazole to lansoprazole, patients with GERD or heartburn previously stabilized while receiving omeprazole experienced more severe symptoms and expressed decreased patient satisfaction. These results suggest a need to monitor symptoms after similar interchange programs.

Cholecystitis caused by hemocholecyst from underlying malignancy.

Massive hemobilia is a well recognized clinical entity, particularly when it presents with jaundice, GI bleeding, and biliary pain. However, occult hemobilia is more difficult to diagnose and has seldom been reported because of its clinically silent nature. In fact, this is usually overlooked until complications arise. Hemocholecyst or clot within the gallbladder may rarely occur in this setting, leading to cystic duct obstruction and cholecystitis. Most previous reports describe cholecystitis resulting from hemocholecyst after iatrogenic trauma. We describe two cases in which hemocholecyst occurred from underlying malignancies, both resulting in cholecystitis (acute or chronic).

Mucinous ductal ectasia in an octogenarian: successful treatment with the Whipple procedure.

Mucinous ductal ectasia is a recently defined neoplasm of the pancreas characterized by excessive mucin production. The natural history of this entity is unknown, and only two cases in people over the age of 80 yr have appeared in the literature. In this report, we review the literature on mucinous ductal ectasia and present the first report of an octogenarian who was successfully treated by the Whipple procedure.

Innervation of an esophageal ectatic submucosal blood vessel in achalasia and a comparison with normals.

Achalasia is a disease of the esophagus characterized by incomplete relaxation of the lower esophageal sphincter, resulting in obstruction. Aperistalsis and dilation of the esophageal body occurs later, contributing to the esophageal dysfunction. Gastrointestinal bleeding in achalasia is an infrequent complication usually caused by stasis ulcer, esophageal varices, carcinoma, or pneumatic dilation of the sphincter. We describe here a patient with longstanding achalasia who bled vigorously from a proximal esophageal site that can be identified as arterial bleeding by endoscopy. Subsequent esophageal resection allowed detailed histological and immunohistochemical examination, which revealed a vascular ectasia. This lesion was associated with an unusually rich network of nerve fibers containing calcitonin gene-related peptide. Neuropeptide Y- and substance P-containing fibers were found to be decreased in this lesion as compared with controls. On the other hand vasoactive intestinal peptide- and nitric oxide synthase-containing fibers appeared quantitatively similar to those of controls. Calcitonin gene-related peptide is known to be involved in angiogenesis and may have played a causative role in the development of this lesion. Vascular ectasia may represent a hitherto unreported complication of achalasia.

Pancreatic pseudocyst with fistula to the common bile duct: radiological diagnosis and management.

A patient was found to have fistulization of a pancreatic pseudocyst with the common bile duct. Resolution of the pseudocyst and the attendant biliary obstruction was achieved with percutaneous biliary drainage alone. The clinical and radiological features of this case are herein presented along with a brief review of the subject.

Sleeping on a wedge diminishes exposure of the esophagus to refluxed acid.

In a randomized crossover study, we compared the effect on gastroesophageal reflux of three sleeping positions: elevation of the head of the bed on standard eight-inch bed blocks; elevation by a foam wedge; or a flat position. Fifteen subjects with moderate to severe reflux symptoms were studied in each position on consecutive nights using continuous intraesophageal pH monitoring. We found no difference in reflux frequency among the positions. The wedge caused a statistically significant decrease in the time that distal esophageal pH was less than 4 as compared to the flat position. The wedge also decreased the longest episode experienced by the subjects. Elevation on blocks caused a similar improvement in parameters but failed in this study to achieve statistical significance. Both elevation by a wedge and on blocks showed a trend towards a decrease in clearance time as compared to the flat position. The patients did not always prefer elevation on a wedge, but for some it is a valuable alternative to elevation by bed blocks.

Human electrogastrograms. Comparison of surface and mucosal recordings.

A method to record the gastric basic electrical rhythm (BER) using skin electrodes is described. Correlation is made with mucosal suction electrodes in 20 volunteers. Successful simultaneous recording from surface electrodes and mucosal electrodes is made in 16/20 subjects (80%). An increase in amplitude of the recorded gastric BER with gastric contractions is demonstrated and discussed. Five patients with gastric motility disturbances and chronic nausea are also investigated. Four of these patients had diabetic gastroparesis. Each had preservation of the gastric BER. The rate was usually normal at three per minute, but during acute nausea episodes which occurred in three of the four, an abnormally increased rate of the BER (tachygastria) was seen. This finding was also seen in a subject with atrophic gastritis and delay of gastric emptying. The surface electrogastrogram may prove to be a useful tool for the investigation of patients with suspected gastric arrhythmias.

Magnesium sulfate-induced water secretion in hamster small intestine.

We studied possible mechanisms of magnesium sulfate (MgSO4)-induced diarrhea. In vivo perfusion of hamster small intestine with an isotonic electrolyte solution containing 50 mM MgSO4 produced nearly three times as much fluid secretion as did a solution containing an equiosmotic amount of mannitol. We found that magnesium was absorbed at a faster rate than mannitol under these conditions, suggesting that differences in solute permeability do not explain the differences in secretory rates. Magnesium ion rather than sulfate appeared largely responsible for the effect as replacement of sulfate with chloride did not diminish the response. MgSO4 perfusion of a proximal intestinal segment did not affect water transport in an isolated distal segment suggesting that release of cholecystokinin or alterations in serum levels of other hormones were not responsible. Intestinal permeability, morphology, and cyclic nucleotide levels were normal after MgSO4 perfusion. Thus, MgSO4-induced diarrhea cannot be explained by the usual mechanisms, and additional processes responsible for intestinal secretion must exist.