A prospective study of pre-illness diet in newly diagnosed patients with Crohn's disease.

BACKGROUND: Environmental factors, including diet, seem to participate in the etiology of inflammatory bowel disease. The kind of dietetic habits before the appearance of the illness in patients with Crohn's disease (CD) has not been studied extensively. AIM: To prospectively assess the kind of food consumption in patients with CD exactly at the time of diagnosis and to identify dietary constituents as risk factors for development of CD. PATIENTS - METHODS: Twenty eight patients with a newly established diagnosis of CD (2-4 weeks), (12 men and 16 women), 30 patients with previously (between 2 - 11 years) established diagnosis of CD (14 men and 16 women) and 38 age- and sex-matched healthy controls (16 men and 22 women) were included in the study. Dietary intake was assessed by means of special questionnaire. RESULTS: Comparisons between controls and newly diagnosed patients showed that increased consumption of milk and yogurt (P = 0.042), fruits (P = 0.0001), citrus (P = 0.0001), vegetables (P = 0.0001), carrots (P = 0.0001), legumes (P = 0.036), fish and selfish (P = 0.001), honey (P = 0.003), and nuts (P = 0.038), was associated with decreased risk for CD. On the other hand, significantly increased intake of fat (P = 0.041), olive oil (P = 0.038), margarine (P = 0.038), sugar (P = 0.02), alcohol drinks (P = 0.009), fried food (P = 0.0001), and pasta (P = 0.0001), was noticed on recently diagnosed patients in comparison with the healthy control group. On logistic regression analysis foods remaining statistically significant were: margarine, pasta, fried foods, fat, olives, sugar (increased risk), and yogurt, honey, fruits, nuts, fish, and citrus fruits (decreased risk). Newly diagnosed patients were significantly overweighed (64%) compared to healthy people (26%) and old patients (7%). CONCLUSION: Significant differences in many kinds of food between newly diagnosed patients with CD, patients with established CD and normal people certainly exist. Our results suggest that specific dietary patterns could be associated with higher or lower risks for CD in adults. However, whether these dietary factors are important for the development of CD or modulate the effect of other environmental factors is unknown.

Risk factors for colorectal polyps: findings from a Greek case-control study.

UNLABELLED: There is a body of evidence showing that several lifestyle and dietary factors are associated with colorectal polyps' formation; however, the magnitude of this association in diverse populations remains unclear. The aim of this study was to investigate this association in a Greek sample. MATERIAL AND METHOD: The study comprised of 52 subjects with histologically confirmed advanced colorectal polyps and 52 healthy controls. Data concerning lifestyle and dietary factors were collected using a validated questionnaire. Logistic regression analysis was used to estimate odds ratios and 95% confidence intervals after adjustment for potential confounders. RESULTS: Physical activity level (95% CI 0.032-0.953, P = 0.044) and consumption of yoghurt (95% CI 0.969-0.996, P = 0.024), cheese (95% CI 0.932-0.996, P = 0.030), fish (95% CI 0.782-0.964, P = 0.008), vegetables (95% CI 0.965-0.998, P = 0.029), and garlic (95% CI 0.005-0.671, P = 0.022) were inversely associated with colorectal polyps. Increasing age (95% CI 1.005-1.231, P = 0.039) and central obesity (95% CI 1.001-1.019, P = 0.025) were strongly associated with their presence. CONCLUSION: Our study indicates that a cluster of modifiable risk factors have significant impact on colorectal polyps' occurrence in Greek population.

Acute idiopathic pancreatitis preceding diagnosis of Crohn's disease. Description of three cases.

UNLABELLED: Acute idiopathic pancreatitis seems to represent a rare extraintestinal manifestation of Crohn's disease usually appearing after the establishment of diagnosis of the intestinal disorder. The aim of this study was to describe the clinicoepidemiological characteristics and clinical course of three patients with Crohn's disease who developed acute idiopathic pancreatitis years before the establishment of diagnosis intestinal disease. DESCRIPTION OF CASES: All patients were suffering from Crohn's disease. In all patients, an extensive work-up aiming to identify an etiological factor involved in the pathogenesis of acute pancreatitis was negative. The main clinical characteristics of the patients were the young age, the mild or moderate degree of severity of pancreatitis, and the concurrent involvement of small and large bowel from Crohn's disease in two of them. There was no preference for either male or female sex. The course of pancreatitis was favorable in all patients. During the follow-up period, ranging from 2 to 8 years, no exacerbation of pancreatitis was noticed. CONCLUSION: This case-series suggests that acute idiopathic pancreatitis could precede diagnosis of Crohn's disease. Clinicians must bear in mind the possibility of the existence of Crohn's disease when they are confronting a young patient with clinical and laboratory features of acute idiopathic pancreatitis.

Simultaneous deregulation of p16 and cyclin D1 genes in pancreatic ductal adenocarcinoma: a combined immunohistochemistry and image analysis study based on tissue microarrays.

PURPOSE: Deregulation of cell cycle control molecules, such as cyclins and their inhibitors, is a crucial event in the carcinogenetic process. Our aim was to identify potential correlations between p16 and cyclin D1 expression in pancreatic ductal adenocarcinoma (PDAC) that affect the biological behavior of this neoplasm. MATERIALS AND METHODS: Using tissue microarray (TMA) technology, 50 paraffin-embedded tissue samples of histologically confirmed primary PDACs were cored twice and re-embedded to the final recipient block. Immunohistochemistry (IHC) was performed using monoclonal anti-p16 and anti-cyclin D1 antibodies. Protein expression levels were determined by performing computerized image analysis (CIA; estimation of Nuclear Labeling Index-NLI). SPSS (chi square test and interrater Cohen's kappa) was used for statistical analysis. RESULTS: Cyclin D1 overexpression was observed in 24/50 (48%) of the examined carcinomas, whereas p16 loss or reduced expression was detected in 40/50 (80%) cases. Statistical significance was noted when correlating grade to cyclin D1 (p=0.038), stage to p16 (p=0.012) and also to cyclin D1 (p=0.011). Interestingly, combined protein alterations (p16 loss and cyclin D1 overexpression) were observed in 23/50 (46%) cases associated with advanced stage (p=0.019). Overall combined expression of the two molecules demonstrated a significantly low value (kappa=0.012; 95% confidence interval-CI: 0.010-0.014). CONCLUSION: A significant proportion of PDACs is characterized by simultaneous protein alterations regarding p16 and cyclin D1 genes. This mechanism of genetic deregulation in cell cycle potentially explains in part the aggressive phenotype of this neoplasm.

Two-stage liver surgery for advanced liver metastasis synchronous with colorectal tumor.

BACKGROUND/AIMS: To evaluate the efficacy of two-stage surgery and multidisciplinary approach, in the treatment of primary colorectal cancer, synchronous with advanced liver metastases. METHODOLOGY: Sixty-two patients who underwent two-stage surgery for advanced metastatic liver disease synchronous with colorectal tumor were studied. In the first-stage surgery, the primary colorectal tumor was resected. Depending on the location of the main tumor mass, ligation and transection of the relevant (right or left) main portal vein branch was done. Subsequently, the metastatic nodules in the contralateral lobe were ablated by microwave therapy. An arterial jet port catheter was also introduced into the hepatic artery via the gastroduodenal artery for locoregional chemoimmunotherapy. Two days after the first-stage surgery locoregional transarterial targeting chemoimmunotherapy was given. The second-stage hemihepatectomy was carried out forty to forty-five days after the initial surgery. As an adjuvant treatment locoregional targeting chemoimmunotherapy was carried out in all patients via the arterial chemoport. RESULTS: Mean survival was 66+/-4 months. There were no operative deaths. CONCLUSIONS: Two-stage liver surgery including, portal vein branch ligation, microwave ablative therapy and transarterial targeting locoregional chemoimmunotherapy is the best treatment for advanced, synchronous metastatic liver disease of colorectal origin. It results in an increase in the overall survival of these patients with good postoperative quality of life, which encourages the hepato-biliary surgeon to venture upon this herculean task thus increasing the resectability rate of the tumor.

Mono-bloc total spleno-pancreaticoduodenectomy for pancreatic head carcinoma with portal-mesenteric venous invasion. A prospective randomized study.

BACKGROUND/AIMS: To evaluate, the early and long-term results of mono-bloc spleno-pancreatic and vascular resection for advanced carcinoma of the head of the pancreas, with portal-mesenteric venous invasion. METHODOLOGY: In a prospective, randomized trial, fifty-six patients with advanced carcinoma of the head of the pancreas with vascular invasion were studied. Patients were randomly divided in two groups A and B. Group A patients underwent an en-bloc spleno-pancreatic and vascular resection. Group B patients underwent a palliative gastro-biliary bypass. Patients in both groups were subjected to adjuvant locoregional chemoimmunotherapy, through an arterial catheter introduced into the superior mesenteric artery via a jejunal arterial branch. RESULTS: The 2- and 5-year survival rates for Group A patients were 81.8% and 18.5%. The respective percentages for disease-free survival were 60.6% and 0%. Two-year survival for group B was nil. CONCLUSIONS: Mono-bloc spleno-pancreaticoduodenectomy and regional vascular resection and reconstruction, with adjuvant locoregional chemoimmunotherapy leads to substantial prolongation of survival and optimization of quality of life.

Endocrine function in abetalipoproteinemia: a study of a female patient of Greek origin.

AIM: To investigate the pituary, genitalia, adrenal, thyroid, parathyroid and pancreatic endocrine function of a female patient aged 37 with abetalipoproteinemia at the time of diagnosis and 5 years thereafter (after application of a modified diet). SUBJECT-METHODS: Serum concentrations of cortisol, A4, ACTH, aldosteron, renin, dehydroepiandrosterone sulfate (DHEA-5), progesterone, 17-OH progesterone, testosterone, SH13G, estradiol, luteinizing hormone, follicle stimulating hormone, T3, T4, TSH, FT3, FT4, parathormone, osteocalcin, prolactin, proinsuline, insulin, glucagon, somatomedin-C (Insulin-like Growth Factor-1, IGF-1), IG171-13P3, 25 (OH) Vitamin D3 and 1-25 (OH) 2 Vitamin D3, were measured by radioimmunoassay. Synactlien test, and 24-hour urine cortisol, were also estimated. Serum leptin estimation was carried-out using a sensitive enzymatic technique. Ionized part of serum calcium was measured by the use of a special machine (CORNING), while bone alkaline phosphatase was measured by radioimmunoassay. RESULTS: Serum progesterone and 17-OH-progesterone were reduced in both examinations. Estimation of serum progesterone performed on the 21th day of the menstrual cycle revealed again values below the lowest normal limit. Serum prolactin was increased both in rest and during movement. The levels of both, somatomedin-C (IGF-1) and leptin were below the lowest normal limit. Despite normal serum parathormone, serum-ionized calcium and 25-OH vitamin D were low, while serum bone alkaline phosphatase was increased. Serum proinsulin was increased, and serum insulin was low. Serum thyroid hormone, glucagon, parathormone, FSH, LH, ACTH, testosterone, estradiol and SH13G were normal. The hormonal profile of the patient estimated 5 years later did not differ substantially suggesting that the metabolic improvement due to the adoption of the modified diet had not any significant impact on it. CONCLUSION: Female patients with abetalipoproteinernia have reduced production of progesterone by the corpus luteum and slightly abnormal bone metabolism. The reduced production of progesterone is probably due to the low levels of serum LDL and cholesterol, while reduced serum levels of Leptin and IG17-1 are probably due to the impairment nutritional status. The adoption of a modified diet does not alter the hormonal profile significantly.

Surgery for Crohn's disease in Greece: a follow-up study of 79 cases.

BACKGROUND/AIMS: The aim of this prospective study was to elucidate the clinical features, indications for surgery and long-term outcome of a series of 79 Greek patients operated on for Crohn's disease. METHODOLOGY: The clinical features and follow-up of 79 out of 155 patients with definite diagnosis of Crohn's disease (51%), who were operated on at least once during the course of their disease, are analyzed. Three main locations of the disease were identified (small bowel, large bowel and small and large bowel). The need for surgery, indications for surgery and outcome of patients were analyzed and compared separately for these three main locations. The mean follow-up period after the first operation was 8.8 +/- 6.5 years. RESULTS: The proportion of men to women was 1.55:1 (P = 0.068). The main indication for surgery was poor response to conservative treatment, followed by obstructive ileus, erroneous diagnosis of acute appendicitis and development of fistulae or abscesses. Statistically significant differences between the three main locations of the disease were found for obstructive ileus (P < 0.01), and bowel perforation (P < 0.0297). Enterectomy and end-to-end anastomosis was the most frequently performed operation. Minor surgical procedures were performed mainly for drainage of perianal abscess. Differences in the number of operations required (one, two and three or more) according to the three main locations of the disease were statistically significant (P < 0.044). Emergency operation was required in 17.3%. Most of the urgently operated patients had only small bowel involvement. Twenty-six percent of patients required a surgical procedure for perianal disease. One or more, major or minor, perioperative complications occurred in 13 out of 79 operated patients (16.4%). No perioperative deaths were noticed. Evolution to cancer was observed in 2% (3 patients). The outcome of patients after the operation was characterized by exacerbations and remissions. A mortality rate of 11.6% was noticed in the follow-up period. However, most deaths were unrelated to the underlying Crohn's disease. CONCLUSIONS: The clinicoepidemiological characteristics of patients with Crohn's disease of Greek origin operated-on for their disease do not differ significantly from those reported from other Western or neighboring Mediterranean countries. However, other parameters such as the relatively low incidence of overall surgical need, the low incidence of colorectal cancer and the low incidence of surgery for perianal disease, all underline the importance of various genetic and environmental factors on the evolution and behavior of the disease in different parts of the world.

Ulcerative colitis in the elderly: clinical patterns and outcome in 51 Greek patients.

PURPOSE: In this study, the clinical characteristics and course of all patients with ulcerative colitis in whom diagnosis of the disease was made at or after the age of 60 (older group), were analyzed and compared with those of patients with ulcerative colitis in whom diagnosis of the disease was made before the age of 60 (younger group). METHODS: The older group consisted of 51 patients (28 men and 23 women; aged 64+/-3.1 years) and the younger group consisted of 362 patients (192 men and 170 women; aged 38.4+/-14.9 years). The mean follow-up times in the two groups were 9.3 and 12.6 years, respectively. RESULTS: No significant differences between the two groups were found as far as the extent of the disease, the severity of the initial episode, and the outcome of the first episode of ulcerative colitis were concerned. However, significantly fewer elderly patients were operated on for their disease compared with younger patients (6.25% vs 22.3%; P = 0.0268). Although some differences in the course of the disease between elderly and younger patients were observed, such as the number of exacerbations and recurrences and the number of patients who developed colorectal cancer, these differences did not reach statistical significance. CONCLUSION: It is concluded that ulcerative colitis in elderly Greek patients runs a rather similar course to that in younger patients. However, some unique characteristics observed in the elderly patients (lower rate of colectomy, absence of patients with colorectal cancer, and increased death rate) could be attributed either to truly different disease behavior in the elderly people or to factors directly related to their advanced age.

Crohn's disease in the elderly: clinical features and long-term outcome of 19 Greek patients.

AIM: To study the clinical course, prognosis, treatment and follow-up of 19 patients with Crohn's disease aged 60 years or over at the time of onset of symptoms. PATIENTS AND METHODS: A series of 12 males and 7 females aged 65 +/- 4. 9 and 66. 6 +/- 6 years at the onset of symptoms and the time of diagnosis, respectively (elderly group), were studied. Another group of patients(83 males, 53 females aged 29.8 +/- 12.4 and 32.2 +/- 12.7 at the onset of symptoms and of diagnosis, respectively) served as a control group (young group). Both groups were followed-up for a mean period of 7.2 and 9.8 years, respectively. RESULTS: The most common site of involvement in the elderly group was the distal ileum (47.4%), followed by large bowel (36.6%) and concurrent large and small bowel involvement (16%). Acute presentation was significantly more common in the older group. Fever and loss of weight were significantly less common in the older group (p<0.05). A higher rate of complications especially acute abdomen, was observed in the elderly group. There were no significant differences in the indication for surgery and type of surgical procedure applied between the two groups. However significantly fewer patients in the elderly group were operated on because of perianal abscess compared to the young group (p<0.05). Follow-up data revealed that elderly patients with Crohn's disease who had been operated upon showed no significant differences in the course of their disease compared to operated young patients. CONCLUSION: Crohn's disease in elderly persons of Greek origin follows much the same pattern as in other developed countries of the world.

Surgery for ulcerative colitis in Greece: clinicoepidemiological features and long-term outcome of 69 consecutive patients.

BACKGROUND/AIMS: In this study, the various clinicoepidemiological characteristics and long-term follow-up of patients operated on for ulcerative colitis in Greece over a period of 15 years, are reviewed. METHODOLOGY: A total number of 69 out of 413 patients with ulcerative colitis (17.8%) seen and followed-up for a mean period of 12 years, had undergone ileorectal anastomosis (45.6%), total proctocolectomy with permanent ileostomy (35.6%), ileal-anal pouch anastomosis (17.6%) and Kock ileostomy (1.5%), mainly for bad response to conservative treatment (78.3%). Other causes for operation were large bowel cancer (8.7%), profound hemorrhage (4.3%), toxic megacolon (1.4%), and rectovaginal fistula (1.4%). Almost half of the operations (45%) were performed between the first and fourth year after the establishment of diagnosis. RESULTS: A number of statistically highly significant differences between the operated and non-operated group of patients were noticed. So, patients operated on had more extensive disease in comparison with non-operated ones and were younger at the time of diagnosis. The overall perioperative morbidity and mortality were 6% and 5% respectively. Survival was not statistically significantly different between operated and non-operated patients and also did not differ significantly between men and women. Most of the deaths in the operated and non-operated group of patients were unrelated to ulcerative colitis. CONCLUSION: It is concluded that the clinicoepidemiological features and outcome of the Greek patients operated on for ulcerative colitis have similarities with those reported from other developed countries of the world.

Cutaneous delayed hypersensitivity in patients with colorectal cancer: application of multi-test.

A prospective study of delayed hypersensitivity was carried out in 63 colorectal cancer (CRC) patients of good nutritional status and 63 healthy controls over a period of 3 years. Delayed hypersensitivity was assessed by application of Multi-test which involves synchronous multiple puncture testing with seven antigens. Subjects were classified in three groups: Immunocompetent, Relatively anergic and Anergic. Logistic regression analysis was applied. The patients had lower mean scores for skin reactions to all tested antigens with the widest differences observed for Trichophyton. The average number of positive reactions was lower for patients than controls; there were no anergic subjects among the controls and the differences between patients and controls were statistically significant. Patients with early disease (Dukes' A and B), had lower scores for all seven antigen reactions than controls, but higher than those with advanced disease. Differences between early stage cases and controls were not statistically significant for any antigen, nor for the total number of positive reactions or the total score. In the late stages of their disease patients with CRC and without malnutrition, or any other kind of acquired immunodeficiency, have impaired cellular immunity in comparison with normal controls.