Antioxidative potential of a combined therapy of anti TNFα and Zn acetate in experimental colitis.

AIM: To evaluate whether combination therapy with anti-tumour necrosis factor α (TNFα) antibody and Zn acetate is beneficial in dextran sodium sulphate (DSS) colitis. METHODS: Colitis was induced in CD1-Swiss mice with 5% DSS for 7 d. The experimental mice were then randomised into the following subgroups: standard diet + DSS treated (induced colitis group); standard diet + DSS + subcutaneous 25 µg anti-TNFα treated group; Zn acetate treated group + DSS + subcutaneous 25 µg anti-TNFα; standard diet + DSS + subcutaneous 6.25 µg anti-TNFα treated group and Zn acetate treated group + DSS + subcutaneous 6.25 µg anti-TNFα. Each group of mice was matched with a similar group of sham control animals. Macroscopic and histological features were scored blindly. Homogenates of the colonic mucosa were assessed for myeloperoxidase activity as a biochemical marker of inflammation and DNA adducts (8OH-dG) as a measure of oxidative damage. RESULTS: DSS produced submucosal erosions, ulcers, inflammatory cell infiltration and cryptic abscesses which were reduced in both groups of mice receiving either anti-TNFα alone or combined with zinc. The effect was more pronounced in the latter group (vs Zn diet, P < 0.02). Myeloperoxidase activity (vs controls, P < 0.02) and DNA adducts, greatly elevated in the DSS fed colitis group (vs controls, P < 0.05), were significantly reduced in the treated groups, with a more remarkable effect in the group receiving combined therapy (vs standard diet, P < 0.04). CONCLUSION: DSS induces colonic inflammation which is modulated by the administration of anti-TNFα. Combining anti-TNFα with Zn acetate offers marginal benefit in colitis severity.

Rectal administration of Lactobacillus casei DG modifies flora composition and Toll-like receptor expression in colonic mucosa of patients with mild ulcerative colitis.

BACKGROUND: An imbalance in gut microbiota seems to contribute to the development of chronic inflammatory disorders of the gastrointestinal tract, such as ulcerative colitis (UC). Although it has been suggested that probiotic supplementation is an effective approach to colitis, its effects on intestinal flora and on mucosal cytokine balance have never been explored. AIM: To evaluate the effect of Lactobacillus casei (L. casei) DG, a probiotic strain, on colonic-associated microbiota, mucosal cytokine balance, and toll-like receptor (TLR) expression. METHODS: Twenty-six patients with mild left-sided UC were randomly allocated to one of three groups for an 8-week treatment period: the first group of 7 patients received oral 5-aminosalicylic acid (5-ASA) alone, the second group of 8 patients received oral 5-ASA plus oral L. casei DG, and the third group of 11 patients received oral 5-ASA and rectal L. casei DG. Biopsies were collected from the sigmoid region to culture mucosal-associated microbes and to assess cytokine and TLR messenger RNA (mRNA) levels by quantitative real-time polymerase chain reaction (RT-PCR). RESULTS: 5-ASA alone or together with oral L. casei DG failed to affect colonic flora and TLR expression in a significant manner, but when coupled with rectally administered L. casei DG, it modified colonic microbiota by increasing Lactobacillus spp. and reducing Enterobacteriaceae. It also significantly reduced TLR-4 and interleukin (IL)-1ß mRNA levels and significantly increased mucosal IL-10. CONCLUSIONS: Manipulation of mucosal microbiota by L. casei DG and its effects on the mucosal immune system seem to be required to mediate the beneficial activities of probiotics in UC patients.

TGF-beta1 and IGF-1 production and recurrence of Crohn's disease after ileo-colonic resection.

BACKGROUND: Recurrence after surgery is a major problem in the treatment of Crohn's disease (CD). Alteration of healing processes may play a role in this phenomenon. Transforming growth factor beta (TGF-beta) and insulin-like growth factor (IGF-1) have pro-fibrogenic properties and are involved in wound-healing mechanisms. The aim of this study was to assess their role in the CD recurrence after ileo-colonic resection. PATIENTS AND METHODS: Twenty patients with CD, who underwent ileo-colonic resection in the period between 1999 and 2005, were enrolled in this study. Tissue samples were obtained from macroscopically diseased and healthy ileum. The TGF-beta1 and IGF-1 mRNAs were quantified by real-time polymerase chain reaction using glyceraldehyde 3-phosphate dehydrogenase as the housekeeping gene. Histological severity of the disease was assessed to quantify the ileal inflammation. Patients' follow-up was investigated. Comparisons and correlations were carried out with nonparametric tests and survival analysis was performed. RESULTS: Histological inflammation was moderately severe in the diseased bowel, while it was absent in healthy segments (P < 0.01). TGF-beta1 production in healthy bowels showed a direct correlation with clinical CD recurrence (tau = 0.43, P = 0.04) and survival analysis showed that patients who expressed high TGF-beta1 mRNA transcripts in healthy intestines had higher cumulative recurrence rates than those who expressed low TGF-beta1 mRNA levels (P = 0.02). CONCLUSION: Our study suggests that the high levels of TGF-beta1 in healthy bowels of patients who undergo ileo-colonic resection for CD are associated with early clinical disease recurrence, while there seems to be no association between IGF-1 and CD recurrence.

Diagnosis and management of Wilson's disease: results of a single center experience.

AIMS: To report on the diagnostic features, management, and clinical outcome after different treatments of Wilson's disease patients followed over a mean period of 15 years. PATIENTS: Thirty-five patients with Wilson's disease referred to the University of Padova's Department of Gastroenterology for diagnosis or treatment were observed for a mean 15 years. The diagnosis was based on clinical symptoms, laboratory tests (ceruloplasmin, urinary, and hepatic copper concentrations), and uptake of the radiostable isotope Cu into the plasma protein pool. Hepatic Cu content was measured by regular follow-up biopsies. Neurologic outcome after therapy was assessed using a newly developed scoring system. RESULTS: Twenty-three (65.7%) patients presented with liver disease; 12 (34.3%) had mixed neurologic and hepatic involvement. All patients had been initially treated with either penicillamine (23) or zinc sulfate (12). The neurologic symptoms became worse or remained stationary in 75% of those treated with penicillamine, whereas zinc treatment improved these symptoms in 90% of treated cases. Both treatments were effective in improving the hepatic symptoms. No differences in hepatic Cu content emerged between follow-up biopsies in either treatment group. Six patients (26%) had to abandon the penicillamine treatment due to side effects. In all, 4 patients underwent liver transplantation, which was successful in 3, with a mean survival after transplantation of 4.6 years; the fourth, who had a severe neurologic impairment, died of central pontine myelinolysis. CONCLUSIONS: Penicillamine and zinc can effectively treat Wilson's disease, though the side effects of penicillamine may be severe enough to prompt its suspension. Liver transplantation remains the treatment of choice for end-stage liver disease.

Urologic complications in Crohn's disease: suspicion criteria.

BACKGROUND/AIMS: Genitourinary complications occur in 4 to 35% of Crohn's disease patients. The aim of this study was to assess the threshold to suspect urologic involvement in Crohn's disease in order to plan the correct surgical management. METHODOLOGY: Medical records of 258 consecutive patients who have undergone bowel resection for Crohn's disease were reviewed. We evaluated recurrent urinary tract infections, fever, dysuria, pneumaturia, fecaluria, abdominal mass at palpation or lower back pain at percussion, abdominal ultrasound and computerized tomography scan reports. Univariate analysis and multivariate analysis were performed with Fisher exact and log-linear tests respectively. RESULTS: Urologic complications were found in 11 patients (4.3%). Fistulizing disease, female gender and inflammatory mass were significantly increased in Crohn's disease patients with urinary tract involvement (p < 0.01). Ultrasound and computerized tomography scan demonstrated good specificity, sensibility, positive and negative predicting values for urologic complications. CONCLUSIONS: In the presence of abdominal mass in a Crohn's disease patient, the following step should be abdominal ultrasound or computerized tomography scan to rule out involvement of the ureter that should be treated previously to improve the intraoperative picture and patient general status.

Expression of costimulatory molecule CD80 in colonic dysplasia in ulcerative colitis: an immunosurveillance mechanism against colorectal cancer?

BACKGROUND AND AIMS: Ulcerative colitis is an established risk factor for colorectal cancer but dysplasia reports are much more frequent than invasive neoplasm diagnosis. The effective activation of T lymphocytes that provide antitumor surveillance requires the presence of costimulation molecules such as CD80 and CD86 on the surface of antigen-presenting cells. The aim of our study was to verify the presence of an in vivo immunosurveillance mechanism in the early stages of colon tumorigenesis. PATIENTS AND METHODS: Expression of CD80, CD86, and IFN-gamma in the colonic mucosa of 21 consecutive ulcerative colitis (UC) patients was quantified using reverse transcription polymerase chain reaction. After a 7-year follow-up period, we reviewed the histology of all surveillance colonoscopy specimens for colonic dysplasia. Correlation, frequency, and survival analyses were performed. RESULTS: CD80 was detectable in seven patients while expression of CD86 and IFN-gamma was evident in all patients. Histology confirmed the presence of dysplasia in eight patients. Patients who had dysplasia showed higher CD80 levels compared to those without dysplasia (p=0.02). Survival analysis demonstrated that cumulative dysplasia rates of CD80-positive patients were significantly higher than those of CD80-negative patients (p=0.04). CONCLUSION: Even if partially limited by a relatively small sample size, our study seems to show an association between CD80 expression and colonic dysplasia in UC patients that may suggest a role for CD80 in the immunosurveillance against colorectal cancer in this early stage of tumorigenesis. On the contrary, CD86 seems to be involved in the inflammatory pathogenesis of UC.

Minimally invasive management of Crohn's disease complicated by ureteral stenosis.

Ureteral involvement due to Crohn's disease occurs in 3% to 6% of cases. Herein, we present a case of a 22-year-old woman with ileocolic Crohn's disease with right hydronephrosis due to compression of the ureter that was resolved with a 3-stage, minimally invasive procedure (preoperative percutaneous nephrostomy, ureteral stent placement, and sequential laparoscopically assisted ileocolectomy). Percutaneous right nephrostomy drainage permitted us to prevent renal damage before surgery, and successive ureteral double-J catheter placement minimized the risk of ureteral damage during the laparoscopic procedure. The safety and feasibility of sequential minimally invasive management of ileocolonic Crohn's disease involving the right ureter was assessed, and a good cosmetic result was achieved.

Role of stapled and hand-sewn anastomoses in recurrence of Crohn's disease.

BACKGROUND/AIMS: Anastomotic recurrence after bowel resection is a major problem in Crohn's disease surgery. The aim of this study is to compare recurrence rate after stapled side-to-side ileo-colonic anastomosis to those after stapled end-to-side or hand-sewn side-to-side anastomosis to distinguish the role of suture technique and anastomotic configuration in the prevention of Crohn's disease recurrence. METHODOLOGY: Eighty-four consecutive patients who had undergone ileo-colonic resection for Crohn's disease were enrolled: 12 of them had stapled side-to-side anastomosis, 36 stapled end-to-side anastomosis and 36 hand-sewn side-to-side anastomosis. We evaluated duration of operation, first bowel movement after operation, postoperative hospital staying, postoperative surgical complications, clinical recurrence and reoperation rate. The statistical analysis was performed using Student's t-test and Fisher exact test. Cumulative recurrence rates were compared using F Cox test and Kaplan-Meier method. RESULTS: No statistically significant difference between the three groups was observed in early postoperative follow up. The stapled side-to-side anastomosis group obtained a better symptom-free survival than the stapled end-to-side group (p=0.04). In the stapled and hand-sewn side-to-side groups reoperation rates were significantly lower than in the stapled end-to-side group (p=0.01 and p=0.05 respectively). CONCLUSIONS: All the three types of anastomosis were demonstrated to be equally safe in early postoperative outcome. A longer follow-up showed a significantly lower incidence of reoperation recurrence in the stapled and hand-sewn side-to-side anastomosis compared to the stapled end-to-side anastomosis group. This result may suggest the configuration of the anastomosis as the key point in the recurrence of anastomotic Crohn's disease.

Health-related quality of life after restorative proctocolectomy for ulcerative colitis: long-term results.

Restorative proctocolectomy (RPC) is the favorite operation for ulcerative colitis, but it may influence health-related quality of life (HRQL). Our aims were to determine the long-term HRQL of patients and its modifications after a 5-year follow-up and to identify any risk factor for a worse outcome. We enrolled 36 patients submitted to RPC (mean follow-up 8.4 +/- 4.7 years), 36 ulcerative colitis (UC) patients, and 36 healthy subjects. We used a previously validated questionnaire that explored bowel symptoms, systemic symptoms, emotional function, and social function. A series of 17 patients had completed the same questionnaire 5 years earlier. Clinical and surgical factors were investigated. Statistical analysis was performed with Student's t-test, Wilcoxon matched-pairs test, and Fisher's exact test. The scores of the RPC patients were significantly better than those of moderate or severe UC patients, similar to those with remission/mild UC, and higher than those of the controls. The scores of patients interviewed 5 years earlier did not change in the present study, except for patients during the first postoperative year, in whom the scores were now significantly better. The analysis of RPC patients in subgroups showed that the use of drugs, high stool frequency, pouchitis, pelvic complications, and younger age at UC diagnosis worsened the HRQL outcome. We concluded that RPC patients, after a long-term follow-up, had an HRQL similar to that of the remission/mild UC patients. Recently operated patients improved their quality of life mainly because of improved emotional function, and patients who had been operated on for a longer time maintained their HRQL. HRQL is influenced by drugs, stool frequency, pouchitis, postoperative pelvic complications, and age at diagnosis.

The role of costimulatory molecules CD80 and CD86 and IFNgamma in the pathogenesis of ulcerative colitis.

Several studies showed that costimulatory signals on antigen presenting cells are up-regulated in inflammatory bowel disease. We quantified the expression of CD80, CD86, and IFNgamma in colonic mucosa of patients affected by ulcerative colitis and correlated it with clinical and biochemical parameters to identify the context of this up regulation. We enrolled 21 patients affected by ulcerative colitis and 6 healthy subjects. We evaluated for each patient gender, age, duration of disease, clinical, endoscopic and histologic disease activity index, medical therapy, ESR, serum CRP, WBC, and serum al-acid glycoprotein. CD80, CD86, and IFNgamma expression in the colonic mucosa was quantified using reverse transcription polymerase chain reaction. Statistical analysis was performed using Mann-Whitney U test and Spearman's rank correlation test. Significance was set at P < 0.05. CD80 was detectable in seven patients, while CD86 and IFNgamma expression was evident in all UC patients. CD80 and CD86 were not detectable in control specimens. Colonic CD80 expression was correlated to the age of the patients. CD86 expression showed an inverse correlation with duration of disease and a direct correlation with serum CRP levels and histologic grade of disease activity. IFNgamma was not correlated with any of the examined parameter. Our study confirms a major role in ulcerative colitis pathogenesis for CD86 which correlates with histologic grade of disease and with serum CRP levels, and its upregulation seems to be higher at the beginning of the disease. In "in vivo" conditions IFNgamma may not be the only factor responsible for CD86 up-regulation in the ulcerative colitis colonic mucosa.

Risk factors for recurrence of stenosis in Crohn's disease.

A major problem in Crohn's disease (CD) surgery is the high frequency of recurrence after bowel resection. Several factors are thought to influence this phenomenon. CD "phenotype" was identified as one of this factors and obstructing CD seems to be a low risk. We analysed the reoperation rate in patients operated for obstructing CD to identify risk factors for postoperative recurrence avoiding any bias due to an high risk phenotype. We reviewed the records of 120 patients treated for stenosing CD and survival analysis was performed using Kaplan-Meier method. Younger age, acute obstruction, emergency conditions, postoperative complications, small bowel disease, ileo-ileal anastomosis and type of suture resulted to be risk factors for CD recurrence.

Diffuse small bowel Crohn's disease treated with side-to-side isoperistaltic strictureplasty: report of two cases and description of a variation of the original technique.

Diffuse small bowel Crohn's disease is unusual and it is characterized by multiple diseased segments involving the jejunum and ileum. The most frequent indication for surgery is an intestinal obstruction, often complicated by a high grade of malnutrition. The natural history of this clinical form is not well defined and the optimal surgical approach remains controversial. We herein present our surgical policy in two cases of diffuse small bowel Crohn's disease, who were particularly at risk of developing short bowel syndrome. We focused our attention on the use of side-to-side isoperistaltic strictureplasty as described by Michelassi for the treatment of stenoses longer than 20 cm. We also propose the application of this technique for the treatment of shorter stenosis cases.

Effect of zinc supplementation on intestinal permeability in experimental colitis.

Increased small-intestine permeability has been documented in experimental colitis in the rat. Zinc supplementation improves mucosal repair in patients with diarrhea, as well as paracellular permeability in malnourished guinea pigs. In this study, we sought to evaluate the effect of zinc supplementation on small-and large-intestine tight junctions in rats with acute colitis. Rats were given zinc at a dosage of 2 or 30 mg/kg body wt or glucose by gavage starting 3 days before colitis was induced through the intrarectal administration of dinitro-benzene-sulfonic acid and for 7 days thereafter. We evaluated small-intestine permeability by the number of tight junctions showing extravasation of lanthanum under electron microscopy. Low-dose zinc affected none of the examined parameters of colitis severity. Rats given high-dose zinc showed colitis of similar macroscopic and biochemical severity. However, zinc-treated rats weighed more than unsupplemented ones. The number of perfused tight-junction complexes was significantly higher in animals with colitis than in controls and in the rats with colitis given high-dose zinc. Zinc may regulate tight-junction permeability, with possible implications for healing processes in inflammatory bowel diseases.

The role of CD40 in ulcerative colitis: histochemical analysis and clinical correlation.

OBJECTIVES: CD40 co-stimulator seems to be implicated in the loss of tolerance against self-antigens in many autoimmune diseases. The evidence suggests that in the pathogenesis of ulcerative colitis there is an activity state against self-antigens of the gut wall and flora. The aim of this study was to analyse the expression of CD40 in ulcerative colitis, comparing it with Crohn's disease and nonspecific inflammation of the colon and to determine whether there is a relationship between its expression and the activity stage of the disease. METHODS: The expression of CD40 in the colonic samples of 51 patients (30 ulcerative colitis, 9 Crohn's disease and 12 nonspecific inflammation) was analysed by immunohistochemistry. Twenty-four patients with ulcerative colitis were scored according to clinical, endoscopic and histological classification. RESULTS: The mean percentage of CD40+ cells per field in the colonic mucosa was: ulcerative colitis 21 +/- 11%, Crohn's disease 24 +/- 9%, nonspecific inflammation 7 +/- 7%. The ulcerative colitis patients were statistically significantly different compared to the patients with nonspecific inflammation (P < 0.005), even when comparing the patients in remission (P < 0.05). The expression in Crohn's disease was similar to that in ulcerative colitis. The expression of CD40 in ulcerative colitis was directly proportional to the state of activity of the disease according to the clinical (P < 0.02), endoscopic (P < 0.01) and histological (P < 0.02) criteria. CONCLUSIONS: The expression of CD40 in the colonic mucosae of patients with ulcerative colitis is significantly increased and is proportional to the state of activity. The results seem to confirm the hypothesis that a loss of tolerance could be involved in the pathogenesis of this disease.