Erythrocyte sedimentation as a measure of Crohn's disease activity: opposite trends in ileitis versus colitis.

To test our hypothesis that the erythrocytic sedimentation rate (ESR) correlates well with clinical activity in inflammatory disease of the colon, but not of the small bowel, we stratified 49 Crohn's disease patients according to their anatomic involvement and then measured the correlations between ESR and clinical activity within each of these anatomical subgroups. For 18 patients with Crohn's disease involving primarily the colon, there was a trend toward a direct correlation between clinical score and ESR (p = 0.15). In the 14 patients with Crohn's disease limited to the colon, this direct correlation was even more pronounced and statistically significant (p less than 0.02). By contrast, an opposite trend was observed for patients with small bowel disease. For the 26 patients with disease involving predominantly the small bowel, as well as for the 22 with disease limited to small bowel, there were statistically significant inverse correlations between clinical score and ESR (p less than 0.04). This difference between the directions of the correlations for Crohn's colitis versus ileitis was statistically significant (p less than 0.05). This study provides further evidence for the importance of analyzing putative indications of disease activity separately for each of the protean forms in which Crohn's disease occurs.

Alterations in serum immunoglobulin G subclasses in patients with ulcerative colitis and Crohn's disease.

We have examined the concentration of immunoglobulin G (IgG) subclass antibodies in the sera of 27 patients with ulcerative colitis and 21 patients with Crohn's disease as well as in 11 normal controls and 11 patients with systemic lupus erythematosus. In comparison with a control mean serum IgG1 concentration of 5173 micrograms/ml, patients with ulcerative colitis exhibited a significantly increased mean serum concentration of 7924 micrograms/ml (p less than 0.05), whereas patients with Crohn's disease had a near normal mean serum IgG1 level of 5898 micrograms/ml. In contrast, control sera had a mean IgG2 level of 2477 micrograms/ml and ulcerative colitis sera had a similar IgG2 level of 2269 micrograms/ml, whereas Crohn's disease sera had a significantly increased mean IgG2 level of 5111 micrograms/ml (p less than 0.05). Patients with systemic lupus erythematosus, like those with ulcerative colitis, had a markedly elevated serum IgG1 level of 15,594 micrograms/ml (p less than 0.001) without a significantly increased IgG2 serum level (3271 micrograms/ml). Neither ulcerative colitis nor Crohn's disease sera exhibited altered levels of IgG3 or IgG4. These data show that alterations in IgG subclass concentrations occur in the sera of patients with active, untreated inflammatory bowel disease, similar to the previously noted changes in the IgG subclasses secreted by lymphocytes from involved inflammatory bowel disease intestinal specimens.

Diazepam versus midazolam (versed) in outpatient colonoscopy: a double-blind randomized study.

Midazolam is a new parenteral benzodiazepine premedication for endoscopy. Consecutive patients were randomized to receive either intravenous midazolam or diazepam as premedication for outpatient total colonoscopy by one endoscopist. Fifty-five patients received diazepam (0.15 mg/kg) and 50 received midazolam (0.07 mg/kg). Both patient and endoscopist were blind to the study drug used. The two groups were similar with respect to age, sex, and indication for colonoscopy. Patients were rated by the endoscopist for degree of cooperation, sedation, and pain during examination. There was significantly more oversedation in the midazolam group than in the diazepam group (p less than 0.05). Immediate procedure recall was less in midazolam patients (p less than 0.005), but on repeat interview the next day there was no difference between the two groups concerning recall of the endoscopy. There was no significant difference between the two groups in the incidence of arm pain. We conclude that in a clinical setting, midazolam does not appear to offer any significant advantage over diazepam, except for cost. Midazolam carries an increased risk of oversedation when it is administered on a milligram per kilogram basis and should instead be titrated individually.

Fulminant herpes simplex hepatitis in a patient with ulcerative colitis.

A 16 year old girl with ulcerative colitis developed hepatitis with a high fever, leukopenia and a marked rise in serum transaminases without jaundice. There were no skin, oral, or genital lesions. Liver biopsy was precluded by abnormalities in coagulation. Postmortem examination of the liver by light and electron microscopy, culture, immunoperoxidase and immunofluorescent staining confirmed the diagnosis of hepatitis due to type 1 herpes simplex virus. Despite the rarity, this viral aetiology should be included in the differential diagnosis of all patients with severe hepatitis. The absence of mucocutaneous lesions should not exclude the diagnosis, especially when other clinical features are compatible.

Evidence for function of Ia molecules on gut epithelial cells in man.

Using freshly isolated Ia+ gut epithelial cells we have been able to demonstrate that these cells can function as accessory cells in an immune response. The cells can act as stimulators in both autologous and allogeneic MLRs. More importantly, these cells are capable of taking up the soluble antigen, tetanus toxoid, processing it, and presenting it to tetanus-primed T cells. These functions appear to relate to the presence of surface Ia in that a hetero-anti-Ia antibody can block these effects. Noteworthy is the finding that the subpopulation of T cells stimulated when epithelial cells are used as accessory cells is the T8+, 9.3-T cell. These cells function as potent antigen-nonspecific suppressor cells in both MLR, T cell antigen responses, and induction of B cell differentiation by PWM. These findings have significant implications in local gut immune responses and may help explain several poorly characterized phenomena of mucosal immunity.