Does living in crowded houses offer protection against the development of inflammatory bowel disease?

INTRODUCTION: The credibility of the "Hygiene hypothesis" in patients with inflammatory bowel disease has been assessed. OBJECTIVE: This survey is aimed at finding an answer for the question: "Does living in crowded or overcrowded houses protect against the development of inflammatory bowel disease?" PATIENTS AND METHODS: Asian immigrants to the United Kingdom who attended inflammatory bowel diseases' clinics during the period of the study and who fulfilled Leonard-Jones criteria were asked to complete a questionnaire. The participants were asked to respond to questions on age, sex, their birth rank, diagnosis, & number of brothers, sisters, sons and daughters. RESULTS: 60% of the participants had four or more brothers and sisters. Forty per cent of the participants grew in crowded houses (occupied the fourth birth rank). CONCLUSIONS: Our presented data do not support any role of the number of house inhabitants in the development of inflammatory bowel disease.

Mechanism of non-specific-fistula-in-ano: Hormonal aspects-Review.

Abscesses could occur anywhere, but quite few that could proceed forward and develop fistulae. Crypto glandular abscess formation concept has been forming the basis for almost all designed strategies for management of cases of idiopathic fistula-in-ano for ages. Yet, this hypothesis failed to explain the reason(s) for the recorded lower incidences of idiopathic anal fistula in females than in males. Gram negative bacteria are largely the causative agents for these anal glands' abscesses that processed further and developed fistulae. Lipopolysaccharide component (LPS) of the bacterial cell wall could significantly attenuate the expression of mRNA of the oestrogen receptors and accordingly reduces the down signalling pathway. Yet, this kind of action could be inhibited in the presence of oestrogen. In addition, tumour necrosis factor-alpha (TNFα) is a key proinflammatory cytokine that induces the secretion of other cytokines and enzymes in various cells and tissues. And LPS could activate pro-inflammatory cytokine by activating plasma membrane proteins (e.g. the toll like receptor 4 [TLR4] and CD14 that leads to the production of TNFα and other pro-inflammatory cytokines). This activation could be enhanced by testosterone but inhibited by oestrogen. These are likely the reasons for the higher prevalence of idiopathic fistula-in-ano in males than in females.

High carbohydrates consumption and inflammatory bowel diseases.

High consumption of potatoes, soft drinks, cornflakes, chocolates, mushrooms and other common examples of complex carbohydrates in the western side of the globe is significant. Similarly, Inflammatory Bowel Diseases (IBD) (Crohn's disease and ulcerative colitis) are also prevalent in these regions. Evidence exists to support that factors, such as lack of zinc (it is common in patients with IBD, in particular Crohn's patients) may significantly affect the activity of some enzymes, such as, disaccharidases and other digesting enzymes of carbohydrates and that would lead to the recruitment of incompletely digested carbohydrates to the terminal ileum and continual stimulation of the immune-response accordingly. This concept may explain the observation of the existence of higher significant percentage of severe disease in Caucasian patients with IBD comparable with the respected Asian patients who consume less.

Implications of abnormal pathology in fulminating colitis on the outcome of surgery.

BACKGROUND: The severe relapse of the diseases in patients with Crohn's disease or ulcerative colitis is associated with high morbidity and mortality. Early prediction for the failure of aggressive medical treatment and consequently, early surgical interference in cases with severe colitis and severe Crohn's colitis are supposed to be effective means for reducing these high rates. METHODS: Patients who presented at the Accident & Emergency Department with severe colitis and severe Crohn's colitis and on whom emergency colectomy was operated were identified and they formed the basis of this study. RESULTS: Patients (n=34) with acute fulminating colitis and their condition required emergency colectomy were seen over a period of 5 years. A strategy of early detection of cases of toxic dilatation and/or perforation proved efficient in reducing morbidity and mortality in cases of severe colitis. The mortality in the presented series was zero and the morbidity occurred mainly in such cases that presented with fulminant distal colitis, which was complicated by proximal faecal loading. CONCLUSION: Diagnosis of proximal faecal loading in cases with fulminant colitis is likely to be an indication for surgery. Further studies are required for confirming this conclusion.

Colorectal cancer and pollution.

The incidence of colorectal carcinoma is increasing in young patients, in contrast to the well established wisdom that it is exclusively diagnosed in patients older than 40 years. In this survey, we examined all possible risk factors, and we recommend a number of measures for early detection in young patients who are at risk of developing this malignant tumor.

Smoking and inflammatory bowel diseases: what in smoking alters the course?

Epidemiological studies provide strong evidence to confirm the correlation between cigarette smoking and inflammatory bowel diseases. This relationship is proved to be positive in Crohn's disease and negative in ulcerative colitis. What in smoking alters the course of inflammatory bowel diseases is still a mystery. Different smoking parts have different and may be opponent actions. Smoking has dual effects. Some of its activities are, sometimes, constructive as they are working in an antagonistic manner to the mechanism of the disease, such as reducing rectal blood flow and accordingly less recruitments of inflammatory mediators to the area of inflammation, enhancement of mucosal production, and consequently, strengthening the membranes, and inhibition of pro-inflammatory mediators' liberation and activity in subjects with ulcerative colitis. Yet the outcome of smoking actions may be affected by the existence of other cofactors. Odd factors, such as shortage of zinc in subjects with Crohn's disease, may facilitate liberation of pro-inflammatory mediators and their activities and accordingly exacerbates symptoms.

Is the DHEAS/cortisol ratio a potential filter for non-operable constipated cases?

Constipation is a significant manifestation of a number of psychological disorders. Published papers recommend using self-assessment questionnaires for discriminating psychological from non-psychological constipated patients before operating on them but reports from major surveys revealed that general practitioners failed to diagnose 70% of depressed patients using self-assessment questionnaires. Lower circulating concentrations of progesterone, 17-hydroxyprogesterone, cortisol, testosterone, androstenedione, and dehydroepiandrostenedione sulfate (DHEAS) during the follicular phase in constipated young women compared with respective controls were found during the follicular phase of the menstrual cycles. During the luteal phase of the cycle, reductions were identified in estriol, cortisol and testosterone in the constipated group. Likewise, circulating concentrations of DHEAS were found to be lower in depressed patients than comparable healthy controls. DHEAS/cortisol ratios in morning serum and salivary samples were lower than those retrieved during other times of the day in depressed patients. The idea of recognizing major depression in constipated patients by measuring DHEAS/cortisol ratios in saliva and serum may be plausible but this possibility needs to be confirmed in well-designed studies.

Oestrogens and Crohn's disease: the missed link.

Observational studies, sometimes, can not provide us with clear answers for very important questions. The answer for a question on whether sex hormones in general, and oestrogen in particular, play some role in inducing and development of Crohn's disease is uncertain. Study design, inclusion criteria, and different formulations of oral contraceptives may partly explain the conflict results of the published reports. But these may be due to the divergent effects of oestrogen, which are based on dose, tissue specificity and cellular environment. This paper is aimed at examining the influence of androgens on the prognosis of Crohn's disease.

Peginterferon {alpha}-2b and ribavirin therapy in chronic hepatitis C genotype 4: impact of treatment duration and viral kinetics on sustained virological response.

BACKGROUND: The response rates and duration of peginterferon alpha (PEG-IFN-alpha) and ribavirin combination therapy in chronic hepatitis C genotype 4, the prevalent genotype in the Middle East and Africa, are poorly documented. AIMS: To compare the efficacy and safety of 24, 36, or 48 weeks of PEG-IFN-alpha-2b and ribavirin therapy in chronic hepatitis C genotype 4. METHODS: In this prospective, randomised, double blind study, 287 patients with chronic hepatitis C genotype 4 were randomly assigned to PEG-IFN-alpha-2b (1.5 mug/kg) once weekly plus daily ribavirin (1000-1200 mg) for 24 weeks (group A, n = 95), 36 weeks (group B, n = 96), or 48 weeks (group C, n = 96) and followed for 48 weeks after completion of treatment. Early viral kinetics and histopathological evaluation of pre- and post treatment liver biopsies were performed. The primary end point was viral clearance 48 weeks after completion of treatment. RESULTS: Sustained virological response was achieved in 29%, 66%, and 69% of patients treated with PEG-IFN-alpha-2b and ribavirin for 24, 36, and 48 weeks, respectively, by intention to treat analysis. No statistically significant difference in sustained virological response rates was detected between 36 and 48 weeks of therapy (p = 0.3). Subjects with sustained virological response showed greater antiviral efficacy (epsilon) and rapid viral load decline from baseline to treatment week 4 compared with non-responders and improvement in liver histology. The incidence of adverse events was higher in the group treated for 48 weeks. CONCLUSION: PEG-IFN-alpha-2b and ribavirin for 36 or 48 weeks was more effective in the treatment of chronic hepatitis C genotype 4 than treatment for 24 weeks. Thirty six week therapy was well tolerated and produced sustained virological and histological response rates similar to the 48 week regimen.

Impact of cigarette smoking on response to interferon therapy in chronic hepatitis C Egyptian patients.

AIM: Smoking may affect adversely the response rate to interferon-alpha. Our objective was to verify this issue among chronic hepatitis C patients. METHODS: Over the year 1998, 138 chronic hepatitis C male Egyptian patients presenting to Cairo Liver Center, were divided on the basis of smoking habit into: group I which comprised 38 smoker patients (>30 cigarettes/d) and group II which included 84 non-smoker patients. Irregular and mild smokers (16 patients) were excluded. Non eligible patients for interferon-alpha therapy were excluded from the study and comprised 3/38 (normal ALT) in group I and 22/84 in group II (normal ALT, advanced cirrhosis and thrombocytopenia). Group I was randomly allocated into 2 sub-groups: group Ia comprised 18 patients who were subjected to therapeutic phlebotomy while sub-group Ib consisted of 17 patients who had no phlebotomy. In sub-group Ia, 3 patients with normal ALT after repeated phlebotomies were excluded from the study. Interferon-alpha 2b 3 MU/TIW was given for 6 mo to 15 patients in group Ia, 17 patients in group Ib and 62 patients in group II. Biochemical, virological end-of- treatment and sustained responses were evaluated. RESULTS: At the end of interferon-alpha treatment, ALT was normalized in 3/15 patients (20%) in group Ia and 2/17 patients (11.8%) in group Ib compared to 17/62 patients (27.4%) in group II (P = 0.1). Whereas 2/15 patients (13.3%) in group Ia. and 2/17 patients (11.8%) in group Ib lost viraemia compared to 13/62 patients (26%) in group II (P = 0.3). Six months later, ALT was persistently normal in 2/15 patients (13.3%) in group 1a and 1/17 patients (5.9%) in group Ib compared to 9/62 patients (14.5%) in group II (P = 0.47). Viraemia was eliminated in 1/15 patients (6.7%) in group Ia and 1/17 patients (5.9%) in group Ib compared to 7/62 patients (11.3%) in group II, but the results did not mount to statistical significance (P = 0.4). CONCLUSION: Smokers suffering from chronic hepatitis C tend to have a lower response rate to interferon-alpha compared to non-smokers. Therapeutic phlebotomy improves the response rate to interferon-alpha therapy among this group.

Reasons for creation of permanent ileostomy for the management of idiopathic chronic constipation.

The aim of the present study was to examine the reasons for initiation of end ileostomy for management of intractable constipation over the last 35 years. A total of 62 patients with intractable constipation, on whom an end ileostomy was created during the period from 1966 to 2001, were recorded. The incidence of initiating a terminal ileostomy as a further surgical intervention to the total number of managed patients in examined studies varied from 2 to 25%. Preoperative unevaluated anal and rectal abnormalities formed the highest proportion compared with other reasons (65%, 40/62). A better understanding of the functional colonic and anorectal abnormalities may facilitate changes in surgical therapy.

Zinc deficiency in men with Crohn's disease may contribute to poor sperm function and male infertility.

In Great Britain, married couples were reported to have between 1.9 and 2.1 children, while men with Crohn's disease had a mean of 1.2 and of 0.4 children before and after diagnosis, respectively. The role of zinc for male fertility is essential. Although lack of zinc in Crohn's disease is well established in up to 70% of patients, a possible relation between zinc deficiency and male subfertility in Crohn's disease remains unclear. This study is aimed at examining a possible link between zinc deficiency in men with Crohn's disease and male subfertility in this group of patients.

Bile duct carcinoma in Egypt: possible etiological factors.

Contrary to an old belief, bile duct carcinoma is not a rare disorder in Egypt. Among 730 patients referred for an ERCP examination, twenty-nine consecutive patients were diagnosed as having bile duct carcinoma. The cause of this type of carcinoma remains unknown. In the present study, only seven of the 29 (24.1%) with bile duct carcinoma patients had associated gallstones. In order to investigate the possible association between typhoid carrier state and bile duct carcinoma, stool cultures were performed for Salmonella typhi and Salmonella paratyphi A and B. Nine out of 23 patients (39.1%) with bile duct carcinoma, 17 out of 50 (34%) with calcular obstructive jaundice, and 1 out of 50 (2%) healthy individuals proved to be salmonella carriers. Statistical analysis of the results confirmed the presence of a significant association between chronic fecal thyphoid carrier state and bile duct carcinoma, while that between calcular obstructive jaundice and bile duct carcinoma was not significant. In conclusion, there might be an association between chronic fecal typhoid carrier state and bile duct carcinoma.