The possibility of resuscitating livers after warm ischemic injury

The onset and course of ulcerative colitis diagnosed in 38 children at or before 10 years of age were reviewed. The mean age at onset was 5.9 years. A family history of inflammatory bowel disease was present in 24% of patients, and 13% had a history of cow milk allergy in infancy. Initially, by radiologic or colonoscopic studies, 71% had total colonic disease, 13% had left-sided colitis, and 6% had proctitis; extensive examination was not performed in 4 patients. Four patients (11%) presented with severe colitis, 14 (37%) with moderate colitis, and 20 (53%) with mild colitis. The most frequent symptoms were abdominal pain (94%), diarrhea (84%), and rectal bleeding (84%). Between 2 and 10 years after diagnosis, 89% of children had total colonic disease and 11% had left-sided disease. All four patients with severe disease at onset responded to medical therapy with one having a colectomy 15 years later with pathology consistent with Crohn's disease. Of those with moderate disease, half had infrequent moderate recurrences and half had intermittent mild disease. One patient had colectomy at 21 years for intractable disease. Of the 20 with mild disease, 16 continued to have intermittent mild recurrences, 1 had chronic mild disease, 2 had moderate recurrent disease, and 1 has remained asymptomatic for 5 years. Psychiatric disturbances requiring therapy were identified in 5 (13%) children. Results are encouraging: after the first 2 years of illness, two thirds of the children have had subsequent mild colitis with infrequent relapses and three quarters consider their life to be of good quality.     

Inflammatory bowel disease in children

Inflammatory bowel disease in children and adults remains the most challenging problem in gastroenterology. There is an increasing body of immunologic and genetic evidence to suggest that Crohn's disease and ulcerative colitis are different diseases, but that once inflammation begins, many common secondary pathways of inflammation are initiated. The major recent conceptual advance is the observation that mice in whom different immunoregulatory pathways are disrupted develop an inflammatory bowel disease. In the case of interleukin-2 knockout mice, the lesion restricted to the colon, is virtually identical to ulcerative colitis in humans, and is initiated by the normal bacterial flora. Yet these mice possess anticolon antibodies, long-considered to be of pathologic significance in ulcerative colitis. These animal models will allow detailed longitudinal studies to be done, and less reliance will need to be placed on cross-sectional studies of chronically inflamed gut from patients.     

Total colectomy with rectal mucosectomy and ileoanal anastomosis for chronic ulcerative colitis in children and young adults

Total colectomy with rectal mucosectomy and ileoanal anastomosis has been utilized as a sphincter-saving operation in young people with chronic ulcerative colitis. From 1977 to 1979, our section of pediatric surgery performed this procedure on 12 children and young adults with chronic ulcerative colitis, with encouraging results. All patients are alive and well, and all have had excellent rectal continence. Follow-up ranges from 7 to 27 months. Eight patients describe an excellent result, two have had a fair result, and two have required a temporary ileostomy. Numerous loose stools have been observed early, but stools become formed by diet and medical management, and early return to school and work has been possible. The number of stools continues to decrease for at least 1 year.     

Measurement of rectal blood flow by laser Doppler flowmetry in inflammatory bowel disease

BACKGROUND/AIMS: Vascular alterations have been suggested as pathogenic factors in inflammatory bowel disease, particularly Crohn's disease. The aim of our study was to assess rectal blood flow in patients with active inflammatory bowel disease involving the rectum. METHODOLOGY: Endoscopic measurement of rectal blood flow was performed by laser Doppler flowmetry in 45 subjects divided into three groups: healthy controls, ulcerative colitis and rectal Crohn's disease. RESULTS: Rectal perfusion was found to be significantly impaired in patients with ulcerative colitis, but not in those with Crohn's colitis. CONCLUSIONS: Our results confirm the role of local ischemia in ulcerative colitis, but do not support the theory that vascular factors play a key role in the pathogenesis of Crohn's disease.     

Effect of chronic nicotine administration on trinitrobenzene sulphonic acid-induced colitis

BACKGROUND: Smoking, probably due to nicotine, has a bivalent effect on inflammatory bowel disease, ameliorating disease activity in ulcerative colitis and with a deleterious effect on Crohn's disease. The effect of nicotine patches in ulcerative colitis is controversial. AIM: To investigate the effect of chronic nicotine use in a rat model of colitis. METHODS: Colitis was induced in Sprague-Dawley rats by rectal administration of 30 mg trinitrobenzene sulphonic acid (TNBS) in 50% ethanol. Nicotine was dissolved in drinking water (2.5, 12.5, 25 and 250 microg/ml), with rats drinking ad libitum. Nicotine administration started 10 days prior to damage induction and had no effect on weight gain or daily food intake of rats. Rats were sacrificed 1 and 5 days after TNBS administration, their colons resected, rinsed, weighed, damage assessed macroscopically (mm2) and microscopically and tissue processed for myeloperoxidase (MPO) and nitric oxide synthase (NOS) activities, leukotriene B4 (LTB4), prostaglandin E2 (PGE2) generation and interleukin-1 (IL-1) serum levels. RESULTS: Nicotine, by itself, caused no damage to the colon. Nicotine had a dose-dependent bivalent effect on colitis, significantly reducing macroscopic damage from 983 +/- 10 mm2 on TNBS alone to 429 +/- 118 mm2 on TNBS plus 12.5 microg/ml of nicotine, and escalating to 1086 +/- 262 mm2 on 250 microg/ml of nicotine. Segmental weight declined significantly (from 2.4 +/- 0.2 to 1.65 +/- 0.20 g/10 cm), on 12.5 microg/ml nicotine, as did MPO activity (from 3.2 +/- 0.4 to 0.7 +/- 0.1 units/g). All these parameters returned to the levels of TNBS alone when the dose of nicotine was increased to 250 microg/ml. Nicotine had no effect on NOS activity, PGE2 generation and serum IL-1 levels, but increased LTB4 generation. CONCLUSIONS: Nicotine has a dose-dependent bivalent effect on TNBS-induced colitis which is not due to reduction in IL-1 serum levels or PGE2 generation, and is not NOS-mediated.     

Gynaecological state of health of 2 654 women in Nurmes 1970-71. A clinical outpatient study

Eighty-one patients who had had colectomy and ileorectal anastomosis for ulcerative colitis or Crohn's disease of the colon from 1 to 13 years previously were interviewed and examined by a surgeon with whom they had had no previous contact. Sixty-four patients (79 per cent) had a satisfactory result. In 12 patients the operation had failed and an ileostomy had been established, and in a further 5 patients the result was considered unsatisfactory. Despite a high incidence of frequent loose stools and minor anorectal complications, most of the patients were satisfied with the result and would not contemplate the alternative of an ileostomy. No patient had developed rectal cancer. Provided that the rectum is examined regularly for pre-malignant or malignant change, colectomy and ileorectal anastomosis offer a satisfactory alternative to proctocolectomy and ileostomy for many patients with ulcerative colitis or Crohn's disease.     

Inflammatory bowel diseases in children]

From an incidence cohort diagnosed during 1962-1987 we identified all patients with onset of IBD before the age of 15 in order to describe the course and to compare course and prognosis with adult onset IBD. The mean incidence of IBD among children below 15 years was 2.2/10(5), 2.0 for ulcerative colitis (UC), and 0.2 for Crohns disease (CD). At diagnosis, UC children had more extensive disease compared to adults (p < 0.05). Abdominal pains were also more frequent. The cumulative colectomy probability was 6% after one year and 29% after 20 years, not different from adults. Regarding disease activity, it was found that 60-70% of UC patients were in remission in the first 10 years of disease, for CD about 50% were in remission. One UC patient developed carcinoma of the sigmoid colon. Time between onset and development of carcinoma was 12 years. For CD no differences in clinical appearance at diagnosis and course between children and adults were found. No deaths occurred among CD patients. Three CD patients were found to have severe growth retardation already at diagnosis. In conclusion, the incidence of IBD is low in childhood. At diagnosis children with UC have more widespread disease than adults. Children with CD do not differ in clinical presentation, course or prognosis compared to adult onset CD. However, growth retardation is a problem among CD patients.     

Growth of prepubertal children with inflammatory bowel disease

BACKGROUND: Growth retardation has been reported in children with chronic inflammatory bowel disease, especially in those with Crohn's disease. Most of these studies concern adolescent patients. METHODS: The growth of 47 prepubertal children (20 boys and 27 girls, mean age at diagnosis 7 years) with inflammatory bowel disease was studied at Tampere University Hospital, Department of Paediatrics. The mean height and height velocity standard deviation scores were calculated at diagnosis and, after that, yearly. The cumulative doses of oral and rectal prednisone per year were calculated. The severity of the disease was scored. The statistical analysis was carried out using the analysis of variance for repeated measurements. RESULTS: During the year preceding the diagnosis, children with inflammatory bowel disease had grown more slowly than their healthy peers. At diagnosis, they were slightly shorter as a group than are healthy children. During treatment and follow-up the mean height velocity of children with inflammatory bowel disease increased (change in the mean height velocity standard deviation scores from -0.84 to +1.08), normalizing the mean heights of these children compared with those of their healthy peers (change in the mean height standard deviation scores from -0.32 to +0.05). In the analysis of covariance, the poorest growth was seen in children with Crohn's disease, scored as severe, and the best growth in children with mild ulcerative colitis. No difference was seen in groups with or without prednisone treatment. CONCLUSIONS: Growth retardation is an important sign of chronic inflammatory bowel disease in prepubertal as well as adolescent children. During treatment, increasing growth velocity brings these children as a group to normal heights for age and sex.     

Incidence of inflammatory bowel diseases in the department of Puy-de-D?me in 1993 and 1994. EPIMICI. Epidémiologie des Maladies Inflammatoires Cryptogenetiques de l'Intestin group

The aim of this prospective epidemiological study was to investigate the incidence of Inflammatory Bowel Disease in the Puy-de-D?me county using the same methodology as EPIMAD's registry. METHODS: From 01/01/93 to 31/12/94, each gastroenterologist (n = 22) collected patients consulting for the first time with clinical symptoms compatible with inflammatory bowel disease. Data were reported on a questionnaire by an interviewer practitioner. The final diagnosis of Crohn's disease and ulcerative colitis was made in a blind manner by two expert gastroenterologists and recorded according to the Calkin's criteria as definite, probable, or possible diagnosis, or unclassifiable chronic colitis or acute colitis. RESULTS: 167 new cases were identified: 112 (67.1%) inflammatory bowel disease for the combined group of definite and probable cases with 79 Crohn's disease (70.5%), 29 ulcerative colitis (25.9%) of which 11 ulcerative proctitis (37.9%), 4 unclassifiable chronic colitis (3.6%) and 55 acute colitis (32.9%). The crude and age-adjusted incidence (per 10(5)/year) was respectively 6.6 and 5.7 for Crohn's disease and 2.4 and 1.9 for ulcerative colitis. The highest age-specific incidence rate for Crohn's disease was between 40-49 years (14.1) and for ulcerative colitis between 80-89 years (6.8). The female/male ratio was 0.8 for Crohn's disease and 1.1 for ulcerative colitis. The median age at the time of diagnosis was 42.6 years for Crohn's disease and 35.3 years for ulcerative colitis. CONCLUSIONS: These preliminary findings revealed a high incidence of Crohn's disease and low of ulcerative colitis in this county. However, these results must be managed carefully because these data were recorded only on two years and the inflammatory bowel disease classified possible and acute colitis require a follow-up.     

A cost-effectiveness analysis of transurethral resection of the prostate and transurethral microwave thermotherapy for treatment of benign prostatic hyperplasia: two-year follow-up

The clinical course and prognosis of ulcerative colitis was studied in a group of 413 Greek patients. The study lasted for 16 years and follow-up was achieved in 95% of the patients. Both sexes were almost equally affected, mainly between the ages of 40-49. Most of the patients lived in cities and had high educational levels. Familial clustering for inflammatory bowel disease was found in 2.7% of the patients. In most of them the disease was confined to the rectosigmoid area or left bowel and was of mild to moderate severity. The disease course included exacerbations--mainly of mild to moderate severity--and remissions. Mortality was absent during first attack, and it was generally low at the completion of the study. Excluding deaths caused by colorectal cancer, most of the deaths were unrelated to the ulcerative colitis itself. Unusual combinations of ulcerative colitis with other diseases, including diseases of autoimmune origin, were noted. There were no differences between men and women in the various clinicoepidemiologic parameters or in the course of the disease. Surgery was performed in 16.7% of patients, whereas surgery at first attack was required in 0.5%. In comparison with the nonoperated group, patients who were operated on were significantly younger at the time of onset of symptoms and had significantly more extensive disease. Factors prognostic of severe attacks and colectomy were extensive disease, young age at onset, and severe recurrences. Evolution to cancer was observed in 1.45%, whereas extraintestinal cancers also appeared in 1.5%. At the completion of the follow-up period, 5.8% of the patients were dead, 16% had only one attack, 2.7% experienced continuous symptoms, whereas in 58.8% of them, the disease course included exacerbations and remissions. On the basis of the outcome of severe attacks and the more favorable short-term prognosis, it could be argued that ulcerative colitis in Greece runs a milder course compared with that of other developed countries in Western Europe and North America.     

A double-blind comparison of oral versus rectal mesalamine versus combination therapy in the treatment of distal ulcerative colitis

OBJECTIVES: The aim of this study was to compare the efficacy of mesalamine rectal suspension enema (Rowasa) alone, oral mesalamine tablets (Asacol) alone, and the combination of mesalamine enema and mesalamine tablets in patients with active mild-to-moderate distal ulcerative colitis. METHODS: Sixty outpatients with ulcerative colitis at least 5 cm above the anal verge and not more than 50 cm, inclusive, and a total disease activity index (DAI) score between 4 and 10, inclusive, were randomized to either mesalamine rectal enema (n = 18) once nightly, oral mesalamine 2.4 g/day (n = 22), or a combination of both treatments (n = 20). Placebo capsules and enemas were used to maintain a blind procedure. Total DAI scores and abbreviated DAI scores were evaluated at wk 3 and 6, and wk 1 and 2, respectively. Patients recorded the amount of blood in stools, urgency, straining at stools, and abdominal pain in daily diaries. Physicians and patients rated overall improvement at each visit. RESULTS: At wk 6, combination therapy produced a greater improvement (-5.2) in total DAI scores than did either mesalamine enema (-4.4) or mesalamine tablet (-3.9) therapy alone; similar treatment differences were observed at wk 3. Compared with patients given mesalamine enemas or mesalamine tablets, combination-therapy patients reported an absence of blood in stools significantly sooner and, at all visits, the combination therapy group had the highest percentage of patients who reported no blood in their stools. Physicians' and patients' ratings of improvement indicated that combination therapy significantly improved disease status, compared with mesalamine tablet therapy alone. All treatments were well tolerated. CONCLUSIONS: The combination of oral and rectal mesalamine therapy was well tolerated and produced earlier and more complete relief of rectal bleeding than oral or rectal therapy alone.     

Use of technetium-tagged white blood cells in patients with Crohn's disease and ulcerative colitis: is differential diagnosis possible?

BACKGROUND: Studies have suggested that scans with technetium-tagged white blood cells (WBC-Tc99m) may be equal to endoscopy in the assessment of extent and activity of inflammatory bowel disease (IBD). OBJECTIVE: We have retrospectively examined the accuracy of WBC-Tc99m scans in differentiating continuous from discontinuous colitis in pediatric IBD. MATERIALS AND METHODS: There were 207 children in the study (96 boys, 111 girls, median age 13 years). This included 29 controls - children with no gastrointestinal disease (NL) who underwent WBC-Tc99m scans for other medical problems. Scans were obtained at 30 minutes and 2-4 hours following injection. Scans were interpreted as showing continuous colitis, discontinuous colitis, or no colitis. RESULTS: In the 77 children with active Crohn's disease (CD) of the colon, the scans revealed discontinuous uptake in 63 children and continuous uptake in 14. In the 29 children with ulcerative colitis (UC), 23 scans showed continuous uptake and 6 revealed discontinuous uptake. Two of these 6 showed focal activity near the appendix, and subclinical appendicitis could not be excluded. Another child was bleeding and the scan could have been misinterpreted as showing small- bowel inflammation. In the last three patients, skip areas were clearly identifiable. In none of these last three patients were the biopsies typical of CD (i. e., no granuloma was identified) nor was inflammation patchy. In summary, of the 106 scans showing inflammation, 6 were classified into the wrong group. CONCLUSION: These data show that WBC-Tc99m scanning can be useful in distinguishing discontinuous from continuous colitis.     

Per anal suturing of a bleeding ulcer to achieve successful hemostasis of massive hemorrhage associated with ulcerative colitis: report of two cases

We report herein the cases of two patients with ulcerative colitis complicated by massive hemorrhage who were successfully treated by per anal suturing of a bleeding ulcer. A 40-year-old woman and a 22-year-old man had suffered from extensive colitis for 8 and 2 years, respectively, and both followed a similar clinical course. They were admitted under emergency conditions and, despite treatment with intravenous high-dose prednisolone and thereafter with intraarterial injections of prednisolone, suffered several attacks of massive hemorrhage with hypovolemic shock. Emergency subtotal colectomy with ileostomy and rectal mucous fistula were performed, but recurrent massive hemorrhage occurred during the early postoperative period. Bleeding from a discrete ulcer in the rectum was subsequently located, and both patients underwent per anal suturing of the ulcer. No recurrent bleeding occurred thereafter, and an ileoanal anastomosis was performed several months later. Massive hemorrhage is a rare complication of ulcerative colitis which is most often resolved by subtotal colectomy without proctectomy. Although bleeding associated with ulcerative colitis usually occurs diffusely, these case reports serve to demonstrate that massive bleeding can also result from a discrete ulcer. We advocate that this condition be treated by an endoscopic or local hemostatic procedure.     

Ulcerative colitis: patterns of involvement in colorectal biopsies and changes with time

Chronic inflammation, both endoscopic and histologic, in a contiguous and symmetric distribution is said to be important in distinguishing ulcerative colitis (UC) from Crohn's disease. Little is known whether this rule holds during the course of the disease and whether endoscopic/histologic correlation persists. In this study, we analyzed histologic patterns of UC in sequential sets of biopsy specimens to assess whether endoscopic and histologic findings correlate with time and treatment and to see whether distribution changes. Two hundred seventeen sets of colorectal biopsy specimens from 797 sites from 41 patients with clinical UC were studied and correlated with endoscopic findings. Each biopsy specimen was classified as definite or suspicious for chronic colitis or normal. Two histologic patterns of disease were identified: (1) diffuse, when all areas in all pieces from a biopsy segment had clear-cut colitis and (2) nondiffuse, when not all pieces were involved or single pieces had disease and normal mucosa both. Of 41 patients, the maximal extent of histologic disease was pancolitis in 30; 25 had less extensive disease at some point in the course. The maximal extent was left-sided in eight patients, seven of whom had less extent at some point. Of the three patients in whom the maximal extent was proctosigmoiditis, in one the inflammation disappeared. Seventy percent of the biopsy sites had diffuse patterns and 30% had nondiffuse. Histologic and endoscopic disease reverted to normal in 22 and 24 of 41 patients, respectively. Endoscopic and histologic findings were similar in 65% of the biopsy sites. Our results indicate that in long-standing UC (1) histologic disease may revert to normal mucosa, (2) because endoscopy alone may be insufficient to identify the mucosa as normal, biopsies should also be performed on the endoscopically normal mucosa, (3) the full extent of UC often is not established by a single set of biopsies, and (4) nondiffuse chronic inflammation and rectal sparing occurs in UC and are not necessarily markers of Crohn's disease.     

Neutrophil signaling alteration: an adverse inflammatory response after burn shock

BACKGROUND: Perinuclear antineutrophil cytoplasmic antibodies occur frequently in adult patients with chronic pouchitis after colectomy and ileal pouch-anal anastomosis for ulcerative colitis. The purpose of the study was to determine the prevalence of perinuclear antineutrophil cytoplasmic antibodies and cytoplasmic antineutrophil cytoplasmic antibody in children and adolescents who undergo colectomy and ileal pouch-anal anastomosis for ulcerative colitis and familial adenomatous polyposis. METHODS: Five groups of children and adolescents (age, <20 years) were studied, with the following histories: acute pouchitis and history of ulcerative colitis; chronic pouchitis and history of ulcerative colitis; pouchitis with Crohn's disease features and a history of ulcerative colitis; no pouchitis and a history of ulcerative colitis; and familial adenomatous polyposis, with or without pouchitis. Antineutrophil cytoplasmic antibody levels and titers were detected in postoperative sera by enzyme-linked immunosorbent assay, and positive results were subtyped by indirect immunofluorescence. RESULTS: The frequency of perinuclear antineutrophil cytoplasmic antibodies and cytoplasmic antineutrophil cytoplasmic antibody in patients with a history of ulcerative colitis were 67% and 15%, compared with a 0% presence in patients with familial adenomatous polyposis (p < 0.001). There was no significant correlation between the frequency of perinuclear antineutrophil cytoplasmic antibodies and ulcerative colitis patient subgroups (patients with and without pouchitis, 66% and 75%). Similarly, there was no significant correlation between the frequency of cytoplasmic antineutrophil cytoplasmic antibodies among ulcerative colitis patient subgroups (patients with and without pouchitis, 19% and 8%). The frequency of cytoplasmic antineutrophil cytoplasmic antibody in patients with Crohn's disease features (50%), was increased, but this difference was not significant. CONCLUSIONS: There is a high frequency of perinuclear antineutrophil cytoplasmic antibodies in children and adolescents who undergo ileal pouch-anal anastomosis for ulcerative colitis, whether or not they have pouchitis. The frequency of cytoplasmic antineutrophil cytoplasmic antibody is lower in this patient population. Additional studies will be required to determine whether the presence of cytoplasmic antineutrophil cytoplasmic antibody is associated with the postoperative development of features of Crohn's disease.     

Crypt hyperplasia related to increased lymphocyte activation in the rectal mucosa of children with ulcerative colitis

The presence of cells positive for interleukin-2 receptors (CD25) and the proportion of Ki-67 positive dividing cells in the crypts were studied with monoclonal antibodies using sensitive immunohistochemical techniques in the rectal biopsy specimens taken from 13 children with inflammatory bowel disease (4 Crohn's disease and 9 ulcerative colitis) and 10 controls. In all specimens, but one, from patients CD25+ cells were found in the surface and crypt epithelium, while in none of controls were seen such cells. The mean percentage of dividing crypt cells was significantly higher in ulcerative colitis (36.0%) and in Crohn's disease (34.6%) than in controls (18.4) (p < 0.001 in both comparisons). In ulcerative colitis, a correlation between CD25/CD3 ratios in the surface and crypt epithelium and the percentage of dividing crypt cells was found. We conclude that activated lymphocytes have a role in the crypt hyperplasia of ulcerative colitis.     

Assessment of dysplasia, mucosal mucins, p53 protein expression, and DNA content in ulcerative colitis patients with colectomy and ileorectal anastomosis

BACKGROUND: Patients with ileorectal anastomosis after colectomy for ulcerative colitis remain at risk of developing rectal malignancy. Detection of mucosal dysplasia has been used for regular screening but is difficult in inflammatory mucosa, prompting the search for complementary markers. METHODS: This prospective study aimed to assess the prevalence of dysplasia, the predominance of sialomucin, DNA aneuploidy, and p53 overexpression as possible predictors of colorectal tumourigenesis, in the rectal mucosa of an unselected group of 27 patients with ileorectal anastomosis performed for ulcerative colitis. Patients had neither neoplastic nor dysplastic lesions on the colectomy specimen and the retained rectum at the time of surgery. One biopsy specimen of each lateral rectal wall was studied, using routine histology, mucin histochemistry, DNA flow cytometry, and the streptavidin-biotin complex method with D07 monoclonal antibodies directed towards the p53 protein. RESULTS: Seventeen, seven, and three patients showed inflammatory lesions of inactive, moderate, and severe active colitis, respectively. Dysplasia, sialomucin predominance, DNA aneuploidy, and p53 overexpression were not detected. CONCLUSIONS: The risk of malignant transformation of the rectal mucosa after ileorectal anastomosis seemed to be low in this ulcerative colitis group without high-grade dysplasia or carcinoma in the previous colectomy specimen, carefully followed up endoscopically and histologically. It remains to be evaluated which of the methods studied above will optimize the histopathologic surveillance of the rectal mucosa of ulcerative colitis patients with ileorectal anastomosis.     

Pediatric colonoscopy

The procedure and results of 50 colonoscopies performed over a three-year period on a group of 43 children (range: 0.3-16 yr; median: 9 yr) are described. The main indications were evaluation for, or control of already known, chronic inflammatory bowel disease (n = 38) and rectal bleeding (n = 8). Following verbal and written information the children were admitted one to two days before the procedure for bowel preparation. Children < 10 years old received general anaesthesia during the colonoscopy (n = 25) and most children > or = 10 years old received an intravenous sedation with pethidine and midazolam (n = 25). In only one case was intravenous sedation not successful. The coecum was visualised in 96% and the terminal ileum intubated in 77% (when intended) of the endoscopies. The most important results obtained were establishment of the diagnosis of inflammatory bowel disease in 21 of 30 suspected cases and the removal of a polyp in two cases. At the time of colonoscopy a "best guess" diagnosis of either ulcerative colitis or Crohn's disease often predicted the histological diagnosis, but endoscopy tended to underestimate the severity and extent of the inflammation as compared to microscopy. There were no complications. We conclude that colonoscopy performed according to our recommendations is a safe and informative procedure for evaluation of the large bowel and terminal ileum in children with intestinal disease.     

Interleukin-1 receptor antagonist in differential diagnosis of inflammatory bowel diseases

BACKGROUND: Immunoregulatory properties of cytokines may mediate disordered inflammatory events in inflammatory bowel diseases (IBDs). On the basis of data obtained in experimental colitis, the hypothesis has been advanced that in IBD the balance between interleukin-1 (IL-1) and the naturally occurring IL-1 receptor antagonist (IL-1ra) might influence disease expression. OBJECTIVE: We studied the profiles of IL-1ra and acute phase proteins produced by activated macrophages to determine whether the level of IL-1ra in peripheral blood is a marker of disease activity in IBD and a possible differential diagnostic marker. PATIENTS AND METHODS: Levels of IL-1ra, serum neopterin, urinary neopterin, alpha 1-glycoprotein and C-reactive protein (CRP) were measured in 80 patients with ulcerative colitis, Crohn's disease or infectious colitis. RESULTS: Levels of IL-1ra were markedly increased in patients with active ulcerative colitis or active Crohn's disease compared with those in patients with infectious colitis. Patients with active Crohn's disease had significantly higher serum IL-1ra levels than patients with active ulcerative colitis. Moreover, a positive correlation was found between levels of C-reactive protein, alpha 1-glycoprotein, and serum neopterin and the level of IL-1ra in active Crohn's disease but not in active ulcerative colitis, strongly suggesting that the pathogenesis of the two conditions differs. CONCLUSION: Levels of IL-1ra in the peripheral blood of patients with IBD are of clinical relevance, representing a potent marker of disease activity and a possible differential diagnostic marker.