Evidence Of Crohn Research Articles

Pediatric Crohn's Disease in the Upper Gastrointestinal Tract: Clinical, Laboratory, Endoscopic, and Histopathological Analysis.

Crohn's disease (CD) is a progressive, multifactorial, immune-mediated disease characterized by chronic inflammation of any part of the gastrointestinal (GI) tract. Pediatric patients present with a more extensive form of the disease, especially in the upper GI tract with various histopathological inflammatory patterns. Our study aims to analyze the clinical, laboratory, endoscopic, and histopathological findings in children with diagnosed CD and compare results on the initial and follow-up tests. We have included 100 children and adolescents with CD, with performed endoscopic and histopathological (HP) procedures. The results of multiple biopsies executed in these 8 years were matched and compared. We found a statistically significant frequency reduction in stool changes (65.52% to 18.18%), weight loss (35.24% to 4%), and abdominal pain (41.86% to 6.67%) as presenting symptoms. There was an improvement in all laboratory values: fecal calprotectin (1000 to 60,8 μg/g), C-reactive protein (12.2 to 1.9 mg/L), and albumin (36 to 41 g/L). On esophagogastroduodenoscopy and ileo-colonoscopy 36.59% and 64.86% patients had specific findings, respectively. A total of 32 patients had evidence of Crohn's disease in the upper GI tract. Non-caseating granulomas were found on 9% of oesophageal, 18% of gastric, and 12% of duodenal biopsies. In the lower GI tract, we have observed a disease progression in the rectum (72.29 to 82.22%) and descending colon (73.49 to 80%). There was no registered disease progression in the upper GI tract. Our study demonstrated a significant decline in the frequency of symptoms and an improvement in laboratory values on the follow-up examinations. More than a third of our patients had specific endoscopic and HP findings in the upper GI tract, and an additional 23% had HP findings highly suggestive of CD. We demonstrated the importance of regular clinical, laboratory, endoscopic, and histopathological assessments of pediatric CD patients.

Effect of the Crohn's Disease Exclusion Diet (CDED) on the Fecal Calprotectin Level in Children with Active Crohn's Disease.

(1) Background: The CDED + PEN (partial enteral nutrition) is a promising method of nutritional treatment in active Crohn’s disease (CD). An increase in fecal calprotectin (FCP) level—a marker of mucosal inflammation—happens to be the first evidence of Crohn’s disease exacerbation that appears ahead of clinical symptoms and usually co-exists with them. In this study, we present our own experience with using the CDED + PEN in the treatment of children with CD and an increased FCP level. (2) Methods: In total, 48 children (male/female: 27/21) aged 4–17 years (median value = 13.43; IQR = 4.00) were treated with CDED + PEN between June 2019 and July 2021. The main inclusion criteria for the study was active CD defined as an FCP level ≥ 250.00 µg/g. Patients with severe clinical manifestation of CD (PCDAI >40.00), as well as ones who started any new concomitant CD treatment later than at least 4 weeks before the start of dietary intervention, were excluded from the analysis. The PCDAI and fecal calprotectin level were assessed at weeks 0 and 12. The primary endpoint was ITT normalization of FCP level, i.e., a result < 250.00 µg/g at week 12. The Wilcoxon Matched Pairs Test was used for statistical analysis. (3) Results: The normalization of the FCP level was obtained in 17 children (35.42%) and an FCP level decrease of at least 50% occurred in 26 patients (54.17%). The reduction in fecal calprotectin level between week 0 and week 12 was statistically significant with a median value of 1045.00 µg/g; IQR = 1188.00, and 363.00 µg/g; IQR = 665.00, respectively (p < 0.05). Among 29 patients who were not in clinical remission at baseline, 16 (55.17%) achieved clinical remission (PCDAI < 10.00) at week 12 and 20 (68.97%) obtained a clinical response defined as at least a 12.50 point drop in PCDAI or remission. In this group, the reduction in PCDAI between baseline and week 12 was statistically significant (median value = 20.00 points; IQR = 7.50 and 5.00 points; IQR = 5.00, respectively (p < 0.05)). All patients with a normal FCP level at week 12 were in clinical remission and 16 (94.13%) of them had a normal CRP (C-reactive protein) value. In 10 children (20.83%) the full course of 12 weeks with CDED + PEN was not completed or the concomitant therapy had been started before week 12 due to the lack of efficacy/intolerance of nutritional treatment. (4) Conclusions: The 12-week course of treatment with the CDED + PEN has a beneficial effect on the fecal calprotectin level in children with active CD. The dietary intervention led to a significant decrease in the FCP level in the studied group and to the normalization of this parameter in every third patient.

Treatment of orofacial granulomatosis: a case report

BackgroundOrofacial granulomatosis is a relatively recent term coined by Wiesenfield et al. in 1985 to define granulomatous lesions of oral mucosa without intestinal involvement. When it presents in a triad encompassing facial nerve palsy, lip swelling, and fissured or furrowed tongue it is called Melkersson–Rosenthal syndrome while monosymptomatic or oligosymptomatic forms are referred to as granulomatous cheilitis. It is an uncommon clinicopathologic entity which is distinct from classic Crohn’s disease. The NOD2 variant which is commonly associated with Crohn’s has not been shown to have any association with orofacial granulomatosis.Case presentationWe present a case of a 31-year-old white man who had painful swelling of the lip with oral ulcers and difficulty eating for 2 to 3 years. He was diagnosed as having granulomatous cheilitis based on characteristic biopsy findings. There was serologic evidence of Crohn’s disease with anti-Saccharomyces cerevisiae antibodies. However, he was not found to have any gastrointestinal involvement based on computed tomography enterography, and upper and lower endoscopies. He failed to respond to nonsteroidal anti-inflammatory drugs, steroids, and dapsone therapy but responded well to high doses of infliximab.ConclusionsOur case questions whether granulomatous cheilitis really exists or is it simply a variant of Crohn’s disease with only oral presentation. Our patient did not have symptoms of Crohn’s disease; moreover, endoscopic studies and computed tomography enterography were unremarkable for evidence of intestinal involvement. Our case is also the first reported case where high-dose infliximab alone has been used with sustained response for approximately 8 months. In conclusion, more research is needed to assess the underlying pathology as well as ideal treatment options for patients with orofacial granulomatosis. We propose that high-dose infliximab should be considered in patients who do not respond to traditional therapies.

Debut of Crohn's disease in a child desensitised to cow's milk

Specific oral immunotherapy (OIT) is a proven therapeutic option in children with persistent food allergy. Several cases of eosinophilic esophagitis have been reported during the long term follow-up, but not inflammatory bowel diseases. The role of food allergy in the pathogenesis of these diseases is unknown. We present an 11 year-old girl who developed cow's milk allergy (CMA) at the age of 5 months followed by mild asthma in her early childhood. Due to persistent CMA she started cow milk OIT at the age of 8. After a long induction phase - 10 months - in which she presented repeated systemic reactions and abdominal pain, tolerance of 200 ml of cow's milk was reached, and serum levels of cow's milk specific IgE and its components decreased (pre-OIT whole milk sIgE 97.9 kUIA/L, casein 97.5 kUIA/L; post-OIT whole milk sIgE 27.2 kUIA/L, casein 22.7 kUIA/L). After 4 months of daily maintenance treatment, she complained about recurrent abdominal pain related to any food ingestion. A pediatric gastroenterologist ruled out the diagnosis of eosinophilic esophagitis, and she was treated with proton pump inhibitors during 18 months while maintaining daily cow’s milk intake. Although the patient improved partially, abdominal pain was not solved. At age 11 an emergency appendectomy was performed because of an acute abdomen caused by a suspected appendicitis. She was advised to maintain a milk-free diet at discharge. One month later she was readmitted for abdominal pain and diarrhea with weight loss. She underwent an exploratory laparotomy with ileum resection upon obtaining macroscopic evidence of Crohn's disease and pathological results which confirmed the diagnostic. Treatment with corticosteroids, azathioprine and 3 cycles of infliximab was initiated, yielding a good response. At present her symptoms are under control using azathioprine 50 mg daily, while tolerating foods containing trace amounts of cow’s milk. In conclusion, we present a case of a girl who developed Crohn’s disease during the maintenance phase of cow milk OIT. At present we have no rationale for the role of OIT in the development of her Crohn’s disease.

Evidence of Crohn's disease-related anti-glycoprotein 2 antibodies in patients with celiac disease.

Autoantibodies to exocrine-pancreatic glycoprotein 2 (anti-GP2) are Crohn's disease (CD) markers. However, CD-specific antibodies have also been found in celiac-disease (CeD) patients, in which type 1 diabetes-specific autoantibodies against endocrine pancreatic targets can be present. We investigated whether anti-GP2 are also present in CeD, a disease like CD which is also characterised by intestinal mucosal inflammation with barrier impairment. Antibodies against GP2, tissue transglutaminase (tTG), deamidated gliadin (dGD), glutamic decarboxylase (GAD), and islet antigen-2 (IA2) were tested in sera from 73 CD patients, 90 blood donors (BD), and 79 (58 de novo) CeD patients (2 consecutive sera were available from 40 patients). IgA and/or IgG anti-GP2 were found in 15/79 (19.0%) CeD patients on at least one occasion, in 25/73 (34.2%) CD patients, and in 4/90 (4.4%) BD (CeD vs. CD, p=0.042; BD vs. CeD and CD, p<0.001, respectively). Amongst the 58 de novo CeD patients, anti-GP2 IgA and/or IgG were present in 11 (19.0%). Anti-GP2 IgA was significantly less prevalent in CeD compared with CD (p=0.004). Anti-GP2 IgA and IgG in CD patients demonstrated a significantly higher median level compared to patients with CeD (p<0.001, p=0.008, respectively). IgA anti-GP2 levels correlated significantly with IgA anti-tTG and anti-dGD levels in CeD Spearman's coefficient of rank correlation (ρ)=0.42, confidence interval (CI): 0.26-0.56, p<0.001; ρ=0.54, CI 0.39-0.65, p<0.001, respectively. The presence of anti-GP2 in CeD patients supports the notion that loss of tolerance to GP2 can probably be a manifestation of an autoinflammatory process in this intestinal disorder.

Histological evaluation in ulcerative colitis.

This review summarizes diagnostic problems, challenges and advances in ulcerative colitis (UC). It emphasizes that, although histopathological examination plays a major role in the diagnosis and management of UC, it should always be interpreted in the context of clinical, endoscopic, and radiological findings. Accurate diagnosis requires knowledge of the classic morphological features of UC, as well as a number of atypical pathological presentations that may cause mis-classification of the disease process, either in resection or biopsy specimens. These atypical pathological presentations include rectal sparing and patchiness of disease at initial presentation of UC in pediatric patients or in the setting of medically treated UC, cecal or ascending colon inflammation in left-sided UC, and backwash ileitis in patients with severe ulcerative pancolitis. Loosely formed microgranulomas, with pale foamy histiocytes adjacent to a damaged crypt or eroded surface, should not be interpreted as evidence of Crohn’s disease. Indeterminate colitis should only be used in colectomy specimens as a provisional pathological diagnosis. Patients with UC are at risk for the development of dysplasia and carcinoma; optimal outcomes in UC surveillance programs require familiarity with the diagnostic criteria and challenges relating to UC-associated dysplasia and malignancy. Colon biopsy from UC patients should always be evaluated for dysplasia based on cytological and architectural abnormalities. Accurate interpretation and classification of dysplasia in colon biopsy from UC patients as sporadic adenoma or UC-related dysplasia [flat, adenoma-like, or dysplasia-associated lesion or mass (DALM)] requires clinical and endoscopic correlation. Isolated polypoid dysplastic lesions are considered to be sporadic adenoma if occurring outside areas of histologically proven colitis, or adenoma-like dysplasia if occurring in the diseased segment. Recent data suggest that such lesions may be treated adequately by polypectomy in the absence of flat dysplasia in the patient. UC patients with DALM or flat high-grade dysplasia should be treated by colectomy because of the high probability of adenocarcinoma. The natural history of low-grade dysplasia (LGD) is more controversial: while multifocal LGD, particularly if detected at the time of initial endoscopic examination, is treated with colectomy, unifocal flat LGD detected during surveillance may be managed by close follow-up with increased surveillance. The surveillance interval and treatment options for UC patients with dysplasia are reviewed in detail.

Two Cases of Diffuse Duodenitis Associated with Ulcerative Colitis

The upper gastrointestinal tract is not generally considered a target organ in ulcerative colitis (UC). However, several cases showing upper gastrointestinal involvement in UC have been reported. In this report, we present 2 rare cases of diffuse duodenitis accompanying pancolonic UC. Case patient 1 was a 44-year-old man who developed diffuse duodenitis shortly after colectomy and was successfully treated with mesalazine. Case patient 2 was a 25-year-old woman who developed diffuse duodenitis under a steroid-free condition and was successfully treated with prednisolone. The 2 patients had Helicobacter pylori-negative duodenitis that resembled colonic lesions of UC in both the endoscopic and histological findings. No evidence of Crohn's disease was found in these cases. We diagnosed both cases as typical UC-associated diffuse duodenitis. The occurrence of gastrointestinal involvement in UC has been attracting attention because such lesions could potentially open a new window for studying the etiology and pathogenesis of UC. Further studies involving a large number of patients are needed to clarify whether the upper gastrointestinal tract is a target organ in UC.

Higher Therapeutic Tacrolimus Trough Levels Are Associated with Fewer Surgical Resections in Crohnʼs Disease Patients Refractory to Anti-TNFα Therapy

Purpose: Several small retrospective studies have reported encouraging response rates of Crohn's disease (CD) patients treated with tacrolimus. We sought to determine the relationship of tacrolimus blood levels to the response rate in Crohn's disease refractory to standard therapies. Methods: This was a single center, retrospective, observational study. Potential cases were identified by searching electronic medical records from January 1, 2000 to April 1, 2010, that included the words “Crohn” and either “tacrolimus” or “Prograf.” Inclusion criteria were symptomatic Crohn's disease refractory to one or more anti-TNFα agent subsequently treated with tacrolimus. Exclusion criteria were: indeterminate colitis; perianal fistulas without other evidence of Crohn's disease; less than one month of follow-up without adverse effects that required termination of therapy; and tacrolimus therapy primarily for post-transplant immunosuppression or treatment of pyoderma gangrenosum. Demographic and clinical data were collected. Response was defined as a clinician's assessment of improvement after at least 7 days treatment of one or more of the following: bowel movement frequency, fistula output, rectal bleeding, abdominal pain, extraintestinal manifestations (EM), or overall well-being. Remission required all of the following: <3 stools/day (excluding subjects with a previous resection), no bleeding, abdominal pain or EM, and increased well-being.Table: [1211]Results: There were 26 treatment courses among 24 eligible patients, with one patient treated with three separate courses of tacrolimus after long intervals. 96% had failed infliximab; 23% had failed two biologics; 8% had failed three biologics. 31% were steroid-dependent. Overall response and remission rates were 65% and 19%, respectively, at a median follow up of 56 months. Data for surgery (resection or diversion) and adverse events (AE) is presented in the table below. Supra-therapeutic trough levels of >15 ng/ml were associated with a less favorable outcome than therapeutic levels. Serious adverse events included one Port-a-Cath infection and 9 (35%) episodes of acute kidney injury. There were no deaths attributable to tacrolimus. Conclusion: In patients with Crohn's disease refractory to anti-TNFα therapy, tacrolimus treatment at a higher therapeutic trough level appears to reduce the need for surgery, but adverse events are frequent.

Crohn's disease and enterovesical fistulae: common things are common

A 39-year-old Caucasian male presented with a 5-day history of acute severe left iliac fossa pain (radiating to the umbilicus), vomiting and episodic pneumaturia associated with brown urinary sediment. There had been no reported alteration in bowel habit, anorexia or weight loss. On examination he was apyrexial and haemodynamically stable with only mild tenderness limited to the area of the left lower rectus sheath, inferior to the umbilicus. Four years earlier he had been diagnosed with Crohn's disease at a nearby hospital, following a similar episode of left iliac fossa pain; the diagnosis of Crohn's disease was based on computed tomography findings of a thickened ascending colon despite normal histology at colonoscopy. Since the diagnosis of Crohn's disease he had remained on regular mesalazine, with five episodes of similar pain (and occasional pneumaturia) treated with intravenous steroids for presumed exacerbations of Crohn's disease. Given the history of pneumaturia he was pending an outpatient magnetic resonance imaging scan to establish the presence of an enterovesical fistula. At admission, initial investigations revealed a negative urine dipstick for leucocytes and nitrites and only mildly raised inflammatory markers. A computed tomography scan demonstrated an abnormal sigmoid colon adherent to the bladder and anterior abdominal wall (Figure 1). There was also evidence of fluid within the left rectus abdominal sheath and of a fistulous tract between the bladder and sigmoid colon (Figure 2). Flexible sigmoidoscopy revealed an area of narrowing with tight angulation in the sigmoid colon and an abnormal red spot of uncertain aetiology, but there was no evidence of Crohn's disease macroscopically or histologically. Flexible cystoscopy showed thickening of the anterior dome of the bladder with a likely fistula opening superiorly, with non-specific cystitis on histology. Multidisciplinary team discussions concluded that the findings were more suggestive of a localized perforation of a sigmoid diverticulum 4 years earlier leading to secondary inflammatory erosion with the creation of a persistent enterovesical fistula. He therefore underwent a sigmoid colectomy and bladder wall repair. At operation a mass was found in the left iliac fossa adherent to the bladder and abdominal wall and 5 ml of pus drained from an abscess in the anterior abdominal wall. Histology showed an inflamed and ulcerated diverticulum in the sigmoid and an acute and chronic inflammation with foreign body type multinucleated giant cell reaction in the bladder. The patient made a good recovery postoperatively with an early discharge and his longstanding medication for Crohn's disease was stopped.

Diffuse enteritis after colectomy for ulcerative colitis: two case reports and review of the literature

Ulcerative colitis (UC) is an inflammatory disease of the colon. Involvement of the small bowel is limited to backwash ileitis or pouch-related conditions. Here, we report two men with UC who presented with small bowel inflammation and even perforation, within 1 month after subtotal colectomy. Endoscopy showed diffuse enteritis. Histology showed marked apoptosis of epithelial cells in both cases. One patient responded to steroids and the other to a calcineurin inhibitor. Both patients had no evidence of Crohn's disease in the small intestine before this event. Several more cases of small intestinal lesions in patients with well-established UC have been reported. The majority typically presented shortly after colectomy and responded well to steroids. The pathogenesis of this enteritis is unknown, but seems to be distinct from Crohn's disease and may be associated with UC and colectomy.

Mesalamine Induced Eosinophilic Organizing Pneumonia

Purpose: Introduction: The 5-aminosalicylates are first-line therapy for treating ulcerative colitis (UC), and are generally well-tolerated and safe. However, despite their minimal systemic absorption, adverse effects include pancreatitis, pneumonitis, and interstitial nephritis. This is the first case of eosinophilic organizing pneumonia as a result of 5-ASA treatment. Case Description: A 28 year old man was in good health until the age of 26, when he presented with bloody diarrhea and was diagnosed with left sided UC with no evidence of Crohn's disease. He was initially treated with 6.75 g of balsalazide, however his symptoms persisted and he was later started on prednisone and an additional 2.4 g of mesalamine (Lialda, Shire Pharmaceuticals Inc., Wayne, PA) for a total molar equivalent of 4.8 g of mesalamine. He was steroid refractory and 6-MP 1.5 mg/kg was added. Symptoms persisted and he was admitted for IV cyclosporine (CSA). He was induced into remission on 4 mg/kg of CSA and placed on PCP prophylaxis. He was discharged on a rapid prednisone taper, oral CSA for 4 months, and continued on his 6-MP, Lialda and balsalazide. Several months later, he developed a non-productive cough and dyspnea. Chest CT revealed lobar consolidation and nodular infiltrates. Bronchoscopic biopsies demonstrated organizing eosinophilic pneumonia, and chronic and non-necrotizing granulomatous inflammation. Initially, all medications were discontinued and he was treated with clarithromycin. His cough resolved, but his bloody diarrhea returned. He was reinduced with CSA and 6-MP, and presently remains in remission 8 months later on 6-MP monotherapy with symptomatic and radiographic resolution of the pneumonia. Discussion: Inflammatory bowel disease itself can cause pulmonary infiltrates that may be associated with granulomas, and reports of inflammatory lung diseases related to 6-MP exist. However, in those circumstances, there is <1-month between onset of symptoms and 6-MP initiation; this patient had been on 6-MP for >6 months at the time of presentation. The eosinophilic inflammatory infiltrate is consistent with a medication reaction, but is not described in those patients with 6-MP exposure. Specifically as well, the presence of non-necrotizing granulomas associated with interstitial pneumonia appears to indicate mesalamine-induced injury. It is unclear whether the balsalazide, with a colonic azo-bonded release, or the Lialda, with an ileal a pH dependent release (allowing for increased potential for systemic absorption), is the culprit offensive agent. While 6MP and IBD can cause inflammatory lung disease, 5-ASA induced interstitial pneumonia is best recognized by its eosinophilic infiltrates and non-necrotzing granulomas.

Intra‐operative pathological diagnosis of chronic ulcerative colitis in the two stage ileal pouch anal anastomosis

The definitive diagnostic biopsy for chronic ulcerative colitis (CUC) is the colon itself. Simultaneous colectomy and ileal pouch anal anastomosis (IPAA) means that the colon only becomes available for pathological assessment intra-operatively. We examined the role of intra-operative pathological assessment including frozen section in distinguishing between CUC and Crohn's colitis, inpatients undergoing simultaneous colectomy and IPAA. Prospective study of 13 patients undergoing simultaneous colectomy and IPAA between Jan 1992 and April 1999. Resected colon was sent for pathological assessment intra-operatively in all 13 patients. Comparison was made between final histology and frozen section. Patient outcome and pouch function was recorded prospectively. Thirteen patients, M:F 5:8, mean age 41 years (range 20-56). Intra-operative pathological assessment including frozen section diagnosed CUC in nine patients, Crohn's disease in two patients and indeterminate colitis in two patients. The two Crohn's patients had subtotal colectomy and ileostomy. The nine CUC patients and two indeterminate colitis patients underwent IPAA. There was complete agreement between intra-operative assessment including frozen section and the final histopathology. At a median follow up of 31 months (8-58 months) all pouches were intact with good function. There has been no evidence of Crohn's disease on subsequent pouchoscopy and pouch biopsy. Pathological assessment, including frozen section of the colon, intra-operatively is a useful adjunct to surgical decision making in those patients undergoing simultaneous colectomy and IPAA.

Adding fuel to the fire: GM-CSF for active Crohn’s disease

Adding fuel to the fire: GM-CSF for active Crohn’s disease

Unusual Case of Mesenteric Venous Thrombosis Associated with Oral Contraceptive Use in an Adolescent Girl

A 16-year-old girl presented with hematochezia and abdominal pain. The patient developed a small bowel obstruction that required a laparotomy, which showed a segment of grossly infarcted small bowel with 3 perforations, localized abscesses, and creeping fat. Resection and an end-to-end anastomosis were performed. Pathologic examination showed underlying mesenteric venous thrombosis with no evidence of Crohn's disease. Hematology workup showed no evidence of a congenitally inherent hypercoagulable state. The use of oral contraceptives was the only predisposing factor identified.

Carcinoid of major duodenal papilla

muscularis propria, and the serosa, with an associated dense desmoplastic reaction but no evidence of Crohn’s disease (D; HE H&E, orig.mag.!200). After an uneventful postoperative course, the patient was discharged without further treatment. Fabrizio Parente, MD Mirko Molteni, MD Andrea Anderloni, MD Marco Lazzaroni, MD Gabriele Bianchi Porro, MD Pier Giorgio Danelli, MD Gianluca Sampietro, MD Pietro Zerbi, MD Academic Department of Gastroenterology Department of General Surgery Pathology Service L. Sacco University Hospital Milan, Italy

Recurrent Perianastomotic Ileo/Jejuno-colic Ulceration

Recurrent Perianastomotic Ileo/Jejuno-colic Ulceration

Perinatal exposure to measles virus is not associated with the development of inflammatory bowel disease.

It has been suggested that early exposure to measles virus, including perinatal exposure via maternal infection, may lead to persistent measles virus infection and the subsequent development of inflammatory bowel disease (IBD). We sought to examine this association in our patient population. Maternal measles infection was identified through the Mayo Clinic diagnostic index, and cases were verified by chart review. Cases were included if infection occurred between the second trimester and 6 months postpartum. The offspring, or a first degree family member, were then interviewed regarding a history of IBD or symptoms which might suggest IBD. Seven cases of maternal infection were identified out of 67,912 pregnancies between 1935 and 1985. One offspring was lost to follow-up through adoption, and the remaining six have no evidence of Crohn's disease or ulcerative colitis after a mean of 38 years of follow-up (range 12-62 years). Evidence for an association between perinatal exposure to measles virus via maternal infection and the subsequent development of IBD was not found in our patient population.

IgM antibody against measles virus in patients with inflammatory bowel disease: a marker of virus-related disease?

Viral infections of the mesenteric microvascular endothelium have been hypothesized as pathogenetic factors in inflammatory bowel diseases. The aim of this study was to determine whether immunoglobulin M (IgM) antibody against measles virus is associated with disease. The IgM antibody was detected by indirect antibody test in 36 patients with evidence of Crohn's disease (23 males and 13 females, median age 40 years, range 20-66), 22 patients with ulcerative colitis (14 males and 8 females, median age 42 years; range 19-65), 59 patients with a chronic active hepatitis (35 males and 24 females, median age 56 years, range 38-77) and 30 blood donors (20 males and 10 females, median age 45 years, range 29-62). Twenty-eight of 36 patients (78%) with Crohn's disease and 13 of 22 patients (59%) with ulcerative colitis tested positive as compared to only 3 of 89 (3.3%) controls (P < or = 0.001). The detection of IgM anti-measles virus in the majority of patients with Crohn's disease and in about half of ulcerative colitis patients as compared to a very low prevalence in patients with other chronic inflammatory disease is consistent with the hypothesis that the measles virus has pathogenetic implications in inflammatory bowel diseases.

Surgical therapy for rectovaginal fistulas in ulcerative colitis

During a 9-year period, six women with ulcerative colitis (UC) and rectovaginal fistulas were surgically treated. Three underwent ileoanal pull-through procedures with simultaneous repair of the rectovaginal fistulas. Two patients had Kock pouches, and one had a Brooke ileostomy because extensive destruction of the rectal sphincter prohibited ileoanal procedures. The three patients who had ileoanal procedures all had excellent functional results. There has been no evidence of Crohn's disease or fistula recurrence. We believe that rectovaginal fistulas occur more frequently in UC than is generally accepted, and they can be safely managed with current reconstructive techniques.

Clinical Features of Gastroduodenal Crohnʼs Disease in Adolescents

Ten cases of gastroduodenal inflammation were diagnosed by endoscopy among a series of 196 children with evidence of Crohn's disease involving other regions of the intestinal tract. Endoscopic and histologic confirmation of upper gastrointestinal tract involvement was performed only in those cases with suggestive symptoms. The mean age at presentation in the 10 cases with gastroduodenal inflammation was 14.6 +/- 1.9 (+/- SD) years, with involvement identified at the time of initial diagnosis of Crohn's disease in five of the 10. Eight of 10 cases occurred in boys. The major presenting symptoms were weight loss in five cases, epigastric pain in three, and recurrent vomiting in two. Hematemesis and melena occurred in only one of the 10 cases. Endoscopic and histological evidence of mucosal inflammation was seen in all 10 cases. Three of 10 cases had noncaseating granuloma present in biopsies of the stomach or duodenum. Two cases also had endoscopic and histological evidence of esophageal involvement. All cases were initially treated with oral corticosteroids, and in each instance a good clinical response was noted. Sucralfate (n = 1), 6-mercaptopurine (n = 1), and H2 receptor antagonists (n = 3) were used as adjunct therapy. After follow-up for 2.7 years (range, 0.5-5.5 years), none of the 10 cases required surgical intervention. Therefore, at least in the short-term, the outlook for adolescents with gastroduodenal Crohn's disease appears to be good and their medical management need not differ from those patients with Crohn's disease involving only more distal portions of the small intestine.