Intestinal Healing Research Articles

Combined Restitutive Therapy for Treatment of Immunosuppressive Refractory Crohn Disease

Crohn’s Disease (CD) is believed to be the result of dys-regulated interactions between a genetically susceptible host and their commensal gut microbiota (1). CD affects over 600,000 Americans and treatment still faces many challenges (2). Pharmacotherapy centers on the use of anti-inflammatories and immunosuppressants (3). However, a sub-set of patients with CD are refractory to immunosuppressive therapy. Recent studies have implicated defects in autophagy and bacterial killing as a possible etiology leading to host-microbe dysregulation (4). This could explain the lack of response to immunosuppression seen in these CD patients. A recent study in adults with CD showed the potential for granulocyte-macrophage colony stimulating factor (GM-CSF) to enhance bacterial killing and restore intestinal homeostasis (5), but very little data exists in pediatric patients (6). Another study reports a role for low-dose naltrexone (LDN, a mu opioid antagonist) in helping restore the epithelial barrier in active CD (7). The mechanism of action of LDN is thought to be through activation of endogenous opioid signaling (8). Recent murine studies have shown that direct mu opioid receptor (MOR) activation can enhance intestinal epithelial healing and prevent epithelial apoptosis (9). Here, we report a combined intestinal-restitutive approach using GM-CSF and loperamide (a peripheral MOR agonist) to induce and maintain remission in a 17-year-old CD patient.

Mo1706 Local Application of Adipose-Derived Mesenchymal Stem Cells Can Lead to Intestinal Fistula Healing - Experimental Study

Background: Local application of adipose-derived mesenchymal stem cells (ADSCs) is a promising method for the treatment of perianal fistula in patients with Crohn's disease. There is a lack of data evaluating the distribution and viability of ADSCs after application. Therefore more studies are needed including the technique of in vivo monitoring. Aim: The aim of the study was to evaluate the effect of ADSCs application on fistula healing regarding their viability and distribution in perifistular region. Methods: Coecostomy was used as a fistula model in Lewis rats. The inguinal adipose tissue was harvested from transgenic donor expressing firefly luciferase (LEW-Tg(Rosa-luc)11Jmsk; Jichi Medical School, Japan). The ADSCs were isolated using collagenase technique and injected (1-2*106 cells/ml) in perifistular tissue of 16 rats. After application of D-luciferin (25mg/kg), animals were imaged in IVIS Lumina XR camera on days 0, 2, 7, 14 and 30. Fistula drainage assessment (FDA) was used to evaluate the fistula healing. Animals from interventional group were compared to 30 rats with untreated fistula. Results: There was no morbidity or mortality after intervention. The fistula was identified as healed according to FDA in 6 (37.5%) animals after ADSCs injection vs. 1 case (3.3%) with spontaneous closure in control group (p< 0.0047). Bioluminescence was strongest 2 days after application (31.2*104 (6.10-11.0*104). The amount of viable cells remained stable during first 7 days, which confirms successful cells seating. The signal started to decrease slowly afterwards day 14: 6.4*104 (0.5-28.8*104) and day 30: 2.8*104 (0.16-16.9*104) (values are medians in p/s/cm2/sr) (fig.1). The luminescence 30 days after injection was significantly higher in animals with healed fistula 8.23*104 (1.18*1041.70*105) vs. 2.75*104 (4.93*103-6.88*104); p=0.18. Conclusion: Perifistular application of ADSCs and in vivo monitoring using bioluminescence are technically feasible and doesn't cause mortality or morbidity. Local treatment with ADSCs led to significantly more frequent fistula closure compared to the control group. The fistula healing was associated with significantly higher concentration of viable ADSCs in perifistular region, which was confirmed by stronger bioluminescence signal. Supported by NT13708

Intestinal Anastomosis

The creation of a join between two bowel ends is an operative procedure that is of central importance in the practice of a general surgeon. Leakage from an intestinal anastomosis can be disastrous, resulting in prolonged hospital stays and increased risk of mortality. To minimize the risk of potential complications, it is important to create a tension-free join with good apposition of the bowel edges in the presence of an excellent blood supply. This review discusses the factors that influence intestinal anastomotic healing, the various technical operations for creating anastomoses, and operative techniques currently used in constructing anastomoses. Tables review the principles of successful intestinal anastomosis, consequences of postoperative dehiscence, factors linked with dehiscence, anastomotic techniques ranked by best blood flow to the healing site, comparison of hand and stapled techniques, leak rates from the Rectal Cancer Trial on Defunctioning Stoma and the Contant and colleagues mechanical bowel obstruction trial, leak and wound infection rates from mechanical bowel obstruction meta-analyses, diseases and systemic factors associated with poor anastomotic healing, lifestyle-associated leakage rates, salvage after anastomotic leakage, standard checks for creation of anastomoses, and steps for left-sided stapled colorectal anastomoses for cancer. Figures show the phases of wound healing, the tissue layers of the jejunum, interrupted and continuous suture techniques, stitches commonly used in fashioning intestinal anastomoses, double-layer end-to-end anastomosis, traction sutures, anatomic relations between the colon and the retroperitoneal organs, single-layer sutured side-to-side enteroenterostomy, Finney strictureplasty, double-layer sutured end-to-side enterocolostomy, double-stapled end-to-end coloanal anastomosis, use of a “glove” port in laparoscopic surgery, and perfusion assessment at the time of anastomotic creation. This review contains 14 figures, 13 tables, and 85 references.

Combined treatment with dipeptidyl peptidase 4 (DPP4) inhibitor sitagliptin and elemental diets reduced indomethacin-induced intestinal injury in rats via the increase of mucosal glucagon-like peptide-2 concentration.

The gut incretin glucagon-like peptide-1 (GLP-1) and the intestinotropic hormone GLP-2 are released from enteroendocrine L cells in response to ingested nutrients. Treatment with an exogenous GLP-2 analogue increases intestinal villous mass and prevents intestinal injury. Since GLP-2 is rapidly degraded by dipeptidyl peptidase 4 (DPP4), DPP4 inhibition may be an effective treatment for intestinal ulcers. We measured mRNA expression and DPP enzymatic activity in intestinal segments. Mucosal DPP activity and GLP concentrations were measured after administration of the DPP4 inhibitor sitagliptin (STG). Small intestinal ulcers were induced by indomethacin (IM) injection. STG was given before IM treatment, or orally administered after IM treatment with or without an elemental diet (ED). DPP4 mRNA expression and enzymatic activity were high in the jejunum and ileum. STG dose-dependently suppressed ileal mucosal enzyme activity. Treatment with STG prior to IM reduced small intestinal ulcer scores. Combined treatment with STG and ED accelerated intestinal ulcer healing, accompanied by increased mucosal GLP-2 concentrations. The reduction of ulcers by ED and STG was reversed by co-administration of the GLP-2 receptor antagonist. DPP4 inhibition combined with luminal nutrients, which up-regulate mucosal concentrations of GLP-2, may be an effective therapy for the treatment of small intestinal ulcers.

FOXP3+ regulatory T‐cell counts correlate with histological response in Crohn's colitis treated with infliximab

Crohn's disease is a chronic inflammatory bowel disease of unknown aetiology. Mucosal inflammatory dysregulation is likely important, with increased production of pro-inflammatory cytokines, including tumour necrosis factor alpha (TNFα). The chimeric monoclonal antibody, infliximab, inhibits TNFα and promotes intestinal mucosal healing. Despite this, many patients still require surgical intervention. Patients who have undergone colonic resection post-infliximab therapy, show markedly variable morphological response to treatment. FOXP3+ CD4+ regulatory T-cells have been shown to have a protective role in autoimmune/inflammatory diseases and their sequestration to the bowel is found in those treated with infliximab. We examined the immunohistochemical profile of lymphoid aggregates in tissue sections from post-infliximab Crohn's colitis resection specimens, classified as morphological responders or non-responders, defined in relation to the absence/presence of mucosal ulceration and active inflammation, and a control group. Results indicated no significant diffences in CD68-positive cell counts but increased FOXP3-positive (P = 0.02) and CD4-positive (P = 0.05) cell counts in responders versus non-responders. Untreated control scores were similar to non-responders. Although based on small study numbers, our results suggest an association between upregulation of FOXP3+/CD4+ regulatory T-cells and morphological response to infliximab therapy. This represents a possible quantitative methodology for monitoring therapeutic response to infliximab therapy, based on immunohistochemical evaluation of endoscopic biopsy specimens.

What a Practitioner Needs to Know About Celiac Disease?

Celiac disease (CD) is an immune-mediated systemic disorder elicited by gluten and related prolamines in genetically susceptible individuals and is characterized by the presence of a variable combination of gluten-dependent clinical manifestations, CD-specific antibodies, HLA-DQ2 or HLA-DQ8 haplotypes and enteropathy. CD is triggered by wheat gluten and related prolamines in barley and rye. Worldwide, the disease affects approximately 1 % of the general population. Clinical features of CD vary considerably. Intestinal symptoms are more common in young children. In older children extra intestinal manifestations affecting almost all organs are seen. IgA tTG antibody, upper GI endoscopy with histological analysis of multiple biopsies of the duodenum and in selected cases HLA DQ2 and DQ8 positivity and endomysial antibodies (EMA) are needed for diagnosis. Currently, the only treatment for CD is a life-long gluten-free diet (GFD). Strict avoidance of wheat, rye, barley and their derivatives will result in intestinal healing and relief of symptoms for the majority of individuals with CD. The GFD is simple in principle, however, completely eliminating all foods and ingredients containing wheat, rye, barley, and most commercial oats can be very challenging. Newly diagnosed CD children should undergo testing and treatment for micronutrient deficiencies specially iron, folic acid, vitamin D, and vitamin B12. Long-term monitoring and follow up of patients with CD is necessary.

Searching for the Molecular Benchmark of Physiological Intestinal Anastomotic Healing in Rats: An Experimental Study

Purpose: This investigation focuses on the physiological characteristics of gene transcription of intestinal tissue following anastomosis formation. Methods: In eight rats, end-to-end ileo-ileal anastomoses were performed (n = 2/group). The healthy intestinal tissue resected for this operation was used as a control. On days 0, 2, 4 and 8, 10-mm perianastomotic segments were resected. Control and perianastomotic segments were examined with an Affymetrix microarray chip to assess changes in gene regulation. Microarray findings were validated using real-time PCR for selected genes. In addition to screening global gene expression, we identified genes intensely regulated during healing and also subjected our data sets to an overrepresentation analysis using the Gene Ontology (GO) and Kyoto Encyclopedia for Genes and Genomes (KEGG). Results: Compared to the control group, we observed that the number of differentially regulated genes peaked on day 2 with a total of 2,238 genes, decreasing by day 4 to 1,687 genes and to 1,407 genes by day 8. PCR validation for matrix metalloproteinases-3 and -13 showed not only identical transcription patterns but also analogous regulation intensity. When setting the cutoff of upregulation at 10-fold to identify genes likely to be relevant, the total gene count was significantly lower with 55, 45 and 37 genes on days 2, 4 and 8, respectively. A total of 947 GO subcategories were significantly overrepresented during anastomotic healing. Furthermore, 23 overrepresented KEGG pathways were identified. Conclusion: This study is the first of its kind that focuses explicitly on gene transcription during intestinal anastomotic healing under standardized conditions. Our work sets a foundation for further studies toward a more profound understanding of the physiology of anastomotic healing.

Effect of infliximab on the healing of intestinal anastomosis. An experimental study in rats

Βackground and aim: Infliximab is effective in the induction and maintenance of remission in Crohn's disease. Whether, the perioperative administration of anti-TNF-a compromises intestinal healing leading to anastomotic failure and increased risk of postoperative complications, remains controversial. The aim of the study was to evaluate the effect of Infliximab on intestinal anastomosis healing. Methods: Fifty six wistar rats were divided into 4 groups: (a) 20 rats were subjected to excision of part of the terminal ileum followed by anastomosis which was evaluated on the 3rd or 7th postoperative day; (b) 20 rats received Infliximab and thereafter, the same surgical protocol as group (a) was followed; (c) 8 rats received Infliximab and served as relative control group; and (d) 8 served as absolute control group.Bursting pressure was used for testing intestinal healing. Additionally, the anastomoses were examined macroscopically, histologically and immunohistochemically for TGFb1, MMP1, MMP2 and Collagen V. The results were confirmed by Western blot analysis. Results: There were no significant differences in bursting pressures and septic intra-abdominal events among non-Infliximab (a) and Infliximab-treated (b) groups. Infliximab-treated (b) group showed mild to moderate inflammation, whereas the non-Infliximab (a) group exhibited severe inflammation. Expression of TGFb1, MMP2 and collagen V was significantly higher in the Infliximab-treated (b) group. Conclusion: Infliximab seems to influence intestinal healing in terms of less inflammatory activity and higher tissue remodeling activity.

Comparison of flunixin meglumine and meloxicam for post operative management of horses with strangulating small intestinal lesions

Ex vivo evidence suggests that cyclo-oxygenase (COX) 2-preferential inhibitor nonsteroidal anti-inflammatory drugs (NSAIDs), such as meloxicam, have a less detrimental effect on intestinal healing than flunixin meglumine (FM). Whether this translates to a beneficial effect in horses with naturally occurring strangulating small intestinal (SSI) lesions is unknown. To compare the clinical outcome of horses with naturally occurring SSI lesions treated with meloxicam or FM. Randomised prospective study. Cases presenting to the Royal Veterinary College Equine Referral Hospital and Bell Equine Veterinary Clinic during 2010 and 2011 in which an SSI lesion was identified at exploratory laparotomy were eligible for inclusion. Horses received either 1.1 mg/kg bwt FM or 0.6 mg/kg bwt meloxicam i.v. q. 12 h. Clinical outcomes and clinical and laboratory parameters associated with endotoxaemia were compared between groups. Sixty cases were enrolled, 32 horses received FM and 28 received meloxicam. There was no difference in signalment, physical examination or surgical factors between groups. The overall survival to discharge was 81%; there was no difference in survival (P = 0.14) or incidence of post operative ileus (P = 0.25) between groups. There was no significant difference between the plasma lipopolysaccharide (LPS) concentrations at 0 h (P = 0.18) or 48 h (P = 0.60); however, there was a significant difference between neutrophil count at 48 h (P<0.05) and at 96 h (P<0.01) with significantly greater cell numbers in horses receiving meloxicam compared with FM. Blinded pain score evaluation showed that more horses receiving meloxicam showed gross signs of pain than those treated with FM (P = 0.04). Nonsteroidal anti-inflammatory drug choice did not affect major clinical outcomes in horses with SSI lesions but had some effects on signs of pain. This study provides no evidence to recommend one NSAID treatment above another based on survival or the incidence of ileus; however, evaluation of a larger number of cases is required.

Comparison of the effects of Mg–6Zn and Ti–3Al–2.5V alloys on TGF-β/TNF-α/VEGF/b-FGF in the healing of the intestinal tract in vivo

To evaluate the different effects of Mg–6Zn alloy and Ti–3Al–2.5V alloy implants in intestinal tract healing, we compared these two different alloys with respect to their effect on a rat's intestinal tract, using serum magnesium, radiology, pathology and immunohistochemistry in vivo. Itwas found using the scanning electron microscope that the Mg–6Zn alloy began to degrade during the first week and that the Ti–3Al–2.5V alloy was non-degradable throughout the process. The Mg–6Zn alloy did not have an impact on serum magnesium. Superior to the Ti–3Al–2.5V alloy, the Mg–6Zn alloy enhanced the expression of transforming growth factor-β1 in healing tissue, and promoted the expression of both the vascular endothelial growth factor and the basic fibroblast growth factor, which helped angiogenesis and healing. The Mg–6Zn alloy reduced the expression of the tumor necrosis factor (TNF-α) at different stages and decreased inflammatory response, which may have been related to the zinc inhibiting TNF-α. In general, the Mg–6Zn alloy performed better than Ti–3Al–2.5V at promoting healing and reducing inflammation. The Mg–6Zn alloy may be a promising candidate for use in the pins of circular staplers for gastrointestinal reconstruction in medicine.

P182 Multiparametric evaluation of Crohn's disease: possible role of intestinal healing beyond mucosal healing

Results: Among 887 patients, a subgroup of 439 CD and 173 UC were included with a mean follow-up of 19 and 15 years respectively. One year after the diagnosis 147 CD patients had NS CD. At 5 years and at the maximum follow-up respectively, 83/147 (56%) and 15/147 (10%) patients still had NS CD. Complications were strictures (29%), fistulizing disease (18%), perianal disease (37%). Immunomodulators and antiTNF were required in 79% and 54% of patients respectively. Prognostic factors for persistent NS CD were older age at diagnosis (38 vs 26 years, p = 0.005), no corticosteroid during the first year (p = 0.036). In UC, 142 patients had NS disease one year after the diagnosis. 102/142 (72%) and 62 patients (44%) had NS UC after 5 years and at the maximum follow-up respectively. Surgery occurred in 19 patients (13%) after a mean time a 164 months. Immunomodulators were needed in 66 patients (47%) and anti-TNF in 37 patients (26%). NS UC was associated with absence of hospitalization for active UC over the first 5 years (p = 0.009) and during the total course of UC (p < 0.0001), no intake of corticosteroid during the first year (p = 0.03). Conclusions: In our cohort representing referall centre recruitment, nearly all CD patients and 2/3 of UC with NS disease at diagnosis became severe with time. Old age at diagnosis was associated with NS CD outcome while absence of hospitalisation during the first year was associated with NS UC outcome. Absence of steroid use during the first year was associated with NS outcome in both diseases.

Dipeptidyl peptidase IV inhibition prevents the formation and promotes the healing of indomethacin-induced intestinal ulcers in rats.

We studied the intestinotrophic hormone glucagon-like peptide-2 (GLP-2) as a possible therapy for non-steroidal anti-inflammatory drug (NSAID)-induced intestinal ulcers. Luminal nutrients release endogenous GLP-2 from enteroendocrine L cells. Since GLP-2 is degraded by dipeptidyl peptidase IV (DPPIV), we hypothesized that DPPIV inhibition combined with luminal administration of nutrients potentiates the effects of endogenous GLP-2 on intestinal injury. Intestinal injury was induced by indomethacin (10mg/kg, sc) in fed rats. The long-acting DPPIV inhibitor K579 was given intragastrically (ig) or intraperitoneally (ip) before or after indomethacin treatment. L-Alanine (L-Ala) and inosine 5'-monophosphate (IMP) were co-administered ig after the treatment. Indomethacin treatment induced intestinal ulcers that gradually healed after treatment. Pretreatment with ig or ip K579 given at 1mg/kg reduced total ulcer length, whereas K579 at 3mg/kg had no effect. Exogenous GLP-2 also reduced intestinal ulcers. The preventive effect of K579 was dose-dependently inhibited by a GLP-2 receptor antagonist. Daily treatment with K579 (1mg/kg), GLP-2, or L-Ala+IMP after indomethacin treatment reduced total ulcer length. Co-administration (ig) of K579 and L-Ala+IMP further accelerated intestinal ulcer healing. DPPIV inhibition and exogenous GLP-2 prevented the formation and promoted the healing of indomethacin-induced intestinal ulcers, although high-dose DPPIV inhibition reversed the preventive effect. Umami receptor agonists also enhanced the healing effects of the DPPIV inhibitor. The combination of DPPIV inhibition and luminal nutrient-induced GLP-2 release may be a useful therapeutic tool for the treatment of NSAIDs-induced intestinal ulcers.

Enhanced intestinal anastomotic healing with gelatin hydrogel incorporating basic fibroblast growth factor

Anastomotic leakage is a common complication of intestinal surgery. In an attempt to resolve this issue, a promising approach is enhancement of anastomotic wound healing. A method for controlled release of basic fibroblast growth factor (bFGF) using a gelatin hydrogel was developed with the objective of investigating the effects of this technology on intestinal anastomotic healing. The small intestine of Wistar rats was cut, end-to-end anastomosis was performed and rats were divided into three groups: bFGF group (anastomosis wrapped with a hydrogel sheet incorporating bFGF), PBS group (wrapped with a sheet incorporating phosphate-buffered saline solution) and NT group (no additional treatment). Degradation profiles of gelatin hydrogels in vivo and histological examinations were performed using gelatin hydrogels with various water contents and bFGF concentrations to define the optimal bFGF dose and hydrogel biodegradability. The anastomotic wound healing process was evaluated by histological examinations, adhesion-related score and bursting pressure. The optimal water content of the hydrogel and bFGF dose was determined as 96% and 30 µg per sheet, respectively. Application of bFGF significantly enhanced neovascularization, fibroblast infiltration and collagen production around the anastomotic site when compared with the other groups. Bursting pressure was significantly increased in the bFGF group. No significant difference was observed in the adhesion-related score among the groups and no anastomotic obstruction and leakage were observed. Therefore controlled release of bFGF enhanced healing of an intestinal anastomosis during the early postoperative period and is a promising method to suppress anastomotic leakage. Copyright © 2013 John Wiley & Sons, Ltd.

Temporal expression of IL-1β and IL-10 in rat skin, muscle, small bowel, and colon wounds: a correlative study

Cytokines play a major role in coordinated wound healing events. We hypothesized that rapid intestinal healing is due to an early upregulation of the pro-inflammatory cytokine interleukin-1β (IL-1β), followed by increases in the expression of the anti-inflammatory cytokine IL-10. We characterized the time course of IL-1β and IL-10 release at four wounds (skin, muscle, small bowel, and colonic anastomosis) after surgery on 38 juvenile male Sprague-Dawley rats. The tissue samples of each site were harvested at 0 (control), 1, 3, 5, 7, and 14 days postoperatively (n=6-8 per group) and analyzed by enzyme-linked immunosorbent assay kits for IL-1β and IL-10. IL-1β expression peaked at days 5 and 7 in small bowel and colonic wounds when compared to skin or muscle. Similarly, IL-10 showed high expression in these time points in small bowel and colonic wounds. However, IL-10 showed the same expression in all time points in muscle and skin tissues except at day 1. The high expression in IL-1β and IL-10 levels in small bowel and colon might explain the accelerated healing process in these wounds in comparison to skin and muscle tissues. Additional studies are required to determine whether IL-1β and IL-10 expression is the major factor defining site-specific differences in healing rates in different tissues. Understanding cytokine action in the wound healing process could lead to novel and effective therapeutic strategies.

Macrophages promote epithelial repair through hepatocyte growth factor secretion

Macrophages play a critical role in intestinal wound repair. However, the mechanisms of macrophage-assisted wound repair remain poorly understood. We aimed to characterize more clearly the repair activities of murine and human macrophages. Murine macrophages were differentiated from bone marrow cells and human macrophages from monocytes isolated from peripheral blood mononuclear cells of healthy donors (HD) or Crohn's disease (CD) patients or isolated from the intestinal mucosa of HD. In-vitro models were used to study the repair activities of macrophages. We found that murine and human macrophages were both able to promote epithelial repair in vitro. This function was mainly cell contact-independent and relied upon the production of soluble factors such as the hepatocyte growth factor (HGF). Indeed, HGF-silenced macrophages were less capable of promoting epithelial repair than control macrophages. Remarkably, macrophages from CD patients produced less HGF than their HD counterparts (HGF level: 84 ± 27 pg/mg of protein and 45 ± 34 pg/mg of protein, respectively, for HD and CD macrophages, P < 0·009) and were deficient in promoting epithelial repair (repairing activity: 90·1 ± 4·6 and 75·8 ± 8·3, respectively, for HD and CD macrophages, P < 0·0005). In conclusion, we provide evidence that macrophages act on wounded epithelial cells to promote epithelial repair through the secretion of HGF. The deficiency of CD macrophages to secrete HGF and to promote epithelial repair might contribute to the impaired intestinal mucosal healing in CD patients.

Roles of pro-angiogenic and anti-angiogenic factors as well as matrix metalloproteinases in healing of NSAID-induced small intestinal ulcers in rats

AimsWe examined changes in the expression of a pro-angiogenic factor, vascular endothelial growth factor (VEGF), and an anti-angiogenic factor, endostatin, as well as matrix metalloproteinase (MMP)-2 and MMP-9 in the rat small intestine after administration of indomethacin and investigated the roles of these factors in the healing of indomethacin-induced small intestinal ulcers. Main methodsMale SD rats were given indomethacin (10mg/kg) p.o. and euthanized at various time points (3–24h and 2–7days) after the administration. To impair the healing of these lesions, low-dose of indomethacin (2mg/kg) was given p.o. once daily for 6days starting 1day after ulceration. Levels of VEGF, endostatin, MMP-2 and MMP-9 were determined by Western blotting. Key findingsThe expression of both VEGF and endostatin was upregulated after the ulceration. Repeated administration of low-dose indomethacin impaired the ulcer healing with a decrease of VEGF expression and a further increase of endostatin expression, resulting in a marked decrease in the ratio of VEGF/endostatin expression. The levels of MMP-2 and MMP-9 were both significantly increased after the ulceration, but these responses were suppressed by the repeated indomethacin treatment. The healing of these ulcers was significantly delayed by the repeated administration of MMP inhibitors such as ARP-101 and SB-3CT. SignificanceThe results confirm the importance of the balance between pro-angiogenic and anti-angiogenic activities in the healing of indomethacin-induced small intestinal damage and further suggest that the increased expression of MMP-2 and MMP-9 is another important factor for ulcer healing in the small intestine.

Intraoperative crystalloid overload leads to substantial inflammatory infiltration of intestinal anastomoses—a histomorphological analysis

It has been shown that crystalloid fluid-overload promotes anastomotic instability. As physiologic anastomotic healing requires the sequential infiltration of different cells, we hypothesized this to be altered by liberal fluid regimes and performed a histomorphological analysis. 36 Wistar rats were randomized into 4 groups (n=8-10 rats/group) and treated with either liberal (+) or restrictive (-) perioperative crystalline (Jonosteril = Cry) or colloidal fluid (Voluven = Col). Anastomotic samples were obtained on postoperative day 4, routinely stained and histophathologically reviewed. Anastomotic healing was assessed using a semiquantitative score, assessing inflammatory cells, anastomotic repair and collagenase activity. Overall, the crystalloid overload group (Cry (+)) showed the worst healing score (P < 0.01). A substantial increase of lymphocytes and macrophages was found in this group compared to the other three (P < 0.01). Both groups that received colloidal fluid (Col (+) and Col (-)) as well as the group that received restricted crystalloid fluid resuscitation (Cry (-)) had better intestinal healing. Collagenase activity was significantly higher in the Cry (+) group. Intraoperative infusion of high-volume crystalloid fluid leads to a pathological anastomotic inflammatory response with a marked infiltration of leukocytes and macrophages resulting in accelerated collagenolysis.

Inflammatory bowel disease epidemiology

The occurrence of inflammatory bowel disease (IBD) is increasing worldwide, yet the reasons remain unknown. New therapeutic approaches have been introduced in medical IBD therapy, but their impact on the natural history of IBD remains uncertain. This review will summarize the recent findings in the epidemiology of IBD. The incidence of IBD in western Europe is twice as high as in eastern Europe, whereas the highest IBD incidence in the world is found in the Faroe Islands. Early intervention with immunosuppressant and biological agents seems to have reduced the colectomy rates for ulcerative colitis, whereas the impact on Crohn's disease has yet to be determined. Mortality in Crohn's disease has not changed despite improvements in medical and surgical management. Specialized care in IBD centres, treatments to target and obtaining mucosal healing, early intervention at relapse and avoiding Clostridium difficile super infection might reduce the mortality rate in the future. The risk of colorectal cancer in Crohn's disease seems to be equivalent to the risk in ulcerative colitis. Patients with small bowel Crohn's disease are at increased risk of small bowel adenocarcinoma. The natural disease course of IBD seems to change along with the new 'treat to target' goal of achieving intestinal mucosal healing. Future population-based studies of unselected IBD cohorts should be considered the gold standard for studies investigating these issues.

Infliximab in the Treatment of Crohn Disease and Type 1 Diabetes

Inhibition of tumor necrosis factor (TNF)-α is an effective treatment for Crohn disease. It is recommended as a second-line therapy in steroid-dependent or -refractory disease, although first-line treatment may improve chances of intestinal mucosal healing (1). In the context of diabetes, TNF-α has been implicated in the development of insulin resistance during obesity (2) and in autoimmune destruction of pancreatic β-cells in an animal model of type 1 diabetes (3), and a recent study demonstrated some preservation of insulin secretion in children with new-onset type 1 diabetes upon TNF-α inhibition (4). Here, we report a case of a 29-year-old Caucasian man who was diagnosed with type 1 diabetes at the age of 27 years on the basis of rapid onset of hyperglycemia, a lean BMI of 22.7 kg/m2, signs of β-cell autoimmunity (autoantibodies to GAD 476 IU/mL [normal value <10] and islet-cell autoantibodies 125 units/mL [normal value <1.5]), and a negative family history of diabetes. Upon treatment with insulin glargine …

Anti-tumour necrosis factor therapy enhances mucosal healing through down-regulation of interleukin-21 expression and T helper type 17 cell infiltration in Crohn's disease

Anti-tumour necrosis factor (TNF) monoclonal antibody (mAb) (infliximab, IFX) has been shown to be highly effective in the management of Crohn's disease (CD). Herein we investigated the potential role of IFX in inducing clinical remission and regulating interleukin (IL)-21 expression and T helper type 17 (Th17) cell infiltration in the intestinal mucosa of CD patients. Twenty-six CD patients were treated with IFX at weeks 0, 2 and 6. Clinical response, mucosal healing, serum C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were evaluated at week 10 after IFX administration. Expression of IL-21, IL-17A and retinoic acid-related orphan receptor C (RORC) in intestinal mucosa were analysed by quantitative real-time polymerase chain reaction (PCR) and immunohistochemistry. Peripheral blood and lamina propria CD4(+) T cells were stimulated with anti-CD3 and anti-CD28 mAbs in the presence of IFX. Cytokine profiles and RORC were determined with enzyme-linked immunosorbent assay (ELISA) and real-time PCR. IL-21 and Th17 cells were found to be expressed highly in inflamed mucosa of active CD patients compared with healthy controls. Ten weeks after IFX infusion, CD activity index, ESR, CRP and intestinal mucosal healing were improved markedly in CD patients, and IL-21 expression and Th17 cell infiltration were decreased significantly compared with those before IFX therapy. In-vitro study demonstrated that IFX treatment could suppress IL-21, IL-17A and RORC expression in cultured CD biopsies. Moreover, IFX was also observed to down-regulate markedly IL-17A, IL-21 and RORC expression by CD CD4(+) T cells. IFX is highly effective in inducing clinical remission and promoting intestinal mucosal healing in CD patients through down-regulation of IL-21 expression and Th17 cell infiltration in intestinal mucosa.