Pouch Inflammation Research Articles

Preclinical development of CAT‐354, an IL‐13 neutralizing antibody, for the treatment of severe uncontrolled asthma

BACKGROUND AND PURPOSEIL-13 is a pleiotropic Th2 cytokine considered likely to play a pivotal role in asthma. Here we describe the preclinical in vitro and in vivo characterization of CAT-354, an IL-13-neutralizing IgG4 monoclonal antibody (mAb), currently in clinical development.EXPERIMENTAL APPROACHIn vitro the potency, specificity and species selectivity of CAT-354 was assayed in TF-1 cells, human umbilical vein endothelial cells and HDLM-2 cells. The ability of CAT-354 to modulate disease-relevant mechanisms was tested in human cells measuring bronchial smooth muscle calcium flux induced by histamine, eotaxin generation by normal lung fibroblasts, CD23 upregulation in peripheral blood mononuclear cells and IgE production by B cells. In vivo CAT-354 was tested on human IL-13-induced air pouch inflammation in mice, ovalbumin-sensitization and challenge in IL-13 humanized mice and antigen challenge in cynomolgus monkeys.KEY RESULTSCAT-354 has a 165 pM affinity for human IL-13 and functionally neutralized human, human variant associated with asthma and atopy (R130Q) and cynomolgus monkey, but not mouse, IL-13. CAT-354 did not neutralize human IL-4. In vitro CAT-354 functionally inhibited IL-13-induced eotaxin production, an analogue of smooth muscle airways hyperresponsiveness, CD23 upregulation and IgE production. In vivo in humanized mouse and cynomolgus monkey antigen challenge models CAT-354 inhibited airways hyperresponsiveness and bronchoalveolar lavage eosinophilia.CONCLUSIONS AND IMPLICATIONSCAT-354 is a potent and selective IL-13-neutralizing IgG4 mAb. The preclinical data presented here support the trialling of this mAb in patients with moderate to severe uncontrolled asthma.

Surgical Outcome of Ileal Pouch—Anal Anastomosis When Used Intentionally for Well-Defined Crohnʼs Disease

Crohn's disease (CD) is considered a contraindication to ileal pouch--anal anastomosis (IPAA). In this study, we compare outcomes of CD and ulcerative colitis (UC) patients undergoing IPAA. Patients were considered to have CD before surgery based on a history of small bowel disease, perianal disease, noncrypt-associated granuloma, or pretreatment skip colonic lesions. Patients were prospectively assessed for pouchitis or CD. Postoperative CD (pouch inflammation into the afferent limb or pouch fistula) or pouch failure (need for permanent diversion) were assessed. Preoperative serum was assayed for IBD-associated antibodies using enzyme-linked immunosorbent assay (ELISA). Seventeen patients with preoperative CD were identified. Seven (41%) patients developed postoperative recurrent CD in the afferent limb (n = 3) or pouch fistulizing disease (n = 4). One patient (6%) required pouch excision. The incidence of postoperative CD was higher (P = 0.002) in preoperative CD patients (41%) than UC patients (11%). There was no significant difference in pouchitis or pouch failure. There was also no significant difference in any preoperative clinical feature between patients with or without postoperative CD. Afferent limb inflammation developed in three (50%) of the six patients with pANCA+/OmpC- expression compared to none of the 11 patients without this serologic profile (P = 0.03). Although the intentional use of IPAA in CD has a higher incidence of postoperative disease vs. UC patients, there was no significant difference in pouch failure. Demographics, clinical features, and serologic factors do not predict outcome of CD patients undergoing IPAA. IBD serology may identify the phenotype manifestation of postoperative recurrent CD.

Hyaluronic acid viscosupplements from avian and non‐mammalian sources exhibit biocompatibility profiles with unique, source‐specific, antigenic profiles

The objective of this study was to evaluate and compare the biocompatibility profiles of hyaluronic acid (HA) viscosupplements from avian and non-mammalian sources. Inflammatory and immune reactions were assessed in models of both clinically relevant and stringent immunological exposure conditions. Experiments were conducted to evaluate tissue reactions and immunological responses and assess antibody formation with the capacity to bind directly to and cross-react with the different viscosupplements. Mice were exposed to viscosupplements using the air pouch inflammation model and specific immunization using Freund's complete adjuvant (FCA). Murine pouch membrane tissue reactions revealed generally mild to moderate responses, with cellular infiltration and cytokine profiles of pouch tissue characteristic of predominantly fibroblastic responses rather than marked inflammatory reactions. In vitro testing indicated that pouch injections did not elicit detectable T-cell proliferative responses, while antibody assays revealed that mice immunized with viscosupplements in FCA and subsequently boosted were capable of mounting an antibody response with a range of specificities. High reactivity to avian serum albumin was seen in sera from mice injected with HA from an avian source, while low positive reactivity to the bacterial antigen Staphylococcal Lipotechoic Acid was observed in sera from mice injected with HA from bacterial sources. These specificities did not indicate any propensity to cross-react, suggesting that patients with adverse immune responses to HA from an avian source should be unresponsive to subsequent injection with HA from a non-avian source. Overall, the findings demonstrate that viscosupplements exhibit good biocompatibility profiles in the murine air pouch, but when provoked to elicit immunological reactions exhibit unique antigenic spectra. These findings suggest that an immunologically mediated immune reaction directed against avian proteins should not necessarily be a contraindication for the administration of non-avian viscosupplements.

P010 Upregulation of gut homing markers on dendritic cells in the functioning and inflamed ileo-anal pouch

P010 Upregulation of gut homing markers on dendritic cells in the functioning and inflamed ileo-anal pouch J. Landy1 *, H.O. Al-Hassi2, E. Ronde2, S. Peake1, N. English2, E. Mann2, D. Bernardo2, C.T. Tee2, R.J. Nicholls3, P.J. Ciclitira4, S.K. Clark5, S. Knight2, A.L. Hart1. 1St Mark’s Hospital, IBD Unit, London, United Kingdom, 2Antigen Presentation Research Group, Imperial College, London, United Kingdom, 3Imperial College, Department of Biosurgery and Surgical Technology, London, United Kingdom, 4St Thomas’ Hospital, Gastroenterology, London, United Kingdom, 5St Mark’s Hospital, Colorectal Surgery, London, United Kingdom

P011 Anti-TNF-alpha induces a dysregulated tissue-homing profile on human immune cells in-vitro

P010 Upregulation of gut homing markers on dendritic cells in the functioning and inflamed ileo-anal pouch J. Landy1 *, H.O. Al-Hassi2, E. Ronde2, S. Peake1, N. English2, E. Mann2, D. Bernardo2, C.T. Tee2, R.J. Nicholls3, P.J. Ciclitira4, S.K. Clark5, S. Knight2, A.L. Hart1. 1St Mark’s Hospital, IBD Unit, London, United Kingdom, 2Antigen Presentation Research Group, Imperial College, London, United Kingdom, 3Imperial College, Department of Biosurgery and Surgical Technology, London, United Kingdom, 4St Thomas’ Hospital, Gastroenterology, London, United Kingdom, 5St Mark’s Hospital, Colorectal Surgery, London, United Kingdom

Multidetector-Row Computed Tomography Enterographic Assessment of the Ileal-Anal Pouch

To describe the multidetector-row computed tomography enterographic (MD-CTE) features of the ileal-anal pouch after ileal pouch anal anastomosis (IPAA) surgery and correlate them with pouch endoscopy and histopathologic findings. All MD-CTE examinations performed on patients who underwent IPAA from July 1, 2005 to December 1, 2010 (n = 35; 16 [45.7%] men; mean age, 37.7 years; age range, 22-72 years) were retrospectively evaluated in consensus by 2 radiologists. All studies were evaluated for the presence of multiple imaging features. Two radiographic scores were then calculated: a total radiographic score and a radiographic active inflammation score. In patients who underwent MD-CTE, pouch endoscopy, and biopsy within 30 days (n = 13), both scores were correlated with findings on pouch endoscopy and histopathology. Of the 35 patients, 33 (94%) had at least one MD-CTE finding of active or chronic pouch inflammation and 27 patients (77%) had at least one MD-CTE finding of active pouch inflammation. Of the 13 patients who underwent endoscopy and biopsy, the total radiographic score demonstrated a strong positive correlation with endoscopic score (r = 0.81; P = 0.001) and a moderate positive correlation with histopathologic score (r = 0.56; P = 0.047). The radiographic active inflammation score demonstrated a strong positive correlation with endoscopic score (r = 0.83; P = 0.0004), but only a weak nonsignificant positive correlation with histopathologic score (r = 0.492, P = 0.087). In patients who had IPAA surgery, findings on MD-CTE correlate positively with findings on pouch endoscopy and histopathology and are sensitive measures for pouch inflammation with high positive predictive value. Thus, MD-CTE can be a useful noninvasive test in the early evaluation of symptomatic patients.

Synergistic anti-inflammatory effects ofLaminaria japonicafucoidan andCistanche tubulosaextract

The anti-inflammatory effects of fuciodan and Cistanche tubulosa (CT) extract were investigated in vitro macrophage culture system and in vivo carrageenan-induced air pouch inflammation model. CT extract inhibited nitric oxide production from activated RAW 264.7 macrophage cells, while fucoidan was inactive. In vivo air pouch inflammation model, carrageenan-induced vascular exudation and increased nitric oxide and prostaglandin E2 concentrations in the exudates were synergistically suppressed by co-administration of fucoidan or CT extract. Moreover, tissue inflammation was substantially attenuated by the combinational therapy. However, there was no synergistic effect against the inflammatory cell infiltration, although fucoidan and CT extract each markedly reduced the cell numbers. Therefore, it is suggested that fucoidan blocks infiltration of inflammatory cells, while CT extract inhibits activation of the cells, and that their combinational treatment could be a promising candidate for the relief of various types of inflammation.

Anti-inflammatory activity of Ajmodadi Churna extract against acute inflammation in rats

Background:Ayurvedic polyherbal formulations are widely prescribed for a wide range of inflammatory conditions, yet, despite widespread use, there has been no systematic documentation of their safety and efficacy.Objective:The present study was undertaken to evaluate the anti-inflammatory activity of aqueous extracts of Ajmodadi churna (AJM) in rats.Materials and Methods:Carrageenan-induced hind paw edema and air pouch inflammation models were used for the study.Results:The extracts showed significant antiinflammatory activity, reducing paw edema volume by 0.417 ± 0.097 and 0.379 ± 0.049, respectively. In the carrageenan-induced air pouch model, AJM reduced total leukocyte count by 73.09 ± 7.13 and 62.17 ± 10.53, granulocyte count by 69.48 ± 5.44 and 63.33 ± 4.13, and myeloperoxidase activity by 14.84 ± 0.91 and 18.44 ± 3.18, respectively, compared to controls.Discussion and Conclusion:AJM significantly reduced paw edema, during the second phase of edema development. In the carrageenan-induced air pouch model, AJM inhibited cellular infiltration into the air pouch fluid. We conclude that AJM is an effective candidate for prevention or treatment of acute inflammation

Impact of budesonide on liver function tests and gut inflammation in patients with primary sclerosing cholangitis and ileal pouch anal anastomosis

Background and aimBudesonide has been studied in patients with primary sclerosing cholangitis (PSC). This study was designed to evaluate the efficacy of oral budesonide on liver function tests in patients with PSC and pouchitis associated with ileal pouch-anal anastomosis (IPAA). Materials and methodsThe study group consisted of 18 pouch patients with underlying ulcerative colitis (UC) and PSC who were treated with 9mg daily of budesonide for their underlying pre-pouch ileitis and pouchitis for 1-3months followed by 3-6mg maintenance for another 9months. Demographic and clinical variables were analyzed. ResultsThe mean age was 39.4±12.4years (range, 21–59years). There was no significant change in aspartate aminotransferase (AST) [median (interquartile range) (IQR) 32 (25, 43.8) vs. 35.5 (25.5, 53), p=0.35], alanine aminotransferase (ALT) [37.5 (25.5, 49.5) vs. 40 (30, 84.3), p=0.29], alkaline phosphatase [142.5 (98.5, 264.5) vs. 126 (94.3, 189.5), p=0.35], serum bilirubin [0.7 (0.4, 1.3) vs., 0.6 (0.4, 1.6), p=0.13] or albumin levels [4.3 (3.9, 4.4) vs. 4.2 (3.8, 4.4), p=0.22] at the end of the treatment period (1year). The revised Mayo Risk Score did not change significantly and three patients required evaluation for liver transplantation during treatment. There was a significant improvement in the endoscopy subscores in the afferent limb and pouch after a year of budesonide treatment (p=0.001). ConclusionsOral budesonide appears to have no impact on liver function tests in pouch patients with PSC. However it significantly improved afferent limb and pouch inflammation in IPAA patients.

Long-Term Followup of Patients with Active J-Reservoirs after Restorative Proctocolectomy for Ulcerative Colitis with regard to Reservoir Function, Mucosal Changes, and Quality of Life

Objective. Study the functional results and mucosal changes in the ileal pouch after restorative proctocolectomy with J-reservoir for ulcerative colitis. Material and Methods. Followup study of 125 patients with J-reservoir with one disease-specific- and one general (SF-36) quality of life-questionnaire, rectoscopy with biopsies, and stool samples to evaluate inflammation, dysplasia, presence of Helicobacter pylori and calprotectin level. Results. Fourteen J-reservoirs were removed or deactivated, leaving 111 patients for followup. The followup time was 6.8 (1–15) years. 87.4% of the patients were satisfied. 93.1% had some kind of functional restriction: food- (75.5%), social- (28.9%), physical- (37%) or sexual restriction (15.3%). 18.6% had often or sometimes faecal incontinence. Low daytime faecal frequency was associated with good quality of life. 13 patients (12.6%) had a less favourable result. There was no pouch-dysplasia. Calprotectin levels were increased in patients with visible pouch inflammation or history of pouchitis. HP was diagnosed by RUT in 42.3%, but was not associated with inflammation or pouchitis. Conclusions. Most patients were satisfied with the J-reservoir in spite of a high frequency of various restrictions. 12.6% (13 patients) had a less favourable functional result, partly due to a high frequency of defecations, pain, pouchitis and inflammation.

Tissue infiltration of IgG4+ plasma cells in symptomatic patients with ileal pouch-anal anastomosis

Background Inflammatory bowel disease (IBD) is reported to be associated with autoimmune pancreatitis. The aim of the study was to investigate serum IgG4 and tissue infiltration of IgG4+ plasma cells in symptomatic patients with ileal pouches. Methods Ninety-seven consecutive persistent symptomatic patients with ileal pouches from our subspecialty Pouchitis Clinic from January to December 2010 were included in the study. Serum IgG4 was measured at the time of presentation. All patients underwent pouchoscopy with pouch biopsies immunostained for IgG4+ plasma cells. Patients with ≥ 10 per high-power field of IgG4+ plasma cells were considered positive for the stain. Results Twenty-eight (28.9%) patients had positive IgG4 immunostaining of pouch and/or afferent limb biopsy, while the remaining 69 patients (71.1%) were IgG4 negative. Demographic and symptoms were similar between the two groups. The median serum IgG4 in the IgG4 positive group was 21.3 (interquartile range 0–41.3) mg/dL vs. 0 (interquartile range 0–18) in the IgG4 negative group. (p = 0.04). On multivariate analysis, the Pouchitis Disease Activity Index (PDAI) endoscopy score in the pouch (odds ratio [OR] 1.66, 95% confidence interval [CI]: 1.21–2.29, p = 0.002) and number of concomitant autoimmune disorders (OR 3.04, 95% CI: 1.22–7.53, p = 0.017) were independent risk factors for the presence of IgG4+ plasma cell infiltration. Conclusions Increased IgG4+ plasma cells were found in 1/4 of IPAA patients with persistent symptoms. The presence of tissue infiltration of IgG4+ plasma cells appeared to be associated with chronic pouch inflammation and concurrent autoimmune disorders.

Relapse of Crohn’s disease following ileal pouch-anal anastomosis: MDCT and MR features

The purpose of our study is to use MDCT and MR imaging to describe the normal ileal pouch and to identify features of Crohn's disease (CD) relapse in patients after ileal pouch-anal anastomosis (IPAA). After total colectomy followed by IPAA, features, optimally evaluated with pelvic MRI, such as fistulas, abscesses, pouch inflammation, and stenoses, indicate CD relapse. Although uncommon, radiologists should be aware that these imaging features strongly favor this diagnosis.

Relationship between endoscopic findings of the pouch and bowel frequency after restorative proctocolectomy in ulcerative colitis

Background and aim: Pouchitis is one of the late complications of restorative proctocolectomy in ulcerative colitis (UC) and is associated with increased bowel frequency. The present study aimed to clarify the endoscopic findings that are associated with bowel frequency. Patients and methods: The macroscopic and microscopic features in the ileum proximal to the pouch, the pouch, and the remnant short rectum in 100 endoscopies on 63 patients were studied retrospectively. Results: Four of 28 (14%) patients had inflammatory changes in the proximal ileum. Sixty-seven percent of patients showed an abnormal appearance of the pouch. Granularity, friability, presence of mucus, erythema, and erosions were significantly related to bowel frequency. ‘Endoscopic pouch activity index’ (EPAI), which is the number of positive findings of diffuse erythema, mucus, friability, ulcer, erosion, and granularity, was strongly associated with bowel frequency (P < 0.0001). Patients without macroscopic inflammation in the rectum had significantly lower bowel frequency than those with mild or moderately active inflammation (P = 0.0294 and 0.0183, respectively). Multivariate analysis revealed that ‘endoscopic pouch activity index’ and histological grade of pouch inflammation were significant factors (P = 0.0004 and P = 0.0429, respectively) influencing bowel frequency. Time–course study demonstrated that changes in EPAI and macroscopic grade of the rectum were significantly related to alteration in bowel frequency (P = 0.0120 and 0.0244, respectively). Conclusion: Erythema, mucus discharge and granularity were significantly related to bowel frequency. EPAI may be useful to evaluate endoscopic pouch inflammation.

Effect of bakuchiol on leukocyte functions and some inflammatory responses in mice.

The effects of bakuchiol, a meroterpenoid isolated from the leaves of Psoralea glandulosa L., on phospholipase A2 (PLA2) activity from different sources, human neutrophil responses, zymosan air pouch and topical inflammation in mice, were investigated. This natural product was a weak inhibitor of secretory and intracellular PLA2 but dose-dependently reduced the formation of LTB4 and TXB2 by human neutrophils and platelet microsomes, respectively. In addition, bakuchiol inhibited degranulation in human neutrophils, whereas superoxide generation was not affected. In mice, bakuchiol decreased cell migration, myeloperoxidase activity and eicosanoid levels in the air pouch inflammation induced by zymosan. After topical administration, this compound was effective as an inhibitor of oedema and myeloperoxidase activity in the 12-O-tetradecanoylphorbol 13-acetate (TPA)-induced ear oedema and significantly reduced the PGE2 content and ear oedema in the arachidonic acid-induced response. Bakuchiol is a natural anti-inflammatory agent able to control leukocytic functions such as eicosanoid production, migration and degranulation in the inflammatory site.

A hypothesis for the mode of action of anti-rheumatic drugs in a model of cartilage destruction.

Abstract We have been using as a model rats and mice with air pouches which develop lining cells closely resembling synovium (Edwards et al 1982; Sedgwick et al 1983). These pouches when sufficiently mature, i.e. 6 days, will respond to a variety of stimuli both immune and non-immune with long lasting exudates containing many migrated leucocytes (Sedgwick et al 1983, 1984a). We examined the breakdown of cartilage in both inflamed and non-inflamed pouches and have found that inflammation protected the rate of loss of proteoglycan from cartilage (Sedgwick et al 1984b. 1985; Willoughby et al 1985). Invariably the cartilage in the inflamed air pouch would float free in exudate while cartilage, in the non-inflamed pouch would adhere to the pouch wall in close proximity to the macrophages and fibroblasts of the lining cells. Unpublished findings from this department (de Brito) have shown that the presence of granulation tissue in close proximity to cartilage will speed proteoglycan loss.

Irritable pouch syndrome is characterized by visceral hypersensitivity

Irritable pouch syndrome (IPS) is a functional disorder in patients with ileal pouch-anal anastomosis (IPAA), which presents with symptoms in the absence of structural abnormalities of the pouch. Thus, it resembles other functional disorders, such as irritable bowel syndrome characterized by visceral hypersensitivity in the presence of normal rectal biomechanics. The aim was to assess pouch biomechanics and perception of balloon distension in different groups of subjects with IPAA and to correlate the findings with clinical features. Pouch tone, compliance, and sensation to balloon distension were measured in 18 patients with IPS, 11 patients with active pouch inflammation (pouchitis or Crohn's disease of the pouch), and 12 asymptomatic subjects with normal pouches. All patients were recruited from a subspecialty Pouchitis Clinic. Scores of sensation of gas, urge to defecate, and pain measured by visual analog scales at various distension pressures were significantly higher in IPS than pouchitis and normal pouch patients. Pouch tone was comparable among the groups and compliance was reduced in the pouchitis group. The visual analog scale showed a trend of correlation with the Pouchitis Disease Activity Index symptom scores in IPS. IPS, like other gut functional disorders, is characterized by visceral hypersensitivity, with normal pouch biomechanics.

Anti-inflammatory activity of Terminalia paniculata bark extract against acute and chronic inflammation in rats

Terminalia paniculata Roxb. (Family-Combretaceae) is a wild tree commonly used in traditional ayurvedic medicine for the treatment of inflammation of parotid glands and in menstrual disorders. To explore the folk use of Terminalia paniculata on pharmacological grounds to evaluate the scientific basis of anti-inflammatory activity. The anti-inflammatory activity of Terminalia paniculata was studied against carrageenan-induced hind paw edema, air pouch inflammation and complete Freund's adjuvant (CFA)-induced arthritis in rats. The aqueous extract of Terminalia paniculata bark (TPW) was administered at the concentrations of 100, 200 and 400mg/kg body weight. TPW showed significant (p<0.05) anti-inflammatory activity by reducing the edema volume in carrageenan-induced paw edema in rats. Further, TPW (400mg/kg) also reduced the carrageenan-induced leukocyte migration (50.92 ± 5.71%) and myeloperoxidase activity (49.31 ± 5.24%) in air pouch exudates. TPW (200mg/kg) exhibits anti-rheumatic and analgesic activities by improving the altered haematological milieu (ESR, CRP, RF, WBC, RBC and Hb) and also by inhibiting the flexion scores and radiographic changes in CFA-induced arthritis. This extract also had significant (p<0.05) effects on the occurrence of secondary lesions compared to CFA control. Terminalia paniculata bark may be a potential preventive or therapeutic candidate for the treatment of chronic inflammation and arthritis.

Increased numbers of immature plasma cells in peripheral blood specifically overexpress chemokine receptor CXCR3 and CXCR4 in patients with ulcerative colitis

Ulcerative colitis (UC) is a chronic inflammatory bowel disease featuring infiltration by plasma cells producing immunoglobulins. We have reported previously the specific and significant proliferation of immature plasma cells in the inflamed colonic and pouch mucosa of UC patients. The aim of this study was to characterize peripheral blood immature plasma cells and the migration mechanisms of such immature plasma cells to inflamed sites in UC. The characteristics of peripheral blood immature plasma cells and chemokine receptor expression were examined by flow cytometry. Expression of mucosal chemokine was quantified using real-time reverse transcription-polymerase chain reaction and immunohistochemistry. The number of peripheral blood immature plasma cells was significantly higher in patients with active UC and active Crohn's disease (CD) than in healthy controls. The proportion of immature plasma cells was correlated positively with clinical activities of UC and CD. Many peripheral blood immature plasma cells were positive for CXCR3, CXCR4, CCR9 and CCR10. Expression of CXCR3 and CXCR4 in UC patients was significantly higher than in controls. CXCL9, CXCL10 and CXCL11 mRNA levels in colonic mucosa of inflamed IBD were higher than in controls. Immunofluorescence study also showed abundant CXCR3-positive immature plasma cells in the inflamed colonic mucosa of UC. Increased numbers of immature plasma cells may migrate towards inflammatory sites of UC via the CXCR3 axis, and may participate in UC pathogenesis.

Crohn's Disease of the Ileal Pouch 16 Years After Proctocolectomy for Ulcerative Colitis

This 34-year-old man is referred to our institution for possible Crohn’s disease. He was diagnosed with ulcerative colitis at age 6 years. His disease was eventually refractory to medical therapy, and he underwent a 2-stage proctocolectomy with ileal J-pouch to anal sewn anastomosis and temporary ileostomy at age 17 years. After takedown of the ileostomy his bowel function stabilized, with 6 stools daily with abdominal cramping pain, fecal urgency, and smallvolume nocturnal fecal incontinence. He had minimal improvement in symptoms with alternating courses of metronidazole and ciprofloxacin. Pouch endoscopy at age 33 showed multiple pouch ulcers. The anti–Saccharomyces cerevisiae antibodies (ASCA) and the perinuclear antineutrophil cytoplasmic antibody (p-ANCA) were negative. He had temporary relief of symptoms with courses of prednisone 20 mg daily, with recurrence after discontinuation. He developed postprandial abdominal cramping pain, abdominal distention, and nausea that gradually worsened and was not relieved by prednisone 40 mg daily. He did not improve with azathioprine. He developed severe bronchospasm during initial infusion of infliximab, and it was discontinued. At the time of referral he appears about 5 kg below ideal weight. The pouch-anal anastomosis is normally patent. Pouch endoscopy reveals multiple deep ulcers in the pouch and ulcers and narrowing of the lumen in the pre-pouch ileum (Figure 1), and biopsies show nonspecific ileitis. A contrast pouchogram shows a fistula from the pouch to the proximal ileum and a stricture in the pre-pouch ileum, with dilatation of the more proximal ileum (Figure 2). He undergoes abdominal exploration; there is a tight stricture at the junction of the pre-pouch ileum and the proximal pouch, and the distal 20 cm of the pre-pouch ileum is markedly dilated. There is a tight stricture in the midpouch, and the proximal pouch is very large. The pouch is disconnected from the anus and reduced in size. Two strictureplasties are performed, and the pouch is reanastomosed to the anus, and a temporary diverting ileostomy is placed. Azathioprine and adalimumab are started. The temporary ileostomy is taken down after 6 months. At 2 years after his most recent surgery, he reports about 6 stools daily, with rare nocturnal fecal incontinence and daily mild abdominal cramping pain. He continues on azathioprine and adalimumab. Pouch endoscopy shows scattered superficial ulcers in the pouch, with a normal pre-pouch ileum. Laboratory studies including C-reactive protein are normal (Figure 3). Case Discussion Despite advances in diagnostic methods during the past 30 years, there remains uncertainty in differentiating ulcerative colitis from Crohn’s disease of the colon in about 10% of patients. This subset of colitis has been termed indeterminate colitis, and more recently the term inflammatory bowel disease unclassified (IBDU) has been proposed. In a European multicenter study of 97 patients with indeterminate colitis as defined by clinical, radiographic, endoscopic, and histologic criteria, 48.5% were negative for both ASCA and p-ANCA. After a mean follow-up of 9.9 years, only 14.9% of those patients with IBDU who were ASCA and p-ANCA negative developed Crohn’s disease (as did the patient in this case discussion) or ulcerative colitis compared with 48% of patients with a positive serology, with ASCA/p-ANCA as a predictor of Crohn’s disease and ASCA/p-ANCA as a predictor of ulcerative colitis. This patient most likely had Crohn’s disease from the onset, with recurrence in the ileal pouch and pre-pouch ileum after colectomy and pouch anal anastomosis. It was not possible to determine by endoscopy whether inflammatory changes limited to the pouch were due to idiopathic pouchitis or to Crohn’s disease. Pouch biopsies occasionally show noncaseating granulomas, indicative of Crohn’s disease, but this is the exception, and no granulomas were found on biopsies in this patient. There was a pouch to ileal fistula as well as ulceration and stenosis in the pre-pouch ileum; these are hallmarks of Crohn’s disease and are not features of idiopathic pouchitis. The patient had minimal improvement with metronidazole and ciprofloxacin, and this is atypical for patients with idiopathic pouchitis, because a majority responds favorably to antibiotics. Failure to achieve an acceptable symptomatic improvement with antibiotics raises the possibility of another etiology for the pouch inflammation, such as Crohn’s disease as in the case of this patient, or obstruction for a

Anti-Inflammatory Effect of Fermented Artemisia princeps Pamp in Mice

Abstract － Essential oil-excluded Artemisia princeps Pamp var Ssajuarissuk (AP) was fermented with Lactobacillus brevis K-1, which was isolated from cabbage Kimchi, and the anti-inflammatory effects of AP and fermented AP (FAP) on lipopolysaccharide (LPS)-induced inflammatory response in peritoneal macro-phages were investigated. AP and FAP inhibited LPS-induced TNF-α, IL-1β, COX-2, iNOS and COX-2 expression, as well as NF-κB activation. AP and FAP also reduced ear thickness, inflammatory cytokine (TNF-α, IL-1β and IL-6) expression and NF-κB activation with 12-O-tetradecanoylphorbol-13-acetate (TPA) induced dermatitis in mice. Furthermore, AP and FAP also reduced exudate volume, cell number, protein amount, inflammatory cytokines (TNF-α, IL-1β and IL-6) expression and NF-κB activation in carrageenan- induced air pouch inflammation in mice. The inhibitory effects of FAP were more potent than those of non-fermented AP. Based on these findings, we propose that FAP can improve inflammatory diseases, such as dermatitis, by inhibiting the NF-κB pathway.Keywords: