Main Category: Crohn’s / IBD
Also Included In: Radiology / Nuclear Medicine
Article Date: 16 Jun 2011 – 3:00 PDT

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A new study from Rhode Island Hospital has found that MR enterography (MRE) without the use of an anti-peristaltic agent were as reliable as CT enterography (CTE) in determining the presence of Crohn’s disease. Additionally, MRE reduces the patient’s exposure to ionizing radiation. The study is now published online in advance of print in the European Journal of Radiology.

Lead author David J. Grand, M.D., director of the Body MRI program at Rhode Island Hospital, found that MR enterography without anti-peristaltic agents results in high diagnostic confidence for the presence or absence of Crohn’s disease when compared to CT enterography. To limit exposure to ionizing radiation in young patients, MR enterography may be considered a first-line study for the evaluation of known or suspected Crohn’s disease.

“This is an important discovery in the diagnostic process for Crohn’s disease,” said Grand. “This information will help us to develop safer approaches toward testing, helping to lower patients’ exposure to radiation, while still maintaining the integrity of diagnosis.”

The study included 26 patients to be tested for known or suspected Crohn’s disease. The patients underwent CTE immediately followed by MRE without the use of an anti-peristaltic agent. Two fellowship-trained abdominal imagers evaluated each study on a 10-point scale for exam quality, level of diagnostic confidence and presence of Crohn’s disease. The CTE and MRE images were reviewed in random order with at least two weeks separating interpretation of the test results of a single patient.

While the quality of the MREs was ranked slightly lower than the quality of the CTEs, both tests were judged with similarly high rankings for level of confidence in interpretation.

Crohn’s disease, a form of imflammatory bowel disease (IBD), is a chronic, relapsing, auto-immune disorder that may affect any portion of the gastrointestinal tract, most commonly the terminal ileum. The incidence of IBD has increased 31 percent in the U.S. since 1991. Cross-sectional imaging is currently a mainstay of evaluation of patients with Crohn’s disease due to its ability to assess the entire bowel and extra-luminal complications including fistula and abscess. Recently, however, MRE has demonstrated excellent efficacy both in detection of Crohn’s disease as well as in differentiation of active from chronic small bowel changes.

While CTE has proven to be an effective tool in diagnosing Crohn’s disease, the radiation dose the patient receives is up to five times higher than that of small-bowel follow through, the test it has largely replaced. In one population-based study, diagnostic imaging exams exposed the majority of Crohn’s patients to an additional annual radiation does equal to the annual background radiation in the U.S., while a subset of patients received up to 11 times this additional dosage.

MRE can eliminate ionizing radiation exposure in the population of patients who often present while young and undergo multiple imaging exams throughout their lives.

Additionally, all published literature to date has used a pharmacologic anti-peristaltic agent to minimize motion artifacts. While the agents may improve subjective image quality, their use has not been shown to be diagnostically necessary and administration complicates exam protocol and increases expense. This study demonstrates that the anti-peristaltic agents may not be necessary, and suggests a simplified protocol of MRE which maintains diagnostic yield while decreasing complexity and expense.

The principle affiliation of Grand is Rhode Island Hospital (member hospital of the Lifespan health system in Rhode Island). Direct financial and infrastructure support for this project was received through the Lifespan Office of Research Administration. The researcher also has an academic appointment at The Warren Alpert Medical School of Brown University.

Source:
Ellen Slingsby

Lifespan

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Main Category: Veterinary
Also Included In: Crohn’s / IBD
Article Date: 10 Jun 2011 – 9:00 PDT

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When a dog turns up in their consulting room with chronic diarrhoea, vomiting and weight loss, then it is quite likely that the vet will call it a case of inflammatory bowel disease. But that is probably the only thing that they can say with any confidence after identifying one of the most enigmatic and frustrating conditions seen in small animal practice.

The cause of the disease is uncertain, the best treatment is still a mystery and even in those patients that do appear to be getting better, then the owner must appreciate that their pet’s condition is only under temporary control, it is rarely ever cured. However, first opinion practitioners may have a better idea of the task awaiting them and improve the odds of a satisfactory response, after attending the session on the diagnosis and treatment of canine disease by Alex German at this year’s BVA Congress. His talk is part of the excellent clinical programme designed by BSAVA to offer a greater small animal science presence at BVA Congress, 22-24 September, London.

Dr German, holder of a European diploma in internal medicine and a lecturer at the Liverpool veterinary school, will explain that IBD is not a single condition but a group of similar disorders characterised by persistent or recurrent gastrointestinal signs, with histological evidence of intestinal inflammation.

In many respects canine IBD is very like the common human condition, though there are key differences in the underlying pathology, he says. The inflammatory process in the intestinal wall will be found on biopsy to be lymphocytic-plasmacytic in origin whereas the two main forms of human IBD are neutrophilic in ulcerative colitis and granulomatous in Crohn’s disease.

Yet in both species the condition is largely seen to be rooted in a defective immune response triggered by a range of infectious, environmental and genetic factors. The search for specific gene factors has so far proved fruitless but the apparently excessive numbers of cases from particular breeds, notably German shepherd dogs, shar peis and Norwegian lundehunds certainly points in that direction.Another breed which is overrepresented in the list of canine IBD cases in the boxer which has a granulamatous form of disease more closely allied with Crohn’s disease. It is a condition for which US researchers appear to have found a trigger in the form of invasive E coli bacteria infiltrating from the dog’s gut. Dr German says there is increasingly strong evidence to show that an abnormal response to the patient’s normal gut flora is a key feature of the disease in many of its different forms.

Once established there does appear to be mainly an immunological problem and steroid therapy will usually be the mainstay of any successful therapy. But antimicrobial treatment can often be helpful in getting the condition under control, and dietary management particularly with low allergenic hydrolised protein may help to keep it that way. The use of probiotics is favoured by some clinicians but there is no convincing evidence that they can provide significant benefits other than as an adjunct therapy in already well controlled cases.

However, achieving the goal of controlling the symptoms of canine IBD is no easy task and the dog’s owner will have to accept a certain amount of trial and error in the treatment until the specific trigger factors can be identified in that individual animal. But once the particular features of the disease have been found then there is every chance that it can go on to enjoy a good quality of life.

Notes

1. Alex German BVSc(Hons), PhD, CertSAM, DipECVIM-CA, MRCVS is a graduate of Bristol University, and received his PhD from the same institution in 2000. He is currently Royal Canin Senior Lecturer in Small Animal Medicine’ at the University of Liverpool. His research interests include small animal gastroenterology and obesity biology.

2. Session title: Diagnosis and treatment of inflammatory bowel disease in the dog, 9.45am Saturday 24 September

3. BVA Congress, in association with BSAVA, will be held in London on 22-24 September 2011 under the theme ‘Vets in a Changing World’.

Source:

British Veterinary Association

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Main Category: Crohn’s / IBD
Article Date: 02 Jun 2011 – 9:00 PDT

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The first study of the social and ethical issues associated with a provocative approach to treatment for ulcerative colitis has found that the majority of potential patients are eager for what is now called “fecal microbiota transplantation” to become available, although many have concerns about donor selection, screening, and methods of delivery.

Bacterial aggregates derived from fecal matter have been used sporadically to treat gastrointestinal disease for more than 50 years. These were often last-ditch efforts aimed at restoring microbial balance for patients with raging intestinal infections. More recently, the approach has produced lasting remissions for a small number of patients with a common disease: ulcerative colitis.

“Once patients get past the yuck factor they find the concept appealing,” said study author David Rubin, MD, associate professor of medicine at the University of Chicago. “They perceive it as ‘natural,’ similar to probiotics. Patients with severe inflammatory bowel disease tend to develop a high tolerance for therapies that others might consider unorthodox.”

Fecal microbiota transplantation (FMT)-also known as fecal bacteriotherapy, among other names-is an effort to calm a troubled bowel by reintroducing the vast diversity of collaborative bowel inhabitants after the usual mix has been disturbed. More than 1,000 different strains of bacteria co-exist peacefully in the typical healthy bowel. But when the delicate balance is altered, by antibiotics or other causes, a few strains can become dominant, leading to severe diarrhea, inflammation and tissue damage.

The first FMT cases, dating back to 1958, were used to treat life-threatening infections caused by aggressive bacteria that had overwhelmed the bowel, driving out the competition. When antibiotics were unable to control the infection, physicians were able to restore balance by injecting the full range of gut bacteria. They did this by collecting fecal matter from a healthy donor and injecting it into the patient’s colon.

In 2003, a team led by Australian physician Thomas Borody published a report on successful treatment of six patients with longstanding ulcerative colitis with this approach. “Complete reversal of UC was achieved in all 6 patients following the infusion of human fecal flora,” the authors reported. “These 6 cases document for the first time the total disappearance of chronic UC without the need for maintenance treatment.”

“This is a fascinating idea, and the early studies show great promise, but we found that no one had looked at the social issues surrounding fecal transplantation,” said Rubin. “Before we offer this, we wanted to find out how patients understood the process and take a look at the ethical issues that could also be raised by this therapy.”

Like an organ transplant, fecal microbiota transplantation begins with finding a donor, often a family member. The treatment team collects a fresh stool sample, at least 200 to 300 grams. The sample is mixed with salt water in a blender and filtered to remove particulate matter. It can be administered to the recipient through a colonoscope, as an enema, or-when the inflamed region is higher in the colon-through a naso-gastric tube.

Rubin and colleagues Stacy Kahn, MD, and Rita Gorawara-Bhat, PhD, organized six focus groups in 2009-2010 with patients or parents of children with ulcerative colitis to “explore the attitudes and concerns” raised by this approach. They published their findings in the June issue of the journal Inflammatory Bowel Disease.

They found that 21 out of 22 patients or parents of patients were interested in trying FMT for themselves or their child; most wished it were already available. They viewed the treatment as more ‘natural’ than using drugs to control the disease, and easier and safer than currently available therapies. Many compared it to probiotics, a popular alternative therapy among patients with colitis.

The major concerns were focused on how donors would be selected and screened. Patients wanted healthy donors, usually family members, and asked that even their diet and medications be considered. A donor who had eaten peanuts recently, for example could be hazardous for a recipient with peanut allergies.

Physicians recommend a workup similar to that of an organ donor, with careful screening for multiple pathogens, including HIV, hepatitis and other viruses, as well as various parasites and worms.

The “yuck” factor came up in the focus group discussions of bacterial delivery. Patients and parent were comfortable with the idea of a “spray” colonoscopy or delivery via enemas, but were disturbed by the idea of using a naso-gastric tube for the transfer of fecal bacteria, although this method has been used to treat Clostridium difficile infections.

“What our study ultimately tells us is that patients are not only tolerant of this therapy but are eager for it to become available,” Rubin said. “A few have already tried this strategy at home, using ‘protocols’ they found on the internet and tools available at any drug store.”

“We hope to begin offering FMT this fall,” he said, “in a carefully controlled, clinical-trial setting.”

“We are getting at least one phone call a week from patients asking about the treatment and when we are going to start treating patients,” said co-author Stacy Kahn, MD, instructor of pediatrics at the University of Chicago.

There are many things we do not yet know about the risks and benefits of FMT, the authors agreed. The safety of such a treatment and broader implications of risk remain unconfirmed, so careful preparation and more study is necessary before this can be offered to patients with ulcerative colitis.

“Many patients do benefit from proven traditional therapies,” Rubin said, “which should always be considered before experimental treatments, no matter how attractive they may sound.”

The National Institutes of Health, the University of Chicago’s Clinical and Translational Science Award, and the Gastrointestinal Research Foundation supported this study.

Source:
University of Chicago Medical Center

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