Charles W. Andrews

Pathologic features and clinical significance of "backwash" ileitis in ulcerative colitis.

Patients with ulcerative colitis (UC) may develop inflammation in the distal ileum thought to be due to “backwash” of cecal contents (“backwash ileitis”). However, a systematic analysis of ileal changes in UC has never been performed, and the prevalence and criteria for “backwash” ileitis have not been defined. The aim of this study was to evaluate the prevalence and spectrum of inflammatory changes in the ileum in patients with UC and to correlate ileal changes with outcome after total proctocolectomy and ileal pouch-anal anastomosis. Routinely processed ileocolonic resection specimens from 200 consecutive patients with clinically and pathologically confirmed UC were evaluated for a wide variety of pathologic features in the ileum and colon. The ileal data were correlated with both the clinical features and the pathologic findings in the colon. Follow-up data were obtained to confirm absence of Crohns disease and to evaluate outcome of ileo-anal pouches. Overall, 34 of 200 (17%) UC patients had inflammatory changes in the ileum (male/female ratio, 16/18; mean age, 42 years); 32 of 34 (94%) had pancolitis, which was significantly higher than the rate of pancolitis (39%) in patients without ileal disease (N = 166) (P < 0.001), but there were no other differences between patients with or without ileal pathology. In the colon, 22 of 34 (65%) patients had severe activity. Ileal changes included villous atrophy and crypt regeneration without increased inflammation (N = 3), increased neutrophilic and mononuclear inflammation in the lamina propria (N = 6), patchy cryptitis and crypt abscesses (N = 21) and focal superficial surface erosions (N = 4), some with pyloric metaplasia (N = 2 of 4). In general, the severity of ileal changes paralleled the severity of colonic activity. However, 2 of 4 (50%) patients with superficial erosions in the ileum had subtotal or left-sided colitis only, and had only mild colonic activity. Other cases showed only mild to moderate colonic activity and patchy or discontinuous involvement of the distal ileum. Upon follow-up of patients with erosions (mean, 48.5 months; range, 26-102 months), none developed manifestations of Crohns disease anywhere in the gastrointestinal tract. The presence of inflammatory changes in the ileum had no effect on the prevalence of pouch complications or on the occurrence of dysplasia or cancer. Ileal changes in UC are not uncommon (prevalence, 17%), are generally mild in nature (villous atrophy, increased inflammation, scattered crypt abscesses), and are not associated with an increased rate of ileo-anal pouch complications, dysplasia, or carcinoma. In some cases, our findings are consistent with a backwash etiology. However, rarely, ileal erosions may occur in patients without cecal involvement, which may indicate that other pathogenetic mechanisms should be considered in the etiology of ileitis in UC patients.

Prospective evaluation of early morphological changes in pelvic ileal pouches

BACKGROUND/AIMS Little is known about the evolution of morphological changes in pelvic ileal-pouch mucosa. This study evaluates prospectively the sequence of early morphological, histochemical, and phenotypic features in pouch mucosal biopsy specimens. METHODS Twenty-two patients with pelvic ileal pouches constructed after total colectomy for chronic ulcerative colitis had biopsies performed at the time of ileostomy closure and after 6 weeks and 6 months of pouch function and were evaluated to assess the type and degree of inflammation, villus atrophy, Paneths cell hyperplasia, mucin histochemical changes, the mucosal proliferative activity using the murine monoclonal antibody 1 (MIB-1), and the expression of the enzyme sucrase-isomaltase. RESULTS Early changes (6 weeks) were characterized by neutrophilic and eosinophilic inflammation, mild villus atrophy, Paneths cell hyperplasia, a partial transition to colonic mucin phenotype, and an increased MIB-1 proliferation index. These features remained relatively stable after 6 months, except for a greater degree of mononuclear infiltration, a progressive increase in the degree of eosinophilic inflammation and a new higher steady state level of crypt epithelial kinetics. Expression of sucrase-isomaltase remained stable. CONCLUSIONS Pelvic ileal pouches develop inflammatory, phenotypic, and kinetic changes early in the course of function but have only a limited potential for colonic type metaplasia. The persistence of these changes is evidence in support of an adaptive response to a new luminal environment.

The effect of transfection of the CEA gene on the metastatic behavior of the human colorectal cancer cell line MIP-101

Carcinoembryonic antigen (CEA) has been shown to increase the metastatic potential of some human colorectal cancer cell lines. To investigate further the mechanisms involved we have produced three clones (6, 8 and 17) from the poorly differentiated human colorectal cancer cell line MIP-101 that have been transfected with the full length cDNA encoding for human carcinoembryonic antigen (CEA). They produce CEA with a mol. wt. of 180000 by Western blotting and secrete it into the culture medium. Clone 6 is a high CEA producer, clones 8 and 17 are intermediate producers. The doubling time for clone 8 was similar to that of the parent cell line while clones 6 and 17 had doubling times nearly twice that of the parent cells. These clones are tumorigenic when injected subcutaneously in nude mice are positive for CEA by immunoperoxidase staining and the mice have elevated blood levels of CEA. Clone 6 formed large aggregates in culture while clone 17 formed smaller aggregates. Clone 8 behaved like the parent cell line with rare cell/cell contact. Clones 6 and 17 also adhered to CEA coated plastic while clone 8, a neo-transfected control and the parent cell line did not. A significant increase in the incidence of hepatic tumors was observed with clone 6 (P < 0.01) and clone 17 (P < 0.02) following intrasplenic injection into nude mice. Immunohistopathology of the hepatic tumors showed strong CEA staining from clones 6 and 17 with weak staining from clone 8. The parent cell line was negative for CEA as were the neo-transfected controls. Of the neo controls none of 10 had liver colonies. Mice injected with clone 6 which developed liver metastasis had the highest plasma levels of CEA (37.3 +/- 8.8 ng/ml). We observed strong CEA staining in Kupffer cells in the normal liver adjacent to the CEA producing tumors. This study provides further evidence for the involvement of CEA in the metastatic process.

A new transcription factor that regulates TNF-α gene expression, LITAF, is increased in intestinal tissues from patients with CD and UC

Background: The proinflammatory cytokine tumor necrosis factor‐&agr; (TNF‐&agr;) plays a key role in the pathogenesis of Crohns disease (CD) and ulcerative colitis (UC). Recently, a new transcription factor termed LITAF (lipopolysaccharide‐induced TNF‐&agr; factor) was shown to mediate TNF‐&agr; expression in human macrophages by direct binding to specific sequences in the promoter region of the TNF‐&agr; gene. Methods: In this report, we identified LITAF in resected ileal and colonic tissues from patients with CD and UC by immunohistochemistry, real‐time polymerase chain reaction, and Western blot analysis. LITAF expression in inflamed and noninflamed areas of the tissues was compared. Results: This is the first demonstration of LITAF, a newly discovered transcription factor that regulates TNF‐&agr; gene transcription in ileal and colonic tissues from patients with either CD or UC. LITAF immunostaining was localized to lamina propria macrophages and was markedly increased relative to tissues from controls without inflammatory bowel disease. In patients with CD, a 5‐fold increase in LITAF mRNA was measurable in noninflamed colonic tissues compared with controls without inflammatory bowel disease. LITAF mRNA in tissues from inflamed areas of the colon was increased by an additional 60% compared with noninflamed tissues. In patients with UC, LITAF mRNA levels in colonic tissues resected from noninflamed areas were elevated 15‐fold above nondisease controls, but they were not different in tissues resected from inflamed areas. Western blot analysis showed that in patients with CD, there was a marked increase in LITAF protein in inflamed areas compared with noninflamed areas. LITAF protein levels were not different between noninflamed and inflamed tissues obtained from patients with UC. TNF‐&agr; mRNA and protein levels paralleled LITAF. Similarly, in inflamed ileal tissues from patients with CD, LITAF is also localized to lamina propria macrophages. LITAF mRNA and LITAF protein were significantly increased in inflamed ileal tissues compared with noninflamed areas. Conclusions: LITAF is readily detectable in ileal and colonic tissues from patients with either CD or UC, is significantly elevated above controls, and is localized to macrophages, a major source of TNF‐&agr;. These data provide strong evidence of a role for LITAF in the pathophysiological regulation of the TNF‐&agr; gene and underscore the potential value of anti‐LITAF strategies in the clinical management of these diseases.

Normal colonic epithelium adheres to carcinoembryonic antigen and type IV collagen.

BACKGROUND/AIMS Human colorectal carcinoma cells bind to collagen and laminin in the basement membrane as well as to carcinoembryonic antigen (CEA) on neighboring cells. The purpose of this study was to determine whether normal colonic epithelial cells bind to CEA, collagen, or laminin. METHODS Intact colonic crypts were isolated from normal mucosa in 13 specimens resected for colorectal carcinoma or colonic diverticulitis. Colonocytes were released from the crypts by treatment with collagenase and deoxyribonuclease and tested for adhesion to CEA, type IV collagen, and laminin in a solid-phase adhesion assay. RESULTS Twelve percent to 25% of colonocytes in all specimens bound to CEA. Colonocytes from seven specimens also bound to type IV collagen, but none of the colonocyte preparations bound significantly to laminin. Monoclonal antibodies to CEA and to the hyaluronate receptor CD44 and enzymatic removal of membrane CEA blocked the adhesion of colonocytes to CEA. CONCLUSIONS First, colonocytes use the same epitopes on CEA and CD44 as colorectal carcinoma cells to adhere to solid-phase CEA. Second, colonocytes bind to solid-phase CEA through CEA-to-CEA homophilic binding. Third, CEA and type IV collagen, but not laminin, are adhesion ligands for human colonocytes.

Sucrase-isomaltase expression in chronic ulcerative colitis and dysplasia☆☆☆

Sucrase-isomaltase (SI) is a mucosal disaccharidase that is present in normal small intestine and fetal colon. It also has been noted in colonic adenomas and adenocarcinomas. We used a polyclonal antibody to human SI to investigate enzyme presence and utility in detecting dysplastic changes in chronic ulcerative colitis. Sections from 32 cases were reviewed for the presence or absence of active colitis and dysplasia. Immunostaining of these cases for SI was performed and the results were reported based on location of immunoreactivity (ie, membrane and cytoplasmic staining in superficial and crypt epithelial cells) and percentage of positivity. Of 81 sections examined, 48 were rated negative for dysplasia (23 inactive colitis, 20 active, and five probably negative) and 28 were rated positive (eight low grade and 20 high grade). Surface membrane staining of epithelial cells was noted in all 28 dysplastic slides and positive cases (sensitivity, 100%) but also in 29 of 48 negative sections (P less than .001). In contrast, cytoplasmic positivity was present in 25 of 28 dysplastic and in only two of 48 negative slides (P less than .0001). The presence of cytoplasmic staining of SI in the superficial or crypt cells revealed a sensitivity of 92% and a specificity of 94%. There were five additional sections rated as indefinite for dysplasia (probably positive or unknown); two showed staining patterns typical of negative slides and three showed positive staining patterns. Of the 18 samples of transitional mucosa next to areas of dysplasia, surface membrane staining of SI was seen in all samples and cytoplasmic staining was seen in 15. We conclude that membrane staining of SI can be detected in inflammatory, regenerative, and dysplastic mucosa in ulcerative colitis. Cytoplasmic staining, however, correlates strongly with the presence of dysplastic change and may help in its detection.

Sucrase-isomaltase is an independent prognostic marker for colorectal carcinoma

PURPOSE: Expression of disaccharidase sucrase-isomaltase (SI) is significantly enhanced during neoplastic transformation of colonic epithelium. Our study was designed to determine whether expression of SI within primary tumors was significantly associated with survival in patients with colorectal carcinoma (CRC). METHODS: SI expression was analyzed by immunohistochemistry in paraffin sections from 182 Stage I to III CRC that had been resected for cure at the New England Deaconess Hospital between 1965 and 1977. Expression was scored as absent or present in 1 to 50 percent or more than 50 percent of tumor cells. Associations were explored among SI expression, other clinical or pathologic variables, and overall survival. The data set is mature, with 91 (56 percent) patients who had died of CRC at a median follow-up of 96 months. RESULTS: Fifty-five percent of primary CRC expressed SI. When the multivariate Cox analysis was performed, nodal status, T stage, primary site, grade, and SI expression were independent covariates. SI expression was not associated with the expression of other clinicopathologic variables but increased the risk of death from colorectal carcinoma by 1.83-fold. DISCUSSION: These results indicate that SI is a prognostic marker for CRC that is independent of stage-related variables in patients who have undergone potentially curative resections.

Localization of tumor-associated glycoprotein DF3 in normal, inflammatory, and neoplastic lesions of the colon

Background. The expression of DF3 was assessed by a monoclonal antibody in normal, inflammatory, and neoplastic conditions in the large bowel.

Ampullary stenosis with biliary obstruction in duodenal Crohn's disease: a case report and review of the literature.

A 24-year-old male was admitted for closure of a loop ileostomy. Three months earlier, he had undergone a total colectomy with an ileal pouch–anal anastomosis (IPAA) for ulcerative colitis (UC) refractory to medical therapy. UC was diagnosed in 1996 after the patient presented with bloody diarrhea. A colonoscopy shortly before the colectomy showed diffuse and continuous colitis from the rectum to the hepatic flexure. Biopsies revealed severe acute and chronic inflammation with gland branching and crypt abscesses consistent with chronic inflammatory bowel disease (IBD). No granulomas were seen. A UGI/SBFT follow-through was normal. The results of an IBD-antibody marker panel from Prometheus, Inc., San Diego, California ([+] PANCA and [−]ASC), were also suggestive of UC. Following the ileostomy closure, the patient developed sinus tachycardia and hypertension, with a heart rate in the 130s and a blood pressure of 200/100. Thyroid function tests were obtained. His thyroid stimulant hormone (TSH) was <0.01 μIU/ml (ref. range, 0.35–5.50 IU/ml) and his free thyroxine level (FT4) was 13.4 IU/ml (ref. range, 1.0–4.0 IU/ml), supporting a diagnosis

Sucrase-Isomaltase Expression in Dysplasia Associated With Barrett's Esophagus and Chronic Gastritis

Aberrant cytoplasmic sucrase-isomaltase has been detected in colonic neoplasia, including dysplasia in ulcerative colitis. We investigated expression by immunostaining in 28 cases of Barretts esophagus and 67 cases of chronic gastritis. Staining location (membrane or cytoplasmic) and percent positivity (< 1% = 0; 1-50% = 1+; > 50% = 2+) were record ed. Fifteen cases with Barretts esophagus were negative for dysplasia, 1 was indefinite, and 12 were positive. All demonstrated surface membrane staining, while 2 of the 15 neg ative (1+) cases, 0 of the 1 indefinite case, and 11 of the 12 dysplastic (2+ in 7) cases revealed cytoplasmic positivity (P < .001). In chronic gastritis (23 were negative, 5 were indefinite, and 39 were positive) all revealed surface membrane staining, whereas cyto plasmic positivity was present in 1 of 23 negative (1+) cases, 1 of 5 indefinite cases, and 37 of 39 dysplastic (2+ in 18) cases (P < .001). In Barretts esophagus and chronic gastri tis, cytoplasmic sucrase-isomaltase expression strongly correlates with the presence of dys plasia. Int J Surg Pathol 2(4).-281-286, 1995