Leena Halme

Cytomegalovirus infection and development of biliary complications after liver transplantation

Background. Cytomegalovirus (CMV) infection is known to cause ulceration and mucosal hemorrhage in the gastrointestinal tract. Gastroduodenal and biliary complications were prospectively evaluated in 100 consecutive liver transplant patients in whom CMV was monitored during the first posttransplant year. Method. Gastroduodenal biopsy specimens were taken from 36 patients by endoscopies and in 28 patients by endoscopic retrograde cholangiopancreatography, and bile duct specimens were taken from three patients who underwent surgical reconstruction because of biliary complication. CMV was demonstrated from blood by the pp65 antigenemia test and from frozen sections of tissue specimens by immunohistochemistry and in situ hybridization. Results. Symptomatic CMV infection, treated with ganciclovir, developed in 49 recipients: 13 (100%) of CMV seropositive donor (D+) seronegative recipient (R−) cases, 29 (45%) D+/R+ cases, and 7 (32%) D−/R+ cases. Duodenal ulcer developed in three and hemorrhagic gastritis in three recipients. CMV antigens were found from the gastroduodenal mucosa in 37 (69%) of the 54 studied recipients. The biliary complication rate was 24%. Preceding or concomitant CMV antigenemia was demonstrated in 75% of patients with a biliary complication (68% in CMV D+/R+ or D−/R+ and 100% in D+/R− recipients). The biliary complication rate was higher among recipients with CMV antigenemia, compared with recipients without (P <0.05). CMV antigenemia, CMV infection, or both in the duodenal mucosa was found in 96% of patients with a biliary complication. In two patients who underwent surgical reconstruction, CMV antigens and DNA were demonstrated in the bile ducts. Conclusions. Liver transplant patients are at risk of developing biliary complications after CMV infection, especially those with primary CMV infection.

Oral findings in patients with active or inactive Crohn's disease

The frequency and type of oral mucosal lesions, dental infections, and salivary constituents were evaluated in 53 patients with Crohns disease, who were divided into inactive, mildly active, and severely active groups on the basis of clinical and endoscopic criteria. Buccal biopsies from nine patients with active disease showed morphologic changes that suggested Crohns disease-related lesions. Panoramic radiographs revealed more infectious foci in the teeth of patients with active Crohns disease than in patients with inactive disease. Salivary flow rate, buffering capacity, total protein, amylase, and IgA and IgG concentrations did not differ with respect to the activity of Crohns disease. The observed mucosal inflammation in patients with active Crohns disease, although high in frequency, was mild and did not need therapy, but the great number of dental infections in association with the activity of Crohns disease should be taken into account in the treatment of these patients.

Factors related to frequency, type, and outcome of anal fistulas in Crohn's disease.

PURPOSE: Relation of clinical factors to frequency, type, and, in particular, outcome of anal fistulas in Crohns disease was studied. METHODS: One hundred twelve patients seen in this hospital between January 1972 and June 1993 who suffered from Crohns disease were included in the study. Those 35 (31 percent) with anal fistulas were reexamined or interviewed and asked about their perianal symptoms and anal control. RESULTS: Rectal involvement of Crohns disease was associated with an increased incidence of anal fistula (49vs.17 percent;P<0.01), especially high ones (82vs.17 percent;P<0.01). Ten of 18 patients with low fistulas underwent fistulotomy; all 10 fistulas healed, but slowly (mean healing time, 7.5 months), and 4 of them recurred. Of eight low fistulas managed by drainage alone, four healed. Finally, 11 of 18 patients with low fistulas had their fistulas healed. Fourteen of 17 patients with high fistulas were primarily treated by drainage and 3 by local surgery. Finally, only three patients had healed fistulas—two after simple drainage and one after local surgery, and seven patients had to undergo proctectomy. Only two patients with low fistulas required proctectomy. Eight patients (33 percent) of those 24 with fistulas in whom anal continence could be assessed, 5 with local surgery and 3 with drainage alone, reported minor defects in anal control. CONCLUSIONS: Fistulotomy is a justifiable option with satisfactory results for low symptomatic anal fistulas associated with Crohns disease, although healing may be delayed and some fistulas will recur. Outcome of high fistulas is less satisfactory, and proctectomy is ultimately required in a number of patients; therefore, for high fistulas a conservative approach is primarily recommended.

Genome-wide search in Finnish families with inflammatory bowel disease provides evidence for novel susceptibility loci

Epidemiological and genetic linkage studies have indicated a strong genetic basis for development of inflammatory bowel disease (IBD) which was recently supported by discovery of the Crohns disease (CD) susceptibility gene termed NOD2/CARD15. We carried out a genome-wide linkage study in Finnish IBD families, providing a particular advantage to map susceptibility genes for ulcerative colitis (UC) within a genetic isolate. Initially, 92 IBD families with 138 affected sib-pairs (ASPs), were genotyped for 429 markers spaced at approximately 10u2009cM intervals. Next, the loci on chromosomes 2p13-11, 11p12-q13, and 12p13-12 were high-density mapped in the extended family cohort of 130 families with 173 ASPs. In this study, the most significant lod scores were observed for the UC families on chromosome 2p11 (D2S2333), in the vicinity of the REG gene cluster which is strikingly overexpressed in the IBD mucosa. The maximum two-point lod score was 3.34 (dominant model), and the corresponding NPL score 2.61. For UC, the second highest two-point NPL score of 2.00 was observed at proximal 12p13, where also some evidence for linkage disequilibrium emerged (P=0.07 and P=0.007 for the basic and extended IBD cohorts, respectively). The highest two-point NPL score for the CD families was 2.34 at D12S78 (12q23) with significant evidence for linkage disequilibrium (P=0.004), and for the mixed (MX) families 2.07 at D4S406 near the linkage peak reported previously. This study confirmed several of the IBD loci that have previously been reported and gives evidence for new IBD loci on chromosomes 2p11, 11p12-q13, 12p13-12, 12q23, and 19q13.

Peripheral arterial disease as a predictor of outcome after renal transplantation

Abstract Our aim was to assess the prevalence of symptomatic and asymptomatic peripheral occlusive arterial disease (POAD) in 129 consecutive diabetic (n= 34) and non‐diabetic (n= 95) patients undergoing renal transplantation. The association of pre‐existent POAD and complaints of claudication, lower limb amputations, and graft and patient survival were evaluated during a 5‐year follow up. A questionnaire on walking capacity, ankle/brachial (ABI) and toe/brachial (TBI) pressure indices as well as the pulse volume recording (PVR) at the ankle were used to assess resting haemodynamics and the presence of POAD 4 days after the transplantation. Unquestionable ischaemia was encountered in 5 (4 %) patients all with a history of intermittent claudication and an ABI equal or below 0.77. While using assessment methods not affected by vessel calcification, i.e. toe pressures and PVR damping, a many‐fold frequency of arterial disease was observed when compared to previous studies. TBI below 0.65 was found in 11 of diabetic (32 %) and in 15 of the others (16%), and a PVR amplitude below 5 min in 28 of diabetics (82 %) and in 34 of non‐diabetics (36 %). During the 5‐year follow up, abnormal TBI and PVR values and diabetes at the time of transplantation were the greatest risk factors for proximal foot amputations. The low TBI levels also indicated a shortened patient survival. However, transplant function was not affected by the presence of abnormal haemodynamic indices at the time of transplantation.

Gingival and dental status, salivary acidogenic bacteria, and yeast counts of patients with active or inactive Crohn's disease

To investigate dental, gingival, and salivary aspects during an exacerbation of Crohns disease, 53 patients with long-standing Crohns disease were clinically, endoscopically, and radiologically examined. The patients were divided in two groups: 32 patients had active disease and 21 patients had inactive disease. Oral examination of the patients did not reveal any statistically significant differences in gingival or dental indexes between the groups, but patients with active disease tended to have higher scores of gingivitis than patients with inactive disease despite the fact that the patients with active disease were younger than those in remission. No differences between the groups were observed in salivary flow rate or buffering capacity. Lactobacilli and yeast counts of saliva tended to be higher among patients with active disease than with inactive disease, but the difference between the groups was significant only for high mutans streptococci counts.

New Approaches in the Management of Rectal Carcinoma Result in Reduced Local Recurrence Rate and Improved Survival

OBJECTIVEnTo find out whether total mesorectal excision (TME) technique alone or combined with preoperative radiotherapy reduces local recurrence rate and improves survival.nnnDESIGNnPartly retrospective (the first period), partly prospective (the second period) study.nnnSETTINGnUniversity hospital, Helsinki, Finland.nnnSUBJECTSn144 patients between 1980 and 1990 and 61 patients between 1991 and 1997 with rectal cancer, who underwent major curative surgery.nnnINTERVENTIONSnA conventional surgical technique was used during the first period and TME alone or combined with preoperative radiotherapy when appropriate during the second period.nnnMAIN OUTCOME MEASURESnPostoperative morbidity and mortality, local recurrence rate, and 5-year survival.nnnRESULTSnAfter anterior resection 4/76 of the patients (5%) during the first period and 8/43 (19%) during the second period developed anastomotic leaks. Operative 30-day mortality was 1% (n = 1) and 0, respectively. Actuarial local recurrence rate was 17% in the first period and 9% in the second period. Actuarial crude 5-year survival improved from 55% to 78% and cancer-specific survival from 67% to 86% between the two study periods.nnnCONCLUSIONSnDespite an increased number of anastomotic complications TME is safe. Refinement of the surgical technique together with preoperative radiotherapy yields lower local recurrence rates and an improved survival compared with conventional surgery alone.

Peritoneal dialysis access : A comparison of peritoneoscopic and surgical insertion techniques

Prospectively collected data were analysed comparing 108 consecutive peritoneoscopically (n = 65) and surgically (n = 43) placed peritoneal dialysis catheters during a three-year period. Catheter-linked mechanical complications occurred more often in the peritoneoscopical group, and pericatheteral leakage ended in catheter loss in 13.8%. Overall probability of catheter survival in the peritoneoscopic group at 12, 24 and 36 months was 73%, 56% and 24%, and in the surgical group 87%, 87% and 66%, respectively (p < 0.05). Rates of infectious complications, peritonitis and exit site infections were similar.

Anal encirclement with polypropylene mesh for rectal prolapse and incontinence

Seventeen selected patients (mean age, 74 years)—14 with rectal prolapse and 3 with persisting anal incontinence after previous operations—underwent high anal encirclement with polypropylene mesh. There was no operative mortality. Prolapse recurred in 2 (15 percent) of the 13 patients followed up for 6 months or more (mean, 3.5 years). Three (27 percent) of the 11 patients with associated anal incontinence improved functionally, as did the three operated on for persisting incontinence, but only one patient regained normal continence. No breakage, cutting out, or infection related to the mesh was observed. Because of the risk of fecal impaction encountered in three of our patients, the procedure is not advocated for severely constipated patients. Despite the somewhat disappointing results regarding restoration of continence, we find this method useful in patients with rectal prolapse who are unfit for more extensive surgery, in controlling the prolapse to an acceptable degree.

Development of acute myelocytic leukemia in patients with Crohn's disease

SummaryIn our hospital within one year two patients with Crohns disease were seen who developed an acute myelocytic leukemia. A review of the literature reveals eight previously reported patients with both Crohns disease and leukemia. Six of the reported 10 patients have had acute myelocytic leukemia and, interestingly, three of them, including our two patients, have shown monocytic differentiation (FAB type M4). It has been suggested that the relative risk of leukemia, especially acute myelocytic leukemia, is increased in patients suffering from ulcerative colitis. More data of patients with Crohns disease and acute leukemia are needed to evaluate the possible association between these diseases.