Margot Shiner

Studies on the intestinal flora. II. Bacterial flora of the small intestine in patients with gastrointestinal disorders.

The type and distribution of bacteria in the jejunal juice of patients with a variety of gastrointestinal conditions that might affect the small intestinal flora were examined. Bacterial colonization of the jejunum defined, in this context, as the occurrence of a bile salttolerant flora consisting of both aerobic and anaerobic bacteria qualitatively resembling that of faeces, was observed only in patients with some form of blind loop. Prominent among the bacteria isolated from these colonized juices were non-sporing anaerobic bacteria, most usually Bacteroides, able to hydrolyse bile salts. No simple correlation between the patients fat excretion and bacterial colonization of the jejunum could be demonstrated.

The small-intestinal mucosa in cow's milk allergy.

Two infants investigated for allergy to cows milk proteins exhibited a local reaginic reaction in the small intestine after ingesting cows milk, as shown by increased mucosal IgE plasma-cells and degranulation of mast cells. IgM plasma-cells and the staining of connective tissue and basement membranes with antisera to IgG and C3 complement were also increased, indicating several simultaneous immune reactions in the intestinal mucosa. These findings may provide a sound basis for diagnosis of such an allergy and for the treatment of similar patients with disodium cromoglycate.

ANTIGEN-ANTIBODY REACTIONS IN JEJUNAL MUCOSA IN CHILDHOOD CŒLIAC DISEASE AFTER GLUTEN CHALLENGE

Abstract Immunofluorescence studies, using unfixed sections to demonstrate immune complexes, were carried out before and after gluten challenge on the jejunal mucosa of thirteen children with treated cœliac disease and one child in whom this diagnosis had been excluded. Positive staining was seen in the region of the basement membranes of villous and crypt epithelia in ten of the thirteen patients, and the immunoglobulin involved was IgA. Parallel histological and ultrastructural studies confirmed that after gluten challenge morphological changes occurred in the lamina propria of these ten patients and that the onset of these changes coincided with the demonstration of immune complexes by immunofluorescence techniques.

INTESTINAL BIOPSY IN THE DIAGNOSIS OF COW'S MILK PROTEIN INTOLERANCE WITHOUT ACUTE SYMPTOMS

4 infants, suspected of cows milk protein intolerance, were placed on an elimination diet and then challenged with cows milk. None reacted clinically, yet in 2 of the 4 patients jejunal biopsy revealed clear histological, ultrastructural, and immunological changes. It is suggested that these changes are the objective criteria on which the diagnosis of cows milk intolerance should be based, and that the clinical evidence derived from milk challenge after an elimination diet may be unreliable.

Ultrastructural changes suggestive of immune reactions in the jejunal mucosa of coeliac children following gluten challenge

The jejunal mucosa of eight coeliac children on a gluten-free diet and two non-coeliac children was studied by light and electron microscopy two to 98 hours after a single challenge dose of gluten. In all coeliac patients the early cytopathological reactions were principally confined to the structures within the subepithelial connective tissue. Changes were observed in the connective tissue fibrils, the basement membranes of epithelial and endothelial cells, the endothelium of small blood vessels, and the type and degree of inflammatory cell infiltration. The timing of these reactions was compatible with the concept that gluten acts as an antigen and combines with antibody in the form of immune complexes in the connective tissue close to the epithelium and to small blood vessels. These changes appeared to precede epithelial cell damage. No subepithelial tissue changes were seen in the non-coeliac patients after gluten challenge.

SMALL-BOWEL ABNORMALITIES IN MULTIPLE SCLEROSIS

Jejunal biopsies were performed in 12 randomly chosen patients with multiple sclerosis. The jejunal mucosa was examined histologically, ultrastructurally, and by tissue immune techniques. Histology showed a normal mucosa in 7 patients, increased inflammatory-cell infiltration in 3, a partial villous atrophy in 1, and a subtotal villous atrophy in the remaining patient. Fine structural abnormalities were seen in 6 of 8 patients studied. These included microvillous changes, increase in theliolymphocytes and epithelial lysosomes, thickening of the connective tissue with or without collagen fibres, and numerous macrophages containing large amounts of membrane-bound electron-dense material. The latter was seen in 5 of the 8 mucosae examined.

EVIDENCE OF CYTOTOXICITY IN ULCERATIVE COLITIS FROM IMMUNOFLUORESCENT STAINING OF THE RECTAL MUCOSA

Abstract Seventeen rectal mucosal biopsy specimens from 11 patients with ulcerative colitis and five biopsy specimens from 5 control patients were studied by tissue immunofluorescence. In all patients with ulcerative colitis, the number of IgG-containing plasma-cells was greatly increased, being highest in those with the most active disease. There was also intense staining of the connective tissue of the rectal mucosa with IgG antisera and a similar staining pattern was seen with the C3 component of complement in these patients. IgA plasma-cells were increased in ten out of seventeen biopsy specimens, and IgM plasma-cells were increased in six out of seventeen specimens. This great increase of IgG plasma-cells may be due to stimulation by bacterial antigens, especially by the strictly anaerobic bacteria, since IgG from the rectal mucosa in ulcerative colitis is known to react strongly with these organisms. The finding of complement deposition in the rectal mucosa suggests that a cytotoxic reaction is occurring and may account for the pathological features, such as ulceration, seen in ulcerative colitis.

The microvilli of the small intestinal surface epithelium in coeliac disease and in idiopathic steatorrhoea

This paper records the electron microscopic appearances in patients with coeliac disease and idiopathic steatorrhoea, and draws attention to the changes in the microvilli.

Coeliac Disease: Histopathological Findings in the Small Intestinal Mucosa Studied by a Peroral Biopsy Technique

Villous atrophy, changes in the surface epithelium, mucosal thickening, and glandular hypertrophy were a feature of all the mucosal biopsies from the small intestine obtained from eight coeliac children. No histological differences were observed between the children previously treated with intermittent gluten-free diets and the untreated children. Serial biopsy studies were carried out on one coeliac child before and after treatment with a gluten-free diet over a period of two years. On the whole they confirmed the irreversible nature of the observed histopathological changes but minor improvements could not be excluded. Mucosal abnormalities in coeliac disease are the same as in adult idiopathic steatorrhoea, where they are observed in patients with or without a response to a gluten-free diet. It is concluded that the elimination of gluten from the diet has little if any influence on the histopathological abnormalities observed in coeliac disease.

The Immunopathology of Coeliac Disease

The response of the jejunal villous epithelial cell and its subepithelial tissues to a single dose of gluten was studied with the electron microscope in 3 coeliac patients treated with a gluten-free diet for 3 years or more and compared with that of a non-coeliac child. Up to 48 h after gluten administration the epithelial cells of the coeliac patients showed no abnormality but the subepithelial basement membrane was thickened, the capillary endothelium showed swelling and there was an increased infiltration of lymphccytes, eosinophils and plasma cells in the intercellular and subepithelial spaces. Epithelial damage was seen at 96 h after gluten in only one of 2 patients. The ultrastructural changes in the non-coeliac child 24 h after gluten were entirely confined to the epithelial cell itself and consisted of large intracytoplasmic vacuoles, lined by smooth membranes which contained fibrous and other unidentifiable material. The absence of an intracellular reaction at least in the early stages following gluten in the coeliac patients could be due to an ineffectiveness in walling-off exogenous material such as gluten and may be of importance in allowing antigenic material to pass through the cell thus setting up immunological reactions in the subepithelial connective tissue and nearby capillary endothelium.