Mitsuro Chiba

High Amount of Dietary Fiber Not Harmful But Favorable for Crohn Disease

Current chronic diseases are a reflection of the westernized diet that features a decreased consumption of dietary fiber. Indigestible dietary fiber is metabolized by gut bacteria, including Faecalibacterium prausnitzii, to butyrate, which has a critical role in colonic homeostasis owing to a variety of functions. Dietary fiber intake has been significantly inversely associated with the risk of chronic diseases. Crohn disease (CD) is not an exception. However, even authors who reported the inverse association between dietary fiber and a risk of CD made no recommendation of dietary fiber intake to CD patients. Some correspondence was against advocating high fiber intake in CD. We initiated a semivegetarian diet (SVD), namely a lacto-ovo-vegetarian diet, for patients with inflammatory bowel disease. Our SVD contains 32.4 g of dietary fiber in 2000 kcal. There was no untoward effect of the SVD. The remission rate with combined infliximab and SVD for newly diagnosed CD patients was 100%. Maintenance of remission on SVD without scheduled maintenance therapy with biologic drugs was 92% at 2 years. These excellent short- and long-term results can be explained partly by SVD. The fecal bacterial count of F prausnitzii in patients with CD is significantly lower than in healthy controls. Diet reviews recommend plant-based diets to treat and to prevent a variety of chronic diseases. SVD belongs to plant-based diets that inevitably contain considerable amounts of dietary fiber. Our clinical experience and available data provide a rationale to recommend a high fiber intake to treat CD.

Pilot Study of Ofloxacin and Interferon-Alpha Combination Therapy for Chronic Hepatitis C without Sustained Response to Initial Interferon Therapy

A controlled trial comparing combination therapy with ofloxacin (OFLX) and interferon (IFN) versus IFN monotherapy was conducted in patients with chronic hepatitis C who failed IFN therapy. Twenty patients were assigned randomly to two groups. Equal doses of recombinant IFN alpha-2b were administered to each group for 24 weeks. For the IFN plus OFLX group, OFLX was administered for 12 weeks at a daily dose of 600 mg. Levels of hepatitis C virus RNA declined significantly from the first month after the start of IFN treatment compared with those before administration in both groups. Serum alanine aminotransferase levels were significantly lower in the IFN plus OFLX group at two and six months after the start of treatment than levels in the IFN group. The fraction of subjects whose levels of serum ALT normalized was also higher in the IFN plus OFLX group. Larger clinical trials should be undertaken.

Cytomegalovirus infection associated with onset of ulcerative colitis

BackgroundIn 2009, a trigger role of cytomegalovirus (CMV) was shown in the development of ulcerative colitis (UC) in mice. Fifteen cases of synchronous onset of CMV colitis and UC have been reported in literature. A careful prospective and retrospective survey identified CMV colitis in newly diagnosed UC patients at 4.5% (3/65 cases) and 8.2% (5/61 cases), respectively. This means that a majority of synchronous CMV colitis may be missed in newly diagnosed UC patients in routine practice. Such a case is presented.Case presentationA 50-year-old woman, with a history of right partial mastectomy two years ago, had a persistent high fever for 9 days, after which a thickness of the colonic wall was detected on abdominal ultrasonography. Laboratory data showed inflammation and 2% atypical lymphocytes with the normal number of white blood cells. Although there was no bloody stool, fecal occult blood was over 1000 ng/ml. Colonoscopy showed diffuse inflammation in the entire large bowel and pseudomembranes in the sigmoid colon. The diagnosis was UC with antibiotic-associated pseudomembranous colitis. Metronidazole followed by sulfasalazine resulted in defervescence and improvement in laboratory data of inflammation. It took one month for normalization of fecal occult blood. Endoscopic remission was simultaneously confirmed. Later, it was found that a report of positive CMV antigenaemia (2/150,000) had been missed. Reevaluation of biopsy specimens using a monoclonal antibody against CMV identified positive cells, although inclusion bodies were not found in hematoxylin and eosin sections. Finally, the case was concluded to be synchronous onset of CMV colitis and UC.ConclusionSynchronous CMV colitis is not routinely investigated in newly diagnosed UC patients. Together with a recent observation in animal studies, it is plausible that a subset (a few to several per cent) of UC patients develop synchronous CMV infection. Further studies are needed to elucidate the plausibility.

Molecular cloning reveals nearly half of patients with Crohn's disease have an antibody to peroxiredoxin 6-like protein

Background and Aim:u2002 Crohns disease (CD) is a chronic inflammatory bowel disease (IBD) of unknown etiology. We aimed to identify the etiological agent of CD using a molecular cloning strategy that was particularly focused on identifying agents causing immune abnormalities and infectious agents.

A Pedigree of Cancer Family Syndrome with an Aggregation of Transitional Cell Cancer of the Urinary Tract

A pedigree of cancer family syndrome with an aggregation of transitional cell cancer (TCC) of the urinary tract is reported. The proband had left (lt) pelvic cancer at the age of 49, and double cancers of the right (rt) fallopian tube and the uterine body at 50. Various types of cancer, including colon cancer and gastric cancer, were found in four out of her seven siblings. In three siblings, TCC of the urinary tract was found. Although TCC has not been described to be a cancer found in cancer family syndrome, this pedigree clearly demonstrates that TCC is one such cancer.

Diffuse gastroduodenitis associated with ulcerative colitis: treatment by infliximab.

Diffuse gastroduodenitis resembling ulcerative colitis in respect to macro‐ and microscopic findings occurs in ulcerative colitis, although it is rare. Reports of gastroduodenitis associated with ulcerative colitis treated with infliximab are rare. A 58‐year‐old man had tarry stool in March 2011. He had a history of ulcerative colitis that was diagnosed in 1984. He underwent subtotal colectomy in 1991. Endoscopy and radiography revealed diffuse friable mucosa throughout the duodenum and an ulcer in the middle of the descending portion, resulting in a narrow portion.In the stomach, numerous small aphthae were observed in the antrum. Biopsy specimens of the duodenum and antrum showed marked inflammatory cell infiltration in both areas and cryptitis in the duodenum. Standard induction therapy of infliximab was started in April. The ulcer in the descending portion became a scar without diffuse mucosal friability in September 2011.

Onset of Ulcerative Colitis after Helicobacter pylori Eradication Therapy: A Case Report.

In Japan, Helicobacter pylori eradication has been approved since 2013 for treatment of H pylori-induced chronic gastritis, in an attempt to reduce the prevalence of gastric cancer, a leading cancer in Japan. H pylori infection affects more than 50% of the worlds population. H pylori eradication therapy is generally safe. To our knowledge, no case of newly diagnosed ulcerative colitis occurring immediately after H pylori eradication therapy has previously been reported.A 63-year-old man received a diagnosis of chronic gastritis and H pylori infection. In early March 2014, primary H pylori eradication therapy was initiated; lansoprazole, amoxicillin, and clarithromycin were administered for 1 week. Beginning on the fourth day, he had watery diarrhea twice a day. From the 11th day, bloody stools and watery diarrhea increased to 6 times a day. Colonoscopy, performed on the 40th day after termination of drug therapy, revealed diffuse inflammation in the distal aspect of the colon, with histologic findings consistent with ulcerative colitis. He was admitted to the hospital and was provided with a semivegetarian diet and metronidazole. He noticed a gradual decrease in the amount of blood in his feces then a disappearance of the blood. A fecal occult blood test on the 11th hospital day recorded 337 ng/mL. Fecal occult blood test is not indicated during macroscopic bloody stool but is indicated after disappearance of bloody stool. Therefore, he achieved clinical remission by the 11th hospital day. He was in remission on discharge.New onset of ulcerative colitis should be added to a list of adverse events of H pylori eradication therapy.

Crohn's disease successfully treated with infliximab in a patient receiving hemodialysis: case report and review of the literature.

AbstractThere is limited information in the use of antitumor necrosis factor &agr;, infliximab, in patients on hemodialysis. In Crohn’s disease (CD), only 3 cases are reported.A 76-year-old man on hemodialysis for renal failure caused by immunoglobulin A nephropathy developed diarrhea and abdominal pains. A marked edema was observed in the pretibia and ankle. An increase of C-reactive protein (CRP) and erythrocyte sedimentation rate, hypoalbuminemia, hypocholesterolemia, and moderate anemia was found. Ultrasonography and computed tomography (CT) found wall thickness in the left colon. Sigmoidoscopy revealed multiple ulcers in the sigmoid colon and noncaseating epithelioid granuloma was found in the biopsy specimen. Barium enema study exhibited collar button signs and longitudinal ulcers in the left colon.A severe form of CD was diagnosed. Metronidazole seemed to decrease CRP but was ineffective in ameliorating diarrhea. Infliximab rather than steroid hormone was chosen for the treatment. Standard induction therapy with infliximab was initiated. Symptoms rapidly improved then disappeared. CD activity index decreased from 747 to a remission level of 134 after 2 infusions of infliximab. Scheduled maintenance infliximab therapy was administered after the induction therapy. Ultrasonography and CT showed a disappearance of the wall thickness of the colon. Adverse reactions were not observed.Infliximab was effective and safe in a patient with CD on hemodialysis. Our case has added additional literature in accordance with previous reports supporting infliximab as effective and safe in patients on hemodialysis.

Conflicting Results on the Efficacy of Enteral Nutrition During Infliximab Maintenance Therapy for Crohn’s Disease Are Correct

We read with great interest about the conflicting results on the efficacy of enteral nutrition during infliximab (IFX) maintenance therapy for Crohn’s disease (CD). Hirai et al. [1] found cumulative remission was significantly higher in the enteral nutrition (EN) group ([900 kcal/day of EN) than in the non-EN group (900 kcal/day of EN). In contrast, Yamamoto et al. [2] found remission was similar for both EN group (1,200–1,500 kcal/day of elemental diet (ED)) and non-EN group (no ED) at week 56: 78 and 67 %, respectively. The purpose of the work reported in both papers was the same and both papers were from Japan. The authors did not provide a complete explanation of the discrepancy between the results for the efficacy of concomitant EN therapy during IFX maintenance therapy [1, 3, 4]. Study subjects in vulnerable remission relapse more easily than those in stable remission. Therefore, subjects in vulnerable remission are suitable for evaluation of the relapse-prevention effect of drugs or EN. IFX induces mucosal healing more effectively than does conventional modalities, for example steroid hormone and total parenteral nutrition [5]. It is now clear that early use of IFX in CD is more effective than conventional late use in induction of remission and prolongation of remission [6, 7]. Therefore, the timing of when IFX is used affects the subsequent prognosis. The earlier IFX is used the more stable is the state of remission. This means that the length of disease duration for the patients studied is critical. In the study by Yamamoto et al. [2], mean disease duration before entry into the EN and non-EN groups was 33 ± 4.4 and 35 ± 4.0 months, respectively. This duration of approximately three years is much shorter than in the ACCENT I study—7.9 years [8], which showed, convincingly, the efficacy of maintenance therapy with IFX in preventing relapse. Disease-duration data are lacking for the subjects in the study by Hirai et al. [1]. Another study investigated the efficacy of EN without IFX maintenance therapy in preventing relapse in CD. Takagi et al. [9] showed the effectiveness of half ED, i.e. intake of approximately half of daily required calories through EN, for prevention of recurrence of CD. In this study, remission of subjects was mostly induced not by IFX but by total parenteral nutrition or total enteral nutrition. Disease duration for half ED and omnivorous diet was 4.1 and 5.6 years, respectively [9]. These results show that the efficacy of EN during IFX maintenance therapy varies depending on the time of IFX administration: there is little benefit for early cases of short disease duration but substantial benefit for old cases of long disease duration.

From Low-Residue Diets to Plant-Based Diets in Inflammatory Bowel Disease

To the Editor, Available data strongly indicate that the greatest environmental factor in inflammatory bowel diseases (IBD) is diet-associated gut microflora [1] that can be altered by a westernized diet [2]. Le Leu et al. [3] reported that dietary red meat aggravates colitis, whereas resistant starch attenuates inflammation in dextran sulfate sodium-induced colitis in mice. The increasing consumption of meat and decreasing consumption of the fiber component, resistant starch, are principal characteristics the Western diet [4, 5]. Therefore, the study by Le Leu implicates detrimental these dietary changes as possibly etiological in the increasing prevalence of colitis as populations adopt Western culture. At present, a low-residue diet (LRD) is recommended in IBD, although no evidence exists that a LRD is superior to a normal diet. Since the LRD lacks substrate for butyrate production, a key substance for the maintenance of colonic homeostasis [6], the LRD may be detrimental. This assumption has been studied in non-gastrointestinal diseases: on the basis of a large, prospective cohort study, Park et al. [7] reported that dietary fiber intake was significantly inversely associated with risk of total death and death from cardiovascular disease, infectious diseases, and respiratory diseases in men and women. Dietary fiber intake was also related to a lower risk of death from cancer in men. We designed a semi-vegetarian diet for IBD that would provide adequate resistant starch with low meat content [2]. Meat is consumed only once in 2 weeks, whereas the diet contains a large amount of dietary fiber per 24 h: 32.4 ± 2.1 g (soluble dietary fiber 6.8 ± 0.7 g, insoluble dietary fiber 23.3 ± 1.6 g) in 2,000 kcal, the inverse of a LRD. In a small-scale observational study of adult Crohn’s disease (n = 22), we reported excellent prevention relapse associated with consumption of the semi-vegetarian diet [2], adding to the variety of current chronic diseases attributed to an imbalance of gut microflora (dysbiosis) or dietary metabolites [8] and expanding on the concept that diet-associated gut microflora are a leading environmental factor not only for IBD but also for a variety of diseases that preferentially affect wealthy nations for which a plantbased diet (PBD) may be beneficial [9, 10]. We hope that clinical studies addressing the efficacy of a PBD in IBD are forthcoming, so that a safe and effective alternative to currently accepted medical therapy will be become widespread.