Ruven Levitan

Studies of Intestinal Microflora: V. Fecal microbial ecology in ulcerative colitis and regional enteritis: relationship to severity of disease and chemotherapy

Summary Quantitative and qualitative microbiological studies of the stools were carried out in 25 patients with untreated ulcerative colitis and regional enteritis. The mild to moderately ill patients with idiopathic ulcerative colitis were noted to harbor a fecal microflora very similar to that of healthy individuals. However, those with regional enteritis and severe ulcerative colitis had increased numbers of colif orms in their stools. Treatment of ulcerative colitis with salicylazosulf apyridine (Azulfidine) tended to increase the numbers of some microbial species, especially Gram-positive forms. These changes did not appear to be related to the severity of disease or the effectiveness of treatment. In a group of normal individuals receiving drug or placebo in a double blind study, salicylazosulf apyridine caused no definite alterations in the fecal microflora. Systemic corticosteroid therapy of ulcerative colitis resulted in little change in the intestinal flora. Modest decreases in the number of fecal colif orms appeared to be associated with clinical improvement.

A Method for Studying Absorption of Water and Solute from the Human Small Intestine

Summary A triple-lumen intubation technique is described whereby absorption or secretion of water, electrolytes, and other solutes can be studied within specific and defined test segments of the human small intestine. The technique allows correction for endogenous water and solute that enter the test segment from digestive secretions. Experiments that were carried out to test the precision of the method have demonstrated the technique to have a high degree of accuracy when 1-hr study periods are used.

Effects of sodium concentration and osmolality on water and electrolyte absorption from the intact human colon

The influence of sodium concentration and osmolality on net water and monovalent electrolyte absorption from or secretion into the intact human colon was studied in healthy volunteers. WHEN ISOTONIC SOLUTIONS CONTAINING NACL AND/OR MANNITOL WERE INFUSED INTO THE COLON: (a) a direct linear relationship between luminal sodium concentration (in the range of 23-150 mEq/liter) and rate of net water, sodium, and chloride absorption was found. No water absorption was found when sodium concentration in the luminal fluid was below 20 mEq/liter; (b) water and sodium absorption from the isotonic test solutions was not enhanced by addition of 80-250 mg/100 ml of glucose; and (c) the rate of water and sodium absorption was decreased markedly when chloride was replaced by bicarbonate in the test solution. WHEN THE COLON WAS PERFUSED WITH HYPERTONIC TEST SOLUTIONS CONTAINING NACL AND MANNITOL OR UREA: (a) water was absorbed from hypertonic NaCl solutions against a lumen-to-blood osmotic gradient of 50 mOsm/kg; (b) when the osmolality of the mannitol solution was increased, water entered the colonic lumen at a more rapid rate. The relationship between the rate of water entering the colon and the osmolality of the test solution was a parabolic one; (c) sodium and chloride entered the colonic lumen at a rate that was lineraly related to that of water entrance when the lumen-to-blood osmotic gradient exceeded 150 mOsm/kg; (d) water flow into the colonic lumen was identical when equimolar urea or mannitol solutions were infused; (e) neither urea nor mannitol was absorbed in significant amounts from the hypertonic solutions; and (f) our results suggest that the equivalent pore radius of the human colon is smaller than the molecular radius of urea (2.3 A).

Manometric Characteristics of the Human Ileocecal Junctional Zone

Summary Five patients with surgical procedures allowing ready access to the ileocecal junction were studied to ascertain the manometric characteristics of this area. A 4-cm zone of elevated pressure was consistently demonstrated at the junction of human ileum and colon. This zone showed a decline in pressure with ileal balloon distention and a rise in pressure with colonic balloon distention. Based on the manometric characteristics of other alimentary tract sphincters, it is concluded that a true sphincter exists at the human ileocecal junction.

Alterations in human intestinal microflora during experimental diarrhoea.

Large quantities of fluid administered through an intestinal tube caused alterations in small bowel bacteriology in four of seven subjects. In two normal individuals, colonic bacteria were found after fluid infusion in areas of the small bowel which previously had none. The faecal microflora was also altered by the fluid purge: anaerobes were reduced in some subjects and large numbers of Enterobacter species emerged in others. In a patient with pancreatic insufficiency and diarrhoea, the concentration of Enterobacter in the faeces was directly related to the number of bowel motions per day. Treatment with pancreatic enzymes curtailed the diarrhoea and markedly reduced these organisms. Intubation showed that Enterobacter were harboured in the small intestine and suppressed in the large bowel during periods of normal bowel action. Diarrhoea caused by pancreatic enzyme withdrawal or fluid purgation removed the colonic inhibition and allowed these organisms to appear in the faeces. Acidic diarrhoea induced by lactose feeding to three hypolactasic patients caused reductions in the numbers of E. coli in the stool but increases in Enterobacter species. Bacteroides also declined in one subject. Certain alterations in small and large bowel bacteriology observed in these forms of experimental diarrhoea have also been described in naturally occurring diarrhoea of diverse aetiologies.

Gastrointestinal and Roentgenological Manifestations of Henoch-Schoenlein Purpura

Summary The clinical and radiological abnormalities observed in 2 children with HenochSchoenlein purpura are reported. These consisted of abdominal pain, vomiting, melena, and intestinal perforation. A coarse mucosa with spiculations was demonstrated roentgenologically. In the 1st case, the gastrointestinal symptoms and radiological abnormalities preceded the typical skin rash. The radiological changes were reversible. The clinical course of the 2nd case was complicated by small bowel perforations, limited to a 20-cm jejunal segment. The described radiological abnormalities are not specific for HenochSchoenlein purpura; however, their presence should alert the clinician and the radiologist to the possibility of this diagnosis even in the absence of a typical skin rash. In patients whose clinical course is stormy, intestinal perforation should be considered as a possible complication.

Acquisition of a Pyloric Septum or Pyloric Duodenal Fistula

A patient with active upper gastrointestinal hemorrhage and previous radiological evidence of duodenal deformity was found to have a gastric ulcer. Nineteen days later, a pyloric septum was observed gastroscopically in the same area. The radiological examinations of the upper gastrointestinal tract were consistent with these endoscopic observations, and a prepyloric mucosal septum was found during surgery. The formation of this prepyloric septum in our patient appears to be the result of peptic ulcer disease with the formation of a fistulous tract connecting the pylorus to the duodenum.

Water and Electrolyte Content of Human Ileostomy Fluid After D-Aldosterone Administration

Summary The effect of intravenous administration of 2 mg of d -aldosterone on the water, sodium, chloride, and potassium content of ileostomy fluid was studied in 4 subjects with long established ileostomies by a balance technique. The ileal effluent did not change significantly in respect to volume, wet weight, or sodium, potassium, or chloride output after aldosterone administration. Under the conditions of our experiments, we were unable to show an effect of d -aldosterone administration on the handling of water, sodium, chloride, and potassium by the small bowel.

Effect of 9-α-Fluorohydrocortisone on the Ileal Excreta of Ileostomized Subjects

Sodium deprivation, produced by sodium restriction or loss, results in a fall in the sodium and a rise in the potassium content of ileal excreta of ileostomized subjects. An endogenous aldosterone secretion has been postulated. To determine whether similar changes could be induced by exogenous mineralocorticoids, 9-α-fluorohydrocortisone, 2 mg per day by mouth, was administered to 5 subjects with stable ileostomy function who had had total colectomies for ulcerative colitis. Balance techniques were used. Contrary to the response seen with sodium deprivation, the 24-hr excretion of sodium was unaffected but mean potassium excretion and concentration in the ileal excreta increased (P

Leukemic infiltration of the sigmoid colon. Report of a case simulating carcinoma with obstruction.

SummaryLarge-bowel obstruction due to a leukemic infiltration of the sigmoid colon in a patient with chronic lymphatic leukemia is reported. This is a previously undescribed complication of this disease.