Shamita B. Shah

Structural changes in oocyte nucleoli ofXenopus laevis during oogenesis and meiotic maturation

Immunoelectron microscopy with anti-nucleolin defined substructures within the multiple nucleoli of biosynthetically active stage II–III oocytes and within the nucleoli of relatively quiescent stage VI oocytes ofXenopus laevis. Dense fibrillar components (DFCs) of nucleoli from stage II–III oocytes consisted of nucleolonemas that radiated from a continuous DFC sheath surrounding fibrillar centers (FCs). Discernible granular regions (GRs) were absent in these same nucleoli. Conversely, stage VI oocyte nucleoli displayed compacted DFCs and prominent GRs. Immunofluorescence microscopy then tracked fibrillarin, nucleolin, and condensed DNA through oogenesis and into progesterone-induced meiotic maturation and nuclear breakdown. In stage II–III oocyte nucleoli, fibrillarin was enriched near the FC-DFC boundaries, while nucleolin was distributed throughout these same DFCs. Both proteins were enriched within the compacted DFCs of stage VI oocyte nucleoli. Staining with (DAPI) 4′,6-diamidino-2-phenyl-indole showed condensed DNA within nucleolar FCs of both stage II–III and stage VI oocyte. Upon nuclear breakdown, we found fibrillarin and nucleolin in small particles and in the surrounding cytoplasm. Although we saw no trace of fibrillarin or nucleolin in nuclear remnants prepared just minutes later, DAPI-stained particles remained within these preparations, thus suggesting that FCs were at least slow to disassemble.

Prevalence of Anal Dysplasia in Patients With Inflammatory Bowel Disease

BACKGROUND & AIMS Although the prevalence of anal dysplasia is higher in some immunosuppressed populations, the prevalence in patients with inflammatory bowel disease (IBD) is unknown. We examined the prevalence of abnormal anal cytology among IBD patients, and its relation to the human papilloma virus (HPV). METHODS Adults with IBD and age-matched healthy controls (HC) were recruited. IBD patients were categorized as nonimmunosuppressed (IBD-N) or immunosuppressed (IBD-I). Anal Papanicolaou tests were performed for HPV testing and classification by a cytopathologist as follows: negative, atypical squamous cells of undetermined significance (ASC-US), low-grade squamous intraepithelial lesion, high-grade squamous intraepithelial lesion, cancer, or unsatisfactory. RESULTS A total of 270 subjects (100 IBD-I, 94 IBD-N, and 76 HC) were recruited. ASC-US were detected in 19 subjects, with a trend toward a higher prevalence among IBD subjects compared with HC (8.8% vs 2.6%; P = .10). The prevalence did not differ with respect to immunosuppression. Crohns disease (CD) subjects had a higher prevalence of ASC-US compared with others with IBD (P = .02). Among those with CD, female sex and disease duration longer than 10 years were risk factors. There were no cases of low-grade squamous intraepithelial lesion, high-grade squamous intraepithelial lesion, or anal cancer in the cohort. HPV was present in 5.3% and 1.5% of subjects with and without ASC-US, respectively (P = .26). CONCLUSIONS Although there was a trend toward abnormal anal Papanicolaou tests in IBD subjects compared with HC, there was no difference based on immunosuppression. The presence of HPV did not correlate with abnormal anal cytology. Risk factors associated with this increased trend include female CD subjects and those with a longer duration of CD. ClinicalTrials.gov number: NCT01860963; https://clinicaltrials.gov/ct2/show/NCT01860963.

1041 Intravenous Cyclosporin in Severe Steroid-Refractory Ulcerative Colitis: Long-Term Follow-Up

OBJECTIVE:Intravenous (IV) cyclosporin (CSA) is an alternative to surgery for patients (pts) with severe ulcerative colitis (UC). We previously published open-label 5-year data, and now present long-term follow-up on the same pts. METHODS:The original 42 pts with IV steroid-refractory severe UC treated with IV CSA from 1991 to 1995 were identified using the University of Chicago IBD registry. Additional information on clinical course, medication use, surgeries and adverse events were collected from electronic and paper charts. Pts who initially received CSA but eventually went to colectomy were referred to as “surgical” pts; those who have avoided colectomy were referred to as “non-surgical” pts. RESULTS:The mean duration of IV CSA was 10.3 days (+/5.4), at a mean CSA level of 379 (+/-126) ng/ mL (HLPC). Initial response was seen in 36 of 42 pts (86%); 11 patients subsequently underwent colectomy at a median of 18 weeks (range 3-79). Twenty-five (60%) of the original 42 pts avoided colectomy in the short-term at a mean follow-up of 23 months. Nineteen of these 25 (76%) pts have continued to avoid colectomy at a median of 81 months. Overall, 45% of the initial pts remained colectomy-free at a mean 75 months (+/44.7). Surgery was avoided in 56% of pts receiving 6-mercaptopurine (6MP) or azathioprine (aza) vs. 27% of those who did not (p=0.014). The rate of 6MP/aza use was higher in nonsurgical pts (79% vs. 40%, p= 0.08). Life analysis predicted 15.5 year “noncolectomy survival” rates of 39% overall; rates were highest in those with 6MP/aza (49% vs. 17%, p= 0.036; Figure 1). Six of 8 pts who repeated IV CSA subsequently underwent colectomy at a median 8.3 months (range 0.1-37) after last IV CSA, despite 6MP/aza in all (mean duration 38.27 months +/31.05). CONCLUSION:Intravenous cyclosporin was successful in avoiding surgery in 45% of severe, IV steroidrefractory UC pts; predicted long-term success is highest in those who received 6MP/aza.

Enhanced imaging technologies in detecting dysplasia in IBD: narrowing or widening our options?

Nuzhat A. Ahmad, Philadelphia, PA Darren M. Brenner, Chicago, IL Andrew T. Chan, Boston, MA Francis K. L. Chan, Hong Kong, China Lin Chang, Los Angeles, CA Tsutomu Chiba, Kyoto, Japan Massimo Colombo, Milan, Italy B. Joseph Elmunzer, Ann Arbor, MI Timothy B. Gardner, Lebanon, NH Lauren B. Gerson, Stanford, CA Colin W. Howden, Chicago, IL W. Ray Kim, Rochester, MN Paul Y. Kwo, Indianapolis, IN Edward V. Loftus, Rochester, MN Josep M. Llovet, New York, NY Julian Panes, Barcelona, Spain Sameer Saini, Ann Arbor, MI Shiv K. Sarin, New Delhi, India Shamita B. Shah, Stanford, CA Amit Singal, Dallas, TX Jan Tack, Leuven, Belgium Michael L. Volk, Ann Arbor, MI Akbar Waljee, Ann Arbor, MI Kenneth K. Wang, Rochester, MN Alex Ford, Leeds, United Kingdom Joel H. Rubenstein, Ann Arbor, MI Alastair J. M. Watson, Norwich, UK

Prevalence and factors associated with gluten sensitivity in inflammatory bowel disease

Abstract Objectives: Gluten sensitivity (GS) arises with celiac disease and has also been found in non-celiac disorders, although its characteristics in inflammatory bowel disease (IBD) are unclear. This study evaluated the prevalence of GS and factors associated with GS in IBD. Methods: Adult IBD patients at a tertiary-care medical center completed a survey of their demographics, medical history, family history, social history and symptoms. Data on IBD characteristics were abstracted from the medical records. Descriptive analyses estimated the prevalence of GS. Multivariable logistic regression assessed the association between GS and patient or disease factors. Results: Of 102 IBD patients (55 Crohn’s disease [CD], 46 ulcerative colitis [UC] and 3 IBD-unclassified), GS was reported in 23.6 and 27.3% of CD and UC patients, respectively. Common symptoms included fatigue, abdominal pain, diarrhea, bloating and hematochezia. There was no difference in these symptoms when comparing patients with and without GS. When evaluating IBD-related factors, GS was associated with having had a recent flare (adjusted odds ratio [aOR] 7.4; 95% confidence interval [CI] 1.6–34.1), stenotic disease in CD (aOR 4.7; 95% CI 1.1–20.2) and dermatologic manifestations (aOR 5.5; 95% CI 1.2–24.1). Conclusion: GS was common in IBD and associated with having had a recent flare. GS may be transient for some patients, whereby dietary recommendations during and after a flare could focus on the avoidance of specific food triggers with possible reintroduction of these foods over time. This study prompts further prospective investigation into the temporal evolution of GS in IBD.

Plant Extract: A Natural Immune Booster for Ulcerative Colitis

this readily available human model of ongoing, chronic infection to elucidate the potential mechanisms of intrauterine transmission, to study the feasibility of neonatal prophylaxis without HBIG, the role of viral factors (including genotype and mutations) in maternal-fetal transmission, and the mechanisms and impact of postpregnancy immune restoration syndrome. A relook at the manner in which efficacy of vaccination is assessed in infants born to mothers with HBV infection is also desirable. An entirely new field is waiting to be seized.

Capsule endoscopy in the diagnosis of suspected small bowel involvement with crohn's disease

A 23-year-old man presented for evaluation of fevers and abdominal pain. He was well until 3 months prior to presentation, when he noted severe rectal pain and blood on his stool. Anoscopy showed a posterior midline anal fissure. Over the following month, he developed fever, for which he took ibuprofen, and he experienced a 20-pound weight loss. He was hospitalized at another institution for evaluation. Laboratory tests were remarkable for iron deficiency anemia, elevated inflammatory markers (erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]), and hypoalbuminemia. Stool studies were negative except for the presence of blood in stool specimens. Blood cultures, computed tomography (CT) of the chest/abdomen/pelvis (using intravenous contrast), and upper gastrointestinal series were normal. A colonoscopy to the cecum revealed a posterior anal fissure and a rectal ulcer. Random biopsies throughout the colon were normal, and biopsies of the rectal ulcer were consistent with ulceration but no inflammation. He was placed on iron supplementation and discharged. He presented to the Stanford Clinic 2 months later with continued fevers and rectal pain on defecation. He also reported night sweats, lethargy, epigastric pain, and diarrhea, with up to five loose bowel movements per day. He noted blood in his stool two times per week. He denied urgency, tenesmus, nocturnal bowel movements, recent travel, and use of antibiotics. There was no family history of inflammatory bowel disease. He continued taking daily ibuprofen for his fevers. His past medical history was significant for a positive purified protein derivative (PPD) tuberculin skin test at age 13. A chest X-ray at that time was negative, and he received prophylactic isoniazid treatment for 9 months. He had allergy to sulfa medications, which caused hives. He denied tobacco use and had no history of sexually transmitted diseases. He was born in Tanzania and immigrated to the United States at age 14. He was pursuing a master’s degree. Physical examination was remarkable for a thin diaphoretic man with body mass index of 20. He had mild epigastric tenderness to palpation. Rectal and perianal examinations were unremarkable. Further laboratory tests were significant for continued iron deficiency anemia, elevated ESR and CRP, hypoalbuminemia, and the presence of blood and leukocytes in a stool specimen. A quantiferon latent tuberculosis test, antinuclear antibody, rapid plasma reagin (RPR) test for syphilis and a human immunodeficiency virus test were negative. Amoeba, Giardia, and celiac serologies were negative, as were stool examinations for bacterial culture, ova and parasites, and Clostridrium difficile toxin. Upper endoscopy demonstrated non-steroidal antiinflammatory drug (NSAID)-induced antral ulcers, and antral biopsies revealed Helicobacter pylori-negative chronic gastritis with ulceration. Duodenal biopsies were normal. The patient initially refused colonoscopy, and thus CT enterography was obtained and revealed only mild hyperemia of the rectal wall, consistent with proctitis (Fig. 1). Repeat upper R. N. Sharaf (&) B. G. Levesque S. Shah P. J. Pasricha Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, Alway Building, Room M 211, 300 Pasteur Drive, MC: 5187, Stanford, CA 94305-5187, USA e-mail: rsharaf@stanford.edu

Fecal DNA Testing for Colorectal Neoplasia in IBD: Could it be as Simple as a Stool Study?

can cause weight loss and may have anti-inflammatory effects. Furthermore only 1 measurement of BMI was analyzedwhen subjects were recruited, whichmayhave been several years before diagnosis, and it is conceivable that BMI closer to diagnosis is more predictive of incident IBD. However, data from 1 cohort in the study suggested only a minimal weight gain of 1.5 kg from recruitment to a mean follow-up of 3.7 years. Although the authors of this study found no association between obesity and development of IBD, they note that only BMI was studied as a measure of obesity, which has a poor linear relationship with total body fat. Alternative measures of adiposity may have more prognostic value, such as waist-to-hip ratio, which is a more accurate marker of central obesity and visceral fat. Furthermore recent studies have suggested that mesenteric fat deposition rather than subcutaneous fat is a primary contributor to inflammation in CD (Gut 2012;61:78–85). Future studies using novel methods to evaluate fat stores, including visceral, subcutaneous, and mesenteric deposits, may help to determine whether obesity is a risk factor for the development of IBD. The developing field of analytic morphometrics, which uses measurements based on imaging to evaluate anatomic features that may predict medical outcomes, could provide answers. A recent study using analytic morphomics found that abdominal subcutaneous fat is an independent predictor of surgical site infections, and that subcutaneous fat improved model predictions of surgical site infections compared with BMI (J Am Coll Surg 2011;213:236–244). That same methodology, when applied to obesity and IBD, may provide more nuanced answers by evaluating specific fat storage deposits and their association with incident IBD. Obesity has been linked with the development of other inflammatory conditions, such as rheumatoid arthritis, which has risen in incidence and prevalence in recent years. Analysis of a cohort from Olmsted County, Minnesota, suggested that obesity accounted for 52% of the increased risk for developing rheumatoid arthritis between 1985 and 2007 (Arthritis Care Res 2013;65:71–77). Creeping fat, recognized for decades as a marker of CD activity, may be a source of disease-promoting adipokines, and is correlated with muscular hypertrophy, fibrosis, and stricturing (Inflamm Bowel Dis 2012;18:1550–1557). The cytokine milieu, which is a byproduct of fat stores, may be associated with development of CD and other inflammatory conditions, such as rheumatoid arthritis. In the end, this large, prospective, cohort study with extended follow-up found no association between incident IBD and obesity as measured by BMI. With the rising incidence of IBD and widespread adoption of Western dietary habits, examination ofmore nuancedmeasures of adiposity such as waist-to-hip ratio and mesenteric fat may provide further clarity (Gastroenterology 2013;144[suppl 1]:S-87).

Atypical Rectal Bleeding: The Challenge of Diagnosing Mild Ulcerative Colitis

A 27-year-old developmentally delayed man presented to Stanford University Medical Center for evaluation of rectal bleeding. He originally developed sporadic rectal bleeding at age 12 without diarrhea and in the absence of foreign travel or use of non-steroidal anti-inflammatory drugs or antibiotics. At that time, colonoscopy showed rectal erythema and inflammation. He was diagnosed with distal ulcerative colitis (UC) and managed with a brief course of steroids, followed by long-term sulfasalazine 1 g twice daily. Clinical remission was maintained with this regimen, but surveillance colonoscopies 8 and 10 years after the initial diagnosis demonstrated persistent rectal hyperemia. At the time of his evaluation at our center, he reported one to two formed non-bloody bowel movements per day without urgency or tenesmus. He denied fevers, chills, night sweats, or weight loss. He also denied any history of arthritis, skin rash, or eye redness or other symptoms suggestive of extraintestinal manifestations of inflammatory bowel disease (IBD). There was no family history of IBD. On physical examination, the patient had a thin body habitus. His abdomen was soft and non-tender. The perineum appeared normal. Laboratory studies showed a hematocrit of 37%, albumin 4.1 g/dl, and normal C-reactive protein. Colonoscopy was performed and revealed normal mucosa from the rectum to the cecum (Fig. 1), and a normal appearing ileocecal valve and terminal ileum. Surveillance biopsies throughout the colon were normal except for an area of dysplasia in the sigmoid colon (Fig. 2); there was no endoscopically visible abnormality in that area. Given the concern for this area of dysplasia, a repeat colonoscopy with chromoendoscopy was performed to determine if a corresponding mucosal lesion was present; however, no lesions were found. The outside pathology slides from the time of diagnosis of UC and subsequent colonoscopies were re-examined by dedicated gastrointestinal pathologists. Review of the histology raised the possibility of solitary rectal ulcer or mucosal prolapse (Fig. 3) rather than UC. In light of this pathologic diagnosis and upon further discussion with the patient and his parents, history revealed that as a youth the patient had the habit of placing foreign objects in his anus. Hence, with this additional history, years of quiescent symptoms, and no clear diagnosis of UC, it was decided in discussion with the patient and his parents to discontinue sulfasalazine and follow the patient clinically. A repeat colonoscopy is planned within 3 years, given the finding of incidental dysplasia on colonoscopic biopsy. Following discontinuation of sulfasalazine, bleeding has not recurred.

Is minimally elevated alfa feto protein (AFP) in patients with cirrhosis associated with hepatocellular carcinoma (HCC)? single center study based on histology of explanted liver specimens

Is minimally elevated alfa feto protein (AFP) in patients with cirrhosis associated with hepatocellular carcinoma (HCC)? single center study based on histology of explanted liver specimens