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Purpose: To study the impact of fused (18)F-fluoro-deoxy-D-glucose (FDG)-hybrid positron emission tomography (PET) and computed tomography (CT) images on conformal radiation therapy (CRT) planning for patients with esophageal carcinoma., Patients and Methods: Thirty-four patients with esophageal carcinoma were referred for concomitant radiotherapy and chemotherapy with radical intent. Each patient underwent CT and FDG-hybrid PET for simulation treatment in the same radiation treatment position. PET-images were coregistered using five fiducial markers. Target delineation was initially performed on CT images and the corresponding PET data were subsequently used as an overlay to CT data to define the target volume., Results: FDG-PET identified previously undetected distant metastatic disease in 2 patients, making them ineligible for curative CRT. The Gross Tumor Volume (GTV) was decreased by CT and FDG image fusion in 12 patients (35%) and was increased in 7 patients (20.5%). The GTV reduction was >or=25% in 4 patients due to reduction of the length of the esophageal tumor. The GTV increase was >or=25% with FDG-PET in 2 patients due to the detection of occult mediastinal lymph node involvement in one patient and an increased length of the esophageal tumor in the other patient. Modifications of the GTV affected the planning treatment volume (PTV) in 18 patients. Modifications of delineation of GTV and displacement of the isocenter of PTV by FDG-PET also affected the percentage of total lung volume receiving more than 20 Gy (VL20) in 25 patients (74%), with a dose reduction in 12 patients and a dose increase in 13 patients., Conclusion: In our study, CT and FDG-PET image fusion appeared to have an impact on treatment planning and management of patients with esophageal carcinoma related to modifications of GTV. The impact on treatment outcome remains to be demonstrated.

Objective: To emphasize the possibility of obtaining good quality and lasting remission of a severe idiopathic protein-loosing enteropathy with corticosteroid therapy., Observation: A 30 year-old woman was hospitalized for edema of the lower limbs related to hypoalbuminemia due to a protein-loosing enteropathy, demonstrated by measurement of alpha-1 antitrypsin clearance. Diagnosis of lupus was evoked but not confirmed. Nutritional treatment failed. Corticosteroids administered in a bolus, and subsequently per os, rapidly led to complete, lasting (22 months later) remission., Discussion: Corticosteroid therapy is the classical treatment of a protein-loosing enteropathy concomitant to disseminated lupus erythematosus, a rare combination. In the absence of lupus, a few cases of remission from a protein-loosing enteropathy have been reported. However, the delay before remission was longer than in our case report, and the remission-free period generally shorter., Conclusion: Corticosteroid therapy is an effective treatment of an idiopathic protein-loosing enteropathy.

Aims: This study was designed to assess the proportion of adult patients with celiac disease who had had undiagnosed symptoms during childhood and to determine the consequences of such diagnostic delay., Patients and Methods: One hundred eighty-four patients with celiac disease (56 males, 128 females, age range 17-88 years) were classified according to diagnosis and symptoms of celiac disease during childhood. Prevalence of short stature, low fertility, clinical osteoporosis, cancer, and autoimmune disease were assessed in each celiac group and compared with a control group matched for gender and age., Results: Compared with the control group, patients with celiac disease were shorter (men 171.4 +/- 9.0 cm vs 176.4 +/- 6.9 cm, P<0.01; women 159.7 + 7.3 cm vs 162.7 +/- 6.2 cm, P<0.01) and had a higher prevalence of symptomatic osteoporosis (5%) cancer (10%), and autoimmune disease (25%). Compared with matched controls and with patients whose celiac disease had been diagnosed during childhood (n=36), or who had remained symptom-free (n=95), patients who had undiagnosed symptomatic celiac disease during childhood exhibited higher prevalence of short stature (26%), low female fertility or low birth weight (36%). Multivariate analysis showed that short stature and low fertility correlated with duration of symptoms before diagnosis; osteoporosis and cancer correlated with age. The prevalence of autoimmune disease was unrelated to early onset of symptoms or delay to diagnosis., Conclusions: Missing the diagnosis of celiac disease in a symptomatic child may lead to short stature and low female fertility.

Aim of the Study: To retrospectively evaluate the efficacy, the duration of response, and the tolerance of Remicade in anoperineal Crohn's disease., Methods: Fifty patients with severe symptomatic and refractory anoperineal Crohn's lesions (38 fistulae and 29 cavitating ulcers and superficial fissures) were treated with 3 intravenous infusions of Remicade (5 mg/kg) at weeks 0, 2 and 6. Efficacy was assessed using Allan's functional score and proctologic examination at 8 weeks (W8) and 24 weeks (W24) after the first infusion., Results: At W8, a response was noted for 71% (27/38) of fistulae and 79% (23/29) of ulcers and fissures. Healing rates were 39% and 49%, respectively. Efficacy of Remicade at W8 did not vary according to sex, number and type of fistulae and other treatments. At W24, 58% (15/26) of patients with fistulae and 63% (10/16) of patients with ulcers or fissures had a response. The response rate at W24 was higher in patients having anoperineal Crohn's lesions for less than one year: 77% vs 32% (P=0.004). Median Allan's score significantly decreased from 3.9 before treatment to 1.7 at W2 (P<0.001), 1.3 at W6 and 0.8 at W8. Median duration of response was 9.5 months (range: 0.5-12.5) after last infusion and was not influenced by associated treatments including immunomodulators. The relapse rate at 1 year was 64% for the responders followed at least one year (n=21). Minor adverse events occurred during 12% of all infusions. Eight patients had an infection, including one pneumonia. Eight patients developed a perineal abscess 16 weeks (range: 4-32) after the first infusion., Conclusion: Remicade is rapidly effective and well tolerated in anoperineal Crohn's lesions, but the high relapse rate stresses the need for long term therapeutic strategies in these patients.

Aims: The incidence of thromboembolic disease is increased in patients with inflammatory bowel disease. Hyperhomocysteinemia is one of the risk factors for thrombosis. The aims were: 1) to assess the prevalence of hyperhomocysteinemia in a large series of patients with Crohn's disease; 2) to search for clinical and biological factors associated with hyperhomocysteinemia., Patients and Methods: One hundred seventy-one patients with Crohn's disease (64 males, 107 females), median age 31 years (range: 16-82), were studied. The median duration of the disease was 7 years. The concentrations of homocysteine, folate, cobalamin and C-reactive protein were measured in serum from blood sample of each patient., Results: The mean concentration of seric homocysteine was 14.8 micromol/L (N: 4.4 - 12.4 micromol/L). Hyperhomocysteinemia was observed in 89 patients (52%). It was significantly associated with age, sex, smoking habit, serum cobalamin level and history of ileal surgical resection (P<0.05). In the group of operated patients, there was a statistically significant association between hyperhomocysteinemia and the length of small bowel resected. In multivariate analysis, sex and smoking were associated with hyperhomocysteinemia., Conclusion: More than half of the patients with Crohn's disease have hyperhomocysteinemia. This result stresses the need for preventing reversible factors associated with hyperhomocysteinemia, such as smoking and cobalamin deficiency, in order to lower the thrombotic risk of patients with Crohn's disease.

Objective: To assess pregnancy outcome in relation to disease activity and maintenance therapy in patients with inflammatory bowel disease., Methods: A postal questionnaire was sent to every woman of child-bearing age followed for inflammatory bowel disease in three referral centers (Rothschild, Saint-Lazare, Saint-Louis). Response rate was 65%., Results: One hundred and forty-four pregnancies (153 fetuses) in 138 women (122 had Crohn's disease) were reported. Outcome of pregnancy was normal (baby > 2500 g, without malformation) in 115 cases (77%). There were 17 cases of preterm birth (11.5%), 3 cases of hypotrophy, and 14 pregnancy losses (9 miscarriages (6%), 4 therapeutic abortions for major malformation (2.8%)). Percentages of normal pregnancy outcome were not different between patients who continued maintenance therapy and those who stopped: respective percentages were 75 vs 73% in patients receiving mesalamine or olsalazine (n = 30), and 60 vs 75% in patients receiving azathioprine (n = 22)., Conclusion: In a selected series of women with inflammatory bowel disease, pregnancy outcome is approaching that observed in a normal population, except for an elevated rate of preterm births. There is no need to stop maintenance therapy with 5-aminosalicylates or azathioprine during pregnancy.

Objective: To evaluate the effects of smoking on the long term clinical course in patients with ulcerative colitis., Methods: The medical charts of 556 patients with ulcerative colitis were reviewed retrospectively. Patients were classified as smokers (n = 85) or nonsmokers (n = 471) according to their smoking status during the course of the disease. Extent of colonic lesions, complications, medical requirements, and actuarial rate of colectomy were compared in smokers and nonsmokers., Results: Mean follow-up (+/- SD) was longer in smokers than in nonsmokers (116 +/- 107 mo, vs 87 +/- 94 mo.). Less smokers than nonsmokers required oral steroids (52 vs 63%, P = 0.05). No difference between the groups was observed regarding the use of salicylates, the need for intravenous steroids, for immunosuppressive drugs, for colectomy, and the occurrence of complications. The actuarial rate of colectomy was less in smokers than in nonsmokers (32 +/- 12% and 42 +/- 6% at 10 years respectively. P = 0.04). Initial and cumulative extent of the disease process did not differ between the groups. However, in the subgroup of patients with limited disease at onset, development of pancolitis was less frequent in smokers than in nonsmokers (14 and 26%, respectively, P = 0.04)., Conclusion: The lesser need for oral steroids and the lower actuarial rate of colectomy in smokers suggest that ulcerative colitis in smokers is characterized by a less severe clinical presentation and a better long term prognosis than in nonsmokers.

Objectives: To determine the risk and predictive factors for colonic extension in patients with ileal Crohn's disease., Methods: One hundred and fifty patients with ileal Crohn's disease and no specific colonic lesions on initial colonoscopy were studied retrospectively (median follow-up: 51 months)., Results: Twelve patients (8%) developed colonic lesions. Ten-year cumulated risks (95% confidence interval) for colonic extension were 17.2% (range: 5.8-28.6) in the whole group, and 22.4% (range: 8.7-36.1) in the group of 86 patients with repeated colonoscopy. Young age at diagnosis was the only factor predicting colonic extension. Seven patients with colonic extension required immunosuppressive therapy but none underwent surgery., Conclusion: Ileal Crohn's disease has a low tendency for colonic extension. Colonic extension has no major prognostic implications.

Objectives: To evaluate the influence of the indication of the first surgical procedure on the prognosis of Crohn's disease., Methods: We compared retrospectively the long-term course of 179 patients operated on for a perforating disease and 322 patients operated on for a nonperforating disease. Mean follow-up was 11 years and 2 months in the two groups., Results: Forty of 179 (25%) and 106 of 322 (33%) patients with perforating and nonperforating diseases underwent a second intestinal resection, respectively. The patients who had been operated on for a perforating disease were significantly more often reoperated on for the same indication, and conversely. Patients with perforating diseases experienced less second resections (actuarial rates: 37 +/- 11% vs 51 +/- 8% at ten years respectively), less post-surgical handicaps (mean index 24.9 vs 27.9), and fewer patients required immunosuppressive drugs (25 vs 35%)., Conclusion: Long-term prognosis of perforating Crohn's disease does not appear to be more severe than that of nonperforating disease.

Objectives: Depending its frequency, the association in the same subject of Crohn's disease and another pathology can be fortuitous or the expression of genetic or environmental interrelationships. The aim of our study was to identify among a series of patients with Crohn's disease preliminary data which would be suggestive of a significant association between Crohn's disease and other pathologies., Patients and Methods: Personal and familial histories were collected in 832 patients with Crohn's disease who were seen consecutively in the same hospital clinic from 1974 to 1994., Results: We found 4 cases (0.5%) of associated Crohn's disease-multiple sclerosis and Crohn's disease-rheumatoid purpura in the same patient. Each of the following genetic diseases was associated with Crohn's disease in one patient (0.1%): Charcot-Marie-Tooth disease, deuteroanopia, multiple exostosis, familial ichthyosis, periodic disease., Conclusion: We describe for the first time sporadic cases of associated Crohn's disease and another rare disease, Charcot-Marie-Tooth disease, familial ichthyosis and periodic disease. We suggest that there is a significant interrelationship between personal and familial histories of Crohn's disease and multiple sclerosis which should be verified in prospective studies.

Objective: To assess the prognosis of pancolitis in ulcerative colitis including survival, colectomy rate, colon cancer risk, activity of disease, functional and socioprofessional impact., Methods: Retrospective study of 130 cases of ulcerative pancolitis referred consecutively to Rothschild Hospital from 1962 to 1993. They were 58 men and 72 women. The mean age at onset of ulcerative colitis was 30 years (range: 5-77). The extension to the right colon was secondary in 68% of patients. The period of observation ranged from 0.8 year to 46 years from the onset, with a median of 10.6 years. Three patients were lost to follow up., Results: Eight patients died, the survival rate being 93% at 10 years. Surgical treatment was performed in 85 patients. The cumulative colectomy rates were 61% and 77% at 10 and 20 years respectively. Colonic cancer developed in three patients, corresponding to a cumulative risk after 25 years of 6% in unoperated patients and 1.9% in the whole series. No cancer occurred after colectomy and ileorectal anastomosis. In the group of unoperated patients there was a decrease of activity of the disease during the first fifteen years. The quality of life of colectomized patients with reestablishment of intestinal continuity and of those treated conservatively did not differ significantly., Conclusion: In this series, long term prognosis of ulcerative pancolitis was favourable. The high colectomy rate was balanced by a very low risk of colorectal cancer.

Aim: The aim of the study was to test the hypothesis that some patients with functional diarrhea could actually suffer from a mild clinical pattern of collagenous or lymphocytic colitis., Patients and Methods: Twenty consecutive patients with chronic diarrhea were included in the study if the colonic mucosa appeared normal during colonoscopy. From multiple colonic biopsies were established a conventional histological diagnosis and a quantitative histological diagnosis. This latter diagnosis was based on the semiquantitative evaluation of epithelial morphological alterations and lamina propria monocellular infiltration, and on the determination of both intraepithelial lymphocyte count and subepithelial collagen layer thickness. Multiple colonic biopsies from 12 control patients without diarrhea were analyzed according to the same protocol., Results: Among the 20 patients with diarrhea, the quantitative diagnosis of collagenous colitis was made in 3 patients (thickness of the collagen band between 11 and 26 microns) and the diagnosis of lymphocytic colitis in one (21% of intraepithelial lymphocytes). The percentage of intraepithelial lymphocytes did not differ between the 16 remaining patients and the controls (12 +/- 5% and 9 +/- 4%, respectively). Similarly, the score of surface epithelial damage and the score of lamina propria infiltration in patients with diarrhea (1.2 +/- 1.0 et 1.7 +/- 1.5) were not different from the values in the control group (1.3 +/- 1.3 et 1.5 +/- 1.2). The mean fecal weight in patients with diarrhea but without colitis was 161 +/- 130 g/d. All the values of fecal weight were below 300 g/d, except in one patient with a past history of truncular vagotomy., Conclusions: These results suggest that most of the patients with functional diarrhea do not suffer from mild clinical patterns of collagenous or lymphocytic colitis.

Unlabelled: Artificial nutrition prior to bowel resection has not been evaluated fully. The aim of the present study was to assess the effects of preoperative artificial nutrition upon postoperative complications, length of resected bowel and relapses of Crohn disease., Results: Between 1990 and 1994, 108 consecutive patients underwent bowel resection for Crohn disease. Thirty nine patients had received exclusive enteral nutrition (n = 14) or parenteral nutrition (n = 25) for 19 +/- 10 days. Patients who had received artificial nutrition were more malnourished and had complicated Crohn disease (fistulae, abscesses) more often than patients operated without artificial nutrition. After 19 days of artificial nutrition, the nutritional state of patients was not significantly improved. Postoperative complication rate was higher in patients operated after artificial nutrition (33 vs. 16%; P = 0.03). Using multivariate prognosis analysis, the extent of colic resection was significantly associated with postoperative complications (P = 0.0003). Length of resected bowel and relapse rates were similar in patients with or without preoperative nutrition., Conclusion: Artificial nutrition prior to bowel resection for Crohn's disease is indicated in patients with the most severe form of the disease. A preoperative nutrition of 19 days does not seem to reduce postoperative complications nor the length of resected bowel.

Objectives: Anticardiolipin antibodies belong to the group of antiphospholid antibodies, and may be seen in association with endothelial damage and recurrent vascular thrombosis. The aim of our study was to determine in patients with Crohn's disease the frequency of anticardiolipin antibodies, and to correlate their presence with clinical activity and treatment of the disease., Methods: One hundred and thirty-eight sera from patients with Crohn's disease and 118 from age-matched controls were tested for IgG anticardiolipin antibodies. In the Crohn's disease group, we determined whether the patients had a past history of vascular thrombosis, a clinically active intestinal disease, or a current immunosuppressive therapy (steroids or azathioprine)., Results: Anticardiolipin antibodies were found significantly more often in patients with Crohn's disease than in controls: 11.0% versus 2.5%, P < 0.02. Three patients with Crohn's disease had a past history of vascular thrombosis, but none of them had anticardiolipin antibodies. The presence of anticardiolipin antibodies was not correlated with the fact that patients had a clinically active disease (P = 0.77), or a current immunosuppressive therapy at the time of the serological test (P = 0.95)., Conclusions: There is a significantly high prevalence of patients with anticardiolipin antibodies during Crohn's disease. The positivity of the test does not seem to be correlated to the existence of a past history of vascular thrombosis, nor to the clinical activity of the disease.

The aim of this study was to look for seasonal fluctuations in the clinical course of Crohn's disease. Eighty-three patients residing in the Paris area were included in the study and they had all undergone continuous clinical monitoring throughout the first three years of the disease. During this period, the clinical activity of the disease was ranked monthly on a semi-qualitative scale ranging from 0 to 4. The dates of corticosteroid treatment and of resection surgery carried out during the first three years of the disease were also recorded. The mean clinical score varied significantly (P < 0.0001) for different months of the year, the three highest scores being recorded during the three months of Spring-time (April, May and June). The number of months of corticosteroid treatment differed significantly (P < 0.05) for the various seasons, the six highest values being reported during Spring and Summer months. The number of intestinal resections differed significantly (p < 0.05) during different seasons, the highest incidence again being reported during Spring. This study demonstrates seasonal variations in the clinical course of Crohn' disease in the Paris area, with a peak occurring in the Spring.

Background: Mesalamine provides a new therapeutic approach in treating Crohn's disease., Methods: To assess the efficacy and safety of slow-release mesalamine (Pentasa) in maintaining remission in Crohn's disease, 161 patients with inactive disease were randomized to receive either Pentasa (2 g/day) or placebo in a 2-year double-blind, multicenter trial. Two strata were defined according to the duration of their remission: < 3 months (n = 64) or 3-24 months (n = 97), presumed to be high and low relapse risk strata, respectively., Results: The probability of relapse was higher in the short-remission placebo group than in the three other groups (p < 0.003), showing there was a significant benefit from Pentasa in the high relapse risk stratum. In this stratum, the 2-year on-going remission rate was of 29% +/- 9% and 45% +/- 11% (mean +/- SD) in the placebo and Pentasa groups, respectively. The incidences of side effects were similar in both groups., Conclusion: Pentasa (2 g/day for 2 years) is a safe and effective maintenance treatment for Crohn's disease when given within 3 months of achieving remission.

Unlabelled: The efficacy of clofazimine (Lamprene) was analysed retrospectively in twenty one patients with anoperineal lesions (APL) of Crohn's disease. Clofazimine is known for its antimycobacterial, antiinflammatory and immunomodifier properties. It is used with success in leprosy and certain dermatological disorders. A number of clinical and laboratory arguments suggest the probability of a role of mycobacteria in the etiology of Crohn's disease., Methods: twenty one patients with ileo-colono-anal or bucco-colono-anal Crohn's disease formed the basis of this study. They had been treated in various ways for APL, without success. They had APL of varying degrees of advancement (primary lesions: seven cases; secondary lesions: ten cases; major advanced lesions: four cases). Treatment with Lamprene was given for three to 38 months (mean: 12 months), the mean cumulative dose being 40 grams (4 to 146). Other therapeutic measures were started simultaneously in twelve patients: medical in six cases, medico-surgical in four cases and surgical only in two cases. The aim of treatment in fourteen cases was to obtain the healing of ulcerated lesions and/or fistulas, in three patients to delay dilatation sessions and in four patients to avoid proctectomy in the short-term., Results: ten patients showed no improvement while eleven were improved (with regression of primary lesions in ten cases). Taking combined treatment into consideration, the link between the result obtained and Lamprene was considered probable in five cases, possible in four cases and uncertain in one case. Lamprene was well tolerated in general. It was not possible to evaluate the efficacy of treatment regarding intestinal disease., Conclusion: the efficacy of Lamprene in ano-perineal lesions of Crohn's disease is possible and is worthy of evaluation in a controlled trial.

One hundred and two patients with Crohn's colitis present on average for 8 years, were studied retrospectively in order to determine whether or not a group of patients existed in whom the disease remained limited to the colon, and if such a group could be identified early on in the course of the disorder. At the time of the diagnosis of Crohn's disease, 34 patients had a concomitant anoperineal lesion, while 68 had disease affecting the colon only. In the latter, at the end of the follow-up period, the disease remained exclusively limited to the colon in 39 cases (57 p. cent). The actuarial rate of non-extra-colonic spread was 75, 40 and 35 p. cent at 5, 10 and 15 years respectively. Spread involved above all the anoperineal region (55 p. cent at 10 years), and less often the ileum (20 p. cent at 10 years). In patients monitored for at least 6 years, there was no significant difference between those in whom disease had spread and those in whom it remained limited to the colon, regarding the main initial clinical findings by history and examination, the same applying after the disease had been present for 3 years. These results would go against the existence of a specific entity of "Crohn's disease affecting the colon as an organ" and support the opinion that coloproctectomy with a pouch should be avoided in colitis due to Crohn's disease.

We report 7 prospectively followed cases of lymphomatous polyposis of the gastrointestinal tract. They were characterized by multiple polypoid lesions affecting several segments of the gastrointestinal tract always involving the colon and the rectum. An ileocecal mass was present in 4 cases. Regional lymph node involvement was constant. Peripheral lymphadenopathy was frequent (5 cases out of 7), as was other extra-digestive extension to the bone marrow (4 cases out of 7) and cavum (3 cases out of 7). The histopathological aspect was that of a small cleaved cells (working formulation) or centrocytic (Kiel classification) non-Hodgkin's lymphoma. The peculiar morphology and phenotype of the tumoral B-lymphocytes suggest their possible follicle marginal zone origin. Lymphomatous polyposis bore a rapidly fatal prognosis in every case (mean survival 20 months). This study of seven patients together with the 20 well-documented cases of the literature confirms the existence of lymphomatous polyposis as a distinctive clinicopathological entity among gastrointestinal non-Hodgkin's lymphoma.

Psoas abscess were found in 6 cases among 166 patients with Crohn's disease between 1985 and 1989; in one case, it was the first sign of Crohn's disease. Diagnosis was usually difficult and should be suspected on the following signs: lower abdominal quadrant pain, psoitis, abdominal mass, sciatica or pain along the course of the femoral nerve. Diagnosis was confirmed in nearly all cases by computerized axial tomography. Effective therapy combines drainage and bowel resection.

There are no absolute diagnostic criteria of ulcerative colitis or Crohn's disease, and the diagnosis rests on convergent clinical, laboratory and morphological findings, the most useful being radiological endoscopic and histological data. The diagnosis is often easy, but at the first acute episode all infectious and parasitic causes must be excluded as they may mimic the cryptogenetic diseases. It may be very difficult to distinguish between ulcerative colitis and Crohn's disease when they are restricted to the colon and rectum. In this respect, diagnostic score systems can be very helpful.

Patients who have an interruption of the small bowel with a high enterostomy usually need parenteral supply or reinfusion of chyme to maintain nutritional and electrolytic balances before restoring intestinal continuity. Ten patients (aged 28-76 years) with a terminal jejunostomy located within the first meter of jejunum were treated by infusion of an elemental diet into the distal small bowel (IEDDSB). In addition, five of these patients had an extensive small bowel resection. IEDDSB was started 32 days after operation and lasted 4 to 8 weeks. Mean daily caloric infusion was 1,732 +/- 666 kcal diluted in 2,860 +/- 808 ml; mean associated oral intake was 1,187 +/- 480 kcal/24 hr, and jejunal fecal losses averaged 3 kg per day. IEDDSB was well tolerated in 4 patients; 5 experienced transient abdominal pain or diarrhea; 1 developed severe and protracted diarrhea. Biological cholestasis was seen before IEDDSB and persisted in most patients; 1 patient developed biliary sludge. Through IEDDSB, nutritional status improved or remained satisfactory in 9 patients, and worsened in 1 patient with sepsis and a short lower intestine. Mean body weight, triceps skin fold, muscle circumference, serum albumin, serum transferrin did not change significantly. Digestive nitrogen balance performed in 6 patients showed a net absorption between 5 and 15 g/24 hr. Fluid and electrolyte balance was maintained in 9 patients and 1 received iterative intravenous saline. Digestive sodium balance showed a net absorption rate greater than 60 mmol/24 hr. in all patients, except the one who required intravenous supply. Postoperative recovery was uneventful in all patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The responsibility of the folate deficiency in some neuropsychiatric disorders is recent knowledge. The role of the folate on the nervous system is not yet well definite, but the action on the metabolism of the amino-acids, on the purine and the pyrimidine synthesis and on the metabolism of the catecholamins are certainly essential. The neuropsychiatric diseases secondary to the folate deficiency are numerous: dementia, schizophrenia like syndromes, insomnia, irritability, forgetfulness, endogenous depression, organic psychosis, pueperal psychosis, peripheral neuropathy, myelopathy (spinal cord syndrome and/or pyramidal tract damage), restless legs syndrome. Clinically the diagnosis may be difficult with sub acute combined degenration secondary to the pernicious anaemia, and the dosage of the folate (in serum, in red-cells and in cerebrospinal fluid) is necessary. The congenital defects in the uptake or utilization of the folate are associated with neuropsychiatric disturbances. The treatment is easy and safe if the vitamin B12 deficiency is eliminated and if employed with caution in epileptic patients because folate can induced seizures.

In patients with chronic gastro-intestinal disease, deciding whether or not to provide nutritional support is difficult. The aim of the present study was to develop an objective index to help clinicians to decide which patients should be treated with nutritional support. Two hundred and two patients were studied prospectively. Seventy-one had an inflammatory bowel disease, 51, a malabsorption syndrome, 59, an esophagogastric disorder, and 21, a pancreatic disease. On admission, nutritional status was assessed by anthropometric and biological measurements, and spontaneous oral caloric intake. Clinical assessment of the nutritional condition was performed by an independent observer. Using discriminant analysis, collected data were correlated to the therapeutic outcome of the patient during the 15 days after admission, i. e. whether or not they received nutritional support. Clinical global assessment proved to be the most discriminant variable: 83 p. 100 of the patients were correctly classified. This variable was deleted from further analysis to obtain an objective index, calculated with four variables: mid-arm muscle circumference, body weight, serum albumin, and caloric oral intake expressed as kcal X IBW kg-1 X day-1. The index classified correctly 84 p. 100 of the patients. This study demonstrates that subjective clinical assessment is the best variable to decide whether or not a gastrointestinal patient should receive nutritional support. We suggest that this index might be of help in these situations.

In 119 gastrointestinal patients, serum transaminases (ASAT) and alkalines phosphatases (AP) were prospectively measured on the first and the twenty first days of a continuous enteral nutrition (CEN) regimen. The exclusion criteria were: recent surgical procedure, transfusion or total parenteral nutrition (TPN), or a cancer during the previous five years. Of the 119 patients, 71 patients were included in the study. The patients received: (a) an exclusive elemental CEN (n = 25, all with Crohn's disease) or non elemental CEN (n = 9), providing 40 kCal/kg of ideal body weight (IBW)/day; (b) a non exclusive non elemental CEN providing a minimum of 30 kCal/kg IBW/day. Of the 56 patients having normal hepatic function tests (HFT) on the first day, only 2 developed mild abnormalities (incidence of 3.6%). Of the 15 remaining patients having abnormal HFT on the first day, HFT improved or returned to normal in 8 cases. During CEN: the appearance of abnormal HFT seems rare, pre-existing abnormalities can improve and there is no associated morbidity. These results suggest that there is no hepatic side effects of CEN, in contrast to TPN, and that CEN must be preferred over TPN whenever the choice is possible.

The nutritional development with three types of enteral diets during 28 days, was compared in 45 patients with malnutrition presenting an active Crohn's disease. Enteral feeding consisted of a polymeric mixture (Realmentyl) administered in addition to a normal oral diet in 11 patients; the same mixture was administered alone exclusively to 9 patients, and an elemental diet (Vivonex HN) administered exclusively to 25 patients. The total caloric intake reached, in the three groups, the mean values of 60.2, 36.9 and 33.8 kcal/kg of ideal weight/day, respectively. 33 patients also received steroids. At the end of 28 days of enteral diet, the improvement in the weight and the anthropometric measurements (muscle circumference, triceps skinfold) was significantly more marked (gain of 6.5 kg) with the supplemental polymeric mixture than with exclusive enteral diet, polymeric diet (+/- 2.0 kg) or basic (+1.2 kg). Transferrin and albumin plasma levels increased in all 3 groups, but much faster with the exclusive elemental feeding, in spite of a higher urinary urea excretion in these patients. The overall nutritional development was significantly better with supplemental polymeric feeding, and was identical in the two other groups. These results confirm that the supplemental polymeric enteral feeding is more effective, from the nutrition standpoint. With an exclusive enteral feeding, the nutritional result is appreciably the same, whether the mixture consists of polymers or basic elements.

Diarrhoea may develop after any surgery of the digestive tract, but its frequency and characteristics vary according to the type of operation. After gastrectomy diarrhoea is rare, moderate and often cryptic. After all but hyperselective vagotomies it is more frequent and may even be disabling and difficult to control. Diarrhoea is observed and may even be disabling and difficult to control. Diarrhoea is observed mostly after intestinal surgery, but it may have nutritional repercussion only after small bowel resections, while its functional repercussions are observed after colonic resections. Diarrhoea depends on the length rather than on the location of the intestinal segment resected, hence the importance of a reserve intestinal tissue below the resection. Thus, jejunal resections are well tolerated, even they are extensive, whereas ileal resections, even short, often result in a diarrhoea which is particularly pronounced when the ilio-coecal region and adjacent colon have been removed. Finally, the presence of an artificial anus increases the intestinal loss and creates its own specific problems.

Fecal losses of water, electrolytes, fat and nitrogen were studied retrospectively in 42 cases (40 patients). To assess the role of the terminal ileum, patients were classified into 2 groups according to the length of resected and/or excluded ileum before the ileocecal junction; group I (n = 17; length less than or equal to 15 cm) and group II (n = 25; length ranging from 15 to 50 cm). In group I, fecal weight and fecal output of sodium, fat and nitrogen were (mean for 24 h) 544 g, 63 mmol, 6.5 g (6.4 p. 100 of ingesta), 2.94 respectively. In group II, fecal outputs were higher; (mean for 24 h) 862 g, 112 mmol, 10.9 g (14.2 p. 100 of ingesta), 4.2 respectively. These differences were statistically significant for fecal weight and fecal output of sodium (p less than 0.001) and for fecal output of fat when expressed as percentage of ingesta (p less than 0.02). These results show that the length of terminal ileum is a major determinant in fecal losses after ileostomy; therefore, it appears to be of major importance to preserve this segment of ileum as much as possible during ileocolic surgery.

The authors report a case of pernicious anaemia in a 41-year old white man; this case has particular features: rise in mean corpuscular volume, neurological manifestation 8 and 2 years respectively before diagnosis, association with selective IgA deficiency. Relations between pernicious anaemia and immunoglobulin deficiency are discussed.

We have studied 54 patients (age 19-83 years) with radiological and/or operative evidence of small bowel radiation injury, in order to assess clinical and biological features, final outcome, and prognostic factors of late radiation enteropathy; 23 of them had undergone previous small-intestinal by-pass or resection. During initial treatment (first 6 months), the patients received symptomatic medical treatment and 17 had a 3-6 week continuous enteral alimentation; 15 were operated on. At entry, 51 out of 54 complained of diarrhea, 32 had repeated vomiting and abdominal pain, 43 were undernourished (36 had lost more than 20 p. 100 of their normal weight, 27 had profound anorexia, 29 had hypo-albuminemia of less than 30 milligrams). Anemia was present in 30 patients. Seventy six and 88 p. 100, respectively, had hypocalcemia and hypomagnesemia, with clinical symptoms in 14 cases. Fourteen patients, 12 of whom had undergone intestinal by-pass or resection, had biological hepatic abnormalities. Six patients died during initial treatment and 5 during follow-up; the actuarial survival rate was 72 p. 100 at four years (65 p. 100 for the unoperated patients, and 79 p. 100 for those previously operated on). Carcinoma was the cause of death in 5 cases. Social activity and state of nutrition were satisfactory in 22 out of the 32 patients seen in 1982 with 6-96 months (mean 29 months) follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of gastric tuberculosis associated with villous atrophy is reported in a sixty-three years old female. Fifteen years before she had a skin-disease whose histology was compatible with a dermatitis herpetiformis. Under treatment by gluten exclusion and anti-tuberculous drugs, a cure of gastric tuberculosis and a dramatic relapse of jejunal morphology were observed.

Intestinal malabsorption was studied in 51 cases (46 patients) with radiological and/or operative evidence of small bowel radiation injury. At the time of the study, 23 patients had not been operated on (MED patients), and 28 had undergone previous small-intestinal by-pass or resection (BP/R patients). Fecal analysis data (n = 51), and results of alpha-1-antitrypsin clearance (n = 24), and of D-xylose (n = 37), folic acid (n = 20) and Schilling (n = 27) absorption tests were compared to the extent and severity of small-intestinal damage assessed radiologically and/or operatively. Mean fecal weight was 311 g/24 h in MED patients and 1,190 g/24 h in BP/R patients. Sixty-five, 43, 86, and 82 p. 100 of MED patients, and 93, 77, 93, and 85 p. 100 of BP/R patients, respectively presented increased fecal weight, sodium, lipid, and nitrogen. In MED patients, there was a significant relationship between the extent and severity of small-intestinal damage and fecal weight, lipid, and nitrogen. In BP/R patients, fecal data were related to those calculated from the site and the extent of the intestinal resection. Fecal losses tended to be more abundant when the residual intestine was severely damaged. Alpha-1-antitrypsin clearance (mean 37 ml/24 h) was increased in 8 out of 9 MED patients and in 11 out of 15 BP/R patients. Its value was not related to the extent and severity of small-intestinal damage.(ABSTRACT TRUNCATED AT 250 WORDS)