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C.L. Rutter1, S.G.R.G. Barton2, D.R. Rutter1.1Centre for Research in Health Behaviour, Department of Psychology, University of Kent at Canterbury, Canterbury, Kent; 2Department of Gastroenterology, Kent and Canterbury Hospital, Canterbury, Kent, UK

Introduction: Irritable Bowel Syndrome (IBS) is a common condition affecting up to 30% of the population. The determinants relating to the uptake of primary and secondary medical care are unclear although IBS patients referred to secondary care have been found to have greater severity of symptoms, greater psychiatric-comorbidity and more negative health beliefs about their illness such as death phobia and catastrophizing. It is unclear whether these health beliefs are pre-existing or develop in response to the symptoms or perhaps in response to having negative test results. This study analyses the health perception (Leventhal et al. 1980; 1984) of IBS patients at the time of diagnosis and again two months later.

Methods: Thirty-five patients with IBS were recruited from the out-patient clinic of the Gastroenterology Department of the Kent and Canterbury Hospital, Kent. Each patient was recruited on their first visit to the gastroenterologist and completed a brief demographic questionnaire. A diagnosis of IBS was determined after taking a complete history of the patient, and receiving clear test results from barium enema or colonoscopy and from bloods. Patients completed the illness perception questionnaire within the first couple of weeks of receiving their IBS diagnosis. Two months later, these patients were contacted again and asked to complete the illness perception questionnaire, the hospital anxiety and depression scale and questions relating to their perceived quality of life and satisfaction with health.

Results: The individual components of the health perception: psychological cause, external cause, timeline, consequences and the possibility for cure / control did not change significantly over the two time points, suggesting that the initial health beliefs regarding their abdominal and bowel symptoms remain fairly steady in the early months after diagnosis. The most predictive component of the health perception was serious consequences. Reporting that IBS has many serious consequences was strongly associated with poor outcome: poor quality of life, dissatisfaction with health and higher scores on the anxiety and depression scales.

Conclusions: This pilot study has shown that the initial health perception of IBS patients remains stable during the first couple months of the diagnosis and also that serious consequence beliefs are predictive of poor outcome and may remain so if left unchallenged. Future researchers should consider the role of these consequences beliefs as a potential predictor of refractory IBS patients.


D.P. Hurlstone, M.J. Carter, D.S. Sanders, S. Mitchell, Z. Harclerode, A.J. Lobo. Gastroenterology and Liver Unit, Sheffield Teaching Hospitals, UK

Introduction: Smoking is an established risk factor for the development of Crohn's disease (CD). Continued cigarette consumption has an adverse effect upon the clinical course of CD. More severe disease, recurrence post-surgical resection and an increase in frequency of relapse are reported. Studies investigating anatomical disease localisation in CD with regards to smoking status have however, proved inconclusive.

Aims: To evaluate the relationship between smoking status and anatomical site of disease in a single centre cohort of CD patients.

Subjects and Methods: All patients with a diagnosis of CD were identified from the Inflammatory Bowel Disease database. Smoking status was determined by postal questionnaire, direct interview and case note review. Anatomical extent was classified as isolated small bowel disease (SBD), terminal ileal/ileo-caecal, colonic or mixed. Patients with indeterminate or ulcerative colitis were excluded. Analysis by way of 2x2 contingency table of smoking status compared to patient sub-groups was performed.

Results: N=511, 202 male (39.5%), mean age at presentation=31 years. See table. Patients with isolated colonic disease were less likely to be smokers at presentation than those with mixed small/large bowel disease (p<0.0001, OR=2.45, 95%CI: 1.66–3.63). Significance remains, comparing isolated colonic with ileo-caecal/SBD(p<0.0001, OR=3.71, 95%CI: 1.77–4.14).

Abstract 259

Conclusion: Patients with isolated colonic CD are less likely to be smokers at diagnosis in comparison to patients with mixed small/large bowel disease and those with ileo-caecal/SBD. Smoking at diagnosis is a risk factor for small bowel Crohn's disease.


E. Ali, P. Crouchman, N. Meadows, I.R. Sanderson, N.M. Croft. Dept of Adult and Paediatric Gastroenterology, Barts and the London, Queen Mary's School of Medicine and Dentistry, London, UK

Introduction: Induction of remission in Crohn's disease can be achieved with exclusive enteral nutrition (EN) or oral steroids. It has been suggested that EN only delays the inevitable use of steroids. In this study we have followed up the outcome of children newly diagnosed in our unit with Crohn's disease.

Methods: The case notes of patients newly diagnosed with Crohn's disease during 1999 and 2000 were reviewed in August 2001.

Results:Patients: 36 patients new patients were diagnosed with a median age of 12.9 years (range 6.67–15.0). 22 had small bowel and colon affected, 7 had small bowel alone and 2 had colonic disease alone. 31/36 had disease severity requiring treatment with EN or steroids. The remaining 5 had localised oral/perianal disease not requiring EN or steroids. Initial treatment: Exclusive polymeric EN (Modulin, Nestle, UK) was started in 30/31 patients, one refused and was treated with steroids. 24/30 (80%) went into remission. 6/30 required steroids to induce remission. 3 were early failures within 2 days (i.e. could not drink the feed or tolerate a naso-gastric tube) and 3 were late failures due to lack of response. Follow up data: The median time of follow up was 1.25 years. Of 24 children successfully treated with EN, 1 has been lost to follow up, 42 % (10/24) remain in remission and 54% (13/24) have relapsed. Of the 13 children who relapsed 54% (7/13) have been successfully treated with EN, 15% (2) failed to respond to EN and started steroids and 23% (3) were treated with steroids. 2/7children who required steroids at presentation remain in remission, 5/7 have had relapses, one of which was treated with EN.

Conclusions: These data confirm that EN is a very effective treatment for newly diagnosed Crohn's disease and can be used successfully for treating relapses. During the period of follow up the majority (58% (18/31)) have exclusively been treated for active disease using EN and have not required steroids. More prolonged follow up will establish the proportion of children who can be repeatedly treated with EN for relapses of their Crohn's disease.


A. Ansari, M. Yaneza, J. Hurst, J. Sanderson. Guy's and St Thomas' Hospital, London, UK

Introduction and Aim: Methotrexate (MTX) is a considered option for medical treatment of steroid dependant Crohn's disease (CD) or those intolerant or resistant to azathioprine (AZA). Few studies involving MTX use have been published. We report the experience of MTX use for CD in a large inflammatory bowel disease clinic.

Methods: MTX use was initiated in 42 patients with CD at a dose of 15- 25mgs/ week orally. Indication for treatment was steroid dependent CD despite AZA (n= 35) or fistula (n= 7). Efficacy was assessed by steroid withdrawal, abbreviated Harvey Bradshaw index or fistula closure. Adverse effects were recorded at each visit.

Results: Length of treatment- mean 34 wks, median 25.5 and range 1- 91 wks. Total MXT dose- mean 693 mgs, median 420 mgs and range 15- 2330 mgs. Ten patients withdrew because of adverse effects: nausea (7), transaminitis- ALT rise (1), headaches (1) and multiple side effects (1). In two patients neutropenia occurred (1 severe and complicated by fungal sepsis), both patients were folate deficient. Haematinics were normal in all other cases. On an intension to treat basis 19 of the 42 patients achieved remission (42%). 16 of the 35 tolerating treatment withdrew steroids (46%), 3 out 7 achieved fistula closure (43%). In 16 of the 42 patients AZA was continued as concurrent treatment (mean dose 0.75mg/kg). Whilst both cases of neutropenia were receiving AZA, overall adverse events were not associated with its concurrent use.

Conclusion: In practice success rates of treating CD with MTX are similar to those suggested by limited trial data, withdrawal is more frequent than with AZA therapy. Concurrent AZA treatment does not appear to be a problem, and is generally safe. However, folate deficiency is a risk factor for severe adverse events.


S. Campbell, S. Ghosh. The Gastrointestinal Unit, University of Edinburgh, Department of Medical Sciences, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK

Background: Cyclosporin is a fungal metabolite and is a powerful immunosuppressant. While response to intravenous steroids is in excess of 60%, the remainder of patients are left with the options of curative panproctocolectomy or administration of intravenous rescue therapy with cyclosporin. There have been conflicting reports with regard to efficacy of IV cyclosporin in acute UC, and there are serious concerns about potential toxicity and opportunistic infections such as pneumocystis carnii pneumonia. To date there has been a paucity of data available to help guide the gastroenterologist in the use of cyclosporin.

Methods: Between 1994 and 2001, there were 16 patients who had received intravenous cyclosporin for acute exacerbation of their known UC (7 female:9 male, mean age 33 years). All patients were treated with and were refractory to IV methylprednisolone (60mg/24hrs). Patients were discharged on a regimen of oral cyclosporin, oral steroids and oral azathioprine.

Results: Median disease duration was 5.4 years (range 0.9–25 years). All patients were initially treated with cyclosporin at a dose of 4mg/kg/day. Nine patients were simultaneously started on oral azathioprine (median dose 1.8mg/kg). Seven patients underwent surgery (panproctocolectomy), although none had surgery after 6 months. Comparisons were made between patients who had <7days IV steroid versus >7 days IV steroid, and other subgroups such as stool frequency at 3 days and CRP at 3 days. There was no statistical significant differences between these groups.

Conclusion: Initial response rate was high (69%). Side effects were documented in the majority of patients, but none of the patients had to discontinue treatment because of these. At 3 years follow-up, 56% of patients avoided surgery. Median bowel frequency at day 3 was higher in patients who finally underwent surgery. Cyclsoporin has a useful role as a 3rd line drug therapy for acute UC patients.


R.J. Atkinson, J.O. Hunter JO. Department of Gastroenterology, Addenbrooke's Hospital, Hills Road, Cambridge CB2 2QQ, UK

Introduction: It appears to be little known that sodium phosphate, a laxative used in bowel preparation for colonoscopy, may potentially damage the colonic mucosa. A 51 year old man undergoing colonoscopy for chronic diarrhoea was found to have severe aphthous ulceration of the sigmoid and histology suggested Crohn's disease. No treatment was prescribed, but three weeks later a second examination, after a phosphate enema rather than sodium phosphate, was both endoscopically and histologically normal. We suspected that the ulcers were caused by the bowel preparation and we therefore reviewed the presence of aphthous ulceration, in a series of reports of colonoscopies where either sodium phosphate (Fleet) or sodium picosulphate (Picolax) had been used for bowel preparation.

Methods: 175 consecutive colonoscopy reports were retrospectively reviewed with respect to age, sex, indication for the exam and the presence of ulceration.

Results: Sodium picosulphate was used in 124 colonoscopies and sodium phosphate in 51. The groups were evenly matched for age and sex. Aphthous ulceration was documented in 4/124 (3.2%) after sodium picosulphate but 7/51 (13.7%) after sodium phosphate {p=0.015; Fisher's Exact Test}. The incidence of ulceration in patients known to have inflammatory bowel disease was only 3/27 and the incidence of ulcers was only significantly increased in the group whose indication for the exam was altered bowel habit. (1/24 [4.2%]; 6/23 [26.1%] {p=0.048; Chi squared test}.

Conclusion: It has been shown previously that sodium picosulphate can cause colonic ulceration. Our series confirms this finding which might potentially lead to an incorrect diagnosis and unnecessary treatment. The use of sodium phosphate preparation in patients suspected of having inflammatory bowel disease may be inadvisable.


K. Negoro, D.A. van Heel, D.P. McGovern, N.J. Lench, D.P. Jewell. Wellcome Trust Centre for Human Genetics, University of Oxford, UK

Introduction: Genetic studies in inflammatory bowel disease have identified several susceptibility loci. Recently genetic variation in the 5q31 cytokine cluster has been linked to and strongly associated with Crohn's disease in the Canadian population (IBD5 locus, Rioux et al., Nature Genetics 2001). Although the disease gene has not been precisely characterised, the cluster contains the immunoregulatory cytokines IL4, IL5 and IL13 involved in Th1/Th2 responses. The role of the IBD5 risk haplotype in ulcerative colitis is unknown.

Aims: (i) To determine, in UK Caucasian cohorts, whether ulcerative colitis is influenced by the 5q31 cytokine cluster risk haplotype, and assess its role in Crohn's disease (CD).

Methods: A genetic variant (IGR2060a_1), unique to the 250kb CD risk haplotype, was genotyped in 457 IBD families (252 UC, 294 CD trios, all UK Caucasian). Family based (ASPEX transmission disequilibrium test, TDT) association analysis was performed. CD analyses were sub-stratified by NOD2 status (carriage of Arg702Trp, Gly908Arg, Leu1007fsinsC).

Results: No association was seen between the 5q31 risk haplotype and ulcerative colitis (TDT Transmitted/Untransmitted: 105/124, P=0.24). Association was confirmed with Crohn's disease (162/114, P=0.006), specifically in CD patients not carrying NOD2 mutations (110/67, P=0.003)(CD NOD2 carriers, 52/47, P=0.3). In the UK population the haplotype plays a lesser role in CD susceptibility than in the Canadian population (T/U CDall 1.4 or CD NOD2neg 1.6 versus CD 2.5; an estimate of genotype relative risk using a multiplicative model).

Conclusion: The 5q31 cytokine cluster risk haplotype does not influence susceptibility to ulcerative colitis and plays a lesser role in genetic susceptibility to Crohn's disease in the UK than in the Canadian population. In addition, these data provide experimental evidence for genetic heterogeneity in Crohn's disease.


D.P.B. McGovern, K. Negoro, D.A. van Heel, N. Lench, D.P. Jewell. Wellcome Trust Centre for Human Genetics and Gastroenterology Unit, University of Oxford, UK

Background: The identification of NOD2 emphasises the role of the innate immune system in the pathogenesis of Crohn's disease (CD). CD14 and PPARγ are positional and functional candidate genes for IBD. Bacterial LPS binds to CD14 and its co-receptor the toll-like receptor 4 leading to NFχB activation. A CD14 promoter SNP is associated with increased protein expression. The peroxisome proliferator-activated receptor γ (PPARγ) gene is located at 3p25, a CD locus (LOD score 4.9) (Duerr et al, AGA 2001). PPARγ agonists antagonize monocyte function through inhibition of activated protein 1 and NFχB. Troglitazone (a PPARγ agonist) ameliorates the features of animal models of colitis. A common PPARγ SNP (Pro12Ala) is associated with type 2 diabetes.

Aims: To test for association between Pro12Ala and the CD14 promoter SNP and IBD.

Methods: The transmission disequilibrium test (TDT) was performed on 457 families containing 294 CD and 254 UC trios. Genotyping was by PCR-RFLP.

Results: See table.

Abstract 265

Conclusions: The CD14 promoter and Pro12Ala polymorphisms are not statistically associated with susceptibility to IBD. However Pro12Ala requires further investigation in a larger cohort of NOD2 positive CD.


D.N. Crichton, I.D.R. Arnott, D. Watts, C. Mowat, J. Hutchinson, H.E. Drummond, J. Satsangi. Gastrointestinal Unit, University Department of Medical Sciences, Western General Hospital, Edinburgh, UK

Introduction: Germline mutations in the Nod2/CARD15 gene have been associated with a susceptibility to Crohn's disease (CD) in North American and European populations but frequency of such mutations in a Scottish population are unknown

Aim: To assess the frequency of Nod2/CARD15 mutations in a Scottish population and document phenotypic associations.

Methods: Genomic DNA was extracted from venous blood of 215 well characterised patients with inflammatory bowel disease (123 CD and 92 ulcerative colitis (UC)) and 46 healthy controls (HC). PCR based genotyping was carried out using allele specific primers designed to identify the three common single base pair polymorphisms previously described (1007fs, G908R, R702W)1,2.

Results: Allelic frequencies for the 3 SMP are displayed in table 1. There were no significant differences between CD, UC and HC. The frequency of the 1007fs mutation in CD patients in this study differs from previously published data (table 2) whereas that of HC does not.

Abstract 266, Table 1 Allelic frequencies of Nod2/CARD15 mutations in study population (comparisons are between CD and HC using chi squared)

Abstract 266, Table 2 Allelic frequency of 1007fs in published series and present study (8 out of the 9 patients heterozygous for 1007fs had ileal disease)

Conclusions: Results from the present study contrast previously published data. Explanations for this discrepancy may include phenotypic heterogeneity ie age of onset, extent of involvement and familial tendency and ethnicity.

1Hampe et al. Lancet 2001.

2Hugot et al. Nature 2001;411:599–603.


T.R. Orchard, P. Gow, D.P. Jewell, R.W.G. Chapman.

Background: The association between PSC and ulcerative colitis is well documented, with up to 80% of PSC patients having evidence of colonic inflammation. Most patients with PSC have a pancolitis which tends to run a quiescent course. However it is associated with a particularly high risk of colonic malignancy, and it has been suggested that PSC associated colitis is a different clinical entity from typical UC. We have previously reported a series of patients with severe PSC and seropositive rheumatoid arthritis. This study was undertaken to compare the prevalence of EIM's in PSC colitis and UC.

Methods: The notes of 976 patients with UC and 72 patients with PSC colitis were reviewed, and information on general disease characteristics and EIM's was obtained. This information was validated by a patient questionnaire administered in outpatients. The prevalence of IBD associated arthritis, rheumatoid arthritis, erythema nodosum and uveitis was compared in the two populations to establish whether there were phenotypic differences. The groups were compared using 2x2 contingency tables and Fisher's exact test.

Results: The prevalence of EIM's in the 2 groups is shown in the table.

Abstract 267

Conclusions: Typical IBD associated arthritis is not seen in PSC colitis, and this is significant even when compared to a subgroup of 232 patients with total UC (p=0.009). In contrast rheumatoid arthritis is more common in PSC colitis than UC. These findings support the concept that PSC colitis and UC are different phenotypic entities.


S. Ganesan1, S. Iyer2, S.P.L. Travis3, S. Davis2, J. Vogt2, R. Jazrawi1, R.J. Tesi2 ,R. Beulow. 1Phase 1 Clinical Trials Unit, Plymouth; 2Sangstat Medical Corporation, Fremont, CA; 3Gastroenterology Unit, Oxford, UK

Introduction: RDP-58 is a D-isomeric decapeptide that inhibits TNFα production in both murine DSS and TNBS-colitis. The effect of RDP58 on spontaneous colitis in non-human primates has been evaluated.

Methods: Rhesus (mean age 9.3 years, weight 4.9 Kg) and cynomolgus monkeys (7.1 years, 3.9 Kg) with spontaneous colitis (>4 months, infection excluded, housed in accordance with US Federal regulations) were given oral or intravenous RDP-58. Stool quality was scored (1-normal; 2- loose; 3-liquid; 4-bloody) twice daily and colonoscopy performed. Response was defined as a reduction in stool score 0-none; 1-minor; >2-good). Duration of response after treatment was recorded.

Results: See table. All responses occurred with 1 day of dosing. No effects on full blood count or metabolic profile were observed. Four animals were colonoscoped and macroscopic resolution of colitis was observed.

Abstract 268

Conclusions: Oral RDP-58 is safe and rapidly effective in primate colitis, with a prolonged duration of effect after dosing for 3 weeks. Phase 1 human volunteer studies are indicated.

269 CIRCULATING MUCOSAL HOMING (β7+) memory t cells are decreased in number and display altered cytokine production in crohn's disease

A.L. Hart1,2, R. Rigby1, A. Jones1, M.A. Kamm2, S.C. Knight1, A.J. Stagg2. 1Antigen Presentation Research Group, Imperial College; 2St Mark's Hospital, Harrow, London, UK

Introduction: Circulating mucosal homing (β7+) memory T cells may be primed in intestinal lymphoid tissue and home selectively back to the gut. Monoclonal antibodies to α4(β7) ameliorate gut inflammation, supporting the functional significance of this population. Analysis of β7+ memory T cells in blood may allow sampling of mucosally relevant cells from an accessible site. We have characterised quantitative and functional changes in β7+ memory T cells in Crohn's disease.

Methods: Whole blood labelling and flow cytometry was used to identify β7+ (β7hi and β7int) and β7- populations within CD3+CD45RA- leucocytes from 7 Crohn's disease patients (CDAI>220) and 10 healthy controls. Production of cytokines (IFNγ, TNFα, IL-10, TGFβ, and IL-2) was determined by intracellular labelling following activation with phorbol-myristate-acetate and ionomycin in the presence of monensin.

Results: The number of T cells was the same in both groups but a greater proportion were memory T cells in Crohn's disease, suggesting a re-distribution to the memory pool as a result of chronic inflammation. The ratio of β7+:β7- memory cells was significantly reduced (p<0.05) in Crohn's disease. Absolute number analysis demonstrated both a fall in the number of β7+ cells and a smaller increase in β7- cells, ruling out a dilution effect of naïve cells and indicating that the disappearance of β7 expressing cells cannot be accounted for by loss of the marker alone. In healthy controls, production of all cytokines increased with β7 expression. Compared with control samples, fewer β7+ cells from Crohn's disease patients produced IL-10 but more produced TGFβ.

Conclusions: Recruitment to inflamed tissue probably contributes to the observed loss of blood β7+ memory cells in Crohn's disease. Alterations in cytokine production suggest selective recruitment of functionally distinct populations. These perturbations in β7+ populations support the development of therapeutic strategies that target these cells.


D.P.V. McGovern, D.A. van Heel, T. Ahmad, N. Lench, D.P. Jewell. Wellcome Trust Centre for Human Genetics and Gastroenterology Unit, University of Oxford, UK

Background: Cytochrome P450 enzymes convert many chemicals (including cyclosporin and endogenous corticosteroids) into more water soluble products thereby facilitating their elimination from the body. CYP3A is the most abundantly expressed P450 in the liver. Up to 90% of the inter-individual variation in CYP3A activity is genetic in origin. CYP3A activity is the sum activity of the family of CYP3A genes including CYP3A5. SNPs in CYP3A5*3 cause alternative splicing and protein truncation resulting in the absence of CYP3A5 in tissues. Cyclosporin and corticosteroids are also substrates of the efflux pump P glycoprotein 170 (Pgp-170) encoded for by the MDR-1 gene. Patients with IBD poorly responsive to medical therapy have increased MDR-1 expression. Recently homozygosity for a polymorphism in exon 26 of MDR-1 has been associated with lower duodenal MDR-1 expression and elevated serum substrate (digoxin) levels.

Aims: To evaluate whether carriage of the CYP3A5*3 SNP and the MDR-1 exon 26 polymorphism predict the need for colectomy in patients with ulcerative colitis.

Methods: Allele counts were compared between 135 patients with UC who needed colectomy and 182 patients with pan-ulcerative colitis who have not required surgery.

Results: CYP3A5*3: Allele frequency was not significantly different between the two groups: colectomy 8.5%, non-colectomy 5.6% (p = 0.33).

MDR-1 exon 26: Homozygosity was not significantly different between the 2 groups: colectomy 21.0%%, non-colectomy 25.2% (p = 0.47). Allele frequency was not significantly different between the 2 groups: colectomy 47.6%, non-colectomy 51.6% (p = 0.32).

Conclusions: These polymorphisms do not predict the need for colectomy in UC. Future studies should examine the role of other polymorphisms within genes involved in drug metabolism.


A.B. Ballinger, V. McDonald.Adult & Paediatric Gastroenterology, Barts & The London, Queen Mary's School of Medicine & Dentistry, London, UK

Impaired linear growth is a major complication of Crohn's disease in young patients. Both undernutrition and direct effects of the inflammatory process contribute to the growth deficit. In the trinitrobenzene (TNBS)-induced colitis model, immunoneutralisation of interleukin-6 increases serum concentrations of insulin-like growth factor-I (IGF-I) and linear growth. Immunoneutralisation of tumour necrosis factor-α (TNF-α) also increases growth but has no effect on IGF-I and thus the mechanisms of growth suppression by TNF-α are unexplained. The purpose of this study was to explore the hypothesis that TNF-α has direct effects on growth plate chondrocytes.

Methods: Growth plate chondrocytes were isolated by collagenase digestion from prepubertal rat tibia and maintained in monolayer culture. After 3 days, varying concentrations of TNF-α or IL-6 were added and cultures maintained for a further 4 days. At the end of the experimental period, cell proliferation and alkaline phosphatase (as a marker of chondrocyte maturation) was measured.

Results: TNF-α inhibited maturation of growth plate chondrocytes in a dose dependent manner (P<0.01, figure). TNF-α had no effect on chondrocyte proliferation. In contrast, IL-6 had no effect on either chondrocyte maturation or proliferation.

Conclusion: The inhibitory effects of TNF-α on linear growth are mediated by inhibition of growth plate chondrocyte maturation. In clinical practice, anti-TNF antibodies may directly increase linear growth by inhibition of TNF-α at the chondrocyte.


D.A.J. Lloyd1, P.J. Neild1, A. Tinto2, A. Majeed3, J.D. Maxwell1, J-Y. Kang. 1.1St George's Hospital, London; 2Office for National Statistics, London; 3University College, London

Aim: To investigate time trends in hospital admissions for Crohn's disease and ulcerative colitis in England from 1989/90 to 1999/00.

Methods: Data were obtained from the Hospital Episodes Statistics (HES) service from 1989/90 to 1999/00 based on records of `Finished Consultant Episodes' in England. Hospital admissions were selected by primary diagnosis (ICD 9: 555 and ICD 10: K50 for Crohn's disease; ICD 9: 556 and ICD 10: K51 for ulcerative colitis) and admissions where a surgical operation, excluding endoscopic procedures, was performed were identified. Day case admissions were excluded. Age standardised hospital admission rates were calculated by comparison with the European standard population.

Results: Over the 10 year study period, the admissions rate for Crohn's disease rose by 14% and the admissions rate for ulcerative colitis rose by 6% (see table). However, admission rates for ulcerative colitis peaked in 1994/95 and declined thereafter. The proportion of patients undergoing surgery increased by 38% in patients with ulcerative colitis but did not change in patients with Crohn's disease.

Abstract 272

Conclusions: Hospital admission rates for Crohn's disease have risen significantly between 1989/90 and 1999/00, while for ulcerative colitis they have increased only slightly and have been in decline since 1994/5. Increasing proportions of patients with ulcerative colitis, but not Crohn's disease, are undergoing surgery. Although these findings could be due to changes in management practice they may reflect true trends in the epidemiology of these two diseases.


J.C. Mansfield, V. Harrison-Diver. Dept Gastroenterology, Royal Victoria Infirmary, Newcastle upon Tyne, UK

Background: Smoking cessation is known to be a key therapeutic event in Crohn's disease, decreasing subsequent relapse rates by up to 50%. Doctors often feel that little can be done to influence a patient's smoking habit and that raising the issue may be a waste of clinic time or even detrimental to good doctor patient relations.

Aim: This study aimed to evaluate a smoking cessation service in Crohn's disease patients.

Methods: Patients with Crohn's disease who were habitual smokers were referred to the smoking cessation service. Information was then sent out which required the patient to make contact with the service to take the referral forward. Counselling, nicotine patches and Zyban were available to the smoking cessation service. Success was determined by measurement of carbon monoxide levels to confirm cessation status.

Results: Over the initial 12 months 18 patients were referred to the service. Nine patients did not make contact. Of the 9 patients who did make contact, 5 have successfully stopped smoking, 1 has been lost to follow up and the other 3 stopped but have relapsed. This represents a success rate of 55% of those making contact with the service.

Conclusion: Referral of Crohn's patients to a smoking cessation service allows patients who are motivated to have appropriate and effective help with smoking cessation. All smokers with Crohn's disease should be encouraged to contact a smoking cessation service.


A.D. de Silva, D.S. Rampton. Department of Adult and Paediatric Gastroenterology, St Bartholomews and the Royal London School of Medicine and Dentistry, Whitechapel, London, UK

Background: We have prospectively tested the suggestion that oral iron therapy increases disease activity in patients with IBD, and that this effect is mediated by pro-oxidant mechanisms.

Methods: 6 iron-deficient patients with ulcerative colitis (UC)(2 active) and 8 with Crohn's disease (CD)(6 active) were given oral ferrous sulphate 200mg tds for 4 weeks. Iron intolerance and disease activity were monitored with symptom diaries and inflammatory markers. Serum antioxidant capacity (AOC) was used to assess systemic oxidant activity.

Results: 3/14(21%) patients, 2 with active CD, 1 with inactive UC, did not tolerate and discontinued oral iron after 3, 15 and 21 days; these patients showed no consistent rise in platelet count, ESR or CRP or fall in albumin or AOC. In the 11 patients completing 4 weeks of iron, mean Hb rose from 10.6 ± 1.6 g/dl (SD) before, to 11.9 ± 1.1 after treatment (p<0.05), and ferritin from 9 mcg/l ± 9 to 23 ± 10 (p<0.05); there were no significant changes in platelet count (367 x 10–9/l ± 126 to 334 ± 75), CRP (11 mg/l ± 7 to 13 ± 13), albumin (41 g/l ± 4 to 41 ± 5), Harvey-Bradshaw Index (for CD patients) (3 ± 2.4 to 3 ± 1.9), Simple Clinical Colitis Activity Index (for UC patients) (3 ± 1.4 to 4 ± 1.3) or AOC (shown as % reduction from background) (25 ± 35 to 29 ± 30). ESR fell following treatment from 40 mm/hr ± 23 to 25 ± 19 (p<0.05). Diagnosis and disease activity prior to therapy had no clear effect on the response to oral iron.

Conclusions: While a minority of patients do not tolerate it, oral iron has no detectable adverse effect on disease activity or serum antioxidant capacity in IBD. Most patients show a good haematological response to oral iron therapy.


S. Webster, D.S. Sanders1, L. Lennard, A.J. Lobo1. University of Sheffield, Section of Medicine and Pharmacology; 1Department of Gastroenterology, The Royal Hallamshire Hospital, Sheffield S10 2JF, UK

Introduction: The immunosuppressive drug azathioprine is well established in the treatment of inflammatory bowel disease (IBD). Myelosuppression occurs in 2 to 5% of IBD patients Thioguanine nucleotides (TGNs) are active azathioprine metabolites, elevated TGNs are associated with myelosuppression.

Aim: To investigate steady-state TGN metabolite concentrations in a large cohort of IBD patients.

Methods: IBD patients who had been taking azathioprine for at least 1 year were studied. Blood samples (10ml) were taken for the monitoring of blood counts and measurement of red cell TGN metabolite concentrations at each clinic visit

Results: 133 patients were recruited into the study. 114 patients had repeat metabolite assays taken over 1 year. 89 of these patients were at TGN steady-state (metabolite assays varied by <50%). The remaining 25 patients had wide variations in TGN concentrations (>2 fold), 10 had dosage adjustments but 15 did not. 11 of these 15 patients had TGN levels below the level of detection, indicating non-compliance. Steady-state TGN concentrations ranged from 59 to 566 pmol/8x108 (median 172) red cells and the azathioprine dosage from 0.3 to 2.8 mg/kg (median 1.6) in the n=89 cohort. Within this group there was no difference in TGN range or azathioprine dosage for patients on monotherapy (n=20), azathioprine and steroids (n=15) or azathioprine and 5-amino salicylic acids (n=42). There was no significant difference in TGN metabolite concentrations between patients in remission (n=80, median TGN 176 pmol) compared to the small number with active disease (n=9, median TGN 153 pmol).

Conclusion: There was a 9 fold range in steady state TGN concentrations between IBD patients in remission. This range was not influenced by concomitant steroid or aminosalicylate therapy. In addition, these metabolites can be used as indicators of compliance with oral azathioprine therapy. 10% of patients were non-compliant.


P. Kennedy, J. Andreyev, B. Gazzard, J. Fell, I. Murray-Lyon, P. Vlavianos, D. Westaby, R. Zeegen.

Chelsea & Westminster Hospital & Imperial College School of Medicine, London, UK

Background: The limitations of corticosteroids in the treatment of Crohn's Disease (CD) are well recognised. About half the patients with CD who initially respond to medical therapy relapse within one year or become dependent on steroids with their associated risk of toxicity. One fifth of patients are unresponsive to steroids and many continue to have refractory disease despite combination therapy with immuno-modulatory drugs. Fistulating CD rarely heals with conventional medical therapy. This underlines the need for an alternative agent in the treatment of active CD. Intestinal mucosal production of TNFα is increased in CD and has a key role in the initiation and propagation of intestinal inflammation. Infliximab (IgG1 chimeric monoclonal antibody) binds soluble and membrane bound TNFα and so acts to neutralise its effect.

Methods: We undertook a retrospective analysis of patients treated with Infliximab for refractory CD in our unit. The clinical indications, treatment protocol and outcome of these patients were reviewed. Clinical records, haematological and biochemical indices and where available endoscopic and histological findings pre and post treatment were evaluated to assess efficacy and tolerability.

Results: Between 2000–2001, 19 patients with CD were treated with Infliximab after 2 consultant gastroenterologists agreed they had failed maximal medical therapy. Clinical indications for Infliximab therapy were fistulating CD (n=5) and refractory luminal CD (n=14). 11/19 had undergone previous GI surgery. 18/19 were unresponsive to and 1 intolerant of steroids. 13/19 had failed to respond to at least 1 immuno-modulatory drug. Infliximab (5mg/kg) was administered by infusion over 2 hours with intravenous steroid and antihistamine cover. 12/19 were treated as out-patients. A repeat course was administered in 13 patients (median interval 8 weeks, range 2–30 weeks). 7 patients had 3 or more infusions. Five patients had a complete response (median 8 weeks, range 2–36 weeks), 12 had a partial response (median 6 weeks, range 4–28 weeks) and 2 did not respond. Two of the 5 patients with fistulating CD, closed their fistulae. Patients requiring surgery (n=4) following therapy had all undergone surgery for their CD previously. No side effects were reported by 15/17 patients. Two patients developed severe headache, precluding further treatment and requiring hospital admission with CT scan and lumbar puncture in one patient.

Conclusions: Our data confirm the previously reported benefit of Infliximab therapy in achieving rapid responses in patients failing other medical therapies. However, our findings suggest that responses are short-lived and patients with steroid resistant CD tended to relapse, questioning the benefit of Infliximab in that group. Patients unresponsive to initial treatment with Infliximab failed to respond to subsequent infusions. Perhaps Infliximab therapy should be considered primarily as a first-line alternative to corticosteroids in the treatment of moderate to severe or fistulating CD.


T. Ahmad1, M. Bunce2, K. Mulcahy-Hawes1, A. Armuzzi1, J. Crawshaw1, O. Large1, K. Welsh3, D Jewell1. 1Departments of Gastroenterology, 2Transplant Immunology, University of Oxford; 3National Heart and Lung Institute, Imperial College, London, UK

Background: A replicated association between UC and the serotype DR2 has been reported in the Japanese. Studies in caucasian populations however have produced more conflicting results. Modern molecular typing has shown that the Japanese association is attributable to DRB1*1502, an allele common in this ethnic group but rare in caucasians. This allele differs from DRB1*1501 by a single amino acid (position 86 of exon 2), located within pocket 1, which may alter peptide binding. DRB1*15 molecular subtyping has been carried out in 5 previous studies of Caucasian patients. Only one (Trachtenberg et al Hum. Immunol. 2000; 61:326) reported an association with DRB1*1502.

Aims: To determine whether DRB1*15 molecular subtypes or linked polymorphisms in nearby genes confer susceptibility to caucasian UC in a large cohort of accurately phenotyped patients.

Methods: LD mapping of 340 polymorphisms across 24 genes was carried out using PCR-SSP. Extended HLA haplotypes based upon DRB1*1501 and *1502 were constructed from these data. Disease associations were evaluated at each allele on these extended haplotypes. 331 accurately phenotyped caucasian UC patients and 354 healthy control subjects were studied.

Results: DRB1*1502 was associated with disease susceptibility (4.2% vs. 0.8%; P=0.004; RR 4.59; CI 1.31–16.11). A rare extended haplotype A*3201-Cw*1202-B*5201-MICA*00901-MICB*0102–1C7H3-DRB5*0101-DRB1*1502-DQB1*0601 was constructed. None of these alleles carried a relative risk of disease greater than DRB1*1502. This allele was not associated with disease phenotype (extent or severity). DRB1*1501 was not associated with disease susceptibility or phenotype.

Conclusion: Although rare in Caucasian UC patients, DRB1*1502 appears to be associated with UC in all ethnic groups. This unique trans-racial concordance suggests that this allele or a closely linked allele determines disease susceptibility.

279 TUMOUR NECROSIS FACTOR ALPHA (TNFα) promoter polymorphisms and colitis associated colorectal neoplasia (cacrn)

C. Murphy, R. Martin, P. Erwin, V. Rudralingam, R. Maxwell, C. Patterson1, J. Sloan2, D. Middleton3, F.C. Campbell. Dept Surgery, 1Dept Epidemiology, Queen's University Belfast, Grosvenor Rd, Belfast BT12 6BJ; 2Dept Pathology, Royal Victoria Hospital, Belfast BT12 6BJ; 3Northern Ireland Regional Histocompatibility and Immunogenetics Laboratory, Belfast City Hospital BT9 7TS, Northern Ireland

Persistent colonic inflammation in ulcerative (UC) and Crohn's colitis (CD) confers increased colorectal cancer risk. Tumour necrosis factor alpha (TNFα) mediates inflammation in colitis. TNFα promoter polymorphisms associated with variable TNFα production. This study tests the hypothesis that TNFα promoter polymorphisms confer cancer risk, in colitis.

Methods: Genotyping for TNFα -863CA and -308GA promoter polymorphisms were carried out by RFLP analysis in 194 colitis patients (127 UC, 62 CD, 5 indeterminate colitis), 31 colitis patients with CACRN (24 carcinomas, 7 high grade dysplasia) and 167 healthy controls.

Results: Linkage disequilibrium was found between TNFα - 863A and - 308A (p<0.05). TNFα - 308A allele frequency was increased in CACRN (38.3.1% CACRN vs 21.2% control; p= 0.01) but was not increased in colitis alone (22.1%). The homozygous TNFα - 308AA genotype was enriched in CACRN (16.7%) vs control (3.1%) p=0.01. TNFα - 863A was increased in colitis vs controls (TNFα - 863A 21.2% colitis vs 12.6% control; p<0.005) but was not associated with CACRN.

Conclusions: In this study, TNFα - 863A associated with colitis but not neoplastic change. The rare TNFα - 308AA genotype was enriched in CACRN and may be useful as a risk marker in cancer surveillance


R. Day1, M. Harbord2, A. Segal2, A. Forbes1. 1St Mark's Hospital & Academic Institute, Watford Road, Harrow, UK; 2Centre for Molecular Medicine, University College, London, UK

Background and Aims: Previous studies have demonstrated a reduction in the number of neutrophils migrating into skin windows in patients with Crohn's disease (CD). This effect may result from an impaired micro-vascular response preventing leukocytes from entering skin windows. This study examines blood flow in microvasculature at sites of skin windows using laser Doppler imaging, a well-established technique for assessing micro-vascular blood flow.

Methods: A novel skin window technique using cantharidin induced skin blisters was used to assess the acute inflammatory response. Blisters were created on the forearms of 7 subjects with inactive CD (male n=5) and 5 healthy controls (male n=5). Activity was assessed using a modified Crohn's Disease Activity Index. Tissue blood flow at the site of blistering was assessed at 8 h and 24 h. The blisters were harvested at 24 h and the number of cells quantified.

Results: At 8 h blister formation was not visible, but blisters were evident in all subjects at 24 h. The number of cells that had migrated into the CD blister at 24 h was lower than in the control group (mean ± SEM: CD 4.23x106 ± 1.644 cells/ml; controls 5.68x106 ± 1.630 cells/ml). Micro-vascular blood flow was significantly increased at 8 h but reduced at 24 h in CD patients compared with controls. Net mean flux values (relative units) for each group are shown in the table (values shown are mean (SEM); unpaired t test).

Abstract 280

Conclusion: Reduced neutrophil migration into CD skin windows may be caused by inappropriate changes to microvascular blood flow. This could result from either a leukocyte or endothelial cell defect leading to impaired diapedesis of cells from the vascular lumen into the surrounding tissue. A defect in innate immunity such as this could account for some cases of inflammatory bowel disease.


O. Azooz, M. Savage, A.B. Ballinger. Adult & Paediatric Gastroenterology & Paediatric Endocrinology, Barts & The London, Queen Mary's School of Medicine & Dentistry, London, UK

Delayed puberty is common in young patients with Crohn's disease. In rats with trinitrobenzene (TNBS)-induced colitis, puberty is also delayed and related to both undernutrition and a direct effect of inflammation. In this model serum concentrations of gonadotrophins and sex steroids are similar to controls and we have speculated that delay in puberty results from end-organ resistance to androgens. The purpose of this study was to test this hypothesis.

Methods: Colitis was induced in 14 prepubertal Wistar rats (age 32 days) by intrarectal administration of trinitrobenzene in ethanol. Half of the colitic group were treated with testosterone (T/colitic, 0.25mg/100g body weight/day s.c.) and the remainder received only vehicle (control/colitic). The control group was healthy free-feeding rats. Food intake and body weight were measured daily and weight of the testicles, seminal vesicles (SV) and prostate determined at sacrifice (46 days). Intestinal inflammation was measured by macroscopic assessment.

Results: TNBS induced distal colitis with macroscopic inflammation (colitic 5.6±2; T/colitic, 6.2±3), hypophagia and reduced weight gain (68±23g) compared to HC (114±9g, P<0.001). Administration of testosterone had no effect on the severity of colitis. Organ weights (SV, prostate) of control/colitic groups were reduced compared to HC, demonstrating the detrimental effect of intestinal inflammation on puberty. These effects were completely or partly overcome by testosterone suggesting that there is not complete end-organ resistance to sex steroids (table).

Abstract 281

Conclusion: Inhibitory effects of intestinal inflammation on end-organ responsiveness are overcome with testosterone, suggesting that any resistance is at least only partial. Testosterone treatment may be useful to induce puberty in young patients with Crohn's disease and delayed puberty.


C.L.E. Osborne, S. Davies, O. Ogunbiye, S. Keshav. Departments of Medicine and Surgery, Royal Free and University College Medical School, London, UK

Introduction: Patients with inflammatory bowel disease (IBD) have a 30% lifetime risk of developing colorectal cancer (CRC). Tumourigenesis in IBD does not follow the stepwise genetic process characteristic of adenomatous polyp progression, hence an alternative molecular pathway is thought to exist. Activation of phosphoinositide-3-kinase gamma (PI(3)Kγ) leads to altered cell activation, growth and apoptosis. Mice deficient in PI(3)Kγ develop invasive adenocarcinoma of the colon, while mice lacking Gαi2, a signalling protein upstream of PI(3)K, develop ulcerative colitis and adenocarcinoma. The PTEN tumour suppressor gene opposes the action of PI(3)Kγ and mice deficient in PTEN develop tumours and autoimmune phenomena. We therefore hypothesised that abnormal PI(3)Kγ signalling may contribute to the development of CRC in patients with IBD.

Method: Expression of PI(3)Kγ and PTEN was investigated in paraffin embedded human tissue sections of approxminately 30 normal colon, active colitis, sporadic CRC and IBD associated CRC by indirect immunohistochemistry. Both positive (anti-CD45 antibody) and negative controls (secondary antibody only) were used.

Results: Approximately 66 percent of tumours arising in patients with IBD lacked PI(3)Kγ expression and in 40 percent PTEN protein expression was absent. Both results were statistically significant when compared with normal tissue. There was no statistical difference in expression of PI(3)Kγ or PTEN in sporadic CRC when compared with normal tissue.

Conclusion: Loss of expression of PI(3)Kγ and PTEN proteins is seen at higher frequency in IBD associated CRC than sporadic CRC. We conclude that aberrant signalling through this pathway may occur together with chronic inflammation, leading to abnormalities in cell cycle progression and apoptosis. This may therefore contribute to the postulated alternative pathway to neoplasia in IBD associated CRC.


T. Kitiyakara, A.S. McIntyre, D.A. Gorard. Wycombe Hospital, High Wycombe, Bucks HP11 2TT, UK

Colon cancer in ulcerative colitis (UC) does not follow the adenoma-carcinoma sequence of non-UC colorectal neoplasia. Polyps with dysplasia do occur in UC, and there is debate whether they should always be managed as dysplasia associated lesion/masses (DALMs) requiring colectomy, or whether some can be managed as sporadic adenomas by polypectomy. There are few data on the prevalence of non-inflammatory polyps in UC; this study aimed to see if adenomatous polyps occur as often in UC as in patients without inflammatory bowel disease (IBD).

The clinical, endoscopy and histology records of 150 patients with UC undergoing colonoscopy were scrutinised for any history of polyps. The control group was 205 patients having colonoscopy for altered bowel habit. Patients with rectal bleeding, anaemia, abnormal barium enema, a personal or family history of colorectal cancer/polyps were excluded as controls, as were those in whom cancer or IBD was found at endoscopy.

The mean (SD) age of UC patients, 48.8 (13.8) years, was not different to that of controls, 51.9 (15.5) years. Sex distribution of 79 m / 71 f in UC, 90 m/ 115 f in controls was similar. In UC, the median (range) disease duration was 10 (0–48) years, and the median number of colonoscopies was 2 (1–10). The most proximally recorded UC extent was pancolitis in 85 (57%) patients, to the hepatic flexure in 16 (11%), to the splenic flexure in 19 (13%), proctosigmoiditis in 18 (12%), proctitis in 12 (8%).

Only 6 UC patients had ever had dysplastic polyps. 2 had a single adenomatous polyp proximal to the colitis segment. 4 patients had dysplastic polyps within the colitis segment. In 2 of these the polyps were treated endoscopically as sporadic adenomatous polyps (1 patient having 2 polyps). In the other 2, the lesions were considered to be DALMs and colectomy advised. In contrast, 24 controls had at least 1 adenomatous polyp, χ2 = 6.7, p<0.01. Metaplastic polyps were found in 4 UC patients (within colitis in 3, proximal to colitis in 1) and in 24 control patients, χ2 = 9.7, p<0.01. 38 UC patients had inflammatory pseudopolyps.

Adenomatous and metaplastic polyps occur less frequently in patients with UC than in patients without IBD. Despite the increased cancer risk in longstanding UC, the colitic mucosa (or possibly drug treatment of UC) seems to protect against the formation of sporadic adenomas.


Z.H. Khan, J. Entwisle, J. de Caestecker, S. Campbell, R.J. Robinson. Department of Gastroenterology, Department of Radiology, Glenfield Hospital, Leicester, UK

Aim: To evaluate the potential of MRI in patients with acute colitis.

Methods: Consecutive patients admitted with acute colitis were studied. All had AXR on admission and MRI of the colon. Axial (T1/T2) and sagittal T1 images were performed according to a predetermined protocol using a Siemens 1.5 Tesla Vision Scanner. The following parameters on AXR were recorded: disease extent, bowel dilatation and wall thickness. At MRI, disease extent, bowel dilatation, wall thickness, changes in peri-colic fat and the presence or absence of free fluid were noted.

Results: To date eleven patients with acute colitis have been included. One male and ten females, mean age 40.7 ( range 22–71) were anlysed. Six out of eleven patients with Powell Tuck score ranging between 8–13 had no or minimal changes on AXR. MRI showed disease extent and established bowel wall thickening in all six cases. Three patients required colectomy and in two of these cases MRI showed free fluid and changes in peri-colic fat.

Conclusions: (1) MRI is more informative than a plain abdominal film in assessing the severity and extent of disease in patients admitted with acute colitis. (2) Features like presence of free fluid and changes in the peri-colic fat may be important prognostic factors.


A. Sawczenko1, B.K. Sandhu1, R.F.A. Logan2.1Department of Gastroenterology, Bristol Children's Hospital, UK; 2Dept of Public Health and Epidemiology, Nottingham, UK

Aim: To determine the relationship between presenting symptoms, site of disease activity and height/weight Z scores at diagnosis of Crohn's Disease (CD).

Methods: Data collected prospectively from the 1998/9 BPSU-BSGRU survey (Lancet : 357; 1093–4) from 364 CD cases aged < 16 years were analysed.

Results: The following correlations between symptoms and site of disease were found ; `weight loss' with jejunal and ileal activity, `lethargy' with left colonic activity, `abdominal pain' with oral, transverse colonic and peri-anal activity, `diarrhoea' with colonic and rectal activity, `bleeding' with jejunal, ileal, and colonic (but not rectal) activity (all p < 0.05). Anorexia was not associated with any specific site activity. Mean height and weight Z scores were reduced at diagnosis (-0.54, 95%CI -0.67 to -0.41, and -1.06, 95%CI -1.21 to -0.92 respectively), with the correlation between height and weight being r = 0.72 (p < 0.0001). There was a negative correlation the time of recall of onset of symptoms to diagnosis (ie `delay') and height (r = -0.22, p < 0.001), but no relationship with weight. The symptom of `weight loss' was associated with reduced weight (mean Z -1.3 versus - 0.7, p < 0.001), as was `anorexia' (mean Z 1.9 versus –1.0, p = 0.01), but there were no correlations with height. The symptom of `abdominal pain' was associated with reduced Z score for height (mean -0.76 versus –0.45, p = 0.03), but not for weight. Jejunal activity was associated both with a lower Z score for weight (mean Z -1.6 versus –1.1, p = 0.017) and height (mean Z –0.9 versus –0.5, p = 0.041). Ileal activity was associated with a lower Z score for weight (mean Z –1.2 versus –0.8, p =0.02) but there was no relationship with height. Fascinatingly there was a relationship between oesophageal disease activity and height (mean Z –0.6 versus –0.2, p = 0.045), but not for weight.

Conclusion: Prolonged symptoms are associated with decreased height at diagnosis, suggesting that earlier recognition of CD may be important. Ileal and especially Jejunal disease are associated with impaired height and weight Z scores at diagnosis. Symptoms give some indication of sites affected.


V. Edge, C. Macdonald, D.A. Burke. Cumberland Infirmary, Carlisle, UK

Patients with long-term chronic illness (e.g. inflammatory bowel disease (IBD) and coeliac disease (CD)) require periodic monitoring of their condition. If stable and otherwise well, alternatives to the traditional method of follow up may prove more practical and acceptable to patients and yet be adaptable to their changing health care needs without loss of contact/ input from specialists. This is particularly pertinent to services covering large geographical areas. Alternatives that have been proposed are nurse led clinics, telephone consultations or a personalised postal questionnaire, with relevant blood tests performed locally. Access to a consultant opinion should still be available.

Aims: To assess patients views regarding follow up of their condition and to determine their preferences in follow up arrangements.

Methods: 100 patients were randomly selected from our IBD and CD database and invited to complete an anonymous postal questionnaire enquiring about their views on follow up.

Results: 78% responded, 1 had recently been discharged, 1 suffered from dementia and 1 was illegible. Therefore 75 replies were analysed (38 IBD, 37 CD). 61 (28 IBD, 33 CD) patients would be willing to be reviewed by a specialist gastroenterology nurse in a clinic, 46 (23 IBD, 23CD) would consider a telephone consultation. 52 (27 IBD, 25 CD) respondents felt an update of their condition could be achieved by a personalised questionnaire with blood tests performed locally for them. 60 patients selected a combination of the options. In 27 cases (14 IBD, 13 CD) while they were prepared to consider alternatives, they would prefer that their follow up continued in the clinic as before. Although CD might be considered to follow a more predictable course when compared to IBD with its likelihood for relapse, there were no significant differences in the responses from the two groups. 19 people did not possess reliable weighing scales to allow home monitoring of their weight.

Conclusions: The majority of patients would accept alternative methods of monitoring their condition while maintaining links with their supervising specialist team. The provision of personal weighing scales would permit home monitoring for all. There are potential benefits to both patient and our overburdened GI services by adopting alternative methods of follow up.


A.R. Hart1, M. Bergmann2, R. Luben3, J. Camus3, S. Oakes3, A. Welch3, S. Bingham3, K-T. Khaw3, H. Boeing2, N.E. Day3. 1University of East Anglia, Norwich, UK; 2German Institute of Human Nutrition, Potsdam, Germany; 3Strangeways Research Laboratories, Cambridge, UK

Background: The causes of ulcerative colitis are unknown, although it is plausible that dietary factors are involved. To address this hypothesis a prospective cohort study is needed to eliminate the biases associated with the previous case-control studies of diet and IBD.

Aims: To conduct a pilot study to determine whether it was feasible to identify subjects who developed ulcerative colitis who are participating in a large European cohort study and to conduct a provisional analysis of the dietary data.

Methods: 25 623 men and women aged 45–74 years in Norfolk (UK) and 27 548 men and women aged 35–64 years in Potsdam (Germany) were recruited to the EPIC Study (European Prospective Investigation Into Cancer & Nutrition). These subjects completed information on diet at recruitment and are being followed up for the development of ulcerative colitis. Each case was matched with four controls and an analysis performed for food groups, adjusted for cigarette smoking.

Results: 20 incident patients with ulcerative colitis (7 women, 13 men) were identified, which is the expected number over the follow-up period. Analysis showed a non-significant positive association with carbohydrate, sugar and fat consumption (for lower vs upper tertiles of consumption: carbohydrate OR=2.8 (95% CI=0.7–11.1), sugar OR=1.8 (95% CI=0.5–7.3, fat OR=1.6 (95% CI=0.5–5.6). A higher fish consumption appeared to protect against the development of ulcerative colitis (lower vs middle tertile OR= 0.5 (95% CI=0.1–2.1 & lower vs upper tertile OR= 0.8 (95% CI=0.2–3.2)).

Conclusions: A prospective cohort study of diet and ulcerative colitis is feasible. Other European centres participating in EPIC now need to be included to increase the number of participants studied so the role of diet in the aetiology of ulcerative colitis can be accurately defined.


M.J. Shale, S.A. Riley. Northern General Hospital, Herries Road, Sheffield S5 7AU, UK

Background: Most patients with inflammatory bowel disease are prescribed regular medications to reduce the risk of disease relapse. Non-compliance with such treatments may increase the risk of relapse and some have suggested an increased risk of colorectal cancer. We have therefore conducted a survey of outpatients with IBD to determine the prevalence of non-compliance with maintenance mesalazine therapy, and to identify possible risk factors.

Methods: Outpatients with quiescent IBD receiving maintenance therapy with delayed-release mesalazine (Asacol) were recruited to the study. Patients underwent a structured interview including assessment of drug compliance and medication use. Anxiety and depression, quality of life, and measures of the doctor-patient relationship were also assessed using validated questionnaires. Poor compliance was defined as taking <80% of the prescribed dose.

Results: 98 patients were studied. 51 were male and ages ranged from 17–85 years. 63% had ulcerative colitis, 27% Crohn's disease and 10% indeterminate colitis. Disease duration was 8.6 (0.2–53) years and patients had taken mesalazine 2.4 (0.4–3.6) g/day for 4.3 (0.2–13) years. 64% of patients were prescribed mesalazine three times daily. 43% reported regular non-compliance. Non-compliance was associated with a younger age, full-time employment, three-times daily dosing, education beyond the age of 16 and the patient's perception of treatment efficacy. Logistic regression revealed the only independent predictors of non-compliance to be three-times daily dosing (OR= 3.1 [95% CI 1.8–8.4]) and full time employment (OR= 2.7 [95%CI 1.1–6.9]).

Conclusions: Non-compliance with maintenance mesalazine is a common problem in patients with inflammatory bowel disease. Three-times daily dosing and full-time employment are the main predictors of non-compliance. These factors should be considered when selecting and advising on maintenance drug regimens.


D. Joy, R. MacPherson, S. Campbell, K. Kingstone, S. Ghosh. Gastrointestinal Unit, Western General Hospital, University of Edinburgh

Introduction: TPMT is a cytosolic enzyme that catalyses the S-methylation of aromatic and heterocyclic sulphydryl compounds including 6-mercaptopurine and azathioprine (AZA). AZA induces TPMT activity variably and unpredictably. We have recently reported that IBD patients with TPMT activity ≥ 20 nmol/hr/ml of RBC relapse more often if AZA is prescribed at doses < 2mg/kg/day. MCV is increased in patients on AZA, but the implications of this increase in guiding AZA therapy is unclear. We investigated the relationship between TPMT activity and MCV in IBD patients maintained on AZA.

Patients and Methods: We recruited a cohort of 84 IBD (45M, 39F) patients (38 Ulcerative Colitis, 46 Crohn's disease) who were maintained on AZA. TPMT activity was determined from blood samples by a radiochemical assay on haemolysed red blood cells (RBC) as previously reported and MCV was obtained on the same day. Relapse rates per year of follow up and time to first relapse were related to respective TPMT activity and MCV.

Results: The MCV did not correlate with TPMT activity (r = 0.025; p =0.8). The mean MCV was 91.45 fl (SD 7.38) in patients with TPMT < 20 nmol/hour/ml of RBC compared with MCV of 92.19 fl (SD 5.77) in patients with TPMT ≥ 20 nmol/hour/ml of RBC (p =NS). A Kaplan-Meier survival curve was constructed based on time to first relapse for patients with MCV ≤ 98 fl compared with MCV > 98 fl and the difference was not significant by log rank analysis.

Conclusion: In IBD patients on AZA, MCV does not correlate with TPMT activity. MCV in IBD is influenced by a number of conflicting factors such as iron or folate deficiency, and cannot be used to determine AZA effect or outcome of therapy.


A.J.G. Bell1,2, A.B. Price1, A. Forbes1, P.J. Ciclitira2, K.H. Wilkinson1, S.W. Rumbles1, R.J. Nicholls1.

1 St Mark's Academic Institute, Harrow; 2 Rayne Institute, St Thomas' Hospital, London, UK

Introduction: Inflammation of the ileum occurs in UC patients. In addition to “backwash ileitis”, pouchitis and pre-stomal ileitis we have observed inflammation proximal to the pouch in the neo-terminal ileum (NTI) and sought to ascertain the characteristics of this “pre-pouch ileitis” (PPI).

Methods: Retrospective notes review of those with ileal abnormalities amongst the 661 consecutive cases undergoing restorative proctocolectomy for UC at a single centre to 1998. Histological slides were reviewed. Staining for colonic metaplasia was undertaken.

Results: 19 cases were found. 3 had Crohn's Disease (CD), 1 had a discrete NSAID stricture. These 4 are termed alternative group (AG). The remaining 15 had characteristic diffuse disease from the NTI-pouch junction proximally for varying distances (PPI group). The disease became milder more proximally in PPI and CD cases. In 3/15 disease was limited to the pouch-NTI junction. 2 of the other 12 had stricturing disease and 1/12 had fistulating PPI. The majority presented with frequency and pain. Extra-intestinal manifestations were seen in 4/15 PPI but 0/4 AG. Smoking was unusual. In the PPI group half had pouchitis but few had had backwash ileitis pre-operatively. A significant distal stricture was present in only 1/15 PPI and 1/4 AG. The pathology was discovered by contrast studies in 8/19, endoscopy in 7/19 and at surgery in 3/19. Roughly a quarter responded to each of antibiotics, IBD therapy or resection with spontaneous remission in the remainder. Histological appearances of resection specimens and biopsies revealed nothing characteristically to distinguish PPI from pouchitis.

Conclusion: 15 cases of pre-pouch ileitis were found in patients with confirmed UC and otherwise normal BaFT with no histological evidence of Crohn's. This disease may have a distinct pathogenesis from Crohn's.


A. Sutherland-Craggs, J.C. Mansfield, M. Hudson, A. Cuthbert, S. Fisher, C. Mathew, S. Bartram, A. Daly, R. Francis, N.P. Thompson. Dept of Gastroenterology and Hepatology, University of Newcastle upon Tyne; Dept of Gastroenterology, Freeman Hospital, Newcastle; Division of Medical and Molecular Genetics, Guy's, King's and St Thomas' School of Medicine, London, UK

Background: Osteoporosis is a common and important complication of Crohn's disease. The risk of osteoporosis is known to be related to body mass index, use of corticosteroid therapy and disease activity. These factors do not fully account for the variation between patients, genetic factors may also be important.

Aim: To determine whether bone density in Crohn's disease is related to NOD2 gene mutations.

Methods: 80 patients had their bone density assessed by DEXA scanning at the lumbar spine, hip and femoral neck. Osteoporosis was defined by WHO criteria as a T(30) score worse than –2.5 at any site, osteopenia as a T(30) between –1 and –2.5. DNA was genotyped for the 3 NOD2 mutations previously shown to be associated with Crohn's disease (SNP 8, 12 and 13).

Results: There are no significant differences (see table 10).

Abstract 291

Conclusion: NOD2 mutations associated with Crohn's disease do not appear to contribute to the incidence of osteoporosis in this condition.


A.P. De Silva1, T. Ahmad1, S. Vermiere2, A. Armuzzi1, K. Mulcahy-Hawes1, S. Travis1, K. Welsh3, P. Rutgeerts2, D. Jewell11. Departments of Gastroenterology, University of Oxford; 2University Hospital, Leuven, Belgium; 3National Heart and Lung Institute, Imperial College, London, UK

Background: The monoclonal anti TNFa antibody, Infliximab offers an alternative to current medical therapy in CD with two thirds of treated patients responding. There are however concerns regarding potential immunogenetic and immunosuppressive effects. TNF promoter polymorphisms at positions –1031, -863, -857 and –308 have been associated with increased transcription and production of TNFa and may therefore influence response to this agent.

Aims: To determine whether polymorphisms in the TNFA and Lymphotoxin alpha (LTA) genes can predict response to Infliximab.

Methods: 3 LTA (+A720C, +C365G and +G249A) and 7 TNFa (-T1031C, -C863A, -C857A, -G380A, -G308A, -G238A, +G488) polymorphisms were genotyped by PCR-SSP in two patient cohorts. Stage 1: 43 Caucasian patients recruited from two UK centres. Response was assessed retrospectively by two blinded physicians and by patient's own assessment of response. Stage 2: Replication of positive findings sought in 154 patients recruited from a single Belgian centre (positive response defined as fall in CDAI >70 / remission a CDAI of <150).

Results: Stage 1: 29/43 (67%) patients responded to Infliximab. Doctor and patient assessment of response was concordant in 43/43 (100%) patients. TNF-1031C was associated with a positive response (P=0.03 positive predictive value 82%). All 5 Patients homozygous for TNF-1031C responded. Stage 2: TNF-1031C and the linked polymorphism TNF-863A were genotyped. No association with clinical response to Infliximab was found.

Conclusions: The polymorphisms studied in the TNFA and LTA genes do not predict response to Infliximab. The association with TNF-1031C observed in Stage 1 is likely to represent a Type 1 error. Alternatively the failure to replicate this genetic association may due to clinical differences between centres in the selection of patients offered Infliximab.


P.J. Erwin, R. Martin, V. Rudralingam, R. Maxwell, J. Sloan1, F.C. Campbell. Department of Surgery, The Queen's University of Belfast, Grosvenor Road, Belfast BT12 6BJ; 1Department of Pathology, The Royal Victoria Hospital, Grosvenor Road, Belfast, Northern Ireland

Background: The vitamin D receptor (VDR) maps to chromosome 12q, which has been identified as a region of interest in inflammatory bowel disease (IBD). VDR is the cellular receptor for 1,25 (OH)2 vitamin D3 which has antiproliferative properties. VDR polymorphisms may confer increased risk of Crohns Disease (CD). This study tests the hypothesis that the Taq1, Fok1 and Apa1 VDR polymorphisms associate with incidence and extent of ulcerative colitis (UC) and CD.

Methods: 141 patients with UC, 71 with CD and 178 healthy controls were genotyped for Taq1, Fok1 and Apa single nucleotide polymorphisms in VDR using allele specific PCR. Clinical risk factors including age of onset, disease extent and duration were recorded.

Results: Homozygotes for the Taq1 polymorphism (`tt') were increased in CD patients (31%) vs control (12%), p=0.001. The Fok1 `f' allele was was associated with extensive colitis in both UC and CD.

Conclusions: The Taq1 `tt' genotype is associated with CD. The Fok1 `ff' genotype is associated with extensive IBD.


C.E. McNaught, J. MacFie, D. Palmer, C.J. Mitchell. The Combined Gastroenterology Unit, Scarborough Hospital, Woodlands Drive, Scarborough YO12 6QL, UK

Introduction: Postoperative sepsis is common in patients with inflammatory bowel disease (IBD). There is increasing evidence to suggest that the passage of bacteria across the gut barrier to sterile extra-intestinal sites is the cause of this septic morbidity. The aim of this study was to document the rate of bacterial translocation (BT) in patients with Ulcerative Colitis (UC) and Crohn's Disease (CD) and relate this to the development of postoperative septic morbidity.

Methods: All patients with IBD who underwent abdominal surgery were entered into this prospective study. Bacterial translocation was assessed through the microbiological culture of a mesenteric lymph node and serosal biopsy, obtained at the start of laparotomy. Septic morbidity was defined as any positive culture in the postoperative period.

Results: Sixty-four patients were recruited into the study, 28 with UC (M:F 18:10, Age 51 years) and 36 with CD (M:F 14:22, 44 years). The overall prevalence of bacterial translocation was 19% (12/64 patients). The most commonly isolated organism from nodes and serosa was Escherichia Coli (42%). Twelve patients (19%) developed 14 septic complications. Enteric organisms were responsible in 86%. Patients with microbiological evidence of BT had a higher incidence of postoperative sepsis (4/12, 33% vs 8/52, 15%, P = 0.15).

Conclusions: Bacterial translocation occurs in patients with IBD and may promote the development of septic morbidity. Our data supports the gut origin of sepsis hypothesis.


D. Meister, J. Bode, S. Ghosh. Gl Unit, University of Edinburgh, Western General Hospital, UK

Introduction: Chronic intestinal inflammation in IBD is caused by inappropriate immune response to luminal antigens, inadequately downregulated by mucosal counter-regulatory mechanisms. TGF-β1 is a potent negative regulator of mucosal inflammation. In CD, elemental diet (ED) heals mucosal ulceration and down regulates the pro-inflammatory response. We aimed to demonstrate if enrichment of ED with TGF-β results in upregulation of mucosal expression of TGF-β1 in IBD tissues compared with ED alone.

Method: Three liquid formulae were used: (1) ED (EO28, SHS Ltd, Liverpool) with addition of bovine colostrum rich in TGF-β (0.9mg TGF-β per 100gm colostrum) (ECO); (2) ED with addition of whey enriched with TGF-β (300mg TGF-β per 1gm whey) (EWT); (3) ED alone. Colonoscopy biopsies from patients with CD (n=23), UC (n=13) and non-inflamed controls (n=19) were incubated for 24h in Waymouth medium diluted 1:20, 1:10 and 1:5 with ECO, EWT and ED, using medium alone as control. Tissue viability in organ culture was determined by BrdU uptake. Immunohistochemical staining was performed for TGF-β1 with a polyclonal rabbit anti TGF-β1 (Santa Cruz Biotechnology, sc-146, UK) diluted 1/50 in 20 % Normal sheep serum (diluted in 0.05 molar TBS, ph 7.6). Crypts and epithelial surface staining was quantified with a Video-Image-Analyser Q500MC (Leica Cambridge, UK) examined under a calibrated x 10 objective. Results are expressed as % of staining expression per mm2 of tissue (mean ± SEM) and compared with one-way ANOVA.

Results: In CD, ECO incubation resulted in a significant increase in TGF-β1 expression in all 3 dilutions 1:20 (43.87±3.19, p<0.0001), 1:10 (27.35±7.13,p<0.0001), 1:5 (29.4±14.0,p=0.009) compared with control medium alone (3.57±0.6). EWT incubation resulted in a similar increase in TGF-β1 expression, 1:20(32.87±5.78,p<0.0001), 1:10(28.1±11.4,p<0.01),1:5 (33.1±11.8,p<0.0001) compared with medium alone (3.57±0.6). ED incubation resulted in a modest increase in TGF-β1 expression reaching statistical significance only in 1:10 (17.72± 5.23 Vs 3.57±0.6, p=0.03). In UC and control tissues, no significant increase in TGF-β1 expression was observed after incubation with ECO and EWT.

Conclusion: Incubation of CD tissue with ED alone only modestly upregulated TGF-β1 expression, but much more marked up-regulation was observed after incubation with ECO and EWT. The effect of these diets on UC and control tissue regarding TGF-β1 expression was not significant. Clinical trials of ECO and EWT in active CD are warranted.


I.E. Koutroubakis, E. Petinaki1, P. Dimoulios, E. Vardas, M. Roussomoustakaki, A.N. Maniatis1, E.A. Kouroumalis. Dept of Gastroenterology, University Hospital, Heraklion; 1Laboratory of Clinical Microbiology, University of Thessaly, Greece

Background: Initiation of a fibrotic process has been suggested as part of the intestinal response to chronic inflammation in inflammatory bowel disease. YKL-40 has been proposed as a new serum marker of fibrosis. We studied therefore the serum levels of YKL-40 in patients with ulcerative colitis (UC) and Crohn's disease (CD) in comparison to healthy controls.

Methods: YKL-40 serum levels were measured in 106 IBD patients (55 UC and 51 CD) and in 50 matched healthy controls using a commercially available enzyme-linked immunosorbent assay (Metra Biosystems, Inc., CA USA). YKL-40 levels were correlated with disease activity, type and localization. UC and CD diagnosis was based on standard criteria. Disease activity in CD was evaluated by using the CDAI score and in UC by the simple clinical colitis activity index. Standard laboratory parameters including red and white blood cell count, haemoglobin, haematocrit, platelet count, albumin, erythrocyte sedimentation rate and C-reactive protein (CRP) were routinely determined in all patients.

Results: Mean serum YKL-40 levels were 91.1± 52.1 ng/ml in UC patients and 94.9± 80.3 ng/ml in CD patients, significantly higher compared to healthy controls (66,2± 22.7 ng/ml) (P=0.015). Concerning the disease activity the mean serum YKL-40 levels were higher in the active compared to inactive phase of both diseases. Moreover, a strong correlation between serum YKL-40 and disease activity score and CRP levels was found (Spearman Rank correlation coefficient r=0.30, P= 0.02). Patients with stenotic CD had mean YKL-40 levels (99.5 ng/ml) not significantly different compared to non stenotic disease (93.8 ng/ml). By contrast, current smokers had significantly lower levels of YKL-40 than non or ex-smokers (69.9 vs 103.6 & 102.9 ng/ml respectively).

Conclusions: Serum levels of YKL-40 are increased in patients with inflammatory bowel disease and this is associated with the inflammatory process rather than with the degree of fibrosis.


R.N. Mazumder1, J. Bode1, J. Lewin3, M.M. McIntyre2, S. Ghosh1. 1Gastrointestinal Laboratory, Department of Medical Sciences and 2Department of Pathology, University of Edinburgh, Western General Hospital, Edinburgh; 3 Electron microscopy unit, Royal Free Hospital and University College Medical School, London, UK

Introduction: Inorganic microparticles as compounds of titanium (Ti), silicon (Si), and aluminium (Al) have been implicated in pathogenesis of chronic inflammatory bowel disease such as Crohn's disease (CD) and benefit of reducing intake of such microparticles has been demonstrated in humans. However, the pro-inflammatory roles of Al, Si and Ti are unclear. Other elements such as chromium are more strongly granulogenic

Aim: We investigated the distribution and composition of inorganic microparticles in resected intestine from IBD patients and controls by light microscopy, confocal microscopy and energy dispersive analysis of X-rays (EDAX) with special reference to chromium.

Methods: Resected human intestines were immunolabelled with CD68 and number of macrophages with inorganic microparticles were quantitated by automated image analysis. Specimens were also prepared for EDAX and analysed in conjunction with a transmission electron microscopy. Selected intestinal tissues were from Crohn's disease, UC and controls [proximal end of cancer bowel].

Results: Immunolabelled, CD68+ ve [macrophages] were significantly greater in CD and UC compared to controls. EDAX revealed compounds of Al, Si and Ti within the macrophages of the inflamed intestine. In addition compounds of chromium by EDAX were identified in the inflamed human intestinal mucosa. The percentage of inorganic microparticle-laden macrophages were (mean±SE): 70±4 vs. 50±5 vs. <1±.3 in Crohn's, UC and controls. The area [%±SE] of mucosa occupied by macrophages were: 6.3±0.3 vs. 4.2±0.2 vs. 2.4±0.1 in CD, UC and controls.

Conclusion: We have confirmed the presence of Ti, Al and Si in intestinal tissues. For the first time we report the presence of chromium microparticles as well within the IBD tissues. Inorganic microparticles particularly chromium have been reported to be granulogenic in skin, lung and joint tissues. Whether chromium microparticles perpetuate chronic inflammation in IBD, especially CD, requires further investigation.


O. Azooz, A.B. Ballinger. Adult & Paediatric Gastro, Barts & The London, Queen Mary's School of Medicine & Dentistry, London, UK

Background: Inflammatory bowel disease is associated with osteoporosis. The aetiology is not clearly understood and may include steroid treatment, reduced calcium intake, inflammatory cytokines and undernutrition.

Aim: To determine the relative contribution of undernutrition and inflammation to increased bone turnover in a model of colitis.

Methods: Wistar rats (n=42) were divided into 3 groups: 1) healthy controls, 2) colitis and 3) pair-fed (PF, healthy animals whose daily food intake is matched to the colitic group, thus separating the effects of undernutrition from inflammation). Colitis was induced by intrarectal administration of trinitrobenzenesulphonic acid (TNBS) in ethanol. At day 5, trunk blood was collected for measurement of osteocalcin (marker of bone formation) and pyridinoline cross-links (PYD, marker of bone resorption) and the colon removed for assessment of severity of inflammation by measurement of myeloperoxidase (MPO). The right tibia was removed for measurement of bone mineral density (BMD).

Results: Administration of TNBS produced distal colitis with a 7-fold elevation in MPO, hypophagia and weight loss. At 5 days body weight of the colitis group was 73% of healthy controls (P<0.001). Weight was similar in colitic and PF groups. There was a 45% reduction in bone formation (osteocalcin), 51% increase in bone resorption (PYD) and a 13% reduction in BMD in the colitic group. Values were similar to those in PF rats. See table.

Abstract 298

Conclusions: There are early and marked changes in bone formation and BMD in intestinal inflammation. Undernutrition is the major determinant. The inflammatory process itself, although severe, does not play a significant role.