Helminths and IBD

While we had a short ley article dealing with the use of helminths as a treatment for IBD, I thought it would be interesting to investigate their use further. Although usually the ingestion of worms would seem counterintuitive to treating disease, the helminth Trichuis suis has been found to be effective in relieving the symptoms of both Crohn's Disease and Ulcerative Colitis.

Unraveling the mechanism of disease for IBD has been difficult, however many studies have come to show the various biological systems which manifest these diseases. It has been found that CD is mostly a Th1 dominated immune response compared to UC. The idea behind the use of helminths is to steer the immune system from a Th1 to a Th2 mediated response. By doing this, it is possible to down regulate the Th1 response which is causing damage to the intestinal walls.

The study Trichuris suis Seems to Be Safe and Possibly Effective in the Treatment of Inflammatory Bowel Disease found the use of helminths to be beneficial in both CD and UC patients. In the study, after one treatment participants were found to have gone in to remission or had drastically lowered their CDAI or SCCAI scores. The study did show that with only one treatment, many experienced a flare up after 12 weeks, however if the treatment is repeated every 3 weeks the beneficial effects may be more lasting. One patient managed to remain in remission for over a year when treated regularly.

It seems that helminths may end up being an effective treatment for IBD, and some suggest that it may even provide a method for immunization. The link between sanitation and IBD prevalance may have to do with helminth contamination in water. Using this link, it may be possible to treat children with helminths in order to "teach" the body an appropriate immune response in order to prevent the autoimmune issues that are found in IBD.

Sources:
Trichuris suis Seems to Be Safe and Possibly Effective in the Treatment of Inflammatory Bowel Disease
Robert W. Summers, M.D., David E. Elliott, M.D., Ph.D., Khurram Qadir, M.D., Joseph F. Urban, Jr., Ph.D., Robin Thompson, M.H.A., and Joel V. Weinstock, M.D.
Department of Internal Medicine, James A. Clifton Center for Digestive Diseases, University of Iowa Health Care, Iowa City, Iowa; and The Immunology & Disease Resistance Laboratory, United States Department of Agriculture, Beltsville, Maryland

THE AMERICAN JOURNAL OF GASTROENTEROLOGY Vol. 98, No. 9, 2003
© 2003 by Am. Coll. of Gastroenterology ISSN 0002-9270/03/$30.00
Published by Elsevier Inc. doi:10.1016/S0002-9270(03)00623-3

Diminished HIV awareness

After our discussion of HIV in Tuesdays class and Dr. Cohen's comment about the younger generations lack of HIV awareness I found an article that proves his point. Recently a high school in suburban Missouri had a HIV scare. Accourding to health officals 50 out of the 1300 student population were potentially exposed to HIV. One student came forward to health officals saying he had HIV and other students may have been exposed. Students may have been exposed through sexual activity, intravenous drug use, tattoos and piercings.

One has to wonder if this would have occured if awareness of risky behaviors and HIV tranmission was higher. As Dr. Cohen stated, it seems as though the younger generation has less knowledge about HIV then in the 90's. This article also shows how little the general population knows about HIV. For example, a rival football team was concerned about playing the high school where the exposures occured and many students want to transfer out of the district.

This article shows how important education about HIV and risky behaviors is still needed.

http://www.comcast.net/articles/news-national/20081024/High.School.HIV/

Diagnosing IBD

I know it was a mentioned a couple times that Crohn's disease and ulcerative colitis have very similar symptoms, and that some doctors actually think they are the same disease. So it occurred to me that it might be difficult to differentiate the two during diagnosis. As everyone knows now from the papers we read the past two weeks, it is important to tell the difference between the two. Treatments for each of the diseases is different and the treatment for one can actually cause the other to flare up. So I did some research on how IBD is diagnosed in patients.

I found out that it isn't easy to definitively diagnose CD or UC. Sometimes they have to eliminate everything else including irritable bowel syndrome (IBS), bacterial, and viral infection. Physician's usually use a complete blood count (CBC), liver function tests, stool samples and an endoscopy or colonoscopy. The colonoscopy or endoscopy is usually the most diagnostic of all the tests. The infected areas of a Crohn's disease is patchy and can have a cobble stone appearance. The lesions can also be go deep into the intestinal lining. In ulcerative colitis the mucosa and sub mucosa layers of the intestinal wall.

References:

http://health.ucsd.edu/specialties/gastro/inflammatory-bowel-disease/diagnosis.htm

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/gastro/inflammatory_bowel/inflammatory_bowel.htm

A short interview with a patient suffering from Crohn's disease

So one of the guys I work with was diagnosed with Crohn's disease and after the articles last Monday I was curious about how his smoking affected him before and after being diagnosed. I asked him a series of questions ranging from smoking to symptoms to his treatment. This is what he told me.
During the hardest times of my disease i.e. during the large flare-up, my liver decreased about 40-50 percent functionality (lack of retaining vitamins, minerals, and nutrients). I did not have surgery; surgery is for the people that cannot control their flare-ups. I quit smoking, but the cessation of my smoking is what caused my Crohn's to flare-up out of nowhere. Since I smoked for quite a long time, they say that the reason the disease was dormant was because i smoked; that created a protective jelly film around my colon, which made it impossible for the white blood cells to attack. My symptoms during flare ups are: Blood in my feces, dizziness, lots of sweating, and many terrible cramp-like stomach aches. During remission, I have a few stomach aches, but nothing more.. maybe a bad poop every once in a while. Right now, I am taking immunosupressive drugs, i.e. 150mg azathioprine daily and a drug infusion called Remicade once every six weeks.

I plan on asking him a few further questions in regards to his diet and other things.

Diet Therapy in Crohn's Disease

When discussing general nutritional therapy, there are two primary forms used in medical practice, enteral and parenteral nutrition. Enteral nutrition, often referred to as tube feeding, allows for feeding into the GIT through a tube inserted nasally and fed into the stomach or small intestine. For long term usage, tubes can be surgically inserted into the stomach or small intestine through an opening made in the abdomen. Parenteral nutrition is the practice of feeding a person intravenously, and it completely bypasses the use of the stomach or intestines.

In terms of Crohn's disease, enteral nutrition is more often used as primary nutritional therapy. Parenteral nutrition is used in special cases or those of a higher severity. The overall goal for the use of diet therapy in Crohns is to correct any nutritional disturbances present and to help control the inflammatory response occurring. Remission rates of patients placed on enteral nutrition range from 53% to 80%; therefore, a direct anti-inflammatory effect of enteral nutrition in Crohn's disease is generally accepted. In one particular study, a decrease in the level of proinflammatory cytokines IL-1, IL-8, and IFN-gamma was observed in patients being treated through enteral nutrition. However, the direct mechanism of action for these observed anti-inflammatory effects is still not known.

Two mechanisms are currently proposed for the therapeutic efficacy of enteral nutrition in Crohns. The first mechanism is that the bowel rest allowed by the enteral feeding results in alteration of the intestinal flora and elimination/reduction of antigens. The second mechanism is that improvement in nutritional status by increase in nutrient intake and absorption aids in the induction of remission and reduction in intestinal protein loss.

Enteral nutrition usually has low compliance among adult Crohn's disease patients. Many find tube-feeding to be inconvenient, and a higher percentage of patients are more responsive to other medical treatments. Often enteral nutrition is seen as an effective adjuvant treatment in many cases. Enteral nutrition is far more widely used in the treatment of children with Crohns, and is often necessary to ensure proper nutrition and growth status.

Parenteral nutrition is used in cases of more severe disease when total bowel rest is a recommendation. It is also used in cases where patients have a poor tolerance to enteral nutrition; however, it is never recommended as a sole therapy in Crohn's disease.

Reference:
Moorthy D. Cappellano KL. Rosenberg IH. Nutrition and Crohn's disease: an update of print and web-based guidance. Nutrition Reviews. 2008; 66(7): 387-397.