Joseph Zimmerman

OBJECTIVES: Treatment with pancreatic enzymes fails to completely correct malabsorption and gastrointestinal symptoms in patients with cystic fibrosis (CF). The aim of the present study was to examine the small intestine of patients with CF without overt evidence of gastrointestinal disease using capsule endoscopy (CE). METHODS: Patients with CF received the agile patency capsule and, depending on the result of that procedure, then underwent standard CE using the PillCam SB capsule (Given Imaging, Yokneam, Israel). A stool specimen was taken on the same day as the CE for determination of the calprotectin level. RESULTS: Forty-two patients with CF ages 10 to 36 years were included; 29 had pancreatic insufficiency. One patient failed to excrete the patency capsule after 36 hours and was withdrawn from the study. Pulmonary function was mild to moderate with FEV1 68.5% +/- 16% predicted. Review of the CE videos showed that most of the patients had varying degrees of diffuse areas of inflammatory findings in the small bowel including edema, erythema, mucosal breaks, and frank ulcerations. There were no adverse events. Fecal calprotectin levels were markedly high in patients with pancreatic insufficiency, 258 microg/g (normal <50). CONCLUSIONS: Small bowel mucosal pathology may be detected using CE in most of the patients with CF. The high fecal calprotectin levels found are suggestive of mucosal inflammation, which may correlate with the CE findings. Additional study is required to examine the possible relation of these mucosal lesions, which may be part of a newly identified enteropathy associated with CF, with persistent intestinal malabsorption in many of these patients.

A review of 93 patients with ulcerative colitis revealed that in 47 (50.5%) symptoms first appeared between 21 and 30 years of age--"early-onset"--and in 26 (27.9%) at the age of 51 years or above--"late-onset." Proctocolitis was more common in late-onset patients (p = 0.077) and in males of both age groups (p = 0.002). Extensive colitis was significantly more common in females (p = 0.002). Patients with late-onset proctocolitis had more bowel movements/day and liver involvement than patients with early-onset disease. The first episode of proctocolitis was more protracted and the ensuing remission of shorter duration in late-onset patients. Most patients with early-onset disease improved on steroid enemas, whereas most patients with late-onset disease required systemic corticosteroid therapy (p = 0.0028). Female patients with early-onset proctocolitis tended to be more severely afflicted than males, with an increased incidence of weight loss, leukocytosis, increased erythrocyte sedimentation rate (ESR), and need for systemic corticosteroid therapy. We conclude that late-onset ulcerative colitis is distinct from early-onset disease in its relative refractoriness to therapy and its predilection for distal colonic involvement.