A 7 8 2 AGA ABSTRACTS GASTROENTEROLOGY, VoI. tO8 , No. 4

l i O R A L CALCIUM AND VITAMIN D DOES NOT IMPACT ON DECREASED BONE DENSITY IN INFLAMMATORY BOWEL DISEASE (IBD): A PROSPECTIVE RANDOMIZED PLACEBO- CONTROLLED STUDY. CN Bernstein, LL Seeger, PA Anton, L Artinian, WG Goodman, SP Geffrey, T Belin, F Shanahan. Depts of Medicine, Radiology and Biomathematics, University of Manitoba, Winnipeg, Man, Canada, UCLA, Los Angeles,CA and University College Cork, Ireland

There is a high prevalence of diminished bone density in patients with ISD. To date there are few data to guide the treatment of bone density problems in these patients, however frequently calcium supplements are prescribed during corticosteroid use. We undertook a prospective, 1 year randomized, placebo-controlled study to determine if calcium and vitamin D supplementation had any impact on bone density, th_Me, L~[S_L. Steroid-using patients with IBD were randomized to receive either calcium carbonate 1000rag + vitamin D 250 IU (ca/vitD) or matching placebo (supplied by Marion Merrell Dew) to be taken as a single A.M. dose. At study entry and at 1 year patients underwent a dual energy x-ray absorptiometry (DEXA) with bone density Z scores obtained at the L2-L4 spine, the hip and ward's triangle. At entry and every 3 months, dietary calcium ingestion (4 day food record) and serum and 24 hr urine were collected. Stat sig=p<0.05. Results: 23 patients were enrolled; 17 completed the entire study including ca/vit D group=9 and placebo=8. 6 withdrawals were because of noncompliance, but no adverse events were seen in any of the 24 enrolled patients. There was no difference between the 2 groups at enrollment in terms of age, sex, disease diagnosis, duration, or activity, total dose of steroid used in the year prior to enrollment, dietary calcium intake, mean serum bone hormone values or mean DEXA Z scores.

Seine(Z~ HiD(Z) Ward'sA(Z~ Dietary ca (mold) ca/vit D Entry -1.74 -1.5 -1.31 800i-_86

1 year -1.42 ,f .25 -0.65 792-+81 (mean: whole yr) placebo Entry -1.25 -1.69 -1.54 611+38

1 year -1.15 -1.78 -1.50 752+72(mean: whole yr) 1 vr ca/vit D vs nlacebo n values:

- " p=0:63 p=0.39 p=0.18 p=0.71(mean: whole yr) There was no significant differences at study completion between DEXA Z scores, % change in DEXA measurements, or bone hormone measurements between the 2 groups. There was no correlation between steroid use during the study and final DEXA results. We correlated total daily intake of calcium (adding f 000mg to the mean daily calcium ingestion of the ca/vii D group) in the total group of 17 with all outcome parameters measured and no significant correlations were found. Final bone density at the spine correlated with 1,25(OH)2vit-D (r=0.59,p=0.01), at the hip and ward's A with PTH (r=0.54,p=0.03 and r=0.54,p=0.02) Conclusions:Calcium supplementation for steroid-using patients with IBD and diminished bone density does not significantly improve bone density after 1 year. Supported in part by PHS Grant# Me1 RR00865.

l iTHE GOBLET CELL (GC) EXPRESSION OF A NOVEL PEPTIDE RECOGNIZED BY A13D8 IN VARIOUS FORMS OF COLITIS. ON Bernstein, NM Pettigrew, WM Weinstein, HS EI-Gabalawy, MV sargent, JA Wilkins. Depts of Medicine and Pathology, University of Manitoba, Winnipeg, Man, Canada, and UCLA, Los Angeles, CA.

A13D8 is a novel IgM moAb that defines a 110 kDa antigen in some lymphoid cells and it is expressed by type B synoviocytes and by chondrocytes. We have found by immunohistochemistry (IHC), that A13D8 is ubiquitously expressed in the enterocytes of the small and large bowel in a granular supranuclear staining pattern, under normal and inflamed conditions, A13D8 is not expressed in the lamina propria but appears to be a secreted product of the epithelium as evidenced by lumenal staining of secreted matter. Furthermore, we found that in bx specimens from patients with active ulcerative colitis (UC) At3D8 expression was retained in the enterocytes but also became prominent ingoblet cells (GCs).We undertook a study to determine if this GC expression during inflammation was specific to UC.Methods: 5p. sections from paraffin embedded, Bouin's-fixed tissue blocks were prepared for IHC from patients with UC(n=t4), Crohn's disease(CD,n=8), pseudomembranous colitis(PMC,n=4), Salmonella colitis(SC,n=l), ischemic colitis(IC, n=2), and collagenous colitis(CC,n=5). IHC was performed using an avidin-biotin complex method with immunoperoxidase staining. The % of GCs expressing A13D8 was determined by counting 20 crypts from 2 separate sections/bx site (by 2 independent investigators). A separate investigator determined inflammation scores (INFL) for each section by a 0-3 scoring system for each of mononuclear cells'+ granulocytes in the lamina propria + granulocytes in the crypts. Crypt epithelial cytologic changes were also scored (EC) 0-3.Results: GC expression was not evident in the noninflamed bxs and evident inhomogeneously in inflamed bxs from patients with UC(12/14), CD (818), SC (1/1), PMC (3/4), IC (1/2). For the CC group, 415 showed no staining and 1 patient showed rare staining (1.5%), despite mean INFL scores of 3.3. Of the UC and CD bxs where the INFL and EC scores were 0 there was never GC expression. The magnitude of the INFL or EC scores and the %A13D8 expression did not significantly correlate (r=0.31,r=0.25, respectively)

GC +ve A13D8 GC -ve A13D8 n value UC INFL 6.2_+0.6 0.8_+0.4 <0.0001

EC 2.2-+0.2 0.6_+2 <0.0001 CD INFL 4.5+-0.5 2.4_+0.9 0.07

EC 1.9_~.2 0.6_-+0.3 0.001 Conclusion: A13D8 moAb identifies antigen(s) ubiquitously expressed in normal and inflamed small and large bowel enterocytes in a granular, supranuclear pattern. However, GCs express this antigen in a patchy fashion and only in the sites of inflammation. The GC expression is not seen in CC a colitis that is not associated with crypt destruction, suggesting a unique response to tissu~ injury. It remains to be proved whether A13D8 recognizes a prohealing or proinflammatory protein, but in either case these data may help explain why these colitides, including UC, may present in a patchy fashion.

I N D I C PIIIINIBII~TION OF ZILEUII]N, A ~ RrTI~E 5 - L I P O X Y ~ II~l-IIBI'E]R, t ~ STRICTURE F ~ T I { ] N

~ATES HEPLINB IN A RAT M ~ OF [}4RONIC COLITIS. X Bertr~n, J Mall@, F Fern~ndez-Ba~ares, E Castell&, R Bartol l , I Ojanguren, M Esteve and N% Gassull. Depts. o f Gastroenterology and Pathology, Research Unit, Hospital Universitari Germans Trias i Pujol. BadalQna. Spain.

Bark~-ouncl/Ailm 5-1ipoxygenase products play a role in inflammatory response. We aimed to assess the ef fect of intracol~nic administration of zileuton (a selective 5- lipoxygenase inhib i tor) on colonic damage and eicosanoid local release in a rat model of co l i t i s . /gefl-~d~. Ninety Sprague-Dawley rats (200-250 g) with trinitrobenzenesulfonic acid (TNBS; 30 mg, 50%) induced c o l i t i s were randomized to dai ly receive placebo (vehicle), 5-aminosalicylic acid (5-ASA) (50 mg/kg) or zileuton (50 mg/kg) intracolonical ly for 4 ~eeks. Local eicosanoid release was mmnitored by intracolonic dialysis throughout the study. Eicosanoid levels (~g/ml) in the dialysates were measured by RIA. The colon was removed for macroscopic and histological assessment at weeks I , 2, and 4 af ter c o l i t i s induction in i0 rats of each group. B~ I t _~ Zileuton signi f icant ly reduced macroscopic damage score af ter 4 weeks of treatment as campared to the other two groups (3.8~0.7 vs 6.5_+0.8 and 6.9!0.9; p=0.034). Less severe str ic ture formation mainly accounted for such a difference (p<O.05). In addition, zileuton, but not placebo or 5-ASA, s igni f icant ly increased intracolonic release of both thr~mboxane B= at week I (2367+722 vs 822~172 and 793+--926; p--O.05) and prostaglandin E= at ~ek 2 (8586_+5128 vs 4082~966 and 305~+945| p=O.O05) and week 4 (7474-+5079 vs 395~575 and 5003_+1003; p=O.04). Zileuton and 5-ASA decreased leukotriene B~ release by 90% at day 3 as compared to placebo. /~]us~imgs: Intracolonic zileuton improves the course of TNSS-induced c o l i t i s as compared to 5-ASA and placebo. This e f f E t may be related to an increased and maintained production of prostaglandin E=, together with inhibi t ion of t i e synthesis of leukotriene B~.

QO,SEI~ OF AZATHIOPRINE (~7~) TO V~INTAIN ~ R I N E (CyA)-I~ P,I~I~ION IN S ~ STEROID-REFRACTORY IN~TuAMMATORY BOWEL DISEASE (IBD). X Bertr~n, F Fern~ndez- Ba~ares, M Esteve, P Humbert, R Planas, MA Gassull. Hospital Germer~s Trias i Pujol, Badalona, Spain.

Baek~: Intravenous CyA is effective and safe in patients with severe steroid-refractory ulcerative colitis (UC), but early relapse is co~mon with oral CyA maintenance therapy. Besides, AZA has been suggested to be effective in maintaining remlssion in chronically active IBD. Aim: TO assess the usefulness of AZA in maintaining CyA- induced remission ira severe steroid-refractory InD. Methods: Fourteen patients with severe IBD (i0 UC, 4 Crohns disease, CD) whose condition did not improve after iO days of i.v. prednisone <i mg/P4~/d) were prospectively included. Intravenlous CyA was added at a dose of 4 mg/kg/d aiming to maintain blood levels between 150 and 300 ng/ml <FPIA, TDX assay, Abbott). All patients who achieved remission after a course of i.v CyA were followed for a meBn 15.:~ months krBr~e 3 to 45> follow-up period. The first 5 patients were treated with oral CyA (8-8 mg/kg/d); the ~emalning patients received AZA (2-2.5 mg/kg/d). 5-ASA drugs were added in all cases. Remission was defined as a modified Truelove's index -<14 <range:8-24) for UC, and s Van Hess activity index <120 for CD. Results: 12 (85:7%) patients (9 UC, 3 CD) achieved remission in 8 4-week period. Res]ponse was already seen at 7 days. In the follow-up, 4 of the 5 patients (80%) (3 UC, 1 CD> on oral CyA relapse~ between 3 and 6 mont~, whereas this occurred in only 1 of 7 (14%) (I UC) on AZA (at 3 months) (p=0.045). CyA blood levels were frequently low in spite of good compliance, end frequent dose adjustments were required. Three of the 4 patients who relapsed on oral CyA achieved remlssion after a new i.v. CyA course, and maintain remission after 30, 36, end 36 months on AZA, respectively. The fohrth patient was lost of the follow-up. No major side-effects were observed. Conclusions: These preliminary results support the efficacy of i.v. CyA in the treatment of severe steroid-refractory IBD, even in CD patients, and suggest that AZA may be better thBn oral CyA to maintain remission. This finding has to be confirmed in rsndomized clinical trials.