The relationships between clinical activity, endoscopic severity, and biological parameters in Crohn's disease have not been thoroughly investigated and a link was therefore sought between these three elements. The following parameters were determined simultaneously in 121 consecutive patients with colonic or ileocolonic Crohn's disease: Crohn's disease activity index, Crohn's disease endoscopic index of severity, and serum albumin, CE2-globulin, a,-antitrypsin, orosomucoid, C reactive protein, erythrocyte sedimentation rate, platelets, lymphocyte and polymorphonuclear cell counts, haematocrit, and faecal a,-antitrypsin concentration. The distribution of these parameters was studied and transformation was used so that data matched the normal distribution closely. A weak but significant correlation (r=032; p<0001) was found between clinical and endoscopic indices in the whole group of patients and this correlation seemed to be homogenous in various patient subgroups (clinically quiescent or active disease, pure colonic disease, untreated patients). Endoscopic or clinical indices were also found to be weakly linked with biological parameters (r<050). Stepwise linear regression identified C reactive protein as predictive of the clinical index, and, successively, C2-globulin, erythrocyte sedimentation rate, faecal a,-antitrypsin, serum orosomucoid, and a,-antitrypsin as predictive of the endoscopic index. Both predictions were poor -the biological variables accounting for only 22 and 44% respectively ofthe clinical and endoscopic index variations. In conclusion, Crohn's disease clinical activity seems to be virtually independent of the severity of the mucosal lesions and biological activity. (Gut 1994; 35: 231-235)

The effects of a chronic load of nonabsorbable sugars on intracolonic bacterial metabolism of carbohydrates and on H2 breath excretion are disputed. However, most of the discussion relies on indirect evidence or on results of in vitro studies. Thus, we attempted to assess directly and in vivo the effects on intracolonic metabolism of lactulose of a chronic oral load of this nonabsorbable disaccharide. 20 g of lactulose was given orally twice daily during 8 d to eight normal volunteers. In all, breath H2 concentration was measured on days 1 and 8 after ingestion of the morning lactulose dose. In four subjects, stools were collected during 2 d at the beginning and at the end of the lactulose maintenance period to measure fecal pH and daily outputs of carbohydrates and P-galactosidase. The four other subjects were intubated on days 1 and 8 to measure the pH and the concentrations of carbohydrates, lactic acid, and volatile fatty acids (VFA) in the distal ileum and cecal contents.Moreover, '4C-lactulose was added to cold lactulose and "CO2 breath outputs determined. Pulmonary H2 excretion fell from day 1 to day 8 (P < 0.05), whereas '4CO2 excretion increased (P < 0.01). Fecal water pH, lactic acid, and VFA concentrations did not vary between the two stool collection periods. 24-h fecal weight, fecal water, and carbohydrate outputs showed a trend to decrease between days 1 and 2 and days 7-8, whereas jlgalactosidase activity rose markedly (P < 0.01). No significant variations were observed for all parameters measured in ileal fluid. In the cecum, areas under the concentration curves decreased from day 1 to day 8 for lactulose, galactose, and fructose (P < 0.01), while an increase was found for lactic acid (P < 0.001), acetic acid (P < 0.0001), and total VFA (P < 0.001). Cecal fluid pH dropped faster (P < 0.05) and to a lower level (P < 0.05) on day 8 than on day 1. These data clearly show that a chronic load of a nonabsorbable sugar induces changes in colonic bacterial metabolic pathways resulting in a better efficiency of the flora to digest the carbohydrate. Introduction Measurement of pulmonary hydrogen (H2) excretion is widely used to diagnose and quantify carbohydrate malabsorption (1-6). However the accuracy of the H2 breath test in the study of chronic carbohydrate malabsorption is debated (1). Perman et al. (7) showed that an 8-d oral administration of lactulose resulted in acidic stools and in a dramatic fall of H2 breath excretion after an oral load of this sugar or of lactose in lactase-deficient patients. From stool homogenate incubations with various sugars, these authors concluded that the fall of H2 production was due to an inhibition of bacterial carbohydrate metabolism by the low colonic pH (7). Unfortunately, they did not measure stool sugar outputs. If their statement was always true, lactose-H2 breath test could be erroneously normal in lactase-deficient patients ingesting every day large amounts of incompletely absorbed carbohydrates, including lactose itself. This is contradictory to the...

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The use of the wireless endoscopy capsule detects significantly more clinically relevant intestinal lesions than video push-enteroscopy in patients with obscure digestive bleeding, raising the diagnostic yield to 67.2 %. Its influence on the clinical outcome for patients needs further investigation.

CE is a highly sensitive examination for the detection of small-bowel lesions in patients with obscure gastrointestinal bleeding, with a specificity lower than that of PE when the clinical outcome is used as the gold standard.

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The list of extraintestinal manifestations of inflammatory bowel diseases does not classically include pancreatitis and pancreatic insufficiency. We report here six cases of unexplained pancreatitis associated with inflammatory bowel disease (five patients with Crohn's disease, one with indeterminate colitis). None of the classical etiologies for pancreatitis was found in our patients; moreover none of them had duodenal localization of Crohn's disease or sclerosing cholangitis, two conditions in which pancreatitis associated with inflammatory bowel disease has been previously described. Pancreatitis was painless (or was associated with moderate and atypical abdominal pain) in four of our six cases; no pancreatic calcification was found in any case; in three patients a total or subtotal exocrine pancreatic insufficiency was evidenced. Endoscopic retrograde pancreatography performed in four subjects showed normal or minimally altered pancreatic ducts even in those with severe pancreatic insufficiency. These cases emphasize the existence of a probably nonfortuitous association of inflammatory bowel disease with pancreatitis. Its recognition could make a significant contribution in the management of inflammatory bowel disease.