The effect of the use of probiotics and the value of estimation of urinary N-methylhistamine as inflammatory marker in mild and moderate ulcerative colitis

Shendy Mohammed Shendy* and Nihal M.El-Assly**Tropical medicine department* and Clinical Chemistry department, Theodor Bilharz Research Institute.

Abstract:Enteric microflora of the gastrointestinal tract becomes aberrant in patients with ulcerative

colitis and the abnormal interaction between microflora and intestinal mucosal immune system leads to mucosal inflammation. Probiotic administration may recover the commensal microflora and normalise the host–microbial interaction. The aim of this work is to evaluate the role of probiotic therapy in inducing and maintaining remission in mild to moderate cases of ulcerative colitis; and the value of estimation of urinary N-methylhistamine as a marker of inflammation in the course of this disease. Materials and methods: this study included 35 patients divided randomly into two groups. Group I of 17 patients (11 males and 6 females) were treated with oral mesalamine (pentasa). Group II of 18 patients (10 males and 8 females) were treated with probiotics (Protexin). All patients were subjected to thorough history taking and physical examination. Stool analysis, colonoscopic examination and multiple biopsies taken from diseased parts were done in all patients. These tests in addition to routine CBC, urine, kidney function tests, serum potassium and liver function tests were done in all patients before, at end of treatment and during follow up. Similarly, ESR, CRP, and urinary N-methylhistamine were estimated in similar way. Results: the disease itself and all the parameters of inflammation showed statistically significant improvement after therapy without significant differences in both mesalamine and probiotic groups. The clinical remission occurred in 1-2 month in most cases in both groups. No improvement was found in one case (5.9%) in mesalamine group and in two cases (11.1%) in probiotic group. Also, CRP became negative in more than half of patients (53%; 9 patients) in mesalamine group and in 8 patients (44.4%) in probiotic group with highly significant reduction in the remaining cases in both groups. Similarly, highly significant reduction in the urinary N-methylhistamine (NMH) level which is another marker of inflammation was found in all patients of both groups with no statistically significant difference in between. Comparing with the whole patients, the non-responding patients showed statistically significant higher level of NMH after three months and at end of treatment (P = 0.041). NMH showed significant direct correlation with other markers of inflammation before and after treatment, such as CRP (P < 0.01) and ESR (P < 0.01), and extent of mucosal lesion in the colon as detected by endoscopy (P = 0.05). Remission was maintained for more than 6 months using probiotic therapy in 85.7% of patients of both groups. Conclusion: it is concluded from this study that treatment with probiotics is effective in inducing and maintaining remission in patients with mildly to moderately severe active ulcerative colitis. Also, N-methylhistamine can be considered a good marker of inflammation and a prognostic factor during treatment. Furthermore, it can be used as a predictive factor for recurrence particularly when its level did not return to normal.

Introduction: Probiotic bacteria favorably alter the intestinal microflora balance, inhibit the growth of

harmful bacteria, promote good digestion, boost immune function and increase resistance to

infection (Smirnov et al., 1993 and Mel’nikova et al., 1993). People with flourishing intestinal colonies of beneficial bacteria are better equipped to fight the growth of disease-causing bacteria (De Simone et al., 1993 and Veldman 1992). Lactobacilli and bifidobacteria (the main constituents of protexin probiotic) maintain a healthy balance of intestinal flora by producing organic compounds—such as lactic acid, hydrogen peroxide, and acetic acid—that increase the acidity of the intestine and inhibit the reproduction of many harmful bacteria (Kawase 1982 and Rasic 1983). Probiotic bacteria also produce substances called bacteriocins, which act as natural antibiotics to kill undesirable microorganisms (Barefoot and Klaenhammer, 1983). Diarrhea flushes intestinal microorganisms out of the gastrointestinal tract, leaving the body vulnerable to opportunistic infection. Replenishing the beneficial bacteria with probiotic supplements can help prevent new infections. The incidence of "traveler’s diarrhea," caused by pathogenic bacteria in drinking water or undercooked foods, can be reduced by the preventive use of probiotics (Scarpignato and Rampal 1995).

Probiotics are involved in the production of several gut nutrients such as short-chain fatty acids, and the aminoacids arginine, cysteine and glutamine. Also they may manufacture B vitamins such as niacin, biotin, vitamin B6 and folic acids. (Bengmark 1998). These beneficial bacteria may also help remove toxins from the gut and exert a beneficial effect on cholesterol levels ((Bengmark, 2000).

In a double-blind trial, a combination probiotic supplement containing Lactobacilli, Bifidobacteria, and a beneficial strain of Streptococcus has been shown to prevent pouchitis, a common complication of surgery for UC (Gionchetti et al., 2000 and 2003). People with chronic relapsing pouchitis received either 3 grams per day of the supplement or placebo for nine months. Eighty-five percent of those who took the supplement had no further episodes of pouchitis during the nine-month trial, whereas 100% of those receiving placebo had relapses within four months. Preliminary evidence suggests that combination probiotic supplements may be effective at preventing UC relapses as well (Venturi et al., 1999). Other uncontrolled studies have yielded promising results, with induction of remission rates of 63% and 68%, in patients with active ulcerative colitis (Guslandi et al., 2003 and Fedorak et al., 2003).

In a study presented during Digestive Disease Week 2006 meeting, 90 patients with ulcerative proctosigmoiditis were randomized to receive 40-mL, 20-mL, or 10-mL enemas containing E coli Nissel 1917* (EcN) at 108 organisms/mL or placebo once daily for 4 weeks. Remission was achieved in 18% of placebo-treated patients, in 27% of those receiving the 10-mL formulation, in 44% of those receiving the 20-mL enema, and in 53% of patients receiving the 40-mL enema. There were no differences in adverse effects seen between the groups. This topical probiotic shows promise for patients with mildly to moderately active ulcerative colitis (Matthes et al., 2006).

Finally it was concluded that enteric microflora of ulcerative colitis patients becomes aberrant and the abnormal interaction between microflora and intestinal mucosal immune system leads to mucosal inflammation. Probiotic administration may recover the commensal microflora and normalize the host–microbial interaction (Bai et al., 2006).

Urinary N-methylhistamine (UMH) which is a stable metabolite of the mast cell mediator histamine may be a useful marker of inflammatory bowel disease (IBD) severity for both Crohn's disease and ulcerative colitis. Studies showed that urinary excretion of UMH was significantly elevated in IBD. It was found to be significantly correlated with clinical disease activity even more than CRP. Also, excretion was strongly correlated with endoscopic severity of

inflammation and extent of intestinal disease. It appears to represent an integrative parameter to monitor clinical and endoscopic disease activity in IBD, which appears to be influenced most likely by mediators released from histamine-containing cells, such as intestinal mast cell subtypes (Winterkamp et al., 2002).

At present, still there are inadequate clinical trial evidences to recommend the use of probiotics in the setting of ulcerative colitis. The aim of this work is to evaluate the role of probiotics in induction of remission and as maintenance therapy in mild to moderate cases of ulcerative colitis as monitored clinically, endoscopically and by measurement of CRP, ESR and urinary N-methylhistamine. Also, our aim is to evaluate the value of estimation of urinary N-methylhistamine as a marker of inflammation in the course of this disease.

Materials and Methods:

This study included 35 patients (21 male and 14 females) of mild to moderate ulcerative colitis limited to left colon as diagnosed by colonoscopic and histopathological examination. They were divided into two groups: Group I: 17 patients (11 males and 6 females) were treated with oral mesalamine (pentasa) 3

gm/day in 3 divided doses and 2 tablets of Tri B (containing folic acid 5 mg, B 1 125 mg and B6 125 mg and B12 125 mcg / tablet) daily.

Group II:18 patients (10 males and 8 females) were treated with probiotics (Protexin) 6 tablets/day in 3 divided doses and 2 tablets of Tri B daily.

Protexin (Probiotics International LTD; Matts Lane, Stoke sub. Hamdon, Somerset TA14 6QE, U.K.) contains the following ingredients: magnesium gluconate, diacalcium phosphate, sorbitol, protexin concentrate, ascorbic acid, magnesium striate, silica, stearic acid, natural lemon flavour, pyridoxine HCl and folic acid. It is a natural multistrain probiotic containing 7 strains of human probiotic bacteria in its concentrate (Bifidobacteria breva and longum; Lactobacilli acidophilus, bulgaricus, casei, and rhamnosus; and Streptococcus thermophilus) in addition to magnesium 25 mg, vitamin B6 1mg, folic acid 0.1 mg vitamin C 30 mg in each tablet. Also each tablet contains 5 x 107 CFU of above bacteria.

All patients were subjected to thorough history taking and physical examination. Stool analysis, colonoscopic examination and multiple biopsies taken from diseased parts were done in all patients. Also, routine CBC, urine, kidney function tests, serum potassium and liver function tests were done in all patients before, during and at end of treatment. Similarly, ESR, CRP, and urinary N-methylhistamine were estimated in similar way.

Plan of treatment and follow up:Patients presenting with symptoms and signs suggestive of ulcerative colitis such as

prolonged loose bowel motions, bloody stool, urgency and/or lower abdominal pain were evaluated as above. Stool analysis repeatedly, CBC, blood chemistry, ESR were done routinely. Colonoscopy or rectosigmoidoscopy was done with minimal preparation after exclusion of other common causes of bloody diarrhea such as bacterial or parasitic infectios. Multiple biopsies were taken from lesions seen. Patients suspected to have mild to moderate UC and confirmed by histopathology (particularly the presence of ulcerations, rectal involvement, absence of deeper invasion, perianal involvement and skip lesions and presence of PMNLs and crypt abscesses) were randomized to take treatment either in the form of mesalamine (pentasa), or the probiotics (protexin). The disease severity is estimated by being confined to left colon, less than 6 motions /day, not associated with extensive bleeding, fever, leukocytosis, high ESR (not more

than 30 in first hour), loss of weight, severe anemia or megacolon. Follow up was carried on by history, physical examination and repeated stool examination, CBC, CRP, urinary N-methylhistamine and ESR till improvement up to 6 months. Improvement of symptoms and laboratory findings was considered success of treatment and confirmed by endoscopic examination of colon within 3 months of start of treatment. All patients were maintained on protexin 2 tablets every day for remaining period of the 9 months as maintenance therapy. During period of maintenance therapy patients were followed up by history, clinical examination, repeated stool analysis, ESR, CRP, and urinary N-methylhistamine. Endoscopy was performed again in patients with clinical recurrence. All recurrent cases were treated with mesalamine and if needed prednisolone according severity.

Estimation of Urinary N-methylhistamine:Urinary excretion of N-methylhistamine was estimated using ELISA kits manufactured by

IBL (Immuno Biological Laboratories, Hamburg Germany). The assay procedure follows the basic principle of the competitive ELISA: the competition between a peroxidase-conjugated and a non-conjugated antigen for a fixed number of antibody-binding sites (rabbit-anti-acylhistamine). The peroxidase-conjugated antigen-antibody complexes bind to the wells of the microtiter strips which are coated with a goat-anti-rabbit antibody. Unbound antigen is then removed by washing. After the substrate reaction, the optical density is measured at 450 nm. The amount of complexes bound to the plate and the optical density is inversely proportional to the analyte concentration of the sample. Quantification of unknowns is achieved by comparing the enzymatic activity of unknowns with a response curve prepared by using known standards (Myers G et al., 1981 and Hermann K et al., 1994).

Detailed Instructions for Use:

The total volume of urine excreted during a 24 hour period should be collected and mixed in a single bottle containing 10 - 15 ml of 6 N hydrochloric acid as preservative. Exposure to direct sun light should be avoided. Urine samples which are not assayed immediately may be stored at -20°C or lower for at least 6 months. Avoid repeated freezing and thawing of samples.

Procedure:

1. Add 50 µl Enzyme Conjugate.

2. Add 50 µl Antiserum and shake the plate carefully.

3. Cover plate and incubate 3 h at Room Temperature (RT) on a shaker.

4. Wash each well four times with 250 µl Wash Buffer.

5. Add 200 µl freshly prepared TMB Substrate Solution.

6. Cover plate and incubate 50 ml urine 20 min at RT on a shaker.

7. Add 100 µl of TMB Stop Solution and mix gently.

8. Read OD at 450 nm within 60 min after stopping.

Standard curve: urine: 2.7 - 219 ng/ml

Data will be analyzed by SPSS program of statistical analysis.

Results:

This study included 35 patients(21 male and 14 females) presented to us in Elite Medical center in Riyadh city, S.A with symptoms and signs suggestive of mild to moderate ulcerative colitis. They were investigated as discussed in the methods and randomly divided into the two treatment groups. The two groups showed no statistical differences in age, sex, number of motions per day, rectal bleeding, abdominal pain, urgency, fever and weight loss. The duration of illness before starting treatment was longer in probiotic group than mesalamine group but not statistically significant (P = 0.092). Again the onset, the course of the disease and the severity of recurrent attacks showed no differences between the two groups. Also, the extent of the disease in the colon and the severity of mucosal lesions as detected by colonoscopic examination did not show any difference between the two groups. All the laboratory findings including stool analysis, total leukocyte count, ESR, CRP, serum potassium and haemoglobin levels are similar in both groups. Also, most of these evaluation parameters showed statistically significant improvement after therapy in both mesalamine and probiotic groups in similar pattern reaching normal or near normal values with improvement of the bowel disease. The duration needed for clinical remission in both groups was similar. This improvement occurred in less than one month in 47.1% in mesalamine group and 61.1% in probiotic group. Most of the remaining cases improved in about two months. This clinical improvement was confirmed by endoscopic examination of the colon and histopathology. No improvement was found in one case (5.9%) in mesalamine group and in two cases (11.1%) in probiotic group. These patients were controlled by the combination of mesalamine and corticosteroid. Also, CRP became negative in more than half of patients (53%; 9 patients) in mesalamine group and in 8 patients (44.4%) in probiotic group with highly significant reduction in the remaining cases in both groups. Similarly, highly significant reduction in the urinary N-methylhistamine (NMH) level which is another marker of inflammation was found in both groups with no statistically significant difference in between. After clinical remission, it was significantly reduced from a mean of 81.06 ± 21.78 to 44.82 ± 15.08 ng/ml in all patients of mesalamine group (P = 0.000) and from a mean of 74.11± 31.75 to 39.22 ± 22.31 ng/ml in all patients of probiotic group (P = 0.000). At the end of follow up and maintenance therapy, the mean urinary N-methylhistamine was significantly reduced further to 34.29 ± 6.28 and 33.22 ± 8.95 ng/ ml (P = 0.001) in mesalamine and probiotic groups respectively. In the three non-responding patients the mean NMH was significantly reduced from120.67 ± 11.72 before treatment, to 72.67 ± 4.16 after 3 months and 47.00 ± 3.61 at end of treatment (P = 0.0 14 for both compared to pre-treatment level and P = 0.022 between the two levels at 3 months and at end of treatment). However, comparison with the whole patients showed statistically significant higher level of NMH in non-responding patients before, after three months and at end of treatment (P < 0.05). Also, relapsing patients showed significantly higher levels than all patients before, after 3 months and at end of treatment (P <0.05). NMH showed significant direct correlation with other markers of inflammation before and after treatment, such as CRP (P < 0.01) and ESR (P < 0.01), and extent of mucosal lesion in the colon as detected by endoscopy (P = 0.05). ESR and CRP were positively correlated with more parameters of colonic inflammation such as pus and blood in stools, leukocytosis, low hemoglobin level, extent, severity and duration of the colonic disease and low serum potassium (P = < 0.01). The severity, extent and duration of the disease were also directly correlated with the number of pus cells and red cells in stool, leukocytosis, ESR, low serum potassium and low hemoglobin level.

Follow up for another period of 6 months with continuation of probiotic therapy after remission in all patients was conducted. Remission was maintained by probiotic therapy for at least 6 months of follow up in 30/35 (85.7 %) of patients. Two patients (11.8%) relapsed in

mesalamine group (after 20 and 25 weeks of stopping mesalamine) and 3 cases (16.6%) in probiotic group (after 18, 19, 24 weeks of clinical remission). These relapsing patients were managed by the addition of mesalamine therapy to their probiotic regimen. All showed remission within the follow up period and maintained on probiotic therapy alone thereafter. More prolonged follow up of these patients was planned for evaluation of the long-term effect of this therapy.

Table 1: Sex distribution of patients among both groups and total patients.

group sex Total in each group

Male FemaleMesalamine group

Count 11 6 17

% within group 64.7% 35.3% 100.0%

% of Total 31.4% 17.1% 48.6%

Probiotics group

Count 10 8 18

% within group 55.6% 44.4% 100.0%

% of Total 28.6% 22.9% 51.4%

Total in both groups

Count 21 14 35

% within group 60.0% 40.0% 100.0%

% of Total 60.0% 40.0% 100.0%

Table 2: The mean age of patients in both groupsStd. DeviationMean agesex group

8.1251611.496389.08902

32.727333.166732.8824

MaleFemaleTotal

Mesalamine group

9.949327.387258.70748

32.100034.000032.9444

MaleFemaleTotal

Probiotic group

Table 3: The duration and some clinical manifestations of patients of two groups.

3.8800 4.4800 2.7647

1.61564 1.12459 1.03256

2.00 3.00 1.00

7.00 6.00 5.00

4.1700 4.2778 2.5556

1.60167 .95828 .92178

3.00 3.00 1.00

8.00 6.00 4.00

Mean

Std. Deviation

Minimum

Maximum

Mean

Std. Deviation

Minimum

Maximum

groupMesalamine group

Probiotics group

Duration ofillness (week)

Number ofmotions

Motions withbleeding

The duration of illness was longer in probiotic group than mesalamine group (P=0.092).

Table 4: Some other clinical manifestations of patients of two groups.group Abdominal pain Urgency High temperature Weight loss

Mesalamine group

None: 8 None: 8 Absent: 15 None: 8

Mild: 5 Sometimes: 5 Present: 2 Loss 2-5 Kg: 6

Moderate: 4 All times : 4 Loss > 5 Kg: 3

Probiotics group

None: 7 None: 9 Absent: 15 None: 11

Mild: 8 Sometimes: 6 Present: 3 Loss 2-5 Kg: 4

Moderate: 3 All times : 3 Loss > 5 Kg: 3

Table 4: history of the disease in the two patient groups:

group Frequency PercentMesalamine group

New Onset 13 76.5

recurrent disease of similar severity 2 11.8

Recurrent disease of milder severity 2 11.8

Probiotics group

New Onset 13 72.2

recurrent disease of similar severity 4 22.2

Recurrent disease of milder severity 1 5.6

Table 5: Extent of the disease as detected by endoscopic examination of the colon in the two patient groups:

Frequency Percent

Mesalamine group

Confined to rectum 4 23.5

Involving rectum and sigmoid 9 52.9

Up to mid-descending colon 2 11.8

Up to splenic flexure 2 11.8Probiotics group

Confined to rectum 6 33.3

Involving rectum and sigmoid 7 38.9

Up to mid-descending colon 2 11.1

Up to splenic flexure 3 16.7

Table 6: Severity of mucosal affection as detected by endoscopic examination of the colon:

Frequency PercentMesalamine group

Mild severity 8 47.1

Moderate severity 8 47.1

Marked severity 1 5.9

Probiotics group

Mild severity 8 44.4

Moderate severity 7 38.9

Marked severity 3 16.7

Table 7: Severity of mucosal affection of the disease as detected by stool examination of the patients of the groups:

group

Number of pus or red cells in HPF

Pus cells in stool RBCs in stool

Count CountMesalamine group

10-30/HPF 6 2

30-100/ HPF 7 8

>100/HPF 4 7

Probiotics group

10-30/HPF 6 3

30-100/ HPF 10 8

>100/HPF 2 7

Table 8: Haemoglobin in gm/dl (Hb) level and Serum potassium (S.K) in the two patient groups before and after treatment:

group Hb before treatment

Hb after treatment

S. K. before treatment

S.K after treatment

Mesalamine group

Mean 11.8 13.70 4.05 4.31

Std Deviation 1.4 1.24 .51 .36

Probiotics group

Mean 12.4 13.78 3.87 4.18

Std Deviation 1.9 1.25 .44 .34

Table 9: Total Leukocytic count (TLC) and Erythrocyte Sedimentation rate in first hour (ESR); in the two patient groups before and after treatment:

group TLC before TLC after ESR before ESR after

treatment treatment treatment treatmentMesalamine group

Mean 6.85 5.69 19.85 15.06

Std Deviation 1.19 1.09 4.86 2.95

Probiotics group

Mean 7.61 6.04 20.11 15.72

Std Deviation 1.76 .97 5.58 3.34

Table 10: Mean value of C - reactive protein (CRP) before and after treatment in both groupsgroup

CRP before treatment CRP after treatment

Mean Std Deviation Mean Std DeviationMesalamine group

37.18 18.15 7.59 8.36Probiotics group

29.78 15.24 7.44 7.06

Table 11: C - reactive protein (CRP) before and after treatment in both groups :

Negative 6-24 mg/L 30-42 mg/L Above 42 mg/LMesalamine

group

CRP before treatment

2 2 7 6

CRP after treatment

9 8

Probiotics group

CRP before treatment

2 6 7 3

CRP after treatment

8 10

Table 12: N-methylhistamine level before and after treatment in both groups

group

Mesalamine group Probiotics group

Mean Std Deviation Mean Std DeviationN-methylhistamine before treatment (ng/ml) 81.06 21.78 74.11 31.75N-methylhistamine after treatment (ng/ml) 44.82 15.08 39.22 22.31N-methylhistamine at end of follow up 34.29 6.28 33.22 8.95

Table 13: N-methylhistamine level before and after treatment in non-responding patientsNon-responding patients Mean Std DeviationNMH before treatment 120.67 11.72NMH after three months 72.67 4.16NMH at end of follow up 47.00 3.61

Table 14: N-methylhistamine level before and after treatment in relapsing patientsRelapsing patients Mean Std DeviationNMH before treatment 113.51 13.16NMH after three months 85.38 5.24NMH at end of follow up 43.82 6.13

Table 15: Duration needed for clinical improvement in the two patient groups: group Frequency PercentMesalamine group

2-4 weeks 8 47.1

1-2 months 7 41.2

2-3 months 1 5.9

No improvement 1 5.9

Probiotics group

2-4 weeks 11 61.1

1-2 months 4 22.2

2-3 months 1 5.6

No improvement 2 11.1

Discussion:

Although the pathogenesis of the inflammatory bowel diseases is not yet well understood, ongoing researches into their underlying mechanisms has allowed the development of several therapeutic modalities. This is an evolving process, with great potential for the future management of these diseases. The hope is that we will eventually be able to prevent and cure these conditions. Our aim is to identify safe and well tolerated agents that are able to rapidly control symptomatic flares and can maintain remission. The intestinal tract contains a complex and diverse society of both pathogenic and non-pathogenic bacteria. Enteric microflora in ulcerative colitis patients becomes aberrant. Moreover, the abnormal interaction between microflora and intestinal mucosal immune system leads the mucosal inflammation and probiotic administration may recover the commensal microflora and normalise the host–microbial interaction (Bai et al., 2006). Therefore, this study was done to explore more the effect of some commercially available probiotic preparation in the management of mildly to moderately severe forms of ulcerative colitis in comparison with mesalamine, the standard agent used in such situations.

In this study, patients were randomized to receive either the classic medication; mesalamine or probiotic bacterial preparation. The two groups were homogeneous in all clinical parameters including age, sex, severity of the symptoms and all laboratory and endoscopic findings. Most patients showed clinical remission within 1-2 months of treatment. Only 3 patients; 1 in mesalamine group and 2 in probiotic group were not responding and corticosteroid was added to mesalamine to control the disease. All parameters have been improved significantly in both groups without statistically significant difference between them. In the earlier preliminary (Rembarken et al., 1999) and double-blind (Kruis et al., 1997 and Gionchetti et al., 2000) trials, a probiotic supplement (non-disease-causing strain of Escherichia coli) was effective in maintaining remission and preventing relapses in patients with ulcerative colitis (UC). Such ability of probiotics to down-regulate intestinal inflammation forced several research groups to investigate strain-specific effects in animal models of colitis. Also, human studies are underway with patients suffering from Crohn’s disease, ulcerative colitis and pouchitis and the European Union is funding a large, multicenter study through its PROGID project (part of the PROEUHEALTH cluster) on probiotics as therapeutics for IBD and other chronic gut disorders (Gionchetti et al., 2003).

In concordance with our study, other two randomized controlled trials have compared EcN (non-pathogenic E coli) with mesalamine for maintenance of remission of ulcerative colitis. Results of these studies suggested a similar efficacy for EcN and mesalamine ( Kruis et al., 2004 and Ishikawa et al., 2003). Another uncontrolled open-label trial of the probiotic VSL#3 for maintenance of remission of ulcerative colitis demonstrated remission rates of 75% after 1 year (Venturi et al., 1999). Other uncontrolled studies involving VSL#3 and S boulardii have yielded promising results, with induction of remission rates of 63% and 68%, respectively, in patients with active ulcerative colitis (Guslandi et al., 2003 and Fedorak et al., 2003).

The duration needed for clinical remission in both groups was similar. This improvement occurred in less than one month in 47.1% in mesalamine group and 61.1% in probiotic group. Most of the remaining cases improved in about two months. This clinical improvement was confirmed by endoscopic examination of the colon and histopathology. No improvement was found in one case (5.9%) in mesalamine group and in two cases (11.1%) in probiotic group. These patients were controlled by the combination of mesalamine and corticosteroid.

Also, CRP became negative in more than half of patients (53%; 9 patients) in mesalamine group and in 8 patients (44.4%) in probiotic group with highly significant reduction in the remaining cases in both groups. Similarly, highly significant reduction in the urinary N-methylhistamine (NMH) level which is another marker of inflammation was found in both groups with no statistically significant difference in between. At the end of follow up and maintenance therapy, further significant reduction in urinary N-methylhistamine was observed (P = 0.001) in both groups. In the three non-responding patients the mean NMH was also significantly reduced after 3 months (P = 0.0 14) and at end of treatment (P = 0.022) for both groups compared to pre-treatment level. On the other hand, comparison with the whole patients showed statistically significant higher level of NMH in non-responding patients before treatment, after three months and at end of treatment (P = 0.041 and P = 0.05). The same was found with relapsing patients who showed significantly higher levels than all patients before, after 3 months and at end of treatment(P <0.05). Also, NMH showed significant direct correlation with other markers of inflammation such as CRP (P = 0.002) and ESR, and extent of mucosal lesion in the colon as detected by endoscopy before and after treatment. Also, the positive correlation of ESR and CRP with parameters of inflammation and their significant reduction after treatment in both groups, adds to general concept of inflammatory down-regulation by both forms of therapy.

The immune response against normal commensal microorganisms is believed to drive inflammatory processes associated with UC. Therefore, modulation of bacterial communities on the gut mucosa, through the use of probiotics, may be used to modify the disease state. Also, probiotic bacteria may modulate mucosal and systemic immune activity and epithelial function. It is stated now that level I evidence exists for the therapeutic use of probiotics in infectious diarrhea in children, recurrent Clostridium difficile-induced infections and postoperative pouchitis. Level II evidence is now emerging for the use of probiotics in other gastrointestinal infections, prevention of postoperative bacterial translocation, irritable bowel syndrome, and in both ulcerative colitis and Crohn’s disease (Fedorak RN and Madsen KL, 2004).

In this study, remission was maintained by probiotic therapy for at least 6 months of follow up in 85.71% of patients of both groups. Thus, it is concluded from this study that this kind of treatment can be beneficial in patients with mildly to moderately severe ulcerative colitis and can also maintain remission in most patients. Also, N-methylhistamine can be considered a good marker of inflammation and a prognostic factor during treatment. Further more, it can be used as a predictive factor for recurrence particularly when its level did not return to normal.

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الحيوية األوليات استخدام - تأثير مثيل ن مستوى وقياسالبول فى الهستامين

والمتوسط البسيط المتقرح القولونى االلتهاب فى

. الهضمى والجهاز والكبد المتوطنة األمراض قسم شريف شندى محمد شندىلألبحاث بلهارس تيودور معهد

الوسط فى واضح اختالل يحدث المتقرح القولونى االلتهاب حاالت فىهذه بين التفاعل أن كما الهضمية، القناة فى المعوية البكتريا من البيولوجى

التهابات إلى يؤدى قد لألمعاء المبطن المخاطى للغشاء المناعى والجهاز البكتريا . فى التوازن هذا إعادة إلى يؤدى قد الحيوية األوليات تناول وان الغشاء بهذا

. العائل مع تفاعلها و الطبيعية البكتريا

الحيويةفى األوليات بهذه العالج دور تقييم هو البحث هذا من الهدف كان قد وعليه والمحافظة الشفاء البسيط احداث المتقرح القولونى االلتهاب مرضى فى

- البول فى الهستامين مثيل ن مستوى قياس من الفائدة كذلك و والمتوسطالمرض . هذا سير فى لاللتهابات كداللة

الدراسة هذه شملت قد االلتها ٣٥و من يعانون المتقرح بمريضا القولونىوتشمل األولى مجموعتين، الى عشوائيا مقسمين المتوسط أو ١٧البسيط

) و ١١مريضا الذكور )٦من ) ( البنتاسا بالميساالمين عالجهم تم االناث منوتشمل الثانية (١٨والمجموعة و ١٠مريضا الذكور ) ٨من عالجهم تم اإلناث من

.( ) براز تحاليل وعمل المرضى جميع فحص وتم بروتكسين الحيوية باألولياتوأخذ قولونى ومنظار الدم فى وبوتاسيوم وكلى كبد ظائف وو دم وصورة

و الترسيب سرعة مثل االلتهاب دالالت وكذلك المريضة األجزاء من خذعاتقبل المرضى لجميع وذلك البول فى الهستامين والمثيل س المتفاعل البروتين

.( شهرا ( عشر أثنى المتابعة مدة نهاية وعند العالج وبعد وأثناء

بينها فروق دون المجموعتين فى المرضى فى داللة ذات تحسنا النتائج وأظهرت . التحسن حدث وقد االلتهاب دالالت جميع و وعالماته المرض أعراض حيث من

يحدث ولم العالج بداية من شهرين إلى شهر من تتراوح مدة فى االكلينيكىمجموعة فى وحالتين الميساالمين مجموعة في فقط واحدة حالة فى تحسن

. فى س المتفاعل البروتين اختفى كما الحيوية فى %٥٣األوليات المرضى من

وفى األولى عالية %٤,٤٤المجموعة داللة ذو انخفاض مع الثانية المجموعة فى . عالية داللة ذو انخفاضا الهستامين مثيل مستوى انخفض كما المرضى باقى فى

أخر كدليل بينها فروق دون المجموعتين فى المرضى جميع فى البول فىالذين المرضى فى أعلى كان العامل هذا مستوى أن حين فى االلتهابات لتحسن

بعد ذلك و داللة ذو علوا المستجيبين عن للعالج يستجيبوا العالج ٣لم من شهوربعد العالج نهاية . ٦وعند تناسبا متناسبا الهستامين مثيل مستوى كان كما شهور

س المتفاعل البروتين و الترسيب سرعة مثل االلتهاب دالالت باقى مع طرديا . فى التحسن استمر وقد بالقولون االلتهاب مقدار مع ٧,وأيضا الحاالت % ٨٥ من

لمدة الحيوية األوليات .٦باستخدام المجموعتين فى شهور

االلتهاب عالج فى استخدامها يمكن الحيوية األوليات أن البحث هذا من يستنتجاستمرار على تحافظ أنها كما الشدة والمتوسط البسيط المتقرح القولونى

جيدة داللة هو البول فى الهستامين مثيل مستوى وأن الحاالت هذه فى التحسنعلى دال كعامل استخدامه الممكن من أنه كما العالج أثناء المرض وسير لاللتهاب

المعدل الى يصل ولم مرتفعا استمر اذا باألخص و المرض فى انتكاسات حدوث . العالج بعد الطبيعى