Probiotics in ulcerative colitis, alphapref

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, B1 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 Female
Mesalamine 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 groups
group sex Mean age Std. Deviation
8.12516
11.49638
9.08902
32.7273
33.1667
32.8824
Male
Female
Total
Mesalamine group
9.94932
7.38725
8.70748
32.1000
34.0000
32.9444
Male
Female
Total
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
group
Mesalamine group
Probiotics group
Duration of
illness (w eek)
Number of
motions
Motions w ith
bleeding
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 Percent
Mesalamine 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 11.8
Probiotics 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 Percent
Mesalamine 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 Count
Mesalamine 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
treatment
TLC after
treatment
ESR before
treatment
ESR after
treatment
Mesalamine 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 groups
group
CRP before treatment CRP after treatment
Mean Std Deviation Mean Std Deviation
Mesalamine group
37.18 18.15 7.59 8.36
Probiotics 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
Mesalamine CRP before treatment
mg/L
2 2 7 6
group
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 Deviation
N-methylhistamine before treatment (ng/ml) 81.06 21.78 74.11 31.75
N-methylhistamine after treatment (ng/ml) 44.82 15.08 39.22 22.31
N-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 patients
Non-responding patients Mean Std Deviation
NMH before treatment 120.67 11.72
NMH after three months 72.67 4.16
NMH at end of follow up 47.00 3.61
Table 14: N-methylhistamine level before and after treatment in relapsing patients
Relapsing patients Mean Std Deviation
NMH before treatment 113.51 13.16
NMH after three months 85.38 5.24
NMH at end of follow up 43.82 6.13
Table 15: Duration needed for clinical improvement in the two patient groups:
group Frequency Percent
Mesalamine 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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تأثير استخدام الأوليات الحيوية وقياس مستوى ن- مثيل الهستامين فى البول
فى الالتهاب القولونى المتقرح البسيط والمتوسط
شندى محمد شندى شريف. قسم الأمراض المتوطنة والكبد والجهاز الهضمى معهد تيودور بلهارس للأبحاث
فى حالات الالتهاب القولونى المتقرح يحدث اختلال واضح فى الوسط البيولوجى من البكتريا المعوية فى القناة
الهضمية، كما أن التفاعل بين هذه البكتريا والجهاز المناعى للغشاء المخاطى المبطن للأمعاء قد يؤدى إلى التهابات بهذا
الغشاء. وان تناول الأوليات الحيوية قد يؤدى إلى إعادة هذا التوازن فى البكتريا الطبيعية و تفاعلها مع العائل.
و قد كان الهدف من هذا البحث هو تقييم دور العلاج بهذه الأوليات الحيويةفى احداث الشفاء والمحافظة عليه فى مرضى
الالتهاب القولونى المتقرح البسيط والمتوسط و كذلك الفائدة من قياس مستوى ن- مثيل الهستامين فى البول كدلالة
للالتهابات فى سير هذا المرض .
و قد شملت هذه الدراسة ٥٣ مريضا يعانون من الالتهاب القولونى المتقرح البسيط أو المتوسط مقسمين عشوائيا الى
مجموعتين، الأولى وتشمل ١٧ مريضا ) ١١ من الذكور و ٦ من الاناث( تم علاجهم بالميسالامين )البنتاسا( والمجموعة
الثانية وتشمل ١١ مريضا ) ١١ من الذكور و ١ من الإناث( تم علاجهم بالأوليات الحيوية )بروتكسين(. وتم فحص
جميع المرضى وعمل تحاليل براز وصورة دم وو ظائف كبد وكلى وبوتاسيوم فى الدم ومنظار قولونى وأخذ خذعات من
الأجزاء المريضة وكذلك دلالات الالتهاب مثل سرعة الترسيب و البروتين المتفاعل س والمثيل الهستامين فى البول
وذلك لجميع المرضى قبل وأثناء وبعد العلاج وعند نهاية مدة المتابعة )أثنى عشر شهرا(.
وأظهرت النتائج تحسنا ذات دلالة فى المرضى فى المجموعتين دون فروق بينها من حيث أعراض المرض وعلاماته و
جميع دلالات الالتهاب. وقد حدث التحسن الاكلينيكى فى مدة تتراوح من شهر إلى شهرين من بداية العلاج ولم يحدث
تحسن فى حالة واحدة فقط في مجموعة الميسالامين وحالتين فى مجموعة الأوليات الحيوية. كما اختفى البروتين
المتفاعل س فى ٣٥ % من المرضى فى المجموعة الأولى وفى ٤،٤٤ % فى المجموعة الثانية مع انخفاض ذو دلالة
عالية فى باقى المرضى. كما انخفض مستوى مثيل الهستامين انخفاضا ذو دلالة عالية فى البول فى جميع المرضى فى
المجموعتين دون فروق بينها كدليل أخر لتحسن الالتهابات فى حين أن مستوى هذا العامل كان أعلى فى المرضى الذين
لم يستجيبوا للعلاج عن المستجيبين علوا ذو دلالة و ذلك بعد ٥ شهور من العلاج وعند نهاية العلاج بعد ٦ شهور. كما
كان مستوى مثيل الهستامين متناسبا تناسبا طرديا مع باقى دلالات الالتهاب مثل سرعة الترسيب و البروتين المتفاعل
س وأيضا مع مقدار الالتهاب بالقولون. وقد استمر التحسن فى ٧،١٣ % من الحالات باستخدام الأوليات الحيوية لمدة
٦ شهور فى المجموعتين.
يستنتج من هذا البحث أن الأوليات الحيوية يمكن استخدامها فى علاج الالتهاب القولونى المتقرح البسيط والمتوسط
الشدة كما أنها تحافظ على استمرار التحسن فى هذه الحالات وأن مستوى مثيل الهستامين فى البول هو دلالة جيدة
للالتهاب وسير المرض أثناء العلاج كما أنه من الممكن استخدامه كعامل دال على حدوث انتكاسات فى المرض و
بالأخص اذا استمر مرتفعا ولم يصل الى المعدل الطبيعى بعد العلاج.

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