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Plasma Viscosity in Inflammatory Bowel Disease

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Plasma Viscosity in Inflammatory Bowel Disease 54 J Clin Pathol 1992;45:54-57 Plasma viscosity in inflammatory bowel disease A J Lobo, S C Jones, L D Juby, A T R Axon J Clin Pathol: first published as 10.1136/jcp.45.1.54 on 1 January 1992. Downloaded from Abstract The advantages of plasma viscosity are that, Aims: To assess the relation of plasma unlike the ESR, its value is independent of viscosity to disease activity in patients packed cell volume, sex, and for practical with inflammatory bowel disease. purposes, age.6 Viscosity is lower in neonates7 Methods: Crohn's disease (n = 60) and and rises slightly in the elderly due to changes ulcerative colitis (n = 71) were diag- in the plasma fibrinogen concentration.8 The nosed on the basis of typical histological use of automated systems reduces the bio- or radiological features. Active Crohn's hazard risks and produces reproducible, disease was defined as a Crohn's disease precise results and these can subjected to activity index of 150 or over. Active quality assurance. Plasma must be separated ulcerative colitis was defined as a liquid as soon as possible and never more than six stool passed three times a day or more hours after venesection, but once separated, with blood. Blood samples were assessed its viscosity may remain stable for several days for haemoglobin concentration, total if kept at 15-200C.2 white cell count, platelets, plasma vis- The initial capital cost of an automated cosity, erythrocyte sedimentation rate, viscometer is currently about £7500 with very serum albumin, and C-reactive protein. low running costs. Measurement of ESR Results: Plasma viscosity was higher in requires a very low initial outlay, but the those with active Crohn's disease com- subsequent running costs are higher. If the pared with those with inactive Crohn's annual running costs are said to include disease or active ulcerative colitis. laboratory disposables, appropriate venesec- Plasma viscosity correlated significantly tion containers, a maintenance contract for the with erythrocyte sedimentation rate, C- viscometer cost, interest repayments on the reactive protein, and platelet count in initial outlay for the viscometer and a sum to patients with Crohn's disease. In ulcer- contribute to its eventual replacement, the ative colitis plasma viscosity correlated approximate respective costs for performing only with serum C-reactive protein. 32 000 (the annual number performed at this Plasma viscosity showed a low sensitivity institution in 1990) measurements of ESR and http://jcp.bmj.com/ for detecting active Crohn's disease, with plasma viscosity would be £10 848 and 48% of those with active disease having a £6464, respectively (P Day, personal plasma viscosity within the laboratory communication). The initial capital outlay reference range. would therefore be recouped within two years Conclusions: Plasma viscosity is related and more rapidly if plasma viscosity was to disease activity in Crohn's disease, but measured from the same blood container as is insufficiently sensitive for it to replace the blood count. on October 1, 2021 by guest. Protected copyright. erythrocyte sedimentation rate as a There are few data on the use of plasma measure of the acute phase response in viscosity in clinical practice. In unselected Crohn's disease. patients attending a general medical and rheumatological clinic plasma viscosity was a more reliable measure of changes in acute phase reactants.4 In rheumatoid arthritis Plasma viscosity can be used as a non-specific plasma viscosity was said to be at least as measure of the acute phase response" and reliable as ESR and C-reactive protein (CRP) may have several advantages over the more in terms of diagnosis, and as an index of widely used erythrocyte sedimentation rate improvement.9 More recently however, (ESR).24 plasma viscosity was found to compare less The first clinical use of plasma viscosity well than ESR with a battery of other measurement was described in 1942, when its measures of inflammation in rheumatoid use in pulmonary tuberculosis was described,5 arthritis.'° and an association between red cell sedi- There are no previous reports of the use mentation and was of plasma viscosity in inflammatory bowel Gastroenterology velocity plasma viscosity Unit, The General noted. The widespread use of plasma viscosity disease. This paper reports the prospective Infirmary at Leeds, measurement, however, was delayed until an evaluation of plasma viscosity measurement in Leeds, LS1 3EX automated system for its measurement a large series of patients with inflammatory A J Lobo S C Jones became available. One such commercially bowel disease. L D Juby available system has been shown to be reliable A T R Axon and precise3 and detailed guidelines for the Correspondence to: assessment of the acute phase response, Methods Dr A J Lobo including the role of plasma viscosity, have One hundred and thirty one patients with Accepted for publication 4 July 1991 been published.2 inflammatory bowel disease attending the gas- Plasma viscosity in inflammatory bowel disease 55 trointestinal service of the General Infirmary, Results Leeds, were studied. Crohn's disease and By the criteria defined above, 21 patients had ulcerative colitis were diagnosed on the basis of active Crohn's disease, 39 had inactive disease; typical histological or radiological features. 24 had active ulcerative colitis (11 mild, 10 Sixty had Crohn's disease. This affected the moderate, three severe) and 47 had inactive J Clin Pathol: first published as 10.1136/jcp.45.1.54 on 1 January 1992. Downloaded from small bowel in 19 (32%), the large bowel in 22 disease. (37%), and both small and large bowel in 19 The plasma viscosity was significantly higher (32%). Seventy one had ulcerative colitis and in those with active Crohn's disease (median the extent was proctitis or proctosigmoiditis in 1-73 mPa.s; range 1 50-2 04) than in those with 39 (55%). Left sided disease (extending not inactive disease (median 1 62 mPa.s; range further than the splenic flexure) in 12 (17%), 1-5-1-92 (figure)). There was a large overlap, and subtotal or total colitis in 17 (24%). In however, between the two groups, and 10 of 21 three patients the precise extent was not known (48%) patients with active disease had values but had been documented to extend to at least within the reference range. In eight of these the splenic flexure. this normal plasma viscosity was associated with an increased CRP (median 77.5 mg/l; CLINICAL ASSESSMENT OF DISEASE ACTIVITY range 23-145), and in two the CRP was not Active Crohn's disease was defined as a Crohn's increased. disease activity index" (CDAI) of 150 or over. Plasma viscosity was also higher in patients The CDAI is a widely used clinical index in with active Crohn's disease compared with which the number of liquid stools per day, those with active ulcerative colitis (median 1 65 general well-being, and abdominal pain over mPa.s; range 15-1-92). There was a trend the previous week are scored and weighted. towards increasing plasma viscosity with The presence of the following clinical features increasing disease severity in ulcerative colitis also contribute to the score: iritis, aphthous but this was not significant (r = 0-22; p = 0 07). ulceration of the mouth, arthritis or arthralgia, In patients with ulcerative colitis plasma erythema nodosum, pyoderma gangrenosum, viscosity correlated with C-reactive protein fever, abdominal mass, perianal disease or (r = 0-25; p = 0-03), but not with any other fistula elsewhere. Use of lomotil or opiates, laboratory measurement. percentage below standard bodyweight, and In Crohn's disease plasma viscosity showed a haematocrit also contribute to the final score. significant correlation with the ESR (Spearman Active ulcerative colitis was defined as a r = 0 77, p = 0 00001), CDAI (r = 0.34, liquid stool passed three times a day or more p = 0009), CRP (r = 0 44, p = 0 001), platelet with blood. The severity of active ulcerative count (r = 0-43, p = 0-001), and correlated colitis was assessed by the criteria of Truelove negatively with albumin (r = -0 44, and Witts.'2 By these criteria patients with a p = 0.002). The inverse correlation with bowel frequency of four motions a day or less, haemoglobin did not reach significance = = and no more than small amounts of macro- (r -0-23,p 0-07). http://jcp.bmj.com/ scopic blood in the stool are considered to have For comparison, the ESR values according mild disease; six or more motions a day with to disease activity are shown alongside the macroscopic blood and one or more of: fever on plasma viscosity values in fig 1A and the CRP two days out of four, tachycardia (mean pulse values are shown in fig 1B. rate greater than 90 beats/min), anaemia The sensitivity and specificity of ESR and (haemoglobin concentration below 10-5 g/l) or plasma viscosity in distinguishing active from ESR greater than 30 mm in one hour, are inactive Crohn's disease depends on the value on October 1, 2021 by guest. Protected copyright. considered to have severe disease. Moderate taken as a cut-off point. Examples are given in severity is attributed to attacks intermediate the table. between mild and severe. LABORATORY ASSESSMENT OF DISEASE ACTIVITY Discussion All patients had blood drawn for haemoglobin Despite the claimed advantages of plasma vis- concentration, total white cell count, platelet cosity over ESR, our data highlight limitations count (Coulter counter; Coulter electronics, in the use of this test in inflammatory bowel Luton), plasma viscosity (Coulter viscometer), disease. The assessment of disease activity in ESR (Westergren method), C-reactive protein Crohn's disease is difficult, and a major clinical (CRP) (Boehring nephelometer; Hoechst UK, problem is to differentiate those with symptoms Hounslow), and serum albumin (sequential due to active disease from those with symptoms multiple autoanalyser with computer; Tech- due to other causes.
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