Abstract:
An apparatus for taking an intestinal sample of a human or animal patient comprises a holder part ( 1 ) and an expandable part ( 2 ) supported by the holder part and having one or more sampling areas ( 8 ) on the surface thereof. The expandable part ( 2 ) is in a non-expanded state rectally insertable into and retractable from the patient&#39;s intestine, and in an expanded state, inserted into the patient&#39;s intestine, the expandable part is capable of contacting the intestinal wall with at least one sampling area ( 8; 14 ). The apparatus further comprises protective livers ( 7   a   , 7   b ) for preventing said sampling area or areas ( 8 ) from contact with the intestinal wall and intestinal fluid at least when the expandable part ( 2 ) in the non-expanded state is being rectally inserted into the patient&#39;s intestine.

Description:
RELATED APPLICATION 
     The present application claims priority under 35 U.S.C. §119(e) of U.S. provisional application Ser. No. 60/163,033 filed Nov. 2, 1999. 
    
    
     TECHNICAL FIELD OF THE INVENTION 
     The present invention relates to the study of pathological changes in the gastrointestinal system, and more particularly to an apparatus for taking intestinal samples as well as to the use thereof. 
     BACKGROUND OF THE INVENTION 
     Among the various techniques that are used today to study pathological changes in the gastro-intestinal system are X-ray contrast examination, computerized tomography and magnetic resonance tomography. Endoscopy, i.e. insertion into the gastrointestinal tract of a stomach or intestinal viewer (gastroscopy, colonoscopy, rectoscopy) makes it possible to inspect the intestinal wall and to take samples from the intestinal mucous membrane (biopsy) which then may be examined by e.g. microscopy. Recently, also intestinal perfusion systems have been used. All these techniques are expensive, time-consuming and more or less trying to the patient. There is therefore a need for a simple methodology that makes it possible to study pathological processes in the intestinal mucous membrane without using biopsy or perfusion. 
     WO 95/32668 discloses a rectal instrument to be used in allergy diagnosis and designed for insertion into the colonic tract to take samples from the lumen of the large intestine after provocation of the mucous membrane with an allergen. The instrument comprises a tube-like element having a terminal part that is expandable, specifically an inflatable balloon. Subareas on the balloon have a diffusable allergen absorbed or adsorbed thereto, and on the same or separate subareas, a receptor(s) for one or more inflammation markers, usually antibodies specific to the relevant marker(s), are bound to the balloon. The instrument is inserted into the rectum, whereupon the balloon is inflated such that the outer surface of the balloon contacts the mucous membrane. The allergen diffuses to the rectal mucous membrane and, if the individual concerned is allergic to the allergen in question, will cause the release of inflammation markers which in turn diffuse to the lumen where they eventually are captured by the receptor(s) on the balloon surface. After the marker or markers have been released and bound to the balloon, the balloon is deflated and the device is removed and analyzed with respect to the bound marker(s). 
     The above instrument has, however, the drawback that the areas with diffusible allergen and the areas with immobilized receptor on the balloon surface may be damaged by contact with the internal sphincter when inserted and retracted through the patient&#39;s anus. It may also be mentioned, that, generally, immobilizing receptors on the balloon surface could cause problems in that hazardous residues from the coupling of the receptor(s) may remain on the surface. 
     SUMMARY OF THE INVENTION 
     The present invention aims at overcoming the disadvantages of the prior art devices or instruments and provide an apparatus for rectal insertion for studying pathological processes in the intestinal mucous membrane without the use of biopsy or perfusion. Like the instrument described in WO 95/32668 above, the apparatus of the present invention is based on contacting an expandable part thereof with the intestinal wall for sampling, and optionally also for provocation of the intestine with allergen. 
     According to a basic concept of the invention, however, the sampling area(s) and provocation area(s), when present, of the expandable part essentially are protected from contact with the intestinal wall when the expandable part is inserted and retracted from the colon through the patient&#39;s anus. 
     The present invention therefore provides an apparatus for taking an intestinal sample in a human or animal patient, comprising a holder part and an expandable part supported by the holder part and having at least one sampling area. In a non-expanded state of the expandable part, the expandable part is rectally insertable, and in an expanded state, the sampling area or areas of the expandable part are capable of contacting the intestinal wall. The apparatus is characterized in that it comprises means for protecting the sampling area or areas from contact with the intestinal wall and intestinal fluid when the expandable part in its non-expanded state is rectally inserted into the intestinal tract. 
     Preferably, the apparatus comprises means for protecting the sampling area or areas also when removing the expandable part from the intestine. 
     While essentially the whole area of the expandable part could be a sampling area, it is preferred that one or preferably, more subareas thereof are used as sampling areas and provocation areas. 
     The sampling area or areas on the expandable part may have one or more receptors for, for example, an inflammation or cancer marker or the like bound to the. surface thereof (similarly as in the device described in WO 95/32668 above). Such inflammation markers may, for example, be derived from neutrophilic granulocytes, eosinophilic granulocytes, mast cells/basophilic granulocytes, or may be a cytokine, a prostaglandin or a plasma protein, such as albumin. 
     While the sampling area or areas in this case may have the receptor(s) immobilized directly to the surface of the expandable part, it is preferred that the sampling area or areas comprise a surface element of suitable material attached to the expandable part surface. Such a material may exhibit a two-dimensional surface to which the receptor or receptors are immobilized, or constitute a three-dimensional matrix structure in which the receptor or receptors are immobilized in depth. 
     Alternatively, and at least in some aspects also preferably, the sampling area or areas comprise absorbing material (without any immobilized receptor) capable of effectively sucking up water and substances dissolved therein (such as proteins, enzymes, hormones etc) when contacted with the intestinal mucosa, such that the content of such substances in the absorbed material may be analyzed. After sampling, a reactant or reactants may be added directly to the absorbing material to detect the presence of a certain substance or substances through a colour reaction or similar. 
     Usually, however, the absorbing material is removed from the expandable part after sampling and the absorbed substances extracted and analyzed separately by various analytical methods, such as electrophoresis, radioimmunological techniques, enzyme immunosorbent assay (ELISA) or nephelometry, just to mention a few. 
     While it is within the scope of the present invention that the apparatus may be designed for sampling at arbitrary sites along the intestinal tract, it is presently preferred to take samples in the lumen of the large intestine. Such sampling may, for example, advantageously be used for testing for markers for allergy, especially food allergy including e.g. celiac disease, after provoking the colonic mucosa with a desired allergen(s), e.g. gluten (as described in the above-mentioned WO 95/32668). 
     The expandable part is advantageously an inflatable member of a flexible or elastic material, for example a balloon or an elastic tubular member. 
     In one embodiment of apparatus according to the present invention, the sampling area or areas on the expandable part are protected by a protective cover until the expandable part has reached the desired section of the intestine to be studied. Prior to or after expanding the expandable part, the cover is removed, e.g. mechanically by pulling means provided on or associated with the apparatus part outside the body, to permit sampling by contacting the sampling area or areas with the intestinal wall. 
     In another embodiment, the sampling area or areas on the expandable part are protected by a cover which may be opened in connection with the sampling and then be re-closed over the sampling area(s) after the sampling is completed. Such a cover may, for example, be of capsule or shell type, for instance a two-part shell or capsule wherein the two parts together, preferably with some overlap, cover the sampling area(s) in the non-expanded state of the expandable part, but which are removed from and expose the sampling area(s) in the expanded state. 
     In still another embodiment, the expandable part is displaceably mounted (e.g. telescopically) within the holder part of the apparatus so that the expandable part is kept within the holder part during the rectal insertion and retraction of the apparatus, and brought out of the holder part at the test site to be expanded. In yet another embodiment, the sampling area or areas on the expandable part are depressed in relation to the remaining surface of the expandable part when the latter is in its non-expanded state to thereby prevent contact with the intestinal wall. If, for example, the expandable part is a balloon or elastic tube or cylinder with sampling elements on the surface, the holder part supporting the balloon or elastic tube may have a recess or recesses for receiving each sampling element when the balloon is deflated. 
     Like the apparatus described in WO 95/32668, the expandable part may also comprise means for allergen presentation to provoke the intestine before the sampling. 
     Such means may be the surface itself of the expandable part or a special element(s) having the allergen(s) diffusively bound or adsorbed thereto. The allergen-presenting area(s) will, of course, also be protected by the protective means at the same time as the sampling area(s). Optionally, the allergen-presenting area or areas may be the same as the sampling areas. 
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS 
     FIG. 1A is a schematic perspective and partly sectional view of an embodiment of an apparatus of the present invention with the expandable part of the apparatus in its expanded state and applied in the rectum of a patient. 
     FIG. 1B is a partial view corresponding to that of FIG. 1A but with the expandable part of the apparatus in its non-expanded state before insertion into the rectum of a patient. 
     FIG. 1C is a partial view corresponding to that in FIG. 1B but showing the expandable part of the apparatus during insertion into the rectum. 
     FIG. 2 is a schematic illustration of separate sampling material member on the expandable part of the apparatus shown in FIG.  1 A. 
     FIG. 3A is a schematic partial view in section of another embodiment of apparatus of the invention with the expandable apparatus part protected by protective means. 
     FIG. 3B is a corresponding view to that in FIG. 3A with the protection means of the expandable part withdrawn. 
     FIG. 4 is a schematic partial view in section of yet another embodiment of apparatus of the invention in a non-expanded state and showing a sampling surface element protected by being received in a recess in the expandable part. 
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
     The apparatus illustrated in FIGS. 1A to  1 C comprises a holder part including a tubular member  1 , and at one end of the tubular member  1 , an expandable part  2 . The latter is typically a balloon or a balloon-like member, for example made of silicone, and extends over an opening  3  (see FIG. 1A) of a channel (not shown) extending through the tubular member  1  and through which air (or other gas or fluid, if desired) may be supplied via a tube  4  attached to a branched tube part  5  of the tubular member  1  to inflate, or expand, the balloon. A through-channel (not shown) extends from the lower end of tubular member  1  to openings  1   a  (FIG. 1B) at the top end thereof and for permitting pressure equalization between the surroundings and the internal parts of the intestine when the apparatus is used. In the illustrated case, the through-channel is connected to a tube  6  attached to the tubular member  1 . 
     The balloon  2  comprises a protective cover of flexible or resilient material. In the illustrated case, and as is best shown in FIG. 1B, the cover is of a two-part capsule or shell type, e.g. of plastics, such as PVC or silicone, comprising a rear (or lower) shell part  7   a  and a fore (or upper) shell part  7   b . In the deflated state of the balloon shown in FIG. 1B, the fore shell part  7   b  slightly overlaps the rear shell part  7   a  such that the two shell parts together totally cover the balloon  2 . (The terms “fore” and “rear”, respectively, refer to the direction of inserting the instrument into the intestine). The rear shell part  7   a  is attached to tubular member  1  at the rear end of the shell part, and fore shell part  7   b  is attached to tubular member  1  at the fore end of the shell part, leaving the remainder of the two shell parts free from the balloon  2 . Alternatively, the shell parts  7   a ,  7   b  are integral with the balloon  2 . 
     The surface of the balloon  2  (FIG. 1A) has, on a central part thereof, a number of pads or patches  8  of absorptive material, e.g. cellulose, attached to the surface thereof, e.g. three or more patches equidistantly spaced along the balloon periphery. The patches  7  may be attached directly to the balloon  2 , or, via another member attached to the balloon surface such as shown by way of example only in FIG.  2 . Here, the patch  8  is attached, e.g. by a stitch  9 , to a support member  10 , e.g. also of cellulose, which in turn is attached to the surface of balloon  2 , e.g. by gluing. In this way, the absorptive capability or structure of the patch is essentially unaffected by the attachment to the balloon. 
     Inflation and deflation, respectively, of the balloon  2  may be achieved by means of, for example, a syringe or a pumping device, such as a flexible or elastic ball or the like (not shown), connected to tube  4  (FIG.  1 A). When inflating the balloon  2  from the deflated state shown in FIG. 1B, the fore and rear shell parts  7   a ,  7   b  are brought apart to expose the area of the balloon  2  supporting the patches  8  as shown in FIG.  1 A. If the material of the shell parts is elastic, the two shell parts may in fact invert as illustrated in FIG. 1A, to expose a major part of the balloon surface. In use, the apparatus described above may readily be inserted through the anus of a patient to be tested. When in the non-inflated state, the diameter of the balloon is preferably smaller than the diameter of the anus i.e. smaller than about 15-20 mm (but larger than about 5 mm). For rectal sampling, for example, the apparatus is inserted to an appropriate position into the rectum of a patient, with the balloon  2  in the non-inflated state. Preferably, the patches  8  are moistened with water prior to using the apparatus. In FIG. 1A, the fore part of the apparatus with the balloon  2  has been inserted into the rectum beyond the internal sphincter, and the balloon has then been inflated to uncover the patches  8  and make them contact the colonic mucosa such as at  11 . When such contact between the patches and mucosa has been maintained for a predetermined time, e.g. 10 to 15 minutes, the balloon is deflated. The deflation itself may cause the protective shell parts  7   a ,  7   b  to return to the patch protecting state shown in FIG. 1B where they enclose the patches  8 . In the illustrated embodiment, however, the rear shell part  7   a  is returned to its protecting state by the forces acting upon the shell part when the balloon is retracted and forced through the anus. In both cases, the patches  8  with absorbed mucous fluid will be efficiently protected by the shell part  7   a  from further contact with the colonic wall and, importantly, when passing the internal sphincter. After the apparatus has been removed from the patient, the absorbing patches  8  which have been in contact with the colonic mucosa are removed from the balloon  2  and the absorbed contents is analysed, e.g. by extraction of the absorbing patches  8 . The extract may then be analyzed by various methods for different substances, primarily proteins, enzymes or hormones. The patches may also be analyzed without extraction by adding directly to the patches, reagents which give a detectable reaction, e.g. a colour reaction, if the substance tested for is present in the pad and may also be a measure of the amount of the substance in question. 
     If the apparatus is used for allergy tests (such as food allergy, including celiac disease), provocation of the intestine may be effected by a desired food allergen (e.g. gluten) contained in the patches  8 . In such a case, the period of contact between the intestinal mucosa and the patches  8  will, of course, be longer, say 15-60 minutes. 
     An alternative design of the expandable part of the apparatus of the present invention is shown in FIGS. 3A and 3B. Like the embodiment in FIGS. 1A to  1 C, the expandable part comprises a balloon  12  attached to a tubular support  13  which may be a colonoscope or rectoscope, for example, or a device or instrument specially designed for the present purposes. For clarity, the balloon  12  is shown inflated in FIGS. 3A and 3B. A plurality of absorbing elements, such as pads or patches  14  of an absorbing material, are fixed to the balloon surface. A protective cover  15  of flexible material is attached to a pulling means  16 , e.g. a rod or, as illustrated, a string extending within the tubular support  13 . When pulling the string  16 , the protective cover  15  is drawn into the interior of the tubular support  13  to expose the absorbing patches  14  on the balloon surface (FIG.  3 B). 
     In use for taking a rectal sample in a patient to be tested, similarly as described above for embodiment in FIGS. 1A to  1 C, the fore part of the illustrated apparatus, with the balloon in a deflated state, is inserted into the rectum of the patient to be tested, the cover  15  then efficiently protecting the absorbing patches  14  from contacting the patient&#39;s sphincter and the rectal wall. Once inserted to the desired position in the rectum, the balloon  12  is inflated. The cover  15  is then drawn into the tubular support  13  as shown in FIG. 3B, thereby exposing the absorbing patches  14  to make them contact the rectal wall and start absorbing material from the mucous surface thereof. After the predetermined contact time, the balloon  12  is deflated and the apparatus is removed from the patient. The patches  14  are then separated from the balloon and analysed as outlined above. 
     FIG. 4 illustrates schematically yet an alternative design of the expandable part of the apparatus, where a tubular support  17  for a balloon  18  has a respective recess  19  for each absorbing patch  20 . In the deflated state of the balloon  18 , the patch  20  is received in the recess  19  with its top surface below the remaining balloon surface as shown in the figure, and thereby protected from contact with the intestinal wall. When the balloon is inflated, it will expand similarly as shown in, for example, FIG. 1A, to contact the patch with the intestinal wall. Upon deflation of the balloon, the patch  20  is sucked into the recess  19  by the negative pressure created in the deflation and is protected when removing the apparatus from the patient. Such recesses for the absorbing patches may, of course, also be used in combination with other apparatus variants of the invention like e.g. those illustrated in FIGS. 1A to  1 C and FIGS. 3A and 3B, respectively. 
     Analysis of the absorbing material may be performed in various ways. A simple procedure is described below by way of example only. After the absorbing patches ( 8 ,  14 ) have been removed from the balloon ( 2 ,  12 ), they are immersed in an extraction buffer, e.g. cetyl-N,N,N-trimethylammonium bromide, 0.3% (w/v) in 0.9% saline. The extraction buffer may, for example, be contained in a syringe with the piston removed, e.g. 2 ml of extraction buffer in a 5 ml volume syringe. After a predetermined time, say, 1 hour, the buffer, including absorbed material contained in the patch or patches, is removed. In the case of a syringe being used, this is accomplished by re-inserting the piston into the syringe and pressing the liquid (including squeezing the patch or patches) into a suitable test container where the expelled liquid is analysed for the presence and, optionally, also quantity, of a desired analyte or desired analytes. Depending on the disease or disorder to be tested for, the analyte may, for example, be an inflammatory mediator, reflecting neutrophilic activity (e.g. myeloperoxidase), eosinophilic activity (ECP=eosinophil cationic protein), or EPO (eosinophil peroxidase or EPX), mast cell/basophilic activity (histamine or tryptase). Further possible analytes are certain cytokines (e.g. IL-6, IL-1, TNF-alfa), prostaglandins (e.g. PGE2). 
     While the invention has been described and pointed out with reference to operative embodiments thereof, it will be understood by those skilled in the art that various changes, modifications, substitutions and omissions can be made without departing from the spirit of the invention. It is intended therefore that the invention embraces those equivalents within the scope of the claims which follow.