J Clin Gastroenterol

Gastric cancer and Helicobacter pylori: biologic and epidemiologic inconsistencies.

Year 1998
Cheli R. Crespi M. Testino G. Citarda F.
No information.
In this report we examine biologic and epidemiologic data with the aim of understanding any correlations between Helicobacter pylori infection and preneoplastic and neoplastic changes. As far as biologic data are concerned, some elements point to the role of H. pylori in the development of preneoplastic and neoplastic changes, such as intestinal metaplasia and dysplasia. The relationship with H. pylori would mainly be due to an increased cellular proliferation with the presence of immature cells in the superficial layers, susceptible to metaplastic or dysplastic modifications. The subsequent passage toward cancer is probably caused by other factors inasmuch as H. pylori is not able to colonize metaplastic or dysplastic areas and hyperproliferation remains at comparable levels, even in the absence of infection. In fact, available epidemiologic data show a high prevalence of H. pylori infection in some geographic areas with a high incidence of gastric cancer. It is also true, however, that there are several populations in which a low neoplastic risk is associated with a high prevalence of infection. We stress the methodologic weaknesses of several studies that attempt to establish a strict association between cancer and H. pylori. Therefore, epidemiologic data are still contradictory and do not permit identifying a precise role of H. pylori as a predominant causative agent in the onset of preneoplastic and neoplastic changes. We conclude that H. pylori behaves as a possible cofactor of other known damaging agents to the gastric mucosa, contributing to the risk of developing neoplastic modifications that may also be subject to individual genetic susceptibility.

Racial differences in the histology, location, and risk factors of esophageal cancer.

Year 1998
Chalasani N. Wo JM. Waring JP.
Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia, USA.
Although esophageal cancer is uncommon in the united states, its high mortality rate and recent increased incidence make it an important malignancy. Because there appears to be significant racial variation in the types of esophageal cancer, we examined a group of black patients with esophageal cancer and compared their risk factors, histology, and location with those of a cohort of white patients with esophageal cancer seen during the same period. We retrospectively reviewed patients with esophageal cancer seen at three major hospitals in Atlanta, Georgia from January 1990 to April 1996. Patients of races other than white or black were excluded from this study, the esophagus was separated into upper, middle, and lower thirds by defined criteria. Of the eligible 234 patients, 129 were black and 105 were white. In blacks with esophageal cancer, squamous cell cancer was the predominant type (92%), and adenocarcinoma was infrequent in whites, adenocarcinoma was more common than squamous cell cancer (66% vs. 32%). Although Barrett's esophagus was distinctly uncommon, smoking and alcohol consumption were significantly more common in blacks. Only 43% of the patients with adenocarcinoma had evidence of barrett's esophagus, all adenocarcinomas were located in the lower third of the esophagus. There appear to be significant racial differences in the types, risk factors, and location of esophageal cancer. Adenocarcinoma and Barrett's esophagus are uncommon in blacks.

Socioeconomic status and ulcer. A prospective study of contributory risk factors.

Year 1998
Levenstein S. Kaplan GA.
Human Population Laboratory, Berkeley, California, USA.
Peptic ulcer is associated with low socioeconomic status. In this study we used longitudinal population-based data to investigate factors other than Helicobacter pylori that might contribute to this association. Of 4597 Alameda County Study participants, 104 developed ulcers between 1965 and 1974. We examined the impact of baseline risk factors on the association between education and incident ulcer. Among women, high school dropouts had a higher risk of incident ulcer than those who attended college (age-adjusted odds ratio [OR], 3.3; 95% confidence interval [CI], 1.5, 7.3). Adjustment for smoking, alcohol, lack of sleep, skipping breakfast, chronic pain, and liver disease eliminated 21.7% of this excess risk, whereas adjustment for psychological characteristics and life stress eliminated 56.5% of the risk; adjusted for all risk factors, the OR was 1.9. Among men, the risk associated with low education was weaker (OR, 1.9; 95% CI, 0.9, 3.9). Health risk behaviors and poor health had a greater impact (55.5% drop in excess risk with adjustment) and psychosocial factors a lesser impact (33.3% drop) in men than in women. Adjustment for heavy on-the-job labor decreased the risk by 77.8%, whereas the fully adjusted OR was 1.0. We conclude that psychological stress, health risk behaviors, analgesic use, and hard physical labor may contribute to the increased risk of ulcer in low socioeconomic populations.

Cytotoxin-associated gene A-positive Helicobacter pylori infection in the elderly. Association with gastric atrophy and intestinal metaplasia.

Year 1998
Pilotto A. Rassu M. Bozzola L. Leandro G. Franceschi M. Furlan F. Meli S. Scagnelli M. Di Mario F. Valerio G.
Department of Geriatrics, S. Bortolo Hospital, Vicenza, Italy.
To evaluate if the infection with strains of cytotoxin-associated gene A (CagA)-positive Helicobacter pylori is associated with either peptic ulcer and gastric atrophy or intestinal metaplasia in the elderly, we studied 71 H. pylori-positive patients older than 62 years old (34 men, 37 women; mean age, 77.5 years; range, 62-89 years) affected with gastric ulcer (GU) (n = 10), duodenal ulcer (DU) n = 22), or chronic gastritis (CG) (n = 39). H. pylori infection was documented by means of gastric histology, rapid urease test, and polymerase chain reaction (PCR) assay performed on gastric biopsies using two sets of primers: one for the ureC gene specific for H. pylori, and the second specific for the CagA gene. H. pylori-CagA positivity was significantly more common in patients with GU (9 of 10, 90%) than with DU (11 of 22, 50%; p < 0.05) or CG (17 of 39, 43.5%; p = 0.01). Gastric atrophy and intestinal metaplasia were significantly more common in CagA-positive patients than in CagA-negative patients (gastric atrophy: 40.54% vs 11.76, p = 0.007; intestinal metaplasia: 40.54% vs 14.70%, p = 0.01). No difference in prevalence of gastric atrophy and intestinal metaplasia was found in patients divided according to pathology (GU, DU, or CG). Logistic regression demonstrated that gastric atrophy and intestinal metaplasia were independent factors significantly associated with CagA-positivity (gastric atrophy: odds ratio = 4.53, 95% confidence interval 1.25-16.4; intestinal metaplasia: odds ratio = 3.44, 95% confidence interval 1.01-11.7). Our findings help to confirm the hypothesis that an infection with CagA-positive H. pylori strains may be catalytic in inducing gastric changes which can evolve into malignancies.

Celiac sprue in patients with chronic oral mucosal symptoms.

Year 1998
Jokinen J. Peters U. Maki M. Miettinen A. Collin P.
Tampere University Hospital, Finland.
Eighty-two consecutive patients with oral mucosal disorders were screened for celiac sprue with serum immunoglobulin A (IgA)-class endomysial and gliadin antibodies. In positive cases the diagnosis of celiac sprue was established by duodenal biopsy. Four patients were positive for endomysial antibodies and 22 for gliadin antibodies. Four (4.9%) patients were found to have celiac sprue: three of them by screening and one was previously diagnosed. Endomysial antibodies were present in all three newly diagnosed patients with celiac sprue, and gliadin antibodies were present in one. Sixteen of 22 patients positive for gliadin antibodies underwent small bowel biopsy, and 15 had normal mucosa. Patients with chronic oral mucosal disorders and a positive endomysial antibody test may suffer from celiac sprue. By contrast, gliadin antibodies were very prevalent even in the absence of celiac sprue.

Crohns disease in the Singapore Chinese population.

Year 1998
Law NM. Lim CC. Chong R. Ng HS.
Department of Gastroenterology, Singapore General Hospital, Singapore.
Crohn's disease (CD) is rare in the Chinese population, but lately there seems to be an increasing trend of CD in the Singapore Chinese population. We carried out a retrospective study of all Chinese patients with CD seen from 1987 to 1993 at the Singapore General Hospital. All patients were regularly followed up and treated. Disease activity was defined by the Organisation Mondiale de Gastroenterologie index. We also compared our series with our first series reported in 1987 and a Western series. There were 32 patients (20 men, 12 women) giving a hospital prevalence of 26.7 per 100,000 patients compared with 3.5 per 100,000 patients in 1986. The mean age was 37.1 years (range, 19-80 years). Twelve patients had small intestinal disease, 9 had colonic disease, and 11 had both. The common presenting symptoms were bloody diarrhea (67%), abdominal pain (53%), loss of weight (47%), and fever (34%). Extraintestinal manifestations were rare. Six patients had no relapse during the follow-up period, whereas the remaining 26 patients had an average of two relapses (range, 1-5). These relapses were complicated by fistulas in 8 patients and strictures in 11 patients. Response to steroids and sulfasalazine was good in most patients. Four patients required repeated surgery despite medical treatment. The prevalence of CD appears to be increasing among the Singapore Chinese population. The clinical features are similar to those of the Western population. Most of our patients responded to standard medical therapy, but further follow-up is needed to assess their long-term clinical outcome.

Higher incidence of diabetes in liver transplant recipients with hepatitis C.

Year 1998
Knobler H. Stagnaro-Green A. Wallenstein S. Schwartz M. Roman SH.
Department of Medicine, Mount Sinai Medical Center, New York, NY 10029, USA.
We assessed the clinical and biochemical parameters associated with the development of posttransplantation diabetes (PTDM) in 52 liver transplant recipients followed up for 1 year. Diabetes was present before transplantation in 9.6% (5 of 52) of patients, and PTDM occurred in 23% (11 of 47) of the remaining liver transplant recipients. Of the 13 patients who had hepatitis C as the cause of their liver failure (HC-LD), 8 (62%) developed PTDM; of the 34 patients with other causes of liver failure, 3 (9%) developed PTDM (p < 0.001). Posttransplantation diabetes was also associated with the development of early posttransplantation hyperglycemia, a higher number of liver rejection episodes, and lower serum albumin levels at 6 months. The association of PTDM with HC-LD remained significant in a logistic regression model after adjustment for potential confounding variables. We conclude that PTDM is common in liver transplant recipients. Associated clinical parameters predictive of PTDM include a diagnosis of HC-LD before transplantation, the development of early hyperglycemia after transplantation, multiple episodes of posttransplantation liver rejection and low serum albumin levels at 6 months. The fact that HC-LD remained an independent risk factor for the development of PTDM may suggest a direct or immune-mediated pancreatic effect of the virus.

Lipase-amylase ratio does not determine the etiology of acute pancreatitis. Another myth bites the dust.

Year 1998
Pezzilli R. Billi P. Barakat B. Miglio F.
Emergency Department, Sant'Orsola Hospital, Bologna, Italy.
We examined the feasibility of the lipase-amylase (L/A) ratio to differentiate alcoholic from nonalcoholic acute pancreatitis in a large prospective series of patients with acute pancreatitis. One hundred fifty-eight consecutive patients with acute pancreatitis were studied. The pancreatitis was of biliary origin in 112 patients, due to alcohol abuse in 26, due to other causes in 8, and of unknown origin in 12. For all patients, serum, amylase, and lipase levels were determined simultaneously, and the L/A ratio was calculated using the amylase and lipase serum levels expressed as multiples of the respective upper normal limit. The ratios in patients with alcoholic acute pancreatitis ranged from 0.3 to 8 and in patients with nonalcoholic acute pancreatitis from 0 to 19.9. A value of 2.2 for the serum L/A ratio was found to be the best cutoff value for differentiating alcoholic from nonalcoholic acute pancreatitis. Using this limit, the sensitivity, specificity, and diagnostic accuracy of the L/A ratio in determining the alcoholic form of acute pancreatitis were 54%, 82%, and 77% respectively. Our study showed that the L/A ratio is not useful in distinguishing alcoholic from nonalcoholic acute pancreatitis.

Pulmonary infections in hospitalized patients with cirrhosis.

Year 1998
Mabee CL. Fromkes JJ. Pacht ER. Ayers LW. Kirkpatrick RB. Sundaram U.
Division of Digestive Diseases, Ohio State University Medical Center, Columbus 43210, USA.
We have further characterized pulmonary infections by bronchoalveolar lavage in hospitalized patients with cirrhosis. Sixty-seven consecutive patients admitted to the Ohio State University Medical Center from 1992 to 1995 with liver disease who underwent bronchoscopy with bronchoalveolar lavage were identified. Twenty-one patients with cirrhosis and pneumonia were further analyzed. During the same period, we consecutively identified 23 patients without liver disease or immunosuppression, 19 patients with HIV infections, and 30 patients with cancer or pharmacologic immunosuppression who had bronchoscopy with bronchoalveolar lavage for pneumonia. These groups were included in these analyses as a control and immunosuppressed controls, respectively. Bronchoscopy isolated respiratory pathogens in 16 patients (76.2%) with cirrhosis and 6 patients (26.1%) in the control group (p = 0.002). Fungal organisms were most commonly found in patients with cirrhosis although several patients had more than one organism identified. The control group had mostly bacterial pathogens; the immunosuppressed controls were commonly infected with opportunistic organisms. Six (85.7%) of 7 patients with cirrhosis and fungal pneumonia died of their respiratory illness. Hospitalized patients with cirrhosis commonly have opportunistic pulmonary infections; diagnostic bronchoscopy and empiric antifungal therapy should be considered in those who do not respond to antibiotics.

Hemobilia due to hepatic artery pseudoaneurysm thirteen months after laparoscopic cholecystectomy.

Year 1998
Ribeiro A. Williams H. May G. Fulmer JT. Spivey JR.
Department of Gastroenterology, Mayo Clinic Jacksonville, FL 32224, USA.
Although vascular complications following laparoscopic cholecystectomy are rare, hemobilia may occur within the first 4 weeks after surgery. We report a 57-year-old woman with hemobilia secondary to a pseudoaneurysm of the right hepatic artery presenting 13 months after laparoscopic cholecystectomy. To our knowledge, such late presentation has never before been reported.

Splenic vein thrombosis secondary to focal pancreatitis diagnosed by endoscopic ultrasonography.

Year 1998
Lewis JD. Faigel DO. Morris JB. Siegelman ES. Kochman ML.
Department of Medicine, University of Pennsylvania Health System, Philadelphia 19104-4283, USA.
We report splenic vein thrombosis diagnosed by endoscopic ultrasonography (EUS) after the failure of extracorporeal ultrasound and contrast enhanced computed tomography to establish the diagnosis in a patient with gastrointestinal bleeding and anemia. Subsequent preoperative magnetic resonance imaging revealed findings of retroperitoneal fibrosis and confirmed the EUS findings. Splenic vein thrombosis is a well-known cause of gastrointestinal bleeding and splenomegaly; pancreatitis and pancreatic tumors are its most common underlying causes. Abdominal ultrasound and computed tomography are frequently used to diagnose splenic vein thrombosis. We discuss the use of EUS for diagnosis of vascular anomalies in the gastrointestinal tract and the association of splenic vein thrombosis, retroperitoneal fibrosis, and pancreatitis.

Tacrine. A cause of fatal hepatotoxicity?

Year 1998
Blackard WG Jr. Sood GK. Crowe DR. Fallon MB.
Department of Medicine, University of Alabama at Birmingham 35294-0007, USA.
Tacrine, an acetyl cholinesterase inhibitor used in the treatment of Alzheimer's disease, often causes reversible abnormalities in liver enzymes, but significant hepatotoxicity is uncommon. We describe fatal hepatic failure associated with tacrine administration. A 75-year-old woman with Alzheimer's disease, taking tacrine for 14 months, developed progressive jaundice. Liver function abnormalities developed during tacrine treatment and led to hepatic failure and death. An extensive evaluation for other etiologies of liver disease was negative. Other potentially hepatotoxic medicines had been administered for at least 2 years before beginning tacrine, and postmortem examination of the liver was consistent with drug-induced hepatotoxicity. Approximately half the patients treated with tacrine have liver enzyme abnormalities develop, primarily in the first 12 weeks of therapy, that resolve with discontinuation of drug or dosage adjustment. Our case of tacrine-associated hepatotoxicity 14 months after the initiation of treatment despite regular biochemical evaluation suggests the potential for delayed and fatal hepatotoxicity with tacrine.

What is the role of Helicobacter pylori in peptic ulcer and gastric cancer outside the big cities?

Year 1998
Sprung DJ. Apter MN.
No information.
Helicobacter pylori is apparently the etiologic agent of 90% of duodenal ulcers (DUs), 80% of gastric ulcers (GUs) not induced by nonsteroidal anti-inflammatory drugs, and gastric carcinoma (GC). Our community-based investigations and retrospective reviews, however, have been unable to substantiate these associations. A retrospective review of 30 patients with GC revealed only 2 (6.6%) patients with H. pylori infection. A retrospective review of all patients with the diagnosis of DU (332) was undertaken. One hundred sixty-six had gastroscopy-confirmed DUs, and 112 had three antral biopsies. Only 36 (32%) of 112 were H. pylori-positive. Of bleeding ulcers, 25% were H. pylori-positive. These findings differ from the literature, and it provoked us to study prospectively all patients undergoing endoscopy. Biopsy specimens were obtained from the cardia and antrum and were stained for H. pylori. Of 272 patients' biopsy specimens, 65 (24%) of 272 were H. pylori-positive. Sixteen DUs were diagnosed, and five (31%) were H. pylori-positive. There were 36 GUs, and 11 (30%) were H. pylori-positive. The prevalence of H. pylori in consecutive patients undergoing endoscopy is 24% in Orlando, Florida. This is not significantly different from the prevalence of H. pylori in patients with DUs and GUs. Further community-based studies are needed to determine the widespread applicability of these data in the United States.

Portal hypertensive gastropathy in noncirrhotic patients. The effect of lienorenal shunts.

Year 1998
Soin AS. Acharya SK. Mathur M. Sahni P. Nundy S.
Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.
We studied 25 consecutive patients with noncirrhotic portal hypertension to determine whether portal hypertensive gastropathy occurred and whether it was related to hypoacidity, hypergastrinemia, or portal venous congestion. Preoperative tests included gastrointestinal endoscopy, gastric mucosal biopsies, gastric acid estimation, and serum gastrin measurements. All patients had a central splenorenal shunt performed during which a full-thickness gastric biopsy was performed. The tests were repeated 3 to 16 months postoperatively. Eight of the 25 patients showed endoscopic evidence of portal hypertensive gastropathy. The shunt procedure reversed the gastropathy in 6 of 7 patients followed up. Mucosal biopsies revealed vascular ectasia in 24 of 25 patients; in 8 of the most severely affected there was partial or complete regression after surgery. The basal and peak acid outputs in the patients were normal for our laboratory at 2.9 +/- 0.25 meq/hour and 16.37 +/- 0.96 meq/hour, respectively. They remained unchanged after surgery. Fasting serum gastrin levels were also normal both before and after surgery. Our findings indicate that venous congestion is the cause of portal hypertensive gastropathy in patients with noncirrhotic portal hypertension and that it can be reversed by a decompressive procedure.

Hepatic nodules as single organ involvement in an adult with Langerhans cell granulomatosis. A case report.

Year 1998
Levy S. Capron D. Joly JP. Cordonnier C. Sevestre H. Delamarre J. Tribout B. Capron JP.
Department of Hepato-Gastroenterology, Amiens Hospital, France.
Liver involvement manifesting as hepatomegaly in Langerhans cell granulomatosis (LCG) is well known, but the definitive diagnosis is generally possible because other organs are involved. We report a 41-year-old white man who presented with cholestasis and liver nodules as an isolated hepatic LCG. The diagnosis of LCG was suspected based on routine histopathologic examination; the diagnosis became definitive 4 years later when Birbeck granules were found in the liver, an uncommon occurrence in this organ. This is an unusual presentation of a benign form of this disease and one of the first that reported Birbeck granules in the liver.

Histologic findings and Helicobacter pylori in duodenal biopsies.

Year 1998
Caselli M. Gaudio M. Chiamenti CM. Trevisani L. Sartori S. Saragoni L. Boldrini P. Dentale A. Ruina M. Alvisi V.
School of Gastroenterology, University of Ferrara, Italy.
We have studied the morphologic aspects of the duodenal bulb in relation to Helicobacter pylori infection in a large group of patients with endoscopically assessed duodenitis to learn more about the pathogenesis of nonspecific duodenitis (bulbitis) and to clarify the specific role of H. pylori. Eight duodenal biopsy specimens in the four quadrants of the first part of the bulb and four gastric antral biopsy specimens were taken in 208 patients. Specimens were fixed in formalin, or in glutaraldehyde, then slides were stained with hematoxylin and eosin, periodic acid-Schiff, and Alcian-Giemsa, and with toluidine blue for semithin sections. Duodenal histology revealed inflammation in 155 (74.5%) and H. pylori-like bacterial bodies in 153 (73.5%) of the patients; H. pylori infection in the gastric antrum was diagnosed in 173 (83.1%) of the patients. Distinguishing histologic aspects appeared to be related to the presence of H. pylori infection. We believe that the present histologic grading of duodenitis correlates better with the natural history of H. pylori infection in the duodenal bulb, and better fits the requirements of a modern classification than the classification commonly used in duodenitis. We conclude that the term H. pylori-linked bulbitis should be adopted as the proper term to identify the particular kind of duodenitis predisposing to peptic ulcer.

Subacute hepatic failure: diagnosis of exclusion?

Year 1998
Dhawan PS. Desai HG.
No information.
Subacute hepatic failure has been a controversial diagnosis ever since it was first identified more than 15 years ago. The Working Committee on Subacute Hepatic Failure has attempted to redefine this entity in which exclusion of preexisting cirrhosis on liver biopsy has been emphasized. Acute viral hepatitis in a patient with asymptomatic chronic liver disease (e.g., hepatitis B or C, Wilson's disease) can be misdiagnosed as subacute hepatic failure in the absence of a liver biopsy. This situation is common in developing countries where the prevalence of feco-orally transmitted (hepatitis A [20 years]) and parenterally transmitted (hepatitis B) viruses is high. To obtain and interpret liver biopsy specimens in such a situation is difficult and hazardous, and hence rarely performed. Acute viral hepatitis in a patient with asymptomatic chronic liver disease should be carefully looked for and excluded, especially in developing countries, before a diagnosis of subacute hepatic failure is confirmed.

Hospitalization for gastrointestinal and liver diseases: the effect of socioeconomic and medical supply factors.

Year 1998
McMahon LF Jr. Wolfe R. Huang S. Tedeschi P. Manning W. Edlund M.
Department of Internal Medicine, University of Michigan, Ann Arbor, USA.
A growing body of research has documented significant variation in health care use between communities. As the health care system is transformed, providers and payers should understand the interaction between a community, its sociodemographic characteristics, and its use of health resources. We describe the association between a population's demographic, socioeconomic, and medical resources and hospital use related to gastrointestinal and liver diseases. We used an all-payer hospital discharge database for Michigan from 1986 to 1988. We identified all medical and surgical hospital admissions during this period from two of the Diagnostic Related Group, Major Diagnostic Categories: No. 6, Diseases and Disorders of the Digestive System; and No. 7, Diseases and Disorders of the Hepatobiliary System and Pancreas. We analyzed age- and sex-specific use rates. Finally, we analyzed the influence of sociodemographic variables from the Area Resource File at the county level, on hospital use, using a Poisson regression model. We noted a significant association between increased hospitalizations and increased age in a community. Hospital beds per capita did not influence admission rates overall, although more hospital beds were associated with more medical admissions. Overall, the total physician supply was associated with more admissions. Finally, the most important socioeconomic variable was education. As the level of education of a county increased, hospital admissions decreased dramatically. The transformation of the health care delivery system presents opportunities and challenges. Understanding the underlying epidemiology of disease and how it interacts with a community's socioeconomic and medical resources or medical supply characteristics will be necessary to meet the community's health needs and to ensure the financial viability of providers. This is especially true when payers use a standard payment in a region, such as Medicare's managed care payment, without adjustments for the underlying population characteristics known to influence use.

Long-term symptom patterns, endoscopic findings, and gastric histology in Helicobacter pylori-infected and -uninfected patients.

Year 1998
DeLuca VA Jr. West AB. Haque S. Katz DL. Ciarolla D. Goldenberg S. Fette G.
Department of Gastroenterology, The Griffin Hospital, Derby, Connecticut 06418, USA.
There is a paucity of data on the long-term behavior of dyspepsia, endoscopic findings, and gastroduodenal histology in patients with or without Helicobacter pylori colonization. We evaluated these parameters during a period of 7 to 19 years (average, 12.3 years) by baseline and follow-up studies. In 36 patients studied, the pattern of gastroduodenal dyspepsia and esophagogastroduodenoscopy findings remained essentially unchanged in 67% and 56% respectively. Dyspepsia patterns did not correlate significantly with either endoscopic or histologic findings, including the severity or location of gastritis in the fundus or antrum, or the presence or absence of H. pylori gastritis. Of 36 patients with adequate biopsies of the fundus and antrum, H. pylori colonization with gastritis was present in 73% but not in 27%. Progression to various degrees of atrophic gastritis was noted in 100% with, and in none without, H. pylori gastritis. In the fundus, atrophy progressed from 14% to 56%, but intestinal metaplasia did not change. In the antrum, atrophy increased from 22% to 64% and intestinal metaplasia increased from 17% to 36%. No patient demonstrated dysplasia, but severe atrophy was seen in the fundus (6%) and antrum (11%). Only two patients (5%) had severe loss of glandular elements and very low pepsinogen I, and thus can be considered to have developed advanced gastric atrophy.

Predictive factors for rebleeding in patients with peptic ulcer bleeding after multipolar electrocoagulation: a retrospective analysis.

Year 1998
Lin HJ. Tseng GY. Lo WC. Lee FY. Perng CL. Chang FY. Lee SD.
Department of Medicine, Veterans General Hospital-Taipei, School of Medicine, National Yang-Ming University, Taiwan.
The role of endoscopic therapy for peptic ulcer bleeding is well-documented. Nevertheless, rebleeding occurs in 10% to 30% of patients, and such patients are at high risk for death without early retreatment or definitive surgery. The aim of our study was to predict which patients would rebleed within 1 month after successful multipolar electrocoagulation of 100 patients with active peptic ulcer bleeding (spurting, oozing, or nonbleeding visible vessel). We had achieved initial hemostasis in 97 patients and carried out univariate and multivariate analyses to predict which patients would rebleed. Rebleeding occurred within 1 month in 17 (17.5%) patients. we correlated 20 clinical and endoscopic factors with rebleeding episodes. With univariate analysis, blood transfusion of 500 ml or more at entry (p < 0.0001) and use of cimetidine (p = 0.01) were statistically significant for rebleeding. With multivariate analysis, use of omeprazole was an independent factor for preventing rebleeding (odds ratio, 7.68; 95% confidence interval, 1.642-35.929). We suggest that omeprazole may help to prevent rebleeding in patients who have had hemostasis with multipolar electrocoagulation.

Autoimmune (Hashimotos) thyroiditis associated with Crohns disease.

Year 1998
Shah SA. Peppercorn MA. Pallotta JA.
Division of Gastroenterology, Brown University School of Medicine, Providence, Rhode Island, USA.
We report the occurrence of autoimmune (Hashimoto's) thyroiditis in three patients with Crohn's disease. Previously, thyroid disease has been described only in association with ulcerative colitis. We review the pertinent literature on thyroid disease in inflammatory bowel disease (IBD) and suggest that this association supports the hypothesis that autoimmunity is involved in the pathogenesis of IBD. Early diagnosis and treatment of thyroid dysfunction in patients with IBD is desirable because thyroid dysfunction worsens the symptoms and course of IBD.

Endotoxemia predicts outcome in acute pancreatitis.

Year 1998
Wig JD. Kochhar R. Ray JD. Krishna Rao DV. Gupta NM. Ganguly NK.
Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
The incidence of complications of acute pancreatitis is high in patients with endotoxemia, and so we determined the endotoxin levels in the blood and peritoneal fluid of patients with acute severe pancreatitis to correlate the levels with any sequelae. Fourteen patients with acute severe pancreatitis were examined with regard to clinical features, biochemical tests, and laparotomy (n = 9). In all coagulation profiles, blood gas analysis, chest and abdominal x-rays, ultrasound, and abdominal computed tomography scan (n = 10) were performed. Qualitative estimation of endotoxin levels was done in peripheral blood and peritoneal and peripancreatic fluid. Ten (71.42%) of 14 patients had endotoxin in the blood, and 9 (64.28%) had it in the peritoneal fluid. Twelve (85.7%) had pulmonary involvement, with hypoxia being the most common (85.7%); among them endotoxin was found in the blood of 10 (83.32%) and in the peritoneal fluid of 8 (66.66%) patients. Renal dysfunction was found in 4 (28.57%) patients; endotoxin was present in the blood of all 4 patients and in the peritoneal fluid of 3 (75%) patients. Cardiovascular abnormality was detected in 8 (57.14%) patients, and endotoxin was present in the blood and peritoneal fluid of all patients. Metabolic abnormality was present in 8 (57.14%) patients; endotoxin was present in the blood of all 8 patients and in the peritoneal fluid of 7 (87.6%) patients. Eight (88.88%) of the 9 patients who required surgery had endotoxemia. Three (30%) patients with endotoxemia survived, whereas all 4 patients without endotoxemia survived. Mean hospital stay was 61.2 days and 46.7 days for endotoxin-positive and endotoxin-negative patients, respectively. We conclude that the presence of endotoxin in blood and peritoneal fluid correlates with the severity, systemic complications, and mortality rates of acute pancreatitis. Endotoxin estimation can identify patients at risk in the early stages of acute pancreatitis.

Endoscopic biliary drainage before pancreaticoduodenectomy for periampullary malignancies.

Year 1998
Marcus SG. Dobryansky M. Shamamian P. Cohen H. Gouge TH. Pachter HL. Eng K.
Department of Surgery, New York University School of Medicine, New York, USA.
Despite decreased operative mortality, pancreaticoduodenectomy (PD) remains a formidable operation with substantial morbidity. We have evaluated the influence of preoperative endoscopic biliary drainage (EBD) on morbidity after PD for malignant biliary obstruction by retrospectively reviewing the medical records of 182 patients undergoing PD between April 1985 and August 1996. Of 52 study patients with malignant obstructive jaundice, 22 underwent preoperative EBD, and 30 were not drained. Eighty-three patients were excluded for bilirubin levels less than 5 mg/dl, 43 had other biliary drainage, and 4 had jaundice with benign pathology. Preoperative, intraoperative, and postoperative factors were compared. The two groups were well matched for clinical presentation and operative characteristics except for lower preoperative values of liver chemistries in patients undergoing EBD. Length of postoperative hospitalization for patients undergoing EBD was 13.5 days, compared with 19 days for patients who were not drained (p = 0.02). Patients who were not drained tended to have more overall complications (p = 0.054). Multivariate analysis revealed time to regular diet (p < 0.0001) and no preoperative drainage (p = 0.04) to be independent factors significantly increasing the length of hospitalization. Endoscopic biliary drainage before PD significantly reduced the length of postoperative hospitalization and was associated with less postoperative morbidity. Further studies, including cost analysis, are warranted.

Treatment of chronic hepatitis C with interferon with or without ursodeoxycholic acid: a randomized prospective trial.

Year 1998
Abdelmalek MF. Harrison ME. Gross JB Jr. Poterucha JJ. Gossard AA. Spivey JR. Rakela J. Lindor KD.
Division of Gastroenterology, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA.
The only effective and approved therapy for chronic hepatitis C is interferon-alpha. Because sustained response rates with interferon alone are disappointingly low, multidrug treatment regimens are currently being investigated. Ursodeoxycholic acid has been used in other chronic liver diseases and can limit hepatocyte injury. To evaluate the potential benefit of ursodeoxycholic acid in combination with interferon-alpha for the treatment of chronic hepatitis C, we conducted a prospective, double-blinded, randomized, placebo-controlled trial comparing the combination therapy of interferon-alpha 2b and ursodeoxycholic acid with interferon alone. Thirty-one patients with chronic hepatitis C were randomized to receive 3 million units of interferon-alpha 2b subcutaneously three times per week and either 13 to 15 mg/kg/day ursodeoxycholic acid or placebo orally for 6 months. The 6-month treatment period was followed by 6 months of observation. Biochemical normalization at the end of treatment occurred in 5 of 14 (36%) patients receiving monotherapy versus 8 of 15 (53%) patients (p = 0.34) receiving combination therapy. No patient treated with interferon alone had a sustained biochemical response 6 months after therapy; however, 3 of 12 patients (25%) treated with combination interferon and ursodeoxycholic acid maintained biochemical normalization at 6 months after therapy (p = 0.08). No difference in liver histology or clearance of hepatitis C viral RNA was noted 6 months after treatment. We conclude that combination therapy with ursodeoxycholic acid and interferon-alpha 2b was no more effective than interferon monotherapy in inducing a biochemical response in previously untreated patients with chronic hepatitis C. Ursodeoxycholic acid, however, may be useful in prolonging the biochemical response to interferon therapy.

Expression of interferon receptor genes (IFNAR1 and IFNAR2 mRNA) in the liver may predict outcome after interferon therapy in patients with chronic genotype 2a or 2b hepatitis C virus infection.

Year 1998
Morita K. Tanaka K. Saito S. Kitamura T. Kondo M. Sakaguchi T. Morimoto M. Sekihara H.
Third Department of Internal Medicine, Yokohama City University School of Medicine, Yokohama, Japan.
Hepatitis C virus (HCV) genotype 2a or 2b is associated with a favorable outcome after interferon therapy. However, 19% to 33% of patients do not respond to therapy. We investigated whether interferon receptor gene (IFNAR1 and IFNAR2 mRNA) expression in the liver before interferon therapy predicts long-term response to therapy in patients with genotype 2a or 2b HCV infection. Twenty-seven patients who subsequently received interferon-alpha therapy underwent liver biopsies before interferon therapy. Hepatic IFNAR1 and IFNAR2 mRNA were determined using a reverse transcription-polymerase chain reaction assay. Twenty (74%) patients responded to interferon therapy, while the remaining seven (26%) patients were nonresponders. The expression rates of IFNAR1 and IFNAR2 mRNA in the liver were significantly higher in responders than nonresponders (p < 0.01, by chi-square test). The presence of either IFNAR1 or IFNAR2 mRNA predicted complete response to interferon treatment, with a positive predictive value of 100%. Multiple logistic regression analysis showed that IFNAR1 and/or IFNAR2 mRNA expression was the only significant predictor of the effectiveness of IFN therapy (p = 0.0002). We conclude that expression of interferon receptor genes in the liver is a useful index for predicting the long-term efficacy of interferon therapy in patients with chronic genotype 2a or 2b HCV infection.

Gastric outlet obstruction caused by microperforation of Helicobacter pylori-related antral ulcer.

Year 1998
Sheikh R. Trudeau W.
Division of Gastroenterology, University of California Davis Medical Center, Sacramento 95817, USA.
We report a Helicobacter pylori-related antral gastric ulcer that continued to cause symptoms despite H. pylori eradication. The patient had progressive gastric outlet obstruction, raising the possibility of a malignancy. On exploratory laparotomy, he was found to have a large inflammatory mass surrounding a contained microperforation.

Hepatocellular carcinoma presenting with paraneoplastic neurologic syndrome in a hepatitis B surface antigen-positive patient.

Year 1998
Hatzis GS. Delladetsima I. Koufos C.
Department of Pathophysiology, Medical School, National University of Athens, Greece.
We report a hepatitis B surface antigen-positive patient who presented with paraneoplastic peripheral sensorimotor polyneuropathy and cranial nerve involvement, 6 months before a diagnosis of hepatocellular carcinoma was made. This makes us think that neurologic manifestations in hepatitis B surface antigen-positive patients warrant investigation to exclude an underlying hepatocellular carcinoma.

Abdominal cocoon in a man: preoperative diagnosis and literature review.

Year 1998
Deeb LS. Mourad FH. El-Zein YR. Uthman SM.
Department of Internal Medicine, American University of Beirut Medical Center, Lebanon.
Sclerosing encapsulating peritonitis, or abdominal cocoon, is a relatively rare cause of intestinal obstruction, described mostly in young adolescent girls. It is characterized by a thick fibrotic peritoneum that wraps the bowel in a concertinalike fashion with some adhesions. Because of its peculiar characteristics, this condition presents many difficulties in preoperative diagnosis. Recognition of the entity results in proper management and prevents unnecessary bowel resection. We report a man with intermittent intestinal obstruction and an abdominal cocoon encasing the small bowel that was diagnosed preoperatively by radiology. To the best of our knowledge, this represents the fourth male patient reported in the medical literature to develop this condition. We briefly review the literature and discuss the preoperative diagnosis and management of sclerosing encapsulating peritonitis.

Celiac sprue presenting during the puerperium: a report of three cases and a review of the literature.

Year 1998
Malnick SD. Atali M. Lurie Y. Fraser G. Geltner D.
Department of Internal Medicine C, Kaplan Medical Center, Rehovot, Israel.
We present three patients in whom there was an acute presentation of malabsorption in the puerperium and in whom the final diagnosis was celiac sprue. The reason for the dramatic increase in the symptoms after delivery, as well as the absence of symptoms before this, is unclear but may be related to immunologic changes that occur during pregnancy.

Melanosis coli in inflammatory bowel disease.

Year 1998
Pardi DS. Tremaine WJ. Rothenberg HJ. Batts KP.
Inflammatory Bowel Disease Clinic and Division of Gastroenterology, Mayo Clinic and Foundation, Rochester, Minnesota, USA.
Melanosis coli is a relatively common condition in which pigment is deposited in macrophages in the colonic lamina propria. The association with anthraquinone laxatives is well described, but melanosis coli has also been described in patients not using these agents. We report 25 patients with inflammatory bowel disease and melanosis coli, 5 (20%) of whom had documented laxative use. Most patients had ulcerative colitis (72%) or Crohn's colitis (24%), and the mean duration of inflammatory bowel disease was more than 7 years. These data raise the possibility that chronic colitis could cause melanosis coli even in the absence of laxative use.

Development of flat adenoma and superficial rectal cancer after pelvic radiation.

Year 1998
Morita H. Koyama N. Tamura Y.
Division of Surgery and Gastroenterology, Tokyo Teishin Hospital, Japan.
Little is known about the early development of rectal cancer in patients with radiation-induced colitis. We describe two patients with a history of radiation colitis who developed rectal cancer. The macroscopic appearance of these lesions suggested that they arose de novo, but the histologic findings were more consistent with progression along the adenoma-to-carcinoma sequence, a hybrid of de novo lesion and adenoma. Early rectal cancer associated with chronic inflammation should be considered if a nonpolypoid adenomatous lesion is detected in a patient who has received pelvic radiation.

Anorectal manometric characteristics in men and women with idiopathic fecal incontinence.

Year 1998
Mitrani C. Chun A. Desautels S. Wald A.
Department of Medicine, University of Pittsburgh School of Medicine, Pennsylvania, USA.
To characterize and compare the anorectal manometric findings of men and women with idiopathic fecal incontinence referred to a tertiary care center for pelvic floor disorders, we reviewed 86 consecutive patients who underwent anorectal manometry during a 13-month period. We determined the etiologies of all patients and analyzed men and women with no obvious cause (idiopathic). The manometric parameters included resting and squeeze anal canal pressures, duration of squeeze pressures, threshold of external anal sphincter contraction, threshold of rectal sensation, and rectal compliance. Thirty-one of 86 patients were classified as having idiopathic fecal incontinence. The mean age of the 7 male patients with idiopathic fecal incontinence was 65 years, (range, 45-78 years) and 63 years (range, 38-83 years) in the 24 women. Compared with male patients, female patients had lower sphincteric pressures and shorter squeeze durations. Both men and women frequently exhibited poor phasic response of the external anal sphincter to rectal distention. We conclude that, compared with men, women with idiopathic fecal incontinence more often exhibit abnormalities of anal sphincteric motor function. The sex-related differences in muscle mass and past traumatic events related to childbirth may partly account for these findings.

Distribution of lymph node metastasis and level of inferior mesenteric artery ligation in colorectal cancer.

Year 1998
Adachi Y. Inomata M. Miyazaki N. Sato K. Shiraishi N. Kitano S.
First Department of Surgery, Oita Medical University, Japan.
To investigate the distribution of lymph node metastasis along the inferior mesenteric artery (IMA) and clarify whether high ligation of the IMA is important or not, we examined the surgical results of 172 patients with cancer of the sigmoid colon and rectum. Histologically, lymph node metastasis was absent in 108 (63%) patients and present in 64 (37%) patients. The distribution was adjacent to the wall of the rectum (35.5%) and sigmoid colon (10.5%), along the IMA (7.7%) and sigmoid colic artery (6.3%), and at the root of the IMA (0.7%, 1 of 135 patients). The presence of lymph node metastasis was predicted by the operative findings of lymph node metastasis (p < 0.01) and serosal invasion (p < 0.05) and by the histologic type of tumor (p < 0.05). These results indicate that lymph node metastasis at the root of the IMA is rare, and complete removal of the pericolic and intermediate nodes (D2 dissection) without high ligation of the IMA is feasible for cancer of the sigmoid colon and rectum.

Ischemic hepatitis: clinical and laboratory observations of 34 patients.

Year 1998
Fuchs S. Bogomolski-Yahalom V. Paltiel O. Ackerman Z.
Department of Medicine, Hadassah University Hospital, Mount Scopus, Jerusalem, Israel.
Ischemic hepatitis, a relatively infrequent disorder occurring in 0.16% to 0.50% of patients admitted to medical intensive care units, often follows episodes of hypotension or acute heart failure. Investigating the clinical characteristics of patients with ischemic hepatitis may add to our understanding of the pathogenesis and significance of this syndrome. We therefore conducted a retrospective analysis of 34 patients to examine the possible contribution of the various baseline characteristics to the severity of the hepatic damage. In all patients liver disease was unexpected and in some, liver dysfunction dominated the clinical picture. All patients had high serum glutamic pyruvic transaminase (SGPT) and lactic dehydrogenase (LDH) levels (mean +/- SE, 2073 +/- 255 international units and 6085 +/- 748 international units, respectively). The mean SGPT/LDH ratio was 0.34. Most patients had coagulopathy with a prolonged prothrombin time (mean +/- SE, 5.86 +/- 1.37 international normalized ratio [INR]). The most common diagnosis on admission was respiratory distress secondary to various causes. Before the development of the hepatic dysfunction, respiratory failure and hypoxemia were observed in 68% of the patients, whereas hypotension was observed in only 38%. More than 90% of the patients had three or more associated comorbid conditions. The most frequent of these were left heart failure (88.2%), right heart failure (67.6%), chronic obstructive lung disease (58.8%), and chronic renal failure (55.9%). During the acute episode, more than 90% of the patients had transient deterioration of their renal functions. Hypoglycemia was noted in 11 patients (32.4%), and the glucose level was inversely correlated with the SGPT level (r = -0.43, p = 0.01). Stepwise multiple regression analysis showed that left heart failure, systolic blood pressure lower than 90 mm Hg, and female gender, together, accounted for 34% of the variance of the peak SGPT levels (p = 0.002). Fourteen (41.2%) patients died during the 3-month follow-up period, but none from the hepatic injury. None of the clinical or laboratory parameters measured predicted mortality. Clearly, ischemic hepatitis is associated with a high risk of death. The characteristic patients are those with multiple underlying systemic diseases and conditions, especially those with left heart failure. Liver function test results and levels of liver enzymes should be monitored in these patients, particularly when they are admitted for respiratory deterioration and episodes of hypotension.

Chronic unexplained liver disease in children with primary immunodeficiency syndromes.

Year 1998
Fiore M. Ammendola R. Gaetaniello L. De Felice C. Iorio R. Vegnente A. Balestrieri B. Palmese G. Sommantico M. Pignata C.
Department of Pediatrics, Federico II University, Naples, Italy.
Liver disease may be found in patients with primary immunodeficiency syndromes because of the high risk of infection with hepatotropic viruses related to the treatment with blood derivatives. The prevalence of liver disease in these patients and its etiology, however, is still not completely understood. We have evaluated the prevalence and the etiology of liver disease in children with different forms of primary immunodeficiencies. Thirty patients included in the study underwent molecular studies to detect common hepatotropic viruses, including hepatitis C and G viruses. Liver involvement was found in 11 of 30 (36.6%) patients. All patients with liver disease had deficiencies of specific immunity, with a prevalence in this subgroup of 47.8%. Liver disease was more severe in patients with T and B cell combined immune disorders than in those with a selective T cell immunodeficiency. Moreover, the severity of the disease correlated with an overall more rapid fatal outcome. A viral etiology was found in only six of these patients, whereas in the remaining five patients, no cause of liver injury was identified. In the virally infected patients, hepatitis C virus was the most common viral agent. In patients with immunodeficiencies, there is a high prevalence of liver disease not fully explained on the basis of the common viral infections.

Hepatitis C viral RNA status at two weeks of therapy predicts the eventual response.

Year 1998
Yamaji K. Hayashi J. Kawakami Y. Furusyo N. Sawayama Y. Kishihara Y. Etoh Y. Kashiwagi S.
Department of General Medicine, Kyushu University Hospital, Fukuoka, Japan.
We investigated the timing of the disappearance and reappearance of serum hepatitis C viral (HCV) RNA in patients with chronic hepatitis C during interferon treatment and follow-up. Serum samples were tested for HCV RNA by polymerase chain reaction in 62 patients with chronic hepatitis C treated with interferon-alpha for 24 weeks. We found that 17 patients obtained complete response, with absence of serum HCV RNA for 6 months after the treatment. Twenty-nine patients had a partial response, with reappearance of serum HCV RNA within 6 months of follow-up, and 16 patients were nonresponders who were positive for serum HCV RNA throughout the observation period. HCV RNA disappeared within 2 weeks of treatment in 31 patients, including all 17 (100%) complete responders and 14 (48.3%) of the 29 partial responders. The patients remaining positive for HCV RNA at the second week were 15 (51.7%) of the 29 partial responders and the 16 nonresponders. In all of the 29 partial responders, viremia recurred within 1 month after the treatment. These results indicate that the status of HCV RNA at the second week of treatment is a useful predictor of effective treatment, whereas status at the first month after cessation of treatment is useful for assessing the effectiveness of interferon itself.

Tamoxifen does not improve survival of patients with advanced hepatocellular carcinoma.

Year 1998
Riestra S. Rodriguez M. Delgado M. Suarez A. Gonzalez N. de la Mata M. Diaz G. Mino-Fugarolas G. Rodrigo L.
Hospital Valle del Nalon, Asturias, Spain.
To discover whether tamoxifen is able to extend the survival of patients with advanced hepatocellular carcinoma, we included 80 patients with cirrhosis and advanced hepatocellular carcinoma in a multicenter, double-blind, placebo-controlled trial in order to analyze the influence of treatment with tamoxifen on survival. The patients were randomized to receive tamoxifen, 40 mg/day (group 1), or placebo (group 2). Both groups were similar in age, sex, etiology of cirrhosis, biochemical, hematologic and hormonal parameters, morphology of the tumor (nodular vs multinodular or massive), Child-Pugh's score, and Okuda's stage. The 1-year survival rate was similar in both groups (30% in group 1 vs 37.8% in group 2; p = 0.31). Tamoxifen treatment was well tolerated by the patients. We conclude that tamoxifen does not extend the survival of patients with cirrhosis and advanced hepatocellular carcinoma.

Alcoholic recidivism after liver transplantation for alcoholic cirrhosis.

Year 1998
Fabrega E. Crespo J. Casafont F. De las Heras G. de la Pena J. Pons-Romero F.
Gastroenterology and Hepatology Unit, University Hospital Marques de Valdecilla, Faculty of Medicine, Santander, Spain.
Liver transplantation (LT) for alcoholic cirrhosis remains controversial. This controversy surrounding LT in alcoholics focuses on the risk of alcohol recidivism and on potential noncompliance with the immunosuppressive regimen, both of which result in graft failure. Our study examined alcohol recidivism after LT by measuring alcohol in urine and its repercussion on the allograft. Forty-four consecutive alcoholic patients and a comparison group of 17 patients receiving LT were included in this study and followed up for a mean of 39.5 +/- 19.6 months. Seven percent (3 of 44) of patients with alcoholic liver disease and 0% of patients in the comparison group admitted to having used alcohol after LT. Alcohol in urine, however, was detected in 18% (8 of 44) of the alcoholic group; therefore the true recidivism rate was higher than the rate admitted. All patients in both groups were compliant with the medications, because the cyclosporine levels were within the therapeutic range in all. On histologic examination the only alcohol-induced lesion found in three of the eight recidivistic patients was steatosis. Therefore, although alcoholic recidivism occurs, it does not seem to affect compliance to treatment profoundly or to compromise graft function. Therefore, LT seems justified for end-stage alcoholic cirrhosis.

Colonic ulcers in a patient with hepatitis C virus-associated polyarteritis nodosa.

Year 1998
Elias N. Sabo E. Naschitz JE. Yeshurun D. Misselevich I. Boss JH.
Department of Internal Medicine A, The Bnai-Zion Medical Center and The Bruce Rapapport Faculty of Medicine, Technion--Israel Institute of Technology, Haifa.
An elderly woman presented with abdominal discomfort, pulmonary infiltrates, acute renal failure, purpura, and massive hematochezia. Numerous colonic ulcers with underlying fibrinoid necrotizing arteritis were found in the colectomy specimen. Anti-hepatitis C virus (HCV) antibodies and HCV RNA were present in the serum. The diagnosis of HCV-associated polyarteritis nodosa was clear. This clinical presentation differs from the more commonly occurring vasculitis complicating HCV infection, which is of the leukocytoclastic type, and is associated with overt liver disease and cryoglobulinemia. In our patient, results of liver tests were normal, there was no cryoglobulinemia, and the vasculitis was of the fibrinoid necrotizing arteritis type. HCV-associated polyarteritis nodosa should be considered in the differential diagnosis of necrotizing fibrinoid arteritis even in a patient with normal liver function test results and in the absence of cryoglobulinemia.

Cricopharyngeal dysfunction in a patient with achalasia.

Year 1998
Nobre e Souza MA. Dantas RO.
Departamento de Clinica Medica, Faculdade de Medicina de Ribeirao Preto, Universidade de Sao Paulo, Brazil.
A 64-year-old man had intense dysphagia and aspiration of 1 month's duration. The patient had lower esophageal sphincter (LES) achalasia and cricopharyngeal dysfunction, with generalized muscle weakness discovered by neurologic examination. Endoscopy showed no lesions of the mouth, pharynx, larynx, or esophagus. The diagnosis of achalasia was made by manometry. The LES did not relax with deglutition; the contractions in the esophageal body were nonperistaltic and of low amplitude; and the upper esophageal sphincter pressure did not decrease after deglutition. A scintigraphic study of the oral and pharyngeal phases of swallowing showed a mouth and pharyngeal retention of 90% of the volume swallowed.

Failure to detect early recurrence of gastric cancer.

Year 1998
Lacueva FJ. Calpena R. Medrano J. Oliver I. Carvajal R.
Pathology and Surgery Department, Miguel Hernandez University School of Medicine, Elche University General Hospital, Spain.
Early gastric cancer recurrence is sometimes difficult to diagnose even by protocols using imaging techniques and tumor markers. We report a gastric cancer recurrence diagnosed by the appearance of a Sister Mary Joseph's nodule that illustrates the lack of sensitivity of these methods. We also discuss the protocol we currently follow for these patients.

Colonic disease in cirrhotic patients with portal hypertension: an endoscopic and clinical evaluation.

Year 1998
Bresci G. Gambardella L. Parisi G. Federici G. Bertini M. Rindi G. Metrangolo S. Tumino E. Bertoni M. Cagno MC. Capria A.
Unita Operativa Gastroenterologia, Azienda Ospedaliera Pisana, Ospedale Cisanello, Pisa, Italy.
Fifty cirrhotic patients with portal hypertension but without colonic or systemic disease underwent lower gastrointestinal endoscopy in order to investigate the effects, if any, of portal hypertension on the colon. Fifty patients without liver or systemic disease, examined by colonoscopy because of irritable bowel syndrome in the same period served as controls. Rectosigmoid varices were observed in 34% of the cirrhotic patients and 2% of the controls. Hemorrhoids were observed in 70% of the cirrhotic patients and 48% of the controls. Multiple vascular-appearing lesions were found in 16% of the cirrhotic patients and 6% of the controls. Nonspecific inflammatory changes were noted in 10% of the cirrhotic patients and 4% of the controls. Simultaneous presence, in the same patient, of rectosigmoid varices, hemorrhoids, multiple vascular-appearing lesions, and nonspecific inflammatory changes, was observed in only five (10%) of the cirrhotic patients. We found polyps in 12% of the cirrhotic patients and 14% of the controls, and a malignant tumor in 4% of the cirrhotic patients. The patients with normal colonoscopic findings were 8% of the cirrhotic patients and 36% of the controls. All patients and controls were followed up for 1 year; there was no gastrointestinal hemorrhage among controls, whereas 34% of the cirrhotic patients had an upper gastrointestinal hemorrhage (88% from esophageal varices, 12% from the stomach) and 4% had a lower gastrointestinal hemorrhage (one from rectosigmoid varices and one from nonspecific inflammatory lesions). Colonic lesions were significantly more frequent in the cirrhotic patients (92%) than in the control group (64%); however, such lesions did not seem specific to the disease and were not statistically correlated with the degree of esophageal varices by Child's grading, the etiology of cirrhosis, or the bleeding risk from the lower gastrointestinal tract.