Pain and dyspepsia after elective and acute cholecystectomy.
Middelfart HV. Kristensen JU. Laursen CN. Qvist N. Hojgaard L. Funch-Jensen P. Kehlet H.
Dept. of Surgical Gastroenterology, Hvidovre Hospital, University of Copenhagen, Denmark.
BACKGROUND: Postcholecystectomy pain occurs in 20-30%. The main cause of this pain remains unclear. Whether the underlying gallbladder disease influences the outcome after cholecystectomy is not fully established. METHODS: A multicenter questionnaire study comparing the occurrence of abdominal pain and dyspepsia 5-10 years after cholecystectomy in 345 (222 women, 123 men) patients cholecystectomized for acute cholecystitis and in a control group of 296 (213 women, 83 men) patients cholecystectomized for uncomplicated symptomatic gallbladder stones. RESULTS: Of 641 questionnaires, 534 (83%) were completed. Complaints of abdominal pain and dyspepsia were found with similar frequencies in the acute cholecystitis and gallstone groups. Women had abdominal pain more often than men (42% versus 29%) (P = 0.01). Although more than one-third complained of abdominal pain after cholecystectomy, 93% had improved or were cured. CONCLUSION: The outcome after cholecystectomy seems to be independent of the underlying gallbladder disease (acute cholecystitis or elective operations for gallstones).
One-week omeprazole treatment in the diagnosis of gastro-oesophageal reflux disease.
Johnsson F. Weywadt L. Solhaug JH. Hernqvist H. Bengtsson L.
Dept. of Surgery, Lund University Hospital, Sweden.
BACKGROUND: Symptoms of gastro-oesophageal reflux are common, and currently available methods for diagnosing reflux disease are expensive and uncomfortable for the patient. The diagnostic value of a treatment test with omeprazole is unclear. METHODS: Patients with dyspepsia including heartburn admitted for upper gastrointestinal endoscopy were studied in a prospective, randomized, double-blind Scandinavian multicentre study. Before entry 188 patients were enrolled, and 160 were randomized to 1-week treatment with 20 mg omeprazole twice daily or placebo. Gastro-oesophageal reflux disease (GERD) was defined as reflux oesophagitis Savary-Miller grades II-III at endoscopy or pH < 4 exceeding 4% of the total time at 24-h oesophageal pH-monitoring and was found in 135 patients. The treatment test was considered positive when the patient's symptoms improved during the treatment week compared with the pretreatment day. RESULTS: The sensitivity in diagnosing reflux disease was 71-81% with omeprazole as a diagnostic test, compared with 36-47% for placebo during treatment days 3-7. The specificity was similar for the two treatment arms during the first days of the study. During the end of the week a larger proportion of the patients with normal endoscopy and pH test responded to omeprazole treatment, giving omeprazole lower specificity than placebo. The investigators' overall evaluation of whether the patient was a responder to the test had a sensitivity of 75% and a specificity of 55% in the omeprazole-treated patients. The corresponding figures in the placebo group were 17% and 92%, respectively. CONCLUSION: One week of omeprazole treatment is a simple diagnostic test with a fairly high sensitivity. The specificity is poor owing to the placebo effect and to the lack of a gold standard in diagnosing reflux disease.
Endoscopic palliation of inoperable cancer of the oesophagus or cardia by argon electrocoagulation.
Heindorff H. Wojdemann M. Bisgaard T. Svendsen LB.
Dept. of Gastrointestinal Surgery C, Rigshospitalet, University of Copenhagen, Denmark.
BACKGROUND: Cancer of the oesophagus and the cardia tends to present late. Palliation of dysphagia is the prospect of most of the patients. This paper reports the use of argon electrocoagulation in 83 patients with inoperable cancer strictures in the oesophagus and cardia. METHODS: The argon electrocoagulation was done by a fibre conducting electricity and argon air to the site of coagulation. After treatment the patients were allowed to take fluids and normal food the same evening or the next morning. After recanalization the patients were treated regularly every 3-4 weeks. RESULTS: Recanalization enabling passage for normal food was achieved with 1 treatment in 48 patients (58%), whereas 22 (26%) needed more than 1 treatment. In 13 patients (16%) the ability to eat normal food was not achieved. In these patients dysphagia improved at least one grade. Perforation was seen in seven patients (8%) and in 1% of treatments. Perforations were successfully treated conservatively in six of the seven patients. Sixty-three patients (76%) died during the investigation period, on average 146 days (range, 43-397 days) after diagnosis. CONCLUSION: Argon electrocoagulation offers an easy, cheap, and safe alternative to treatment with laser photocoagulation and expandable metal stents.
An analysis of seven different methods to diagnose Helicobacter pylori infections.
Andersen LP. Kiilerick S. Pedersen G. Thoreson AC. Jorgensen F. Rath J. Larsen NE. Borup O. Krogfelt K. Scheibel J. Rune S.
Dept. of Clinical Microbiology, National University Hospital (Rigshospitalet), Copenhagen, Denmark.
BACKGROUND: It has been debated which diagnostic test should be preferred for the diagnosis of Helicobacter pylori in patients with gastroduodenal diseases. METHODS: The H. pylori infection was diagnosed prospectively in 97 untreated patients. H. pylori was diagnosed by means of tests based on five different principles: 1) culture, 2) microscopy (HLO), 3) urease activity (urea breath test (UBT) and urease test on biopsy specimens (CLO test)), 4) DNA detection (polymerase chain reaction (PCR)), and 5) IgG antibody detection (enzyme-linked immunosorbent assay (EIA) and Western blotting (WB)). RESULTS: This study showed that two positive tests out of five tests, based on different principles, were most reliable for predicting the H. pylori infection. Most tests had specificities and predictive values for a negative result greater than 90%. The most important difference between the tests was the sensitivity and the predictive value for a positive result (PPV). WB, HLO, UBT, and PCR had sensitivities and PPV greater than 75%. CONCLUSIONS: The non-invasive tests UBT and WB are reliable, both alone and in combination, and they are recommended for the pre-endoscopic diagnosis of H. pylori. WB is recommended as a confirmative test for antibody detection by EIA. When patients have an upper endoscopy, we recommend taking biopsy specimens for culture and histology because of the additional information obtained about susceptibility, virulence determinants, and morphology, including the degree of inflammation.
Association of CagA-positive and CagA-negative Helicobacter pylori strains with patients symptoms and gastritis in primary care patients with functional upper abdominal complaints.
Heikkinen M. Mayo K. Megraud F. Vornanen M. Marin S. Pikkarainen P. Julkunen R.
Dept. of Medicine, Kuopio University Hospital, Finland.
BACKGROUND: CagA-positive Helicobacter pylori strains have been reported to be associated with peptic ulcer or malignancy more often than cagA-negative strains. Less is known about the relation of H. pylori serology (CagA-negative or CagA-positive) to histologic changes in the stomach of patients with functional upper abdominal complaints. The association of H. pylori status with patient symptoms or with different subgroups of non-organic dyspepsia is also obscure. In the present study patients' symptoms and their relation to H. pylori serology (H. pylori-negative, H. pylori-positive but CagA-negative, and H. pylori-positive and CagA-positive) were evaluated in general practice patients who had functional upper abdominal complaints. The association of H. pylori serology with different symptom-based subgroups of functional upper abdominal complaints was also assessed. The severity and activity of inflammation and the presence of atrophy and intestinal metaplasia in the antrum and body were evaluated and compared with H. pylori status. METHODS: Four hundred consecutive unselected dyspeptic patients in primary care were investigated by means of gastroscopy, upper abdominal ultrasound, laboratory screening including H. pylori and CagA serology, and other examinations if needed. Of these patients 193 with functional upper abdominal complaints were enrolled in this study. RESULTS: Of the study patients 87 (45%) were H. pylori-negative, 70 (36%) were H. pylori- and CagA-positive, and 36 (19%) were H. pylori-positive but CagA-negative. There were no differences in the occurrence of any dyspeptic symptoms between H. pylori-related subgroups. Nor was there an association between H. pylori status and symptom-based subgroups in our study patients. Inflammation of the stomach was related to H. pylori infection, but CagA-seropositive patients did not have moderate or severe inflammation more often than CagA-seronegative ones. CagA-seropositive patients with functional upper abdominal complaints did not have atrophic changes or intestinal metaplasia in the stomach more often than those who were CagA-negative. CONCLUSIONS: H. pylori or more specific CagA serology is not associated with any specific symptom profile of dyspepsia or with any symptom-based subgroups in patients with functional upper abdominal complaints in primary care. The study patients with CagA seropositivity did not have more severe histologic changes in the stomach than the patients who were H. pylori-seropositive but CagA-seronegative.
Prevention of gastric ulcer recurrence with tetraprenylacetone.
Nagasawa Y. Tatsuta M. Iishi H. Ishiguro S.
Dept. of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Japan.
BACKGROUND: The role of cytoprotective agents in the treatment of ulcers remains unclear. In the present study we investigated the effect of tetraprenylacetone (TAP), a cytoprotective agent, on healing and recurrence of gastric ulcers infected with Helicobacter pylori and on the mucosal microvascular architecture of healed gastric ulcers. PATIENTS: Ninety-five gastric ulcer patients with H. pylori infection were studied. METHODS: Gastric ulcer patients with H. pylori infection received 20 mg omeprazole (44 patients) or 20 mg omeprazole and 150 mg TAP (46 patients) in random fashion. Ulcer healing was assessed with endoscopy 12 weeks after the start of treatment. The patients with healed ulcer were followed up for another 12 months without further therapy. During endoscopic examination at week 12, biopsy specimens were obtained from healed gastric ulcers, and the gastric mucosal microvascular architecture of the biopsy specimens was observed by means of the alkaline phosphatase staining method. RESULTS: The rate of ulcer healing at week 12 was similar in patients treated with omeprazole with and without TAP. However, at or within 12 months of the start of follow-up observation, ulcers recurred significantly less frequently in patients treated with both omeprazole and TAP than in those treated with omeprazole alone. Alkaline phosphatase staining methods showed that the mucosal microvascular architecture improved significantly more frequently in healed gastric ulcers that had been treated with both omeprazole and TAP than in those treated with omeprazole alone. CONCLUSIONS: Treatment with TAP plus omeprazole significantly decreases ulcer recurrence through TAP's improved mucosal restoration.
Double-blind trial of omeprazole and amoxicillin in the cure of Helicobacter pylori infection in gastric ulcer patients. The Ulcer Study Group, Germany.
Meining A. Hochter W. Weingart J. Sommer A. Klann H. Simon T. Huber F. Bolle KH. Hatz R. Fischer G. Lehn N. Stolte M. Bayerdorffer E.
Medical Dept. II, Klinikun Grosshadern, University of Munich, Germany.
BACKGROUND: Our aim was to investigate the efficacy of omeprazole and amoxicillin in curing Helicobacter pylori infection in gastric ulcer patients. METHODS: In a double-blind trial 185 H. pylori-positive gastric ulcer patients were prospectively randomized to receive 40 mg omeprazole twice daily and either 750 mg amoxicillin three times daily or 750 mg amoxicillin placebo three times daily on days 1-14, followed by 20 mg omeprazole daily on days 15-56. RESULTS: Twenty-seven patients were excluded because of lack of compliance or missed follow-up examinations; one patient receiving amoxicillin discontinued treatment owing to side effects. On an intention-to-treat basis, omeprazole/amoxicillin led to cure of H. pylori infection in 67.1% (47 of 70) of patients not using non-steroidal anti-inflammatory drugs (NSAIDs)/aspirin (ASA) and in 46.7% (14 of 30) of those taking NSAIDs/ASA (P < 0.05). With the omeprazole/placebo regimen, H. pylori infection was cured in 8.8% (no NSAIDs), and 0% (NSAIDs). CONCLUSIONS: The use of NSAIDs/ASA may limit the efficacy of omeprazole/amoxicillin in curing H. pylori infection in gastric ulcer patients.
Antroduodenal manometry findings in patients with slow-transit constipation.
Glia A. Lindberg G.
Dept. of Surgery, Karolinska Institutet, Huddinge University Hospital, Sweden.
BACKGROUND: The results of subtotal colectomy for slow-transit constipation are unpredictable. Abdominal pain, distension, and bloating often persist after operation. To ascertain whether patients with slow-transit constipation may have a generalized intestinal motor disorder, we studied the antroduodenal motor activity in 20 consecutive patients with slow-transit constipation. METHODS: All patients underwent symptom registration, whole-gut transit time, anorectal manometry, electromyography of the anal sphincter, the balloon expulsion test, and defecography to characterize their constipation. The motor activity of the the gastric antrum and the proximal small bowel was monitored for 5 h, using a pneumohydraulic water-perfused manometry system with six channels. RESULTS: Twelve patients (60%) had abnormal patterns of motor activity: abnormal propagation or configuration of phase III in 9 of 12 patients, bursts of non-propagated phasic activity in 8 of 12 patients, and sustained periods of intense phasic activity in 3 of 12 patients. One patient had generalized hypomotility with low-amplitude contractions. In addition, an abundance of so-called discrete clustered contractions was found in 6 of 20 patients. CONCLUSION: A significant proportion of patients with slow-transit constipation have manometric findings that indicate a generalized motor disorder of the gut. The clinical significance of this finding is still unclear.
Bacterial overgrowth, intestinal transit, and nutrition after total gastrectomy. Comparison of a jejunal pouch with Roux-en-Y reconstruction in a prospective random study.
Iivonen MK. Ahola TO. Matikainen MJ.
Dept. of Surgery and Clinical Physiology, Tampere University Hospital, Finland.
BACKGROUND: Jejunal pouches after total gastrectomy have been introduced to diminish postgastrectomy symptoms and improve nutrition. However, the effect of a pouch on the intestinal bacteriology and transit is controversial. METHODS: Bacterial overgrowth was measured with the glucose breath test and the mouth-to-caecum transit time (MCT) by means of the lactulose breath test after total gastrectomy and Roux-en-Y reconstruction in 24 patients with a pouch (Pouch group) and in 22 patients without a pouch (Roux-en-Y group). Postoperative symptoms were evaluated with a standard questionnaire, and nutrition was measured by blood chemistry and weight loss. RESULTS: MCTT was 110 +/- 44 min in the Roux-en-Y group and 117 +/- 44 min in the Pouch group (NS). Eighty-six per cent of the patients in the Roux-en-Y group and 91% of the patients in the Pouch group had bacterial overgrowth (NS). Transit time was shorter in patients with severe dumping than patients without dumping (60 +/- 28 min versus 115 +/- 41 min; P = 0.04). Maximal hydrogen concentration in the glucose breath test correlated negatively with serum albumin and iron concentrations and with postoperative weight loss, and positively with serum alkaline phosphatase activity. CONCLUSIONS: Bacterial overgrowth is common in the upper intestine after total gastrectomy. Pouch reconstruction does not delay the transit of liquids. Bacterial overgrowth may be one of the main aetiologic factors in postgastrectomy malnutrition.
Inflammatory bowel disease in Iceland, 1980-89. A retrospective nationwide epidemiologic study.
Bjornsson S. Johannsson JH. Oddsson E.
Dept. of Medicine, Reykjavik Hospital, Iceland.
BACKGROUND: A previous nationwide epidemiologic study of inflammatory bowel disease (IBD) in Iceland in 1950-79 showed a low but steadily rising incidence. The incidence of IBD in Iceland in 1980-89 was investigated and compared with reports from neighboring countries. METHODS: Cases were retrieved by a review of all small- and large-intestinal tissue specimens with any type of inflammation submitted to the only two departments of pathology in Iceland. All small-intestinal X-ray records suggestive of Crohn's disease (CD) in the three major hospitals were also screened. All hospital and outpatient records of cases suggestive of IBD were then reviewed using accepted criteria for confirmation or exclusion. RESULTS: The mean annual incidence of ulcerative colitis (UC) was 11.7/100,000, and that of CD 3.1/100,000. The highest age-specific incidence of UC was in the group 30-39 years old and for CD in the group 60-69 years old. The most frequent involvement at diagnosis of UC was proctitis only, in 54%, and in CD colon only, in 54.7% of the patients. CONCLUSIONS: This study shows a continuing increase in the incidence of both diseases. Compared with the period 1970-79, there has been an almost twofold increase in the mean annual incidence of UC and more than a threefold increase of CD, a statistically significant increase in both instances.
Alpha1-antitrypsin alleles and phenotypes in patients with inflammatory bowel disease.
Folwaczny C. Urban S. Schroder M. Hofmann B. Noehl N. Konig A. Loeschke K. Fricke H.
Medical Clinic, Klinikum Innenstadt, Ludwig-Maximilian University, and Medical-Immunologic Laboratory, Munich, Germany.
BACKGROUND: Several studies suggest an imbalance of protease activation and inhibition in inflammatory bowel disease. Alpha1-Antitrypsin (AAT), one protease inhibitor of paramount importance, exists in numerous subtypes, some of them representing deficient phenotypes. The present study evaluated the prevalence of AAT-alleles and phenotypes in patients with inflammatory bowel disease. METHODS: The study population comprised 74 patients with Crohn's disease and 61 patients with ulcerative colitis. Isoelectric focusing was used for AAT subtyping. The prevalence of AAT alleles and phenotypes was compared with the frequency in 752 healthy unrelated controls. RESULTS: The rare phenotype M2F was detected in one patient with ulcerative colitis. No further significant differences in the distribution of AAT alleles or phenotypes between patients with inflammatory bowel disease and the healthy controls were observed. CONCLUSION: The low prevalence of deficient AAT subtypes does not point towards a contribution of AAT deficiency in the pathophysiology of IBD.
CD44 splice variants as prognostic markers in colorectal cancer.
Wielenga VJ. van der Voort R. Mulder JW. Kruyt PM. Weidema WF. Oosting J. Seldenrijk CA. van Krimpen C. Offerhaus GJ. Pals ST.
Dept. of Pathology, Academic Medical Center, University of Amsterdam, The Netherlands.
BACKGROUND: Splice variants of CD44 play a causal role in the metastatic spread of pancreatic carcinoma in the rat. In previous studies we have shown that homologues of these CD44 isoforms (CD44v6) are overexpressed during colorectal tumorigenesis in man and that CD44v6 overexpression is associated with an unfavorable prognosis in this disease. In the present study we have assessed the prognostic significance of CD44 variants containing exon v5. In addition, we have used a panel of different antibodies against CD44v6 and applied a combined scoring system to improve its value as prognosticator. METHODS: Expression of CD44 variants was studied by immunohistochemistry on frozen tissue sections, and the prognostic value of the CD44 variant expression was assessed using univariate and multivariate analysis. RESULTS: Our studies show that expression of CD44v6, but not CD44v5, has significant prognostic value. Analysis of CD44v6 expression by means of a combined scoring system, on the basis of a panel of three different monoclonal antibodies (mAbs), makes CD44v6 a highly significant prognostic marker that is independent of Dukes stage, tumor grade, or tumor localization. CONCLUSION: Assessment of CD44v6 expression by a combination of mAbs yields an independent prognosticator that may be of value in identifying patients with a high propensity to develop distant metastasis.
The risk of gastric carcinoma and carcinoid tumours in patients with pernicious anaemia. A prospective follow-up study.
Kokkola A. Sjoblom SM. Haapiainen R. Sipponen P. Puolakkainen P. Jarvinen H.
Second Dept. of Surgery, Helsinki University Central Hospital, Finland.
BACKGROUND: This endoscopic follow-up study was undertaken to evaluate the risk of gastric cancer (GC) and carcinoids in patients with pernicious anaemia (PA) and to analyse whether early detection of GC could be provided by regular endoscopic follow-up. METHODS: Screening gastroscopy was performed in 71 patients with pernicious anaemia, and thereafter they were followed up with gastroscopies at 3-year intervals for a mean time of 5.8 years. Standardized incidence ratios (SIR) were calculated, the expected number being based on incidence rates in the whole Finnish population. RESULTS: Two GCs were found during the follow-up period; one of these patients was asymptomatic and the other had abdominal symptoms. The SIR was 5.0 (95% confidence interval, 0.6-18). Eight carcinoids were detected, and all but one were removed endoscopically, and no metastases were found. The patients who had carcinoid tumours were younger at the diagnosis of PA than those who did not develop carcinoids (mean, 40 versus 55 years). Additionally, the patients with carcinoids had longer duration of PA (mean, 11 versus 5 years). CONCLUSIONS: During the follow-up period the risk of GC was increased. The risk of gastric carcinoids seems to be very high in patients with pernicious anaemia when compared with a normal population, but they are mostly relatively benign tumours. Regular routine gastroscopic follow-up is not indicated in patients with pernicious anaemia.
Hepatobiliary alterations in patients with inflammatory bowel disease: a multicenter study. Caprilli & Gruppo Italiano Studio Colon-Retto.
Riegler G. D'Inca R. Sturniolo GC. Corrao G. Del Vecchio Blanco C. Di Leo V. Carratu R. Ingrosso M. Pelli MA. Morini S. Valpiani D. Cantarini D. Usai P. Papi C. Caprilli R.
Dept. of Gastroenterology, IInd University of Naples, Italy.
BACKGROUND AND METHODS: Four hundred and eighty-four patients with inflammatory bowel disease underwent clinical examination, ultrasonography, and biochemical liver function tests, to estimate the prevalence of hepatobiliary alterations. The patient group included patients without a history of liver disease. Controls were recruited from patients with functional symptoms. RESULTS: More patients with ulcerative colitis than controls had liver steatosis and increased alkaline phosphatase levels. Factors increasing the probability of liver damage were long-standing disease, the presence of moderate/severe disease activity, and treatment with steroids and mesalazine. A significant association was found between biliary disease and long-standing colitis and also therapy with steroids and mesalazine. Alkaline phosphatase and aminotransferase levels were significantly higher in Crohn's disease patients than in controls. Hepatic and biliary damage was found more commonly in the 1st year after diagnosis. CONCLUSIONS: The monitoring of hepatobiliary function is suggested for patients with inflammatory bowel disease, even in the absence of symptoms and history.
Incidence and prevalence of primary biliary cirrhosis, primary sclerosing cholangitis, and autoimmune hepatitis in a Norwegian population.
Boberg KM. Aadland E. Jahnsen J. Raknerud N. Stiris M. Bell H.
Dept. of Medicine, Aker University Hospital, Oslo, Norway.
BACKGROUND: The relative frequencies of the autoimmune liver diseases primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), and autoimmune hepatitis (AIH) have not been studied. We therefore performed an epidemiologic investigation to describe the incidence and prevalence of the three diseases in a defined population. METHODS: Patients with PBC, PSC, or AIH admitted to Aker University Hospital in Oslo were prospectively registered during the 10-year period 1986-95. This hospital serves a defined population of 130,000 inhabitants. The mean yearly incidence and the point prevalences at the end of each year were calculated. RESULTS: During the 10-year period 21 patients with PBC, 17 with PSC, and 25 with AIH were diagnosed. The mean annual incidence per 100,000 was 1.6 for PBC, 1.3 for PSC, and 1.9 for AIH. The point prevalences per 100,000 on 31 December 1995 were 14.6, 8.5, and 16.9 for PBC, PSC, and AIH, respectively. CONCLUSIONS: The prevalences of PBC and AIH are of the same order of magnitude and about twice as high as that of PSC. These epidemiologic data can be used to estimate the number of liver transplantations required due to autoimmune liver diseases.
Dieulafoys vascular malformation: role of endoscopic ultrasonography in therapeutic decision-making.
Nesje LB. Skarstein A. Matre K. Myking AO. Odegaard S.
Medical Dept. A, Haukeland Hospital, Deaconess Hospital, University of Bergen, Norway.
BACKGROUND: Dieulafoy's vascular malformation may cause severe, potentially life-threatening gastrointestinal bleeding. Endoscopic diagnosis may be difficult because of minute mucosal lesions, and additional intramural abnormalities are usually not encountered. Endoluminal high-frequency ultrasonography is a new modality for imaging intramural and perivisceral structures. METHODS: We report two cases of recurrent severe gastric bleeding in which different endosonographic modalities were used in the diagnosis of Dieulafoy's malformation, and the impact of endosonography on therapeutic strategy is discussed. In the first case a radial-scanning 7.5/12-MHz echoendoscope and a linear 20-MHz miniature probe were applied for B-mode imaging in a stable-state patient who had undergone previous endoscopic sclerotherapy, and arterial flow signals from the small intramural lesion were recorded using a 10-MHz transendoscopic pulsed Doppler probe. In the other case urgent endosonography was performed shortly after a bleeding episode, disclosing an aberrant large-calibre artery entering the gastric wall with a long submucosal branch. RESULTS: Both patients were successfully operated on with a transabdominal approach. CONCLUSION: Endosonography is a quick and safe diagnostic method and should be considered when vascular malformations are suspected as the cause of gastric bleeding.
Intraductal ultrasonography may localize islet cell tumours negative on endoscopic ultrasound.
Menzel J. Domschke W.
Dept. of Medicine B, University of Munster, Germany.
Two patients with suspected insulinoma and one patient with a gastrinoma were referred to our hospital for preoperative tumour localization. Conventional imaging methods and even endoscopic ultrasonography did not detect any tumour in the pancreatic parenchyma. During endoscopic retrograde cholangiopan-creatography ultrasound miniprobes with a 2-mm diameter were applied via the biopsy channel of the duodenoscope. After insertion of the ultrasound probe into the pancreatic duct intraductal sonography (IDUS) was able to depict the tumours. The two insulinomas (1.8 x 2 mm and 5 x 8 mm, respectively) could be localized, as could the gastrinoma, which had a diameter of 6 mm. IDUS diagnosis was confirmed by surgery as the tumours were resected. Follow-up showed no evidence of tumour recurrence.
Different effects of white and red wine on lower esophageal sphincter pressure and gastroesophageal reflux.
Pehl C. Pfeiffer A. Wendl B. Kaess H.
Dept. of Gastroenterology and Hepatology, Hospital Bogenhausen, Munich, Germany.
BACKGROUND: White wine and beer induce gastroesophageal reflux (GER). We investigated the effects of white and red wine on lower esophageal sphincter pressure (LESP) and GER. METHODS: Twenty healthy volunteers received 300 ml white wine, red wine, or water together with a standardized meal. The LESP was continuously monitored with a Dent sleeve the 1st h postprandially, and the esophageal pH measured with a glass pH electrode. RESULTS: The LESP was decreased after intake of white wine (median, 14.9 mmHg; range, 5.6-19.5 mmHg) compared with red wine (20.4 mmHg; 13.1-22.3 mmHg; P < 0.05) and tap water (19.5 mmHg; 16.2-29.1 mmHg; P < 0.01). The fraction time esophageal pH
The symptomatic effect of cisapride in patients with irritable bowel syndrome and constipation.
Farup PG. Hovdenak N. Wetterhus S. Lange OJ. Hovde O. Trondstad R.
Dept. of Medicine, Gjovik County Hospital, Norway.
BACKGROUND: Cisapride improves symptoms in patients with idiopathic constipation. This trial compares the effect of cisapride with that of placebo in patients with irritable bowel syndrome (IBS) and constipation. METHODS: Seventy patients were randomized to 12 weeks' treatment with 5 mg cisapride three times daily or placebo in a double-blind trial. The dose could be doubled after 4 weeks in patients without satisfactory improvement. The patients scored their symptoms on a 100-mm visual analogue scale (VAS) (0 = best, 100 = worst), and the investigators evaluated the symptomatic effect. RESULTS: The dose was doubled in 17 and 23 patients in the cisapride and placebo groups, respectively, after 4 weeks. The patients' mean VAS score for global evaluation of IBS symptoms in the cisapride and placebo groups was 73 and 71 mm, respectively, at the start of treatment and 47 and 41 mm at the end. The difference between cisapride and placebo at the end was 6 mm in favour of placebo (95% confidence interval (CI), -6, 18) (NS). The investigators evaluated the effect as good or excellent in 39.2% and 58.8% in the cisapride and placebo groups, respectively. The difference in favour of placebo was 19.5% (95% CI, -5, 44) (NS). Nor were any statistically significant differences seen between cisapride and placebo in the other effect factors. CONCLUSIONS: The trial seems to exclude a clinically significant effect of 15-30 mg cisapride daily in patients with IBS and constipation during a 12-week treatment period.
Failure to confirm association of vac A gene mosaicism with duodenal ulcer disease.
Go MF. Cissell L. Graham DY.
Dept. of Medicine, Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas 77030, USA.
BACKGROUND: Mosaicism of the Helicobacter pylori vac A gene comprises two families of allelic variations of the signal sequence region (s1, s2) and of the mid-region (m1, m2). Initial studies suggested that peptic ulcer disease correlated with the s1 subtype of vac A. We compared the prevalence of various vac A genotypes of H. pylori isolates obtained from duodenal ulcer (DU) patients and subjects with simple gastritis. Those isolates with s1 type were further examined to determine whether the specific vac A s1 (s1a versus s1b) genotype enabled prediction of gastroduodenal disease. METHODS: H. pylori isolates were obtained from 38 patients with endoscopically documented DU and 39 individuals with asymptomatic H. pylori gastritis from Houston, Texas. The vac A genotype of each isolate was determined by polymerase chain reaction (PCR) amplification of genomic DNA for specific regions of the vac A gene. Those isolates with s1 vac A subtype were further examined to determine whether they had s1a or s1b mosaicism. RESULTS: There was no difference in frequency of the s1 genotype of isolates obtained from patients with duodenal ulcer or asymptomatic H. pylori gastritis in this sample (84% versus 79%, respectively; P = 0.77). The s1/m1 vac A genotype was detected in isolates from 16 duodenal ulcer patients versus 15 with H. pylori gastritis (P = 0.82). Detailed analysis of the s1 region failed to show a correlation of either s1a or s1b with duodenal ulcer. Both s1a and s1b genotypes were detected in 24 strains, and both m1 and m2 mid-gene PCR amplicons were seen in 16 strains. CONCLUSIONS: We were unable to use H. pylori vac A genotyping to predict type of gastroduodenal disease in our patient sample. This failure to confirm an association of vac A genotype and duodenal ulcer disease differs from samples from other regions. This most likely represents an example of differences in H. pylori strains infecting host populations in different geographic regions. This study confirms the importance of establishing statistical associations with isolates from widely separate geographic regions before concluding that disease-related associations exist.
Differing patterns of Helicobacter pylori gastritis in patients with duodenal, prepyloric, and gastric ulcer disease.
Schultze V. Hackelsberger A. Gunther T. Miehlke S. Roessner A. Malfertheiner P.
Dept. of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany.
BACKGROUND: We investigated the risk relationship between histotopographic patterns of Helicobacter pylori gastritis and peptic ulcer site. METHODS: Three hundred and eighty-three infected patients were classified as having duodenal ulcer (n = 79), prepyloric ulcer (n = 39), gastric (angular) ulcer (n = 28), and no ulcer (n = 237). Antral and corpus biopsy specimens were taken. Sydney system-based scores for bacterial density and activity and degree of gastritis were added to antral and corpus sum scores (SS) (range, 0-9). These were used to categorize the phenotype of gastritis. In addition, the presence or absence of mucosal atrophy was taken into account. The relative risk for ulcer association with these conditions was calculated. RESULTS: High-grade antral (SS > 5) associated with mild to moderate corpus (SS > 5) gastritis increased duodenal (RR = 4.9; confidence interval (CI), 2.8-8.5) and prepyloric ulcer risk (RR = 2.99; CI, 1.4-6.2). High-grade gastritis in the antrum (SS > 5) and corpus (SS > 5) increased gastric ulcer risk (RR = 3.7; CI, 1.6-8.3). Antral atrophy and/or intestinal metaplasia is associated with an increased gastric ulcer risk (RR = 3.3; CI, 1.4-7.8). CONCLUSION: The pattern of H. pylori gastritis may define a risk for peptic ulcer at various sites, but additional factors, not reflected in histology, also contribute to this risk.
Epidermal growth factor and transforming growth factor alpha in duodenal ulcer and non-ulcer dyspepsia patients before and after Helicobacter pylori eradication.
Konturek PC. Bobrzynski A. Konturek SJ. Bielanski W. Faller G. Kirchner T. Hahn EG.
Dept. of Medicine I and Institute of Pathology, University of Erlangen-Nuremburg, Erlangen, Germany.
BACKGROUND: Epidermal growth (EGF) and transforming growth factor alpha (TGFalpha) are potent gastric secretory inhibitors, mitogens, and mucosal protectors, but the impact of Helicobacter pylori infection on their mucosal expression and luminal release has not been clarified. METHODS: In this study, gene and immunoreactive and immunohistochemical expressions of EGF and TGFalpha were assessed in the gastric mucosa of 15 H. pylori-negative healthy normals, in 22 H. pylori-positive duodenal ulcer patients (DU) and in 24 H. pylori-positive non-ulcer dyspepsia patients (NUD). All studies in DU and NUD patients were repeated after 2 weeks of triple therapy (amoxicillin + clarithromycin + omeprazole) and 4 weeks and 2 years later. RESULTS: Immunohistochemical expression of EGF and TGFalpha in H. pylori-positive DU and NUD was significantly higher than in H. pylori-negative normals, and this increase persisted at 2 and 4 weeks after therapy but normalized 2 years later. EGF mRNA was detected in the gastric mucosa of H. pylori-positive DU before and at 2 and 4 weeks after H. pylori eradication, but it was not found 2 years after the eradication of H. pylori or in gastric mucosa of H. pylori-negative control subjects. TGFalpha mRNA was detected in the gastric mucosa independently of H. pylori status, with the stronger expression observed in the gastric mucosa of H. pylori-positive DU and NUD before eradication than after this procedure. Plasma gastrin, which was significantly increased in H. pylori-positive DU, normalized already after 2 weeks of triple therapy. The eradication rate as determined by histology after triple therapy reached 86.3% in DU patients and 90.5% in NUD patients. Two years after the eradication the H. pylori reinfection rate was 4.5% among DU patients and 4.2% among NUD. Treatment of DU patients with triple therapy resulted in complete ulcer healing. CONCLUSIONS: 1) Chronic H. pylori infection and resulting antral gastritis are associated with increased plasma gastrin and increased mucosal cell proliferation, probably due to enhanced expression of EGF and TGFalpha, and 2) the H. pylori eradication results in a decrease in plasma gastrin, but the increase in gastric TGFalpha and EGF content is sustained, suggesting that they may be involved in ulcer healing.
Efficacy of oral hyposmolar glucose-based and rice-based oral rehydration salt solutions in the treatment of cholera in adults.
Bhattacharya MK. Bhattacharya SK. Dutta D. Deb AK. Deb M. Dutta A. Saha Choudhury A. Nair GB. Mahalanabis D.
National Institute of Cholera and Enteric Diseases, Calcutta, India.
BACKGROUND: Recent animal experiments and clinical trials have shown that both osmolarity and rice as the organic components are important factors for net intestinal absorption of an oral rehydration salt solution. METHODS: In a controlled clinical trial 123 male adult patients with severe cholera, after initial rehydration with intravenous Ringer's lactate solution, were randomly assigned to receive one of the four oral rehydration salt solutions: WHO ORS, ORS containing 70 mmol/l Na+ and 16.2 g/l glucose, rice ORS containing 50 g/l rice and 90 mmol/l Na+, and rice ORS containing 50 g/l rice and 70 mmol/l Na+. All patients received 300 mg of doxycycline as a single dose. RESULTS: Patients who received rice-low-sodium ORS subsequently had lower (P < 0.05) stool output, ORS consumption, and diarrhoea duration than the other three ORS groups. CONCLUSIONS: We conclude that rice-based low-sodium ORS is superior for treating adult cholera.
Increased luminal nitric oxide in inflammatory bowel disease as shown with a novel minimally invasive method.
Herulf M. Ljung T. Hellstrom PM. Weitzberg E. Lundberg JO.
Dept. of Pharmacology, Karolinska Institute, Stockholm, Sweden.
BACKGROUND: The production of nitric oxide (NO) is increased in ulcerative colitis, as shown by bioassays of NO synthase activity in mucosal biopsy specimens. We wanted to develop a less invasive method for measurement of NO directly in the rectum in patients with inflammatory bowel disease (IBD). METHODS: We studied 10 patients with active ulcerative colitis, 6 with active Crohn's disease, 6 with non-active ulcerative colitis, and 24 controls without inflammation A tonometer balloon catheter was inserted in the rectum and inflated with 5 ml of NO-free air. After 15 min of incubation the sample was extracted, and the NO concentration was immediately analysed with a chemiluminescence technique. RESULTS: Patients with active disease had greatly increased concentrations of NO in the rectum as compared with controls and patients with non-active disease. CONCLUSIONS: During inflammation in the large intestine increased amounts of NO are released from the mucosa. Measurements of NO directly in the rectum could be of help in further understanding the role of this gas in IBD. Moreover, it is tempting to speculate that this minimally invasive method could be clinically useful as a diagnostic tool and in monitoring the effect of therapy.
Long-term observation of the perinuclear anti-neutrophil cytoplasmic antibody status in ulcerative colitis patients.
Vecchi M. Bianchi MB. Calabresi C. Meucci G. Tatarella M. de Franchis R.
Dept. of Gastroenterology and Digestive Endoscopy, Institute of Internal Medicine, University of Milan, IRCCS Ospedale Policlinico di Milano, Italy.
BACKGROUND: Perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA) have been regarded as a possible immunogenetic marker of ulcerative colitis. If this were true, the p-ANCA status of a given patient should be constant over time; however, little information is available on this issue. METHODS: One hundred and forty-five sera collected from 40 ulcerative colitis patients during a mean follow-up period of 50.6 months were tested for p-ANCA reactivity by indirect immunofluorescence. RESULTS: At base line 24 patients (60%) were p-ANCA-positive, with no relationship to gender distribution, age at diagnosis, disease activity, or extension. During follow-up, changes in p-ANCA status occurred in 10 patients (25%). P-ANCA positivity during follow-up was associated with more aggressive forms of disease, whereas p-ANCA negativity was associated with stable remission. CONCLUSIONS: Changes in the p-ANCA status over time occur in some ulcerative colitis patients. P-ANCA behaviour is associated with different clinical patterns of disease.
Comparison of nuclear matrix protein composition in colon cancer and dysplasia.
Izzo RS. Pellecchia C.
Dept. of Medicine, Nassau County Medical Center, East Meadow, New York 11554, USA.
BACKGROUND: Abnormal nuclear morphology associated with cancer may reflect changes in the proteins of the nuclear matrix. METHODS: Nuclear matrix (NM) proteins were isolated from colonic tissue and analyzed by two-dimensional gel electrophoresis. RESULTS: Several matrix proteins that were found in ulcerative colitis (UC) dysplasia (n = 5) and/or UC cancer (n = 4) were not identified in normal colonic tissue. UC dysplasia tissue showed three specific NM proteins with molecular masses of 49.2 kDa, 20.0 kDa, and 19.0 kDa, whereas 29.0-kDa and 32.0-kDa proteins were specific to UC cancer. Three proteins with 59.5-kDa (pI 6.3 and 6.6) and 33.75-kDa (pI 7.5) masses were common to both dysplasia and cancer tissue. CONCLUSIONS: These data suggest that NM proteins may have a role in the transition of tissue towards the malignant phenotype.
The effect of treatment with alpha-interferon on hepatitis G/GBV-C viraemia. The CONSTRUCT Group.
Jarvis LM. Bell H. Simmonds P. Hawkins A. Hellum K. Harthug S. Maeland A. Ritland S. Myrvang B. von der Lippe B. Raknerud N. Skaug K.
Dept. of Medical Microbiology, University of Edinburgh, UK.
BACKGROUND: Hepatitis G virus (HGV) or GBV-C is frequently detected in patients co-infected with hepatitis C virus (HCV). This study investigated host and virologic factors influencing the response to HGV/GBV-C to alpha-interferon treatment. METHODS: HGV/GBV-C was detected and quantified by nested polymerase chain reaction. The influence of variables such as liver biopsy appearance, liver function abnormalities, and response of HCV to interferon treatment was monitored. RESULTS: Fourteen of the 25 HGV/GBV-C-infected patients treated with interferon (3-6 MIU three times a week for 6 months) became non-viraemic during treatment, although all relapsed after treatment withdrawal at 6 months, with no net change in virus load between 0 and 12 months. CONCLUSIONS: Predictive factors for clearance of HGV/GBV-C viraemia by interferon were pre-treatment severity of liver disease (median Knodell score of 4, compared with 7 for non-responders; P = 0.030) and alanine aminotransferase levels (median, 114, 182 for non-responders; P = 0.039). Clearance was associated with the treatment response of HCV. Nine of 13 who cleared HGV/GBV-C also cleared HCV, compared with 3 of 11 HGV/GBV-C non-responders; P = 0.05). The shared susceptibility of HGV/GBV-C and HCV to interferon treatment suggests a link between the mechanism of clearance of the two viruses.
A scoring system for early differentiation of the etiology of acute pancreatitis.
Stimac D. Lenac T. Marusic Z.
Internal Clinic, Gastroenterology Division, Clinical Hospital Center Rijeka, Croatia.
BACKGROUND: The purpose of this study was to find a new scoring system for early differentiation between the two commonest etiologies of acute pancreatitis (biliary and alcoholic), because biliary pancreatitis can be treated early by endoscopic sphincterotomy, whereas such treatment is unnecessary in alcoholics. METHODS: One hundred and forty-five patients satisfied the requirements for participation in the study and were divided into groups A (alcoholic pancreatitis) and B (biliary pancreatitis). Seven variables (serum and urine amylase, aspartate aminotransferase (ASAT), alanine aminotransferase (ALAT), alkaline phosphatase (ALP), lipase/amylase (L/A) ratio, and erythrocyte mean corpuscular volume (MCV)) that differed in a statistically significant manner between patients of the two groups were included in the scoring system. Each parameter was counted as 0 or 1 on the basis of its values, so the patients reached scores from 0 to 7. RESULTS: Scores > or =4 (P < 0.0001) were consistently present in biliary pancreatitis, whereas alcoholics scored
Human immunodeficiency virus-related abdominal pain in South Africa. Aetiology, diagnosis and survival.
O'Keefe EA. Wood R. Van Zyl A. Cariem AK.
Dept. of Medicine, University of Cape Town, Somerset Hospital, Greenpoint, South Africa.
BACKGROUND: Abdominal pain in acquired immunodeficiency syndrome (AIDS) patients is often a marker of an underlying opportunistic pathologic condition. There are no data on HIV-related abdominal pain in Africa. METHODS: Forty-four consecutive Cape Town patients with advanced human immunodeficiency virus (HIV) infection (CD4 < 200) and abdominal pain were studied prospectively to determine aetiology and survival. RESULTS: A probable cause of pain was identified in 37 (84%): disseminated Mycobacterium tuberculosis infection in 11, cryptosporidiosis in 6, cytomegalovirus infection in 6, and atypical mycobacterial infection in 2. Gastrointestinal lymphoma and pancreatitis were not seen. Fever, hepatomegaly, respiratory symptoms, abnormal chest radiograph, and adenopathy, ascites, or abscesses on ultrasound had predictive diagnostic value for disseminated M. tuberculosis. Fifty-one per cent of abdominal pain patients survived 6 months, compared with 73% of all AIDS patients (P < 0.001). CONCLUSIONS: The aetiology of HIV-related abdominal pain in Cape Town reflects the high local prevalence of tuberculosis. Clinical and ultrasound features facilitate diagnosis. Abdominal pain is associated with poor survival.
Metachronous small-bowel adenocarcinoma in coeliac disease: gluten-free diet is not protective.
Kingham JG. Ramanaden D. Dawson A.
Dept. of Gastroenterology, Singleton Hospital, Swansea, UK.
Coeliac disease is associated with an increased risk of certain gastrointestinal malignancies, especially of the small bowel. Metachronous malignancies are well established in the colon, where adenocarcinoma is common, but are exceptional in the small intestine. We describe a young woman with a long history of malabsorption who was shown to have coeliac disease complicated by a small-bowel adenocarcinoma. The cancer was resected, and the coeliac disease went into complete remission on a strict gluten-free diet. Fifteen years later she developed iron deficiency anaemia. Investigations showed a metachronous small-bowel adenocarcinoma but continuing remission of the coeliac disease. The case provides strong evidence against a causative role for the enteropathy of active coeliac disease in small-bowel adenocarcinoma and against a protective effect of a gluten-free diet in tumour development. Predisposition to adenocarcinoma in coeliac disease is probably genetic.
Lansoprazole, amoxicillin, and clarithromycin triple therapy in vagotomized patients with dyspeptic complaints. A randomized, double-blind, placebo-controlled, clinical study without pretreatment diagnostic upper endoscopy.
Lindsetmo RO. Johnsen R. Revhaug A.
Dept. of Gastrointestinal Surgery, Tromso University Hospital, Norway.
BACKGROUND: The Maastricht Consensus Report advises that, in Helicobacter pylori-positive patients after surgery for peptic ulcer disease, H. pylori should be eradicated. The aim of the present study was to investigate the symptomatic response of H. pylori eradication in previously vagotomized peptic ulcer patients with persistent dyspeptic complaints. METHODS: The study was performed as a randomized, double-blind, placebo-controlled study. Pretreatment diagnostic upper endoscopy was omitted. All the results were submitted to intention-to-treat and efficacy analyses. RESULTS: We could not find any differences between the two groups with regard to intensity or frequency of upper abdominal pain, nausea, heartburn, or other abdominal symptoms during the 12-month follow-up. The triple therapy eradication rate was 88% at both 3- and 12-month controls. CONCLUSION: Vagotomized peptic ulcer patients with persistent dyspeptic complaints should undergo a diagnostic upper endoscopy to detect ulcer recurrence before H. pylori eradication treatment is considered.
The ability of enteric diarrhoeal pathogens to ferment starch to short-chain fatty acids in vitro.
Krishnan S. Rajan DP. Ramakrishna BS.
Wellcome Trust Research Laboratory, Dept. of Gastrointestinal Sciences, Christian Medical College Hospital, Vellore, India.
BACKGROUND: Short-chain fatty acids (SCFA), produced in the normal colon by bacterial fermentation, are decreased in acute diarrhoea. This may have deleterious effects on epithelial function in the colon. METHODS: The ability of several diarrhoeal pathogens to produce SCFA when incubated with starch in vitro was studied. Isolated pathogens were incubated for 24 h with either no added substrate, glucose, or starch under anaerobic conditions, and SCFA were quantitated by gas-liquid chromatography. RESULTS: Unlike the normal colonic flora, the pathogens produced acetate but not propionate or butyrate. D-Lactate was also produced by all the pathogens studied. When the pathogens were incubated in anaerobic medium containing starch, significantly greater amounts of acetate and significantly lesser amounts of lactate were produced. CONCLUSIONS: The inability of enteric pathogens to produce butyrate may impair epithelial cell function, whereas production of D-lactate may enhance mucosal damage in diarrhoeal disease. The presence of luminal starch may be helpful in shifting the fermentation profile to a more favourable pattern.
Depressive symptoms in adult coeliac disease.
Ciacci C. Iavarone A. Mazzacca G. De Rosa A.
Dept. of Gastroenterology, University of Naples Federico II, Italy.
BACKGROUND: Psychic symptoms and depression have been reported in coeliac disease (CD). The aim of this study was to explore depression in a large cohort of adult CD patients. METHODS: Depressive symptoms were evaluated in 92 adult coeliacs, 100 normal controls (NC), and 48 chronic persistent hepatitis (CPH) patients by means of a modified version of the Zung Self-Rating Depression Scale (M-SDS). CD patients were evaluated for the level of knowledge about CD and the compliance with diet. RESULTS: The M-SDS score differentiated CD patients from NC. Age at diagnosis and duration of and compliance with diet did not correlate with depression. Three main factors could be identified with the M-SDS: 'reactiveness', 'pessimism', and 'anhedonic-asthenic'. CONCLUSION: Depressive symptoms are a feature of CD; they are present to a similar extent in patients with childhood- and adulthood-diagnosed CD. The results underline the relevance of personal psychologic resources, which play a fundamental role in determining and sustaining depression.
IgA- and IgG-class antihuman umbilical cord antibody tests in adult coeliac disease.
Sulkanen S. Collin P. Laurila K. Maki M.
Institute of Medical Technology and Medical School, University of Tampere, Finland.
BACKGROUND: An antiendomysium antibody test using human umbilical cord as antigen has recently been introduced. METHODS: We determined IgA- and IgG-class antihuman umbilical cord (HUC-ab), antireticulin (ARA), and antigliadin antibodies (AGA) in 92 untreated adult coeliac patients, in 95 non-coeliac subjects, and in 4 coeliac patients with selective IgA deficiency. Tissue antibodies were measured with an indirect immunofluorescence method and AGA with an enzyme-linked immunosorbent assay. RESULTS: Of adult coeliac patients 85% were positive for IgA-class HUC-ab, 78% were positive for ARA, and 80% for AGA; the specificity for HUC-ab and ARA was 100%, and for AGA 86%. Combination of HUC-ab, ARA, and high-titre AGA increased the sensitivity to 96% without loss of specificity. IgG-class HUC-ab was positive in 12% of coeliac patients, in all four coeliac patients with IgA deficiency, and in none of the controls. CONCLUSIONS: The HUC-ab test is highly specific but not 100% sensitive for detecting adult coeliac disease. A combination of the IgA-class HUC-ab, ARA, and high-titre AGA tests is recommended. In selective IgA deficiency the IgG-class HUC-ab test seems to work well.
Fecal alpha-1-antitrypsin excretion in children with diarrhea.
Lisowska-Myjak B. Pachecka J. Sokrates O. Brzozowska-Binda A. Torbicka E.
Dept. of Biochemistry and Clinical Chemistry, Medical University of Warsaw, Poland.
BACKGROUND: The aim of this study was to compare the concentration and immunoelectrophoretic characterization of alpha-1-antitrypsin (AAT) excreted in random fecal samples in children with acute and chronic diarrhea and in control groups. METHODS: Thirty-two children with diarrhea and 23 healthy children were evaluated. The concentration and characterization of AAT were determined by radial immunodiffusion and crossed immunoelectrophoresis, respectively. RESULTS: The increase in the concentration of fecal AAT was more than the upper limit for the control group (1.25 mg/g of dry stool mass) in the patients with chronic infectious diarrhea and in 52% of those with chronic non-infectious diarrhea but not in those with acute diarrhea, infectious or non-infectious. Immunoelectrophoretic analysis showed two forms of fecal AAT in both sick and healthy children. The alterations in the concentration of fecal AAT did not correlate with the immunoelectrophoretic pattern of AAT. CONCLUSION: Our results suggest that the determination of fecal AAT could give clinically useful information about the difference between infectious and non-infectious diarrhea and the activity of characterizing disease with diarrhea.
Time trends for peptic ulcer disease in Denmark, 1981-1993. Analysis of hospitalization register and mortality data.
Andersen IB. Bonnevie O. Jorgensen T. Sorensen TI.
Dept. of Medicine 261, Hvidovre University Hospital, Copenhagen, Denmark.
BACKGROUND: Since the mid-1980s there has been great improvement in the available diagnostic tools and treatments for peptic ulcers. The aim of this study was to determine whether these improvements have been paralleled by decreasing age- and sex-specific hospitalization and death rates for peptic ulcers in Denmark. METHODS: The study was based on all discharges from Danish somatic hospitals as registered in the National Hospital Discharge Registry and all the death certificates as registered in the Danish National Board of Health from 1981 through 1993, when a diagnosis of peptic ulcer was recorded. The age- and sex-specific and age-adjusted hospitalization and death rates were estimated. RESULTS: In men the age-adjusted hospitalization rate for all types of peptic ulcers decreased by 0.88, but the mortality increased by 1.19. In women the age-adjusted hospitalization and mortality increased for all types of peptic ulcers. The increasing mortality was mainly due to bleeding and perforated duodenal ulcers. The analysis of the age-specific hospitalization and mortality for peptic ulcer complications showed that the increasing trends mainly occurred among the elderly. CONCLUSION: The improved medical treatment of peptic ulcers has not been paralleled by decreasing hospitalization or death from complicated peptic ulcers in Denmark. On the contrary, we found an increasing hospitalization and mortality from peptic ulcer complications, particularly in elderly Danish people.
Antigastric autoantibodies and gastric secretory function in Helicobacter pylori-infected patients with duodenal ulcer and non-ulcer dyspepsia.
Faller G. Winter M. Steininger H. Konturek P. Konturek SJ. Kirchner T.
Institute of Pathology and Dept. of Internal Medicine I, University of Erlangen-Nurnberg, Erlangen, Germany.
BACKGROUND: Autoantibodies against epitopes located at the canaliculi of human parietal cells occur in about 30% of Helicobacter pylori-infected patients. This has led to the hypothesis that gastric secretory function could be inhibited by anticanalicular autoantibodies in H. pylori gastritis. METHODS: Forty-four H. pylori-infected patients with and without duodenal ulcers were screened for anticanalicular autoantibodies by means of immunohistochemistry. Plasma gastrin levels and basal and maximal gastric acid output were determined. RESULTS: Fasting gastrin levels were significantly increased in the group with anticanalicular autoantibodies. In the group of patients with non-ulcer dyspepsia the presence of anticanalicular autoantibodies was significantly correlated with an impaired basal acid secretion. CONCLUSIONS: Antigastric autoimmunity in H. pylori gastritis seems to be relevant for gastric hyposecretion either directly by inhibiting the proton pump or indirectly through the development of gastric mucosa atrophy.
Evaluation and validation of a Crohns disease inflammatory activity index reflecting pattern of endoscopic severity.
Simonis B. Heine M. Heene DL. Gladisch R.
Dept. of Internal Medicine I and Institute of Pathology, Mannheim University Hospital, University of Heidelberg, Germany.
BACKGROUND: This study was designed to investigate objective variables assessing the inflammatory activity of Crohn's disease accessible for routine management and their suitability to act as surrogate indicators for endoscopic alterations. METHODS: Thirty-six patients were included in a prospective study and underwent endoscopic investigation, 18 with clinically exacerbated disease and 18 after acute-phase conservative therapy. The endoscopic findings were classified to define the dependent variable, yielding two categoric levels: acute active disease and remission. The extent of affected mucosal area was not taken into consideration. The serum variables alpha1-antitrypsin, acid alpha1-glycoprotein (AGP), C-reactive protein (CRP), sialic acids, prealbumin (PAB), and albumin were used as independent variables to predict the dependent variable. To compare the results with common indices, the Crohn's Disease Activity Index (CDAI) and van Hees Index were calculated. RESULTS: The following model was calculated by stepwise logistic regression analysis: if AGP (mg/dl) -4.2 x PAB (mg/dl) > or =0.8, then endoscopically active disease will be predicted with a sensitivity of 100% and a specificity of 95% (P < 0.001). The predictive values of the single variables, CDAI, and van Hees Index were lower. For validation of results an analogous study was performed including 44 patients, 29 with active disease and 15 controls. The existence of the model was confirmed, again showing high values for sensitivity (86%) and specificity (100%). CONCLUSIONS: On a qualitative level focusing on clinical relevance, the endoscopic and biologic findings of Crohn's disease are highly associated. In addition to clinical assessment, usage of the developed index as a rationale contributing to therapeutic decisions in the short- and long-term management might be reasonable.
Chronic inflammatory changes in the pouch mucosa are associated with cholangitis found on peroperative liver biopsy specimens at restorative proctocolectomy for ulcerative colitis.
Aitola P. Matikainen M. Mattila J. Tomminen T. Hiltunen KM.
Dept. of Surgery, Tampere University Hospital and Medical School, University of Tampere, Finland.
BACKGROUND: The clinical syndrome of primary sclerosing cholangitis (PSC), diagnosed in about 5% of patients with ulcerative colitis (UC), has been shown to be associated with pouchitis after ileal pouch-anal anastomosis. The aim of this study was to ascertain whether UC patients with cholangitis on liver biopsy at proctocolectomy, with or without the clinical syndrome of PSC, have an increased risk of inflammatory changes in the ileal reservoir mucosa and clinical pouchitis. METHODS: Of the consecutive 81 UC patients treated with restorative proctocolectomy with ileal J reservoir at Tampere University Hospital between 1985 and 1991, 73 with peroperative liver biopsy were included. A peroperative liver biopsy was obtained during proctocolectomy. After a median follow up of 64 months, pouch biopsy specimens were obtained. Periods of clinical pouchitis were diagnosed by means of clinical criteria alone or by clinical criteria combined with the results of previous pouch endoscopies in all patients. RESULTS: Ten patients (14%) showed histologic features consistent with small-duct PSC on liver biopsy. Endoscopic retrograde cholangiography had previously been performed on four of these patients, and all four had large-duct PSC. Patients with cholangitis had significantly more severe chronic, but not acute, inflammation in the pouch mucosa than patients without cholangitis. At least one episode of pouchitis occurred in 30% of the patients without cholangitis as compared with 90% of the patients with cholangitis. Chronic pouchitis was more frequent in the group with cholangitis than in the group without it (70% versus 11%). CONCLUSIONS: The only means of detecting all UC patients with cholangitis is a liver biopsy. Cholangitis, either with the clinical syndrome of PSC or found on liver biopsy, seems to be a risk factor for chronic-type inflammatory changes in the pouch mucosa and for the development of pouchitis.
Gastric cancer and premalignant lesions in atrophic gastritis: a controlled trial on the effect of supplementation with alpha-tocopherol and beta-carotene. The Helsinki Gastritis Study Group.
Varis K. Taylor PR. Sipponen P. Samloff IM. Heinonen OP. Albanes D. Harkonen M. Huttunen JK. Laxen F. Virtamo J.
National Public Health Institute, and Dept. of Clinical Chemistry, University of Helsinki, Finland.
BACKGROUND: Vitamin E and beta-carotene are considered to decrease the risk of gastric cancer both in humans and in laboratory animals. We studied the effect of dietary supplementation with alpha-tocopherol and beta-carotene on the end-of-trial prevalence of premalignant and malignant lesions of the stomach in older men with atrophic gastritis. METHODS: The study was carried out within the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study (ATBC study) in Finland, in which 29,133 male smokers aged 50-69 years were randomly assigned to receive daily 50 mg alpha-tocopherol, 20 mg beta-carotene, both of these agents, or placebo, for 5-8 years. Serum pepsinogen was determined at base line and after 3 years' supplementation to find men with atrophic gastritis. A low serum pepsinogen I level, indicating atrophic gastritis of the corpus area of the stomach, was found in 2132 men. These men were invited to have upper gastrointestinal endoscopy (gastroscopy), which was performed on 1344 subjects after a median supplementation time of 5.1 years. RESULTS: Neoplastic alterations were found in 63 of the men (4.7%): 42 with definite dysplasias of low grade (moderate dysplasia), 7 with definite dysplasias of high grade (severe dysplasia), 11 with carcinomas (of which 7 were 'early' cancers), and 3 with carcinoid tumors. Neither alpha-tocopherol (relative risk, 0.98; 95% confidence interval, 0.57-1.69) nor beta-carotene (relative risk, 1.13; 95% confidence interval, 0.65-1.95) supplementation had any association with end-of-trial prevalence of gastric neoplasias after adjustment for other possible risk factors. The effect was not modified by base-line serum level or dietary intake of vitamins, prevalence of Helicobacter pylori infection, or other covariates. CONCLUSIONS: We thus conclude that supplementation with alpha-tocopherol or beta-carotene for 5 years has no major impact on the occurrence of neoplastic changes of the stomach in older male smokers with atrophic gastritis.
Expression of CD44 and variant proteins in human colorectal cancer and its relevance for prognosis.
Ropponen KM. Eskelinen MJ. Lipponen PK. Alhava E. Kosma VM.
Dept. of Pathology and Forensic Medicine, University of Kuopio, Finland.
BACKGROUND: CD44 is a cell adhesion molecule often expressed in the form of various splice variants. The role of standard CD44 isoform (CD44s) and its variants in colorectal carcinogenesis is partly conflicting. Therefore, we compared the expression of CD44s (hermes-3) and its splice variants (v3 and v6) with traditional prognostic factors in 194 colorectal cancer patients treated at Kuopio University Hospital and followed up for a mean of 14 years. METHODS: Formalin-fixed, paraffin-embedded tissue sections from 194 patients with colorectal carcinoma were examined immunohistochemically to detect the expression of different forms of CD44. The hypothesis that CD44s, CD44v3, and CD44v6 expression intensities and distribution in cancer cells correlated with survival was tested with the log-rank test, hazard ratios, and their confidence intervals. RESULTS: In high-grade tumours CD44s and CD44v6 expression intensities and CD44s percentages were stronger than in low-grade tumours. CD44v6, CD44v3, and CD44s expression intensities in tumour epithelium were also stronger in Dukes C and D tumours than in A and B tumours. In the univariate survival analysis patients with strong CD44s, CD44v3, and CD44v6 expression intensities in tumour epithelium had lower cancer-related survival than the patients who had weak CD44s, CD44v3, and CD44v6 expression intensities. Recurrence-free survival was also shorter in patients with intense signals for CD44v3 and CD44v6 in tumour epithelium. In the multivariate analysis the CD44v6 expression intensity in tumour epithelium predicted independently both cancer-related and recurrence-free survival in T1-4N0-3M0 and T1-3N0M0 cases. In addition, the CD44v3 expression intensity in tumour epithelium was a significant predictor of RFS in T1-3N0M0 cases. CONCLUSIONS: These results strongly suggest that the CD44 splice variants v6 and v3 have prognostic significance in colorectal cancer.
Benzodiazepine-like compounds in the plasma of patients with fulminant hepatic failure.
Zeneroli ML. Venturini I. Corsi L. Avallone R. Farina F. Ardizzone G. Centanaro M. Arrigo A. Schreier P. Kleinschnitz M. Baraldi M.
Dept. of Medical Symptomology and Methodology, University of Modena, Italy.
BACKGROUND: Benzodiazepine-like compounds have been implicated in the pathogenesis of encephalopathy after fulminant hepatic failure. METHODS: The levels and the nature of benzodiazepine-like compounds were determined in six cases of fulminant hepatic failure during the course of the disease. Blood samples were collected on admission and a few days later, when the neurologic status had improved in five cases and immediately before death in one case. The compounds were measured in sera with a binding technique after high-performance liquid chromatography purification and analyzed with mass spectrometry. RESULTS: Their levels were highly variable in those with severe encephalopathy and were still increased on awakening in some cases. Diazepam and N-desmethyldiazepam were inconsistently present. CONCLUSIONS: The inconsistent presence of benzodiazepine-like compounds in encephalopathy after fulminant hepatic failure and their persistence, in some cases, at high levels on awakening from coma seem to indicate that the encephalopathy is not strictly dependent on the levels of these compounds.
Comparative clinical evaluation of the 13C-mixed triglyceride breath test as an indirect pancreatic function test.
Loser C. Brauer C. Aygen S. Hennemann O. Folsch UR.
Ist Medical Dept., Christian-Albrechts University of Kiel, Germany.
BACKGROUND: Breath tests using stable isotopes of carbon or hydrogen are increasingly becoming established for the evaluation of various gastrointestinal functions, including measurement of exocrine pancreatic insufficiency. We wanted to evaluate the clinical relevance of the non-invasive, non-radioactive 13C-mixed triglyceride breath test in comparison with the secretin-caerulein test as the 'gold standard' of pancreatic function testing and with faecal chymotrypsin and elastase 1 in patients with mild and severe exocrine pancreatic insufficiency. METHODS: The secretin-caerulein test, faecal fat analysis, 13C-mixed triglyceride breath test, faecal elastase 1, and chymotrypsin and various morphologic investigations were done in 26 patients with mild (n = 13) or severe (n = 13) exocrine pancreatic insufficiency and 25 patients with gastrointestinal diseases of non-pancreatic origin. Twenty-seven healthy volunteers served as normal controls. After a 12-h fast 200 mg mixed triglyceride (1,3-distearyl,2(carboxyl-13C)octanoyl glycerol) were orally administered with a test meal, and breath samples were taken before and at 30-min intervals for 5 h thereafter, and the increase in 13C/12C isotopic ratio in breath was analysed by mass spectrometry. Various modifications of the test procedure were investigated. RESULTS: Specificity for impaired pancreatic function was higher for faecal elastase (90%) and equal for faecal chymotrypsin (82%) as compared with the various variables of the 13C-mixed triglyceride breath test (69-85%). The sensitivity of the 13C-mixed triglyceride breath test for total and separately for mild and severe exocrine pancreatic insufficiency was higher (total, 69-81%) than that of faecal chymotrypsin (total, 56%) but lower than faecal elastase (total, 92%). CONCLUSION: The 13C-mixed triglyceride breath test very sensitively reflects severe exocrine pancreatic insufficiency (steatorrhoea) but has limited sensitivity for the detection of mild cases. With regard to the higher sensitivity and specificity, the higher practicability, and the much lower cost, determination of faecal elastase 1 concentrations is superior to the 13C-mixed triglyceride breath test and therefore remains the most reliable indirect pancreatic function test available today.
Aspirin-induced gastritis, like Helicobacter pylori-induced gastritis disinhibits acid secretion in humans: relation to cytokine expression.
Hamlet A. Lindholm C. Nilsson O. Olbe L.
Centre for Gastroenterological Research, Dept. of Surgery, Sahlgren's Hospital, Goteborg, Sweden.
BACKGROUND: Helicobacter pylori infection contributes to hypergastrinemia and hypersecretion of acid by blocking inhibitory reflex pathways to gastrin and parietal cells normally activated by antral distention. Our aim was to investigate whether a similar blockade of inhibitory responses could be provoked by inducing gastritis with aspirin, thus implicating a common inflammatory component, possibly a proinflammatory cytokine(s). METHODS: We studied the effects of antral distention on stimulated acid secretion and gastrin release in H. pylori-negative volunteers, before and after 3 days of aspirin therapy (2 g daily). Immediately before the examinations, the severity of gastric mucosal injury was evaluated macroscopically and histologically, and the production of interleukin (IL)-1beta, IL-6, IL-8, tumor necrosis factor (TNF)-alpha, and interferon (IFN)-gamma was determined by immunohistochemistry. RESULTS: Most subjects had severe gastric injury after aspirin therapy, resulting in a substantially increased production of IL-1beta, IL-6, and IL-8 but not of TNF-alpha and IFN-gamma in the antral mucosa. In these subjects the acid-inhibitory response was abolished or markedly reduced. Conversely, aspirin therapy failed to affect the gastrin release in all subjects studied. CONCLUSIONS: The disinhibition of acid secretion in response to antral distention is a joint feature of the gastritis induced by aspirin and H. pylori infection, possibly related to the increased production of IL-1beta, IL-6, and IL-8. The H. pylori-related hypergastrinemia apparently has a different background.
Effect of Helicobacter pylori infection on gastric juice pH.
Furuta T. Baba S. Takashima M. Futami H. Arai H. Kajimura M. Hanai H. Kaneko E.
First Dept. of Medicine, Hamamatsu University School of Medicine, Japan.
BACKGROUND: How Helicobacter pylori infection affects gastric acid secretion is still unclear. METHODS: Gastric juice pH, ammonia concentration in gastric juice, serum gastrin level, and grade of gastritis in accordance with the Sydney System were determined for patients with gastric ulcer (GU) and duodenal ulcer (DU) before and after treatment with lansoprazole and amoxicillin, and results were compared with those of H. pylori-negative controls. RESULTS: Scores for H. pylori density, atrophy, metaplasia, and activity of gastritis in the corpus were higher in patients with GU, especially those with proximally located GU, than in those with DU. Gastric juice pH was significantly higher in GU patients than in DU patients and controls. After H. pylori eradication, gastric juice pH and serum gastrin levels in both GU and DU patients were significantly decreased to control levels. In patients without eradication, no significant changes in these factors were observed. CONCLUSIONS: These findings suggest that H. pylori infection and gastritis in the corpus suppress acid secretion and increase gastric juice pH, resulting in hypergastrinemia, and that eradication of H. pylori normalizes acid secretion and serum gastrin levels.
Accuracy of seven different tests for the diagnosis of Helicobacter pylori infection and the impact of H2-receptor antagonists on test results.
Lerang F. Moum B. Mowinckel P. Haug JB. Ragnhildstveit E. Berge T. Bjorneklett A.
Dept. of Internal Medicine, Ostfold Central Hospital, Fredrikstad, Norway.
BACKGROUND: In this study we compared the accuracy of seven diagnostic tests in diagnosing Helicobacter pylori infection. METHODS: Over 1 year 351 consecutive dyspeptic patients were tested for H. pylori infection by means of antral biopsy specimens for the rapid urease test (RUT), culture, microscopy (acridine stain), and the laboratory urease test (LUT) and, in addition, with 14C urea breath test (UBT), IgG serology, and IgA serology (Orion Diagnostica Pyloriset New EIA-G and New EIA-A). The criterion for H. pylori infection was a minimum of three positive tests. Before being tested, 38% of the patients had used an H2-receptor antagonist (H2RA). RESULTS: Two-hundred and twenty-four patients (64%) were H. pylori-positive. The sensitivity and specificity of the tests were as follows (percentages): RUT, 85, 99; culture, 93, 100; microscopy, 81, 98; LUT, 80, 100; UBT, 95, 95; IgG serology, 99, 91; and IgA serology, 88, 91. The accuracy of the RUT and LUT was reduced in patients receiving H2RA therapy (P=0.04 and 0.01, respectively). CONCLUSIONS: Culture, UBT, and IgG serology were all superior to the other four tests in diagnosing H. pylori infection. Invasive urease-based tests were less accurate in patients receiving H2RAs.
Processing-independent analysis in the diagnosis of gastrinomas.
Jorgensen NR. Rehfeld JF. Bardram L. Hilsted L.
University Dept. of Clinical Biochemistry, Rigshospitalet, Copenhagen, Denmark.
BACKGROUND: This study evaluates whether a new analytic principle, processing-independent analysis (PIA), offers better specificity and sensitivity than the conventional gastrin radioimmunoassay in the diagnosis of gastrinomas. METHODS: Plasma concentrations of alpha-amidated gastrins and the total progastrin product were measured with radioimmunoassay and with PIA, respectively, in 512 samples taken for gastrin measurement and in a selected group of gastrinoma patients (n=10). RESULTS: Among the 512 patients were 9 with gastrinomas. In plasma from these patients the median degree of amidation (ratio of alpha-amidated gastrins to total progastrin product) was 75% (range, 25-98%), whereas in the other groups the medians varied from 41% to 86%. In the second group of gastrinoma patients all had a degree of amidation of less than 50%. CONCLUSIONS: In screening for gastrinomas PIA offered no diagnostic advantages in comparison with conventional gastrin radioimmunoassay. However, in selected patients who in spite of normal or slightly increased concentrations of amidated gastrins were still suspected of having gastrinoma, additional measurement of the total progastrin product showed incomplete processing of progastrin and thus proved helpful in establishing the diagnosis.
Disappearance of gastric mucosa-associated lymphoid tissue in coeliac patients after gluten withdrawal.
Cuoco L. Cammarota G. Tursi A. Papa A. Certo M. Cianci R. Fedeli G. Gasbarrini G.
Institute of Internal Medicine, Dept. of Gastroenterology, Catholic University, Rome, Italy.
BACKGROUND: Mucosa-associated lymphoid tissue (MALT) develops in gastric mucosa in response to chronic antigenic stimulation, such as Helicobacter pylori infection. However, reactive lymphoid follicles have been found also in the stomach of H. pylori-negative coeliac patients, suggesting that other environmental factors may be involved in MALT genesis. The aim of our study was to evaluate the effects of gluten withdrawal in H. pylori-negative coeliac patients with gastric MALT. METHODS: We studied 23 H. pylori-negative untreated coeliac patients with gastric MALT. All patients underwent determination of antigliadin (AGA) and antiendomysium antibodies (EMA) and upper endoscopy with multiple biopsies in duodenum, gastric corpus, and antrum. Lymphoid follicles and H. pylori status were assessed by histopathologic and enzymatic analysis. All patients were started on a gluten-free diet and were reevaluated after 12 months. To consider their adherence to the gluten-free diet we relied on direct patient questioning. Thirteen patients who had strictly adhered to the gluten-free diet constituted our study group. Ten patients who had not strictly adhered to gluten withdrawal from their diet constituted the control group. RESULTS: Regression of MALT was obtained in 9 of 13 (69%) patients who strictly followed the gluten-free diet; in the control group MALT disappeared in 2 of 10 (20%) patients (P=0.0361). DISCUSSION: Disappearance of reactive lymphoid follicles in the gastric mucosa of H. pylori-negative coeliac patients after gluten withdrawal suggests that antigens related to alimentary gluten may constitute persistent stimuli for development of gastric MALT in coeliac patients.
Low symptomatic load in Crohns disease with surgery and medicine as complementary treatments.
Andersson P. Olaison G. Bodemar G. Almer S. Arvidsson M. Dabrosin-Soderholm J. Nystrom PO. Smedh K. Strom M. Sjodahl R.
Dept. of Medico-Surgical Gastroenterology, University Hospital, Linkoping, Sweden.
BACKGROUND: The treatment of Crohn's disease has changed owing to the recognition of its chronicity. Medical maintenance treatment and limited resections have evolved as major concepts of management, regarded as complementary, and both aim at reducing the symptoms. METHODS: We investigated the symptomatic load in Crohn's disease as reflected in a cross-sectional study of the symptom index, physicians' assessment, and the patients' perception of health. A cohort of 212 patients from the primary catchment area and 125 referred patients were studied. RESULTS: Of catchment area patients, 83% were receiving medication, and the annual rate of abdominal surgery was 5.7%. Corresponding figures for the referred patients were 82% and 10.3%. According to the symptom index, 87% of catchment area patients were in remission or had only mild symptoms; according to the physicians' assessment, 90% were. The patients' median perception of health was 90% of perfect health according to the visual analogue scale. The figures were similar for referred patients, except that referrals were considered more diseased by the physician. CONCLUSION: The great majority of patients with Crohn's disease are able to live in remission or experience only mild symptoms.
Listeria monocytogenes in Crohns disease.
Chiba M. Fukushima T. Inoue S. Horie Y. Iizuka M. Masamune O.
First Dept. of Internal Medicine, Akita University School of Medicine, Akita City, Japan.
BACKGROUND: In an immunohistochemical study a higher rate of reactivity of intestinal tissues to the antibody against Listeria monocytogenes was reported in Crohn's disease as compared with controls. METHODS: Seventy-six intestinal tissues, either therapeutically resected or biopsied, from 31 patients with Crohn's disease, 20 with ulcerative colitis, and 21 with non-inflammatory bowel disease were studied. DNA extracted from intestinal tissues by proteinase K treatment was used for nested polymerase chain reaction (PCR), using two sets of primers. PCR products were analyzed with agarose gel electrophoresis and subsequent Southern blot analysis. RESULTS: Our amplification system could detect 9 pg of L. monocytogenes DNA. L. monocytogenes was detected in only one sample, that from a patient with ulcerative colitis. CONCLUSIONS: Our study does not support the etiologic significance of L. monocytogenes in Crohn's disease.
Predictive factors influencing the therapeutic response to diuretic treatment of ascites in nonazotemic cirrhotic patients.
Ljubicic N. Kujundzic M. Banic M. Vrkljan M.
Dept. of Gastroenterology and Hepatology, Sestre Milosrdnice University Hospital, Zagreb, Republic of Croatia.
BACKGROUND: A low-sodium diet and diuretics, although widely used, are not always the most satisfactory therapy for treatment of ascites in nonazotemic patients with liver cirrhosis. The objective of this investigation was to analyze various predictive factors influencing the therapeutic response to diuretic treatment of ascites in these patients. METHODS: Twenty-seven patients with nonazotemic liver cirrhosis and ascites were initially treated with spironolactone, 200 mg/day. If no response was observed, furosemide was added at 40-120 mg/day. Before and during the diuretic therapy 30 clinical and laboratory variables were investigated as possible predictive factors influencing the therapeutic response to diuretics. The renal arterial resistive index (RI) (reflecting renal vascular resistance) was estimated with duplex Doppler ultrasonography. RESULTS: Sixteen of the 27 patients (59%) responded to spironolactone alone, whereas 6 patients (22%) responded to combined diuretic therapy with spironolactone and furosemide. Five patients (19%) did not respond to diuretic treatment. Eight of the 30 variables analyzed were statistically significant as possible predictive factors influencing the diuretic response: previous episodes of ascites and gastrointestinal hemorrhage, the presence of peripheral edema, the amount of ascites, plasma renin activity, plasma aldosterone concentrations, urinary sodium excretion, and renal interlobar arterial RI. In all patients who had diuretic-resistant ascites, renal interlobar arterial RI was greater than 0.70. Only 9% of patients who responded satisfactorily to diuretic therapy had interlobar arterial RI greater than 0.70. CONCLUSIONS: According to our results, consideration for combining the clinical findings with noninvasively measured renal arterial RI using duplex Doppler ultrasonography would be mandatory in identifying a subgroup of cirrhotic patients with ascites who are at high risk for diuretic unresponsiveness.