Increased prevalence of gallstone disease and impaired gallbladder motility in patients with Barrett's esophagus

The prevalence of gallstones in patients with Barrett's esophagus (BE) and their gallbladder motility relative to that of healthy volunteers and GERD patients without BE were investigated. Of the 707 patients reviewed, 203 (125 males and 78 females) had BE. The prevalence of gallstones was significantly higher in the patients with BE than in those without BE (34 vs. 20%, respectively). The gallbladder functions of 22 patients with GERD, 27 patients with BE and 21 healthy volunteers were assessed by ultrasonography before and after a test meal. The patients with BE had significantly higher fasting volume and residual volume, but lower ejection volume, ejection fraction and ejection rate values than those of the healthy controls. None of the ultrasonographic parameters of patients without BE were significantly different from those of the controls. Patients with BE have a more complex gastrointestinal motility disorder that involves the gallbladder, and this makes this subset of patients with GERD more prone to gallstone disease.

Improved glycemic control in pancreatic diabetes through intensive conservative insulin therapy

OBJECTIVE

The aim of this study was to evaluate the effectivity and safety of insulin therapy in patients with DM secondary to underlying chronic pancreatitis with initially inappropriate glycemic control.

METHODS

Pancreatic DM patients treated with oral antidiabetics (OAD) or pre-mixed insulin (PMI) with HbA1c ≥7.0% were recruited. Intensive conservative insulin treatment (ICT) (Group A, n = 16) or PMI (Group B, n = 8) was introduced instead of OAD, or the initial PMI therapy was switched to ICT (Group C, n = 10). The changes in HbA1c, fasting plasma glucose, body weight and hypoglycemic events from baseline to 2 years were followed.

RESULTS

The patients in Group A and B had been treated with oral antidiabetics for 55 ± 68 months before switching to insulin therapy. The level of HbA1c had worsened from 8.3 ± 1.5% to 9.8 ± 1.7% during this period. The ICT had reduced HbA1c significantly from 9.7 ± 1.8% to 7.6 ± 1.4% after 12 weeks, in Group A, and five patients had HbA1c<7.0%. The introduction of PMI in Group B reduced HbA1c from 10.0 ± 1.4% to 9.0 ± 0.6% by 12 weeks. None of the patients had HbA1c<7.0%. By 12 weeks, the introduction of ICT in Group C had reduced the level of HbA1c from 8.8 ± 1.7% to 7.7 ± 1.2%. Two patients reached HbA1c<7.0%. There were two severe hypoglycemic episodes during the 2 years, one-one case in Group A and B.

CONCLUSIONS

Oral medication becomes insufficient early in pancreatic DM. Long-term improvement of glycemic control can be achieved through intensified insulin therapy and in selected cases through PMI with a low risk of hypoglycemia.

Antibody and cell-mediated immune response to whole virion and split virion influenza vaccine in patients with inflammatory bowel disease on maintenance immunosuppressive and biological therapy

OBJECTIVE

Influenza vaccination is recommended for inflammatory bowel disease (IBD) patients on immunosuppressive therapy. The objective was to evaluate the antibody and cell-mediated immune response to the split and whole virion influenza vaccine in patients with IBD treated with anti-TNF-α and immunosuppressive therapy.

PATIENTS AND METHODS

One hundred and fifty-six immunocompromised IBD patients were vaccinated. Fifty-three patients (control group) refused vaccination. Split virion vaccine and whole virion vaccine were used. Serum samples were obtained for pre- and postimmunization antibody titers to influenza vaccine (A/California/7/2009 [H1N1], A/Victoria/361/2011 [H3N2], B/Wisconsin/1/2010-like B/Hubei-Wujiagang/158/2009). Cell-mediated response was evaluated using an interferon (INF)-γ, interleukine (IL)-2 and tumor necrosis factor (TNF)-α ELISA.

RESULTS

Postimmunization titers of both influenza subtypes increased significantly after the administration of split virion vaccines compared to the controls and to those who received whole virion vaccine. The antibody titers of Influenza B also increased significantly in patients immunized with split vaccine and treated with anti-TNF-α therapy. After influenza vaccination, the level of serum IL-2 significantly decreased. No serious side effects developed occurred after influenza vaccination, and the influenza-like symptoms did not differ significantly between vaccinated versus control patients. The relapse of the disease was observed in only 10% of the patients and was more common in vaccinated than in control subjects.

CONCLUSION

Split virion vaccines seem to be more effective than whole virion vaccines. Measuring the antibody responses is worthwhile in patients treated with immunosuppressants to determine the efficacy of influenza vaccination.

Variations of magnesium, iron, copper and zinc during the colonic wound healing process: experimental study on rabbits

The role of trace elements in the wound-healing process is still controversial. Their variations within a normal colonic wound healing have never been studied. An experimental study on rabbits was designed to study magnesium, iron, copper and zinc variations in blood, normal colonic walls and colonic anastomoses on each of the first 7 postoperative days. No major variations of Mg could be observed. Fe decreased in blood as well as in colonic walls and anastomoses. Cu increased in blood, whereas it decreased in colonic walls and anastomoses. Zn decreased in blood, whereas it increased in colonic walls without significant changes in anastomoses. The role of Fe seemed to be rather difficult to understand. Plasma mobilization seems to explain the local use of Zn, while early tissue release with further return in blood occurred for Cu. The importance of a well-balanced nutritional status is underlined to prevent and correct the variations of trace elements in the postoperative course.

The mechanisms of the inhibitory effect of ethanol on gastric emptying involve type A CCK receptors

The mechanisms involved in the mediation of the inhibitory effects of ethanol on gastric emptying were studied in adult male rats. The gastric emptying was determined by measuring the amount of phenol red recovered from the stomach after intragastric administration. Intragastric administration of a 2.5 g kg(-1) body weight dose of ethanol resulted in inhibition of the gastric emptying. Prior intraperitoneal treatment with lorglumide (CR-1409), a selective CCK-A receptor antagonist, abolished the inhibitory effect of ethanol on the gastric emptying. This observation furnishes evidence indicative of the involvement of type A CCK receptors in the mediation of the inhibitory effect of large doses of ethanol on the gastric emptying.

Efficacy of combined anti-TNF-alpha and surgical therapy in perianal and enterocutaneous fistulizing Crohn's disease--clinical observations from a tertiary Eastern European center

BACKGROUND AND AIMS

Recently, anti-TNF-alpha therapy has increasingly been used in the treatment of perianal Crohn's disease (PCD), but there is only limited data regarding its short- and long-term efficacy.

MATERIAL AND METHODS

The medical records of 68 patients treated with anti-TNF-alpha for PCD were assessed retrospectively. Rate of complex fistulas was 75%. Every patient received induction therapy, but in 20 cases the treatment was discontinued before week 52 due to funding regulations, an allergic reaction, or compliance problems. On week 12, the luminal activity decreased in more than 80% of the cases and the complete remission (CR) rate was about 60%; by the end of the first year, this ratio did not change substantially. Complete fistula closure was achieved in 26 cases (38.3%) and 53 patients (51.5%) showed a partial response during the 1-year period. Regarding both perianal and luminal activities, CR rate was achieved in 23 cases (33.8%). However, after the biological therapy was discontinued, recurrence of fistulas could be detected in every second patient. Additional surgical intervention was performed in 45% of patients during the 1-year period (seton drainage of fistulas and abscess drainage).

CONCLUSION

The anti-TNF-alpha therapy combined with surgery is an effective treatment of PCD. Approximately every third patient revealed complete fistula closure, while half of the other cases showed a partial response. Due to the high rate of fistula recurrence after stopping the biological therapy, more than 1 year of anti-TNF-α treatment may be beneficial.

Anti-tumor necrosis factor-α induced systemic lupus erythematosus in a patient with metastatic Crohn's disease--what is the role of anti-TNF antibody?

Biological therapies are supposed to trigger the development of autoimmune diseases. We report a case of a 27-year old woman presenting with drug induced systemic lupus erythematosus (SLE) associated with infliximab therapy. The development of paradoxical inflammation in immune-mediated inflammatory diseases patients treated with anti TNF-α suggests that an unknown inflammatory pathway may be provoked by inhibiting TNF-α. We suppose that in our case a cross reactivity between anti-infliximab antibodies and autoantibodies may lead to the development of TNF-induced immune disease.

A renewed insight into Barrett's esophagus: comparative histopathological analysis of esophageal columnar metaplasia

Specialized intestinal metaplasia (SIM) is considered as a premalignant condition of the esophagus, but other types of esophageal metaplasia are commonly neglected. A standardized histopathological analysis was focused not only on SIM but also on the presence of metaplastic processes typical of additional glands. A morphological study using standardized histopathological tests was carried out between 2004 and 2007, with biopsies taken from esophageal mucosa of 826 consecutive patients. Mean age and male : female ratio of patients were 55.6 ± 14.7 and 1.1 : 1, respectively. Only 4.1% (n = 34) of all cases proved to have SIM. The remainder of the cases (n = 615; 74.4%) contained cardiac-fundic mucosa without SIM. Some samples exhibited superficial mucous glands, pancreatic acinar metaplasia (PAM), and ciliated metaplasia accounting for 24% (n = 198), 14.9% (n = 123), and 0.2% (n = 2), respectively. SIM was colocalized with superficial mucous glands (103/198 superficial mucous gland cases; P < 0.001). Low-grade dysplasia (n = 51; 6.2%) and high-grade dysplasia (n = 9; 1.1%) were found mainly in SIM (37/51; 9/9; P = 0.071) with male preponderance (3 : 1 at low-grade and 2 : 1 at high-grade dysplasia). PAM was found mainly in cases without dysplasia (103 of 123 pancreatic metaplasias; P < 0.001). SIM alone in the esophagus is rare, and its frequent association with cardiac mucosa-type metaplasia testifies to transition of mucinous-goblet cell through pseudogoblet cells. PAM rather indicates absence of dysplasia, but superficial mucous glands predicts that SIM follows dysplasia.

Bolus administration of steroid therapy is more favorable than the conventional use in preventing decrease of bone density and the increase of body fat percentage in patients with inflammatory bowel disease

INTRODUCTION

The effects of short course of corticosteroids on the metabolic processes and bone formation has not been well studied. Our aim was to compare the efficacy, the side effects and the bone and lipid metabolisms in IBD patients using bolus or conventional tapering of methylprednisolone for 12 weeks.

PATIENTS AND METHODS

Nineteen IBD patients received intravenous methylprednisolone of 1mg/kg for 5 days tapered by 4 mg per week. Patients were prospectively randomized in two groups. In "conventional" group (I) steroids were given daily. In "pulse" group (II) weekly doses of steroids were given on special days of the week. The body mass index (BMI) was measured before and after the corticosteroid therapy. Blood samples were collected to assess glucose level, electrolytes, cholesterol and triglyceride levels, inflammatory parameters, cortisol, osteocalcin and crosslaps values. Total body composition analysis was performed at the beginning and at the end of the steroid therapy.

RESULTS

In Group I, BMI increased, total body bone density decreased significantly at the end of the steroid therapy. Body fat percent showed a tendency to be higher at the end of steroid therapy in Group I. Cholesterol level increased significantly in Group I patients. The decrease in serum cortisol level was more remarkable in Group I vs. Group II after steroid therapy. Less side-effect occurred in Group II vs. Group I.

DISCUSSION

Our results suggest that bolus tapering of corticosteroids may have more favorable short term outcome than conventional tapering that may revolutionize steroid therapy in IBD.

"Ulcerative crepitus" -- a case with subcutaneous emphysema and pneumomediastinum without colonic perforation or toxic megacolon in ulcerative colitis successfully treated conservatively

A 19-year-old man with a 1-year history of ulcerative colitis presented with fever, bloody diarrhea and severe dehidration. He was on po.48 mg methylprednisolon and 3 g mesalazine daily, and has recently finished taking chlarythromycin for Campylobacter jejuni infection. On physical examination, no abdominal tenderness was found, but surprisingly, extensive bilateral subcutaneous emphysema was detected in the supraclavicular regions. Laboratory tests proved anaemia, elevated white blood cell count, thrombocyte count and CRP levels. Stool culture was negative. Chest X-ray and CT scan revealed pneumomediastinum and subcutaneous air on the neck spreading to the scapular regions. Besides blood transfusion, iv. cyclosporin therapy was initiated (200 mg/day) along with iv. methylprednisolon (1mg/kg/day) and iv. ceftriaxon (2 g/day). Stool frequency and bloody stools decreased remarkably within one week, and subcutaneous emphysema has resolved. Colonoscopy one week later revealed deep, extensive ulcerations in the transverse and descending colon without any sign of previous perforation. Cyclosporin and methylprednisolon was continued orally. Pneumomediastinum and subcutaneous emphysema in ulcerative colitis are unusual complications, typically linked to retroperitoneal colonic perforation or toxic megacolon, and are extremely rare without preceding endoscopic procedures. Except from two cases in the literature, conservative treatment with iv. antibiotics and steroids failed to save from urgent surgical procedure, resulting in a partial or total colectomy. In our case we were able to avoid urgent surgery by the immediate use of iv. cyclosporin in combination with iv. steroids and antibiotics, while the outcome of the bowel remains questionable in the next few months.

Sepsis and hepatitis together with herpes simplex esophagitis in an immunocompetent adult

Herpes simplex virus (HSV)-induced sepsis affects immunocompromised patients. We report here the case of an immunocompetent adult with sepsis, hepatitis, renal failure and esophagitis. The possibility of HSV should be considered in cases of sepsis without any evident cause, even in immunocompetent patients. The characteristic endoscopic and histological findings of the associated esophagitis may assist the etiology of sepsis.

Does the endoscopic appearance of the ileocecal valve suggest the severity of Crohn's disease in the terminal ileum?

Despite ileoscopy being the only procedure, which can accurately detect mucosal abnormalities in the ileum, it is performed only in 5-15% of the colonoscopies.

AIM

The aim of this study was to retrospectively determine the predictive value of the endoscopic findings of the ileocecal valve (ICV) in patients with CD.

METHODS

Data of 100 ileal or ileocolonic CD patients (45 females, 55 males, mean age 27.6 years, range 5-66), who underwent ileocolonoscopy between 2004 and 2008, were reviewed. Macroscopic appearance of the ICV and the endoscopic severity of the ileum evaluated by the Simple Endoscopic Score for Crohn's Disease were determined by re-evaluating the examinations recorded on DVDs in all cases. Histological scoring was performed in 56 cases. Statistical analyses were performed to assess relationships between the normal-looking ICV and the histological and endoscopic scores of the ileum and the correlation between the severity of the ileal inflammation and the macroscopic appearance of the ICV.

RESULTS

A macroscopically normal appearance of the ICV was detected in 30 patients. 60% of these patients were diagnosed with mild, 26.7% with moderate and 13.3% with severe endoscopic ileal inflammation. ICV was affected by CD in 70 patients, in whom significantly more severe ileal inflammation (p=0.005) was detected than in patients with normal-looking ICV.

DISCUSSION

Our results suggest that ileal exploration should be attempted in every suspected CD patients, because, although the appearance of the ICV correlates with the severity of the ileal inflammation, a normal-looking ICV does not correspond to normal ileal mucosa in almost one third of the cases.

Rectal Tumour Staging with Endorectal Ultrasound: Is There Any Difference between Western and Eastern European Countries?

Background. Rectal tumour management depends highly on locoregional extension. Rectal endoscopic ultrasound (ERUS) is a good alternative to computed tomography and magnetic resonance imaging. However, in Hungary only a small amount of rectal tumours is examined with ERUS. Methods. Our retrospective study (2006-2012) evaluates the diagnostic accuracy of ERUS and compares the results, the first data from Central Europe, with those from Western Europe. The effect of neoadjuvant therapy, rectal probe type, and investigator's experience were also assessed. Results. 311 of the 647 ERUS assessed locoregional extension. Histological comparison was available in 177 cases: 67 patients underwent surgery alone; 110 received neoadjuvant chemoradiotherapy (CRT); ERUS preceded CRT in 77 and followed it in 33 patients. T-staging was accurate in 72% of primarily operated patients. N-staging was less accurate (62%). CRT impaired staging accuracy (64% and 59% for T- and N-staging). Rigid probes were more accurate (79%). At least 30 examinations are needed to master the technique. Conclusions. The sensitivity of ERUS complies with the literature. ERUS is easy to learn and more accurate in early stages but unnecessary for restaging after CRT. Staging accuracy is similar in Western and Central Europe, although the number of examinations should be increased.

[Efficacy of tumor necrosis factor-alpha inhibitors in fistulising perianal Crohn's disease]

INTRODUCTION

Tumor necrosis factor-alpha inhibitors are increasingly used in the treatment of severe Crohn's disease.

AIM

The aim of the authors was to assess retrospectively the short and long term efficacy of tumor necrosis factor-alpha inhibitors in fistulising Crohn's disease.

METHOD

Responses to therapy was determined using Crohn's Disease Activity Index, Perianal Disease Activity Index, the rate of complete fistula closure and the additional surgical procedures during biological therapy.

RESULTS

After 12 weeks the perianal activity was decreased in more than 80% of the cases, and the complete remission rate was about 60%. After one year of therapy about one third of the patients had fistula closure, but after cessation of the biological therapy recurrence of fistulas was detected in every second patient. In most cases additional immunosuppressive therapy was necessary during biological treatment. During the one-year therapy period additional surgical treatments were performed in 45% of patients; seton insertion and abscess drainage were the most frequent procedures.

CONCLUSIONS

Tumor necrosis factor-alpha inhibitor therapy is effective in the treatment of perianal Crohn's disease, however, additional immunosuppressive drugs and rectum sparing surgical procedures were necessary during the one-year treatment period. Because of the high rate of fistula recurrence, long term tumor necrosis factor-alpha treatment may be useful.

[Better quality of life after surgery treatment in patients with colitis ulcerosa: what is the price]

Exacerbations of ulcerative colitis (UC) have a great impact on patients' quality of life. Only a few data is available about the effect of surgery on the quality of life in patients with UC.

AIM

of our study was to evaluate the outcome and the impact of surgery on the quality of life of patients with UC.

PATIENTS AND METHODS

183 UC patients [mean age at the diagnosis: 33.23 years (12-69 years), female/male ratio: 95/88] were hospitalized in our tertiary clinic because of exacerbation of UC requiring parenteral corticosteroid therapy between 1998 and 2007. Data of 46 patients undergoing colectomy were analyzed retrospectively. Outcome of surgery, frequency of early and late complications, the alteration of the number of hospitalizations and outpatient visits, the number of medication, the income and the disability grade were assessed in detail. The patients were also asked to complete questionnaires to compare their quality of life before and after colectomy. The follow up period was 3.3 years. Data were analyzed using two-sample t-test and one-way analysis of variance. P value lower than 0.05 was considered statistically significant.

RESULTS

74% of the colectomized patients underwent ileal pouch anal anastomosis procedure, 11 patients needed definitive ileostomy and in one case, ileorectal anastomosis was requested by the patient. Early complications occurred in 24, late complications in 23 patients (pouchitis in 13 cases). The need for hospitalization and the number of medication decreased significantly, while significant improvement was shown in the patients' quality of life after colectomy compared to the preoperative condition. Colectomy did not have an impact on the patients' income in 64.5% of the cases and no alteration of the disability grade was detected in 32% of the patients.

DISCUSSION

Our results show that surgery may results in a good quality of life in the majority of the patients, however, further management may be necessary due to the late postoperative complications.

The ursodeoxycholic acid-p-aminobenzoic acid deconjugation test, a new tool for the diagnosis of bacterial overgrowth syndrome

OBJECTIVE

To determine the possible complementary role of the ursodeoxycholic acid-p-aminobenzoic acid (UDCA-PABA) loading test in the diagnosis of intestinal bacterial overgrowth.

DESIGN

A prospective clinical study.

PATIENTS AND METHODS

The hydrogen breath and UDCA-PABA tests were performed simultaneously in 68 patients with suspected contaminated small bowel syndrome (CSBS), and in 10 healthy control subjects. The hydrogen breath test was performed by oral loading of 25 g of lactose and/or 10 g of lactulose. The UDCA-PABA test was carried out by oral loading of 250 mg of UDCA-PABA conjugate, followed by measurement of the amount of PABA excreted in the urine. The diagnosis of bacterial overgrowth was considered to be established when either the hydrogen breath test or the UDCA-PABA test produced abnormal results.

RESULTS

Thirty-five of the 68 patients proved to have CSBS. In 13 of these 35 patients, only the enhanced urinary PABA excretion (11.7 +/- 1.42 mg vs. 3.6 +/- 0.68 mg) indicated bacterial overgrowth, 15 of the 35 patients gave only a positive hydrogen breath test, and in the remaining seven cases the results of both tests were abnormal. In eight CSBS patients, the urinary excretion of PABA was decreased significantly following 10-day tinidazole treatment (5.5 +/- 1.29 mg vs. 13.1 +/- 2.07 mg).

CONCLUSION

The UDCA-PABA test is a valuable clinical method for the detection of bacterial overgrowth, especially in cases where hydrogen production alone fails to reveal CSBS. It is also a useful procedure for evaluating the efficacy of antibacterial treatment.

[Pancreatic cancer or autoimmune pancreatitis: endosonography as a diagnostic reviser]

Conventional radiologic imaging (abdominal ultrasound, computer tomography) used in the differential diagnosis of post-hepatic jaundice can frequently provide inaccurate diagnosis. Inflammatory lesions may mimic neoplastic processes and malignancy may be accompanied by perifocal inflammation resulting in histological misdiagnosis. Furthermore, chronic and autoimmune pancreatitis are associated with an increased risk for pancreatic cancer. Radial endosonography has become a markedly important method in the imaging of the pancreas. It has a crucial role in the diagnosis and staging of pancreatic cancer. The authors present three cases where the diagnosis of pancreatic cancer determined by conventional imaging techniques (abdominal ultrasound, computer tomography, endoscopic retrograde cholangiopancreatography) was excluded or confirmed by the radial endosonography. The authors conclude that radial endosonography is an essential complementary method among imaging techniques of the pancreas and in tumor staging. Application of that may prevent unnecessary surgeries, which is obviously useful for patients and cost effective for health care providers.

[Hungarian data on inflammatory bowel diseases: analytical data on ulcerative colistis]

Prospective data collection seems to be essential in evidence-based medicine. Because of the new therapeutic options, the need for standard data collection and testing has significantly increased. In Hungary, a registry for patients with inflammatory bowel disease has already been set up, which makes it possible for clinicians to collect prospective data on their patients.

AIM

Basic characteristics of the database of patients with ulcerative colitis are presented in this paper.

METHODS

The inflammatory bowel disease registry uses the programme of Microsoft Access database management system. Data are stored in a central server.

RESULTS

The incidence of inflammatory bowel diseases has been permanently increasing in Hungary; however, its overall prevalence is still low among the European countries. The frequent administration of immunosuppressive medications (azathioprine and corticosteroids) and their increased doses worsen the estimation of the activity.

CONCLUSIONS

1., It would be very useful to gain prospective data from all national centres. This kind of database would be able to give a complete picture regarding the Hungarian therapeutical practice. 2., Medications of patients may alter the clinical value of the laboratory findings in the process of determining the severity of the disease.