[Peptic diseases]

The therapeutical acquisitions of the year 2004 are: 1. The sequential treatment of the Helicobacter pylori infection reaches an eradication rate of 95%. 2. The use of COX-2 inhibitors reduced significantly the gastrointestinal side effects of anti-inflammatory treatments. Since cardiac averse effects of certain COX-2 inhibitors had been reported, the treatments with COX-2 inhibitors came widely into question. In the case of patients with risk of NSAID induced gastrointestinal toxicity, the alternative is to return to a treatment with non specific NSAID associated to an prophylactic PPI treatment.

Gastro-esophageal reflux and esophageal motility disorders in morbidly obese patients

BACKGROUND

Morbid obesity has long been considered as a contributing factor to gastro-esophageal reflux, but the literature contains conflicting data on the subject. The authors studied a large number of morbidly obese candidates for bariatric surgery with objective means, in order to better define the incidence of gastro-esophageal reflux disease (GERD) and esophageal motility disorders in this population.

METHODS

Morbidly obese patients, in whom indication for bariatric surgery was confirmed after complete evaluation, were included consecutively during a 4-year period. The evaluation included history of reflux symptoms, upper GI endoscopy, 24-hour pH monitoring, and stationary esophageal manometry.

RESULTS

345 patients were studied, of whom 35.8% reported reflux symptoms. Endoscopy showed a hiatus hernia in 181 patients (52.6%), and reflux esophagitis in 108 (31.4%). 24-hour pH monitoring revealed an elevated De Meester score in 163 patients (51.7%). Manometry was normal in 247 patients (74.4%), and showed a decreased lower esophageal sphincter pressure in 59 (17.7%). Esophagitis and abnormal pH testing were more common in patients with symptoms or hiatus hernia, and the incidence of esophagitis was higher with abnormal pH testing. Esophagitis was associated with increased weight and abdominal obesity.

CONCLUSIONS

This study confirms the increased prevalence of GERD in the morbidly obese population. Upper GI endoscopy should be performed routinely during evaluation of morbidly obese patients for bariatric surgery. When both conditions coexist, effective treatment is probably best provided by Roux-en-Y gastric bypass, which produces effective weight loss and correction of pathological reflux.

Absence of nocturnal acid breakthrough in Helicobacter pylori-positive subjects treated with twice-daily omeprazole

BACKGROUND

Proton pump inhibitors (PPIs) taken twice daily do not effectively control night-time intragastric pH; nocturnal acid breakthrough (NAB) (arbitrarily defined as intragastric pH < 4 lasting longer than 1 h) occurs in more than 75% of patients. The effectiveness of PPIs depends rather on the Helicobacter pylori status.

OBJECTIVES

To investigate the effectiveness of two regimens of omeprazole in H. pylori-positive subjects as well as the occurrence of NAB.

PATIENTS

Fifteen otherwise healthy H. pylori-positive subjects participated in this randomized, crossover, double-blind study.

METHODS

Night-time intragastric pH-metry was performed before (baseline) and on day 7 of two treatment courses with omeprazole (1 x 20 mg and 2 x 20 mg). A 14-day (minimum) wash-out period was respected between the two treatment courses.

RESULTS

Group medians (10-90% confidence intervals) for night-time intragastric pH (22:30-06:30 h) were as follows: baseline, 2 (1-6.1); 1 x 20 mg, 5 (3.3-6.9; P < 0.001 versus baseline); instead of, 2 x 20 mg, 6.3 (4.9-7.1; P < 0.001 versus baseline, P = 0.02 versus omeprazole 1 x 20 mg). The percentage of time with intragastric pH < 3 was 65.4% during baseline (P < 0.05 versus both omeprazole regimens), 27% with once-daily omeprazole (P = 0.001 versus omeprazole 2 x 20 mg) and 0% with twice-daily omeprazole. NAB occurred in eight (53.3%) subjects with once-daily omeprazole and in no subject taking twice-daily omeprazole.

CONCLUSIONS

In H. pylori-positive subjects, twice-daily omeprazole is highly effective in controlling nocturnal intragastric acidity. NAB does not occur in those subjects and there is no need to add bedtime H2-receptor antagonists to this regimen.

Favourable effect of regular intake of fermented milk containing Lactobacillus johnsonii on Helicobacter pylori associated gastritis

BACKGROUND

Lactobacillus johnsonii (Lj1) had an in vitro and in vivo inhibitory effect on Helicobacter pylori. Fermented milk containing Lj1 (LC1), coadministered with antibiotics had a favourable effect on H. pylori gastritis.

AIM

Evaluate the effect of LC1 intake without antibiotics on H. pylori gastritis.

METHODS

Fifty H. pylori positive healthy volunteers were randomised in a double-blind study to LC1 or placebo. Gastric biopsies from the antrum and corpus were obtained before, and after 3 and 16 weeks of treatment, for histology and quantitative cultures.

RESULTS

Severity and activity of antral gastritis was reduced after 16-week LC1 intake (pretreatment and 16-week inflammatory cell score: 6.0 +/- 0.8 vs. 5.3 +/- 0.1; P=0.04). H. pylori density decreased in the antrum after LC1 intake (3-week: 4.4 +/- 0.6; 16-week: 4.3 +/- 0.5 log10 colony forming units (cfu) vs. pretreatment 4.5 +/- 0.4 log10 cfu; P=0.04, respectively). Mucus thickness increased after 16 weeks of LC1 consumption (change of mucus thickness with LC1 and placebo in the antrum: 0.6 +/- 1.3 vs. -0.2 +/- 1.0, P=0.01; in the corpus: 0.3 +/- 1.1 vs. -0.6 +/- 1.5, P=0.03).

CONCLUSION

LC1 intake had a favourable, albeit weak, effect on H. pylori associated gastritis, particularly in the antrum. Regular ingestion of fermented milk containing L. johnsonii may reduce the risk of developing disorders associated with high degrees of gastric inflammation and mucus depletion.

Favourable effect of regular intake of fermented milk containing Lactobacillus johnsonii on Helicobacter pylori associated gastritis

BACKGROUND

Lactobacillus johnsonii (Lj1) had an in vitro and in vivo inhibitory effect on Helicobacter pylori. Fermented milk containing Lj1 (LC1), coadministered with antibiotics had a favourable effect on H. pylori gastritis.

AIM

Evaluate the effect of LC1 intake without antibiotics on H. pylori gastritis.

METHODS

Fifty H. pylori positive healthy volunteers were randomised in a double-blind study to LC1 or placebo. Gastric biopsies from the antrum and corpus were obtained before, and after 3 and 16 weeks of treatment, for histology and quantitative cultures.

RESULTS

Severity and activity of antral gastritis was reduced after 16-week LC1 intake (pretreatment and 16-week inflammatory cell score: 6.0 +/- 0.8 vs. 5.3 +/- 0.1; P=0.04). H. pylori density decreased in the antrum after LC1 intake (3-week: 4.4 +/- 0.6; 16-week: 4.3 +/- 0.5 log10 colony forming units (cfu) vs. pretreatment 4.5 +/- 0.4 log10 cfu; P=0.04, respectively). Mucus thickness increased after 16 weeks of LC1 consumption (change of mucus thickness with LC1 and placebo in the antrum: 0.6 +/- 1.3 vs. -0.2 +/- 1.0, P=0.01; in the corpus: 0.3 +/- 1.1 vs. -0.6 +/- 1.5, P=0.03).

CONCLUSION

LC1 intake had a favourable, albeit weak, effect on H. pylori associated gastritis, particularly in the antrum. Regular ingestion of fermented milk containing L. johnsonii may reduce the risk of developing disorders associated with high degrees of gastric inflammation and mucus depletion.

Endoscopic fluorescence detection of intraepithelial neoplasia in Barrett's esophagus after oral administration of aminolevulinic acid

BACKGROUND AND STUDY AIMS

Barrett's esophagus is strongly associated with adenocarcinoma. Early malignant transformation of the Barrett's mucosa is often not visible endoscopically and may remain undetected until the invasive adenocarcinoma stage. Endoscopic surveillance is currently carried out on random four-quadrant biopsies at 1-2 cm intervals. Endoscopic fluorescence detection of protoporphyrin IX induced by 5-aminolevulinic acid can identify premalignant lesions. This study evaluates endoscopic fluorescence detection in patients having Barrett's esophagus and compares the results to those of standard endoscopy with random four-quadrant biopsies.

PATIENTS AND METHODS

The study included 30 examinations in 28 patients (22 men, 6 women; age range 37-78 years, mean age 60 years,), with five patients having known intraepithelial neoplasia. A dose of 20 mg/kg of 5-aminolevulinic acid was given orally 5 hours before examination. Random four-quadrant biopsies were performed 4-6 weeks before endoscopic fluorescence detection.

RESULTS

Of the biopsies taken during the endoscopic fluorescence detection procedure, 28 % (23/81) were true positives. More than one-third of the false-positive results were due to inflammation. None of the 97 control biopsies taken on nonfluorescing areas during endoscopic fluorescence detection were dysplastic. Endoscopic fluorescence detection showed low-grade intraepithelial neoplasia in five patients which was not diagnosed with random four-quadrant biopsies, while random four-quadrant biopsies alone showed three low-grade intraepithelial neoplasias that were invisible during endoscopic fluorescence detection. All high-grade intraepithelial neoplasias or adenocarcinomas (2/2) were detected with both methods.

CONCLUSIONS

Fluorescence detection achieved a similar performance when compared with four-quadrant random biopsy, but resulted in fewer biopsies (81 for endoscopic fluorescence detection vs 531 for random four-quadrant biopsies).

13C urea breath test (UBT) in the diagnosis of Helicobacter pylori: why does it work better with acid test meals?

BACKGROUND

Acid test meals may improve the accuracy of the (13)C urea breath test (UBT). This has been attributed to changes in gastric emptying rather than to the effects of gastric pH on Helicobacter pylori urease.

AIMS

To determine whether enhancement of (13)CO(2) excretion in the UBT in H pylori infected volunteers by acidification of a test meal is due to a delay in gastric emptying.

METHODS

Urease activity in vitro was measured in intact bacteria and in bacterial homogenates. Urease activity in vivo was assessed by means of the UBT. Eleven H pylori infected subjects underwent UBTs with neutral Ensure (pH 7.0), acidified Ensure (pH 3.0), and apple juice (pH 3.0). Gastric emptying was assessed by (13)C sodium acetate breath test.

RESULTS

From pH 7 to pH 3, the in vitro urease activity of intact bacteria increased sixfold. In contrast, urease activity of bacterial homogenates was inactivated by low pH. In vivo, urease activity, as measured by the UBT 20 minutes after meal ingestion, was higher with apple juice (delta (13)CO(2)=21.1; p=0.03) and acidified Ensure (delta (13)CO(2)=25.5; p=0.01) than with neutral Ensure (delta (13)CO(2)=12.5). Gastric emptying was faster with apple juice (T(max)=36.7 (8) minutes) but not with acidified Ensure (T(max)=63.3 (5) minutes; p=0.06) than with neutral Ensure (T(max)=65.0 (3) minutes; p=0.04).

CONCLUSIONS

The higher UBT found with acidified compared with neutral test meals was independent of the emptying rates of the test meals but may have been due to medium acidity dependent activation of intra-bacterial urease in intact H pylori.

Acid inhibition on the first day of dosing: comparison of four proton pump inhibitors

BACKGROUND

Rapid and consistent acid suppression on the first day of dosing may be important in treating acid-related disorders.

AIM

To compare the antisecretory activity and onset of action of single doses of rabeprazole, lansoprazole, pantoprazole, omeprazole capsule, omeprazole multiple unit pellet system (MUPS) tablet and placebo in healthy Helicobacter pylori-negative subjects.

METHODS

This cross-over, double-blind, randomized study was performed in 18 H. pylori-negative subjects. Twenty-four-hour intragastric pH monitoring was performed on the day of treatment (once-daily dose of rabeprazole 20 mg, lansoprazole 30 mg, pantoprazole 40 mg, omeprazole capsule 20 mg, omeprazole MUPS tablet 20 mg or placebo).

RESULTS

The intragastric pH (3.4) and time at pH > 4 during the 24 h post-dose (8.0 h) were significantly greater with rabeprazole than with lansoprazole, pantoprazole, omeprazole capsule, omeprazole MUPS tablet or placebo (P <or= 0.04 for rabeprazole vs. the others). Daytime and night-time pH values were higher with rabeprazole and lansoprazole than with pantoprazole, omeprazole capsule and omeprazole MUPS tablet (P </= 0.04).

CONCLUSION

Rabeprazole was the most potent acid inhibitor of all the proton pump inhibitors tested during the first day of dosing.

Endoscopic interventions for preneoplastic and neoplastic lesions: mucosectomy, argon plasma coagulation, and photodynamic therapy

The classical treatment of neoplastic lesions is surgical resection. Improved detection of early lesions has offered new therapeutic strategies. Thus, for the last 20 years it has been increasingly attempted to undertake endoscopic resection of such tumors. While there is no doubt that morbidity and mortality are lower than after surgery, it was assumed that the long-term prognosis is not as good as with surgery. Surprisingly, however, the 5-year survival rates are excellent. Therefore, in local mucosal lesions of colon, stomach, and esophagus, endoscopic removal has become standard treatment. In Barrett's esophagus, the treatment modality it is still discussed controversially, despite encouraging results. Since we are yet not able to completely eliminate the premalignant specialized intestinal epithelium of the esophagus, it is still uncertain whether eradication of the malignant or dysplastic lesion is sufficient.

Helicobacter pylori infection in Swiss adolescents: prevalence and risk factors

OBJECTIVE

This investigation sought to study the influence exerted by demographic and socioeconomic factors on the prevalence of infection in adolescents living in Switzerland.

DESIGN

Epidemiological study spanning 3 years.

METHODS

We included 196 15- to 16-year-old adolescents from a north-eastern Swiss city in our study, recruited by the school health service during a medical check-up in the years 1999, 2000 and 2001. infection was detected by ELISA using 2nd generation anti- IgG antibodies. Demographic and socioeconomic data were collected by questionnaire.

RESULTS

infection was found in 19 of the 196 (9.7%) tested adolescents. tested positive in, respectively, 13 (7.3%) of the 176 natives and six (30%) of the 20 (P = 0.01 chi-squared) subjects from foreign countries. infection was significantly highly correlated with demographic factors but did not correlate with most of the socioeconomic factors.

CONCLUSION

The rate of infection among Swiss adolescents is one of the lowest in Europe. Nevertheless, an important disparity is evident between the rate of infection observed in the native population and that among immigrants. High living standards available to the majority of the population may explain the minor influence of socioeconomic factors on infection in our country.

Photoeradication of Helicobacter pylori using 5-aminolevulinic acid: preliminary human studies

BACKGROUND AND OBJECTIVES

Helicobacter pylori (HP) is an endemic pathogenic bacterium causing gastritis and gastroduodenal ulceration in humans and is linked to the development of gastric malignancies. These first human in vivo studies investigated the photoeradication of HP using laser and white light.

STUDY DESIGN/MATERIALS AND METHODS

In 13 HP-positive volunteers, a zone of gastric antrum was irradiated with laser (410 nm, 50 J/cm(2)) or endoscopic white light (10 J/cm(2)) 45 minutes after oral 5-aminolevulinic acid (5-ALA) 20 mg/kg. HP-eradication was assessed by biopsy urease test and HP-culture from irradiated and control zones 5 minutes, 4 and 48 hours post-irradiation.

RESULTS

A maximum eradication effect was achieved at 4 hours post-irradiation when 85% of biopsies in the monochromatic and 66% in the white light exposed zones, and 58 and 33% in the respective control zones were HP-negative.

CONCLUSIONS

HP numbers were greatly reduced following exposure to 5-ALA and either laser or white light in vivo. Photoeradication appears feasible, but further light dosimetry and the development of convenient application methods is required.

Budesonide treatment for collagenous colitis: a randomized, double-blind, placebo-controlled, multicenter trial

BACKGROUND & AIMS

Collagenous colitis is an idiopathic microscopic colitis characterized by chronic watery diarrhea, a typical subepithelial collagen layer, and lymphoplasmacellular infiltration. We investigated the effect of budesonide on symptoms and histology in patients with collagenous colitis in a randomized, double-blind, placebo-controlled multicenter trial.

METHODS

Patients with chronic diarrhea and histologically proven collagenous colitis were randomized to receive either oral budesonide (Entocort capsules; AstraZeneca, Sodertalje, Sweden) 9 mg/day for 6 weeks or placebo. Complete colonoscopy was performed before and after treatment. Histopathology was assessed by a single pathologist blinded to the patients' treatment. Clinical symptoms were assessed by standardized questionnaires.

RESULTS

Fifty-one patients were randomized; 45 patients were available for per protocol analysis. The rate of clinical remission was significantly higher (P < 0.001) in the budesonide group than in the placebo group (per protocol 86.9% vs. 13.6%, respectively; intention-to-treat 76.9% vs. 12.0%, respectively). Histologic improvement was observed in 14 patients of the budesonide group (60.9%) and in 1 patient of the placebo group (4.5%; P < 0.001). Two patients in the budesonide group (7.7%) and 1 patient in the placebo group (4.0%) discontinued treatment prematurely because of side effects.

CONCLUSIONS

Oral budesonide (Entocort capsules) is an effective and safe treatment modality for patients with collagenous colitis. Long-term follow-up of these patients is necessary to investigate whether clinical and histologic remission is sustained.

Performance of multidetector computed tomography colonography compared with conventional colonoscopy

BACKGROUND AND AIMS

This was a prospective blinded study to compare computed tomography (CT) colonography, performed with multidetector arrays CT scan (MDCT), with conventional colonoscopy for the detection of colorectal neoplasia.

METHODS

Fifty patients were examined by MDCT after standard bowel preparation and rectal air insufflation in the supine and prone positions. Data sets were examined by one radiologist and one gastroenterologist blinded to the patient's history and colonoscopy results. Patients subsequently underwent colonoscopy on the same day, which served as the gold standard.

RESULTS

Nine of 11 lesions >10 mm (82%), 5/15 lesions of 6-9 mm (33%), and 1/42 polyps <5 mm (3%) were detected by MDCT colonography. One false positive result for a structure larger than 10 mm was described. Nineteen of 21 patients who had no lesions during conventional colonoscopy were considered free of lesions by MDCT colonography, yielding a per patient specificity of 90%.

CONCLUSION

MDCT colonography provides good data quality and has good sensitivity and specificity for the detection of colonic lesions of 10 mm or more.

Effect of investigator experience in CT colonography

The aim of this study was to determine the impact of the learning curve on the diagnostic performances of CT colonography. Two blinded teams, each having a radiologist and gastroenterologist, prospectively examined 50 patients using helical CT scan followed by colonoscopy. Intermediate data evaluation was performed after 24 data sets (group 1) and compared with data from 26 subsequent patients (group 2). Parameters evaluated included sensitivity, specificity, false-positive and false-negative findings, time of data acquisition and interpretation. Using colonoscopy as the gold standard, sensitivity for CT colonography was for lesions >5 mm 63% for both teams for group 1 patients; for group 2 patients sensitivity was 45% for team 1 and 64% for team 2. Specificity per patients was for patient group 1 42% for team 1 and 58% for team 2; for patient group 2 it was 79% for both teams ( p=0.04 for team 1; p=0.2 for team 2). Comparing group 1 with group 2, the number of false-positive findings decreased significantly ( p=0.02). Furthermore, the mean time of data evaluation decreased from 45 to 17 min ( p=0.002) and the mean time of data acquisition from 19 to 17 min. With increasing experience, specificity and the time required for data interpretation improved and false positives decreased. There was no significant change of sensitivity, false-negative findings and time of data acquisition. A minimum experience of the readers is required for data interpretation of CT colonography.

Antibiotic prophylaxis of infective endocarditis during digestive endoscopy: over- and underuse in Switzerland despite professed adherence to guidelines

BACKGROUND AND STUDY AIMS

Guidelines for antibiotic prophylaxis of infective endocarditis associated with gastrointestinal endoscopy are not uniform. Though based on weak scientific evidence, they do represent an attempt to unify the management of antibiotic prophylaxis. We investigated whether physicians who profess to adhere to these guidelines actually do apply them correctly.

MATERIALS AND METHODS

A questionnaire was sent to all 195 Swiss gastroenterologists asking whether they adhered to antibiotic prophylaxis guidelines and under what conditions did they apply antibiotic prophylaxis in gastrointestinal endoscopy. We analysed whether the Swiss gastroenterologists who claim to adhere to these guidelines actually do so in practice.

RESULTS

The response rate to our questionnaire was 95%. Of the Swiss gastroenterologists, 60% correctly employ antibiotic prophylaxis guidelines in gastroscopy, as do 47% in colonoscopy. In therapeutic endoscopy, the percentage of correct antibiotic prophylaxis use depends upon the type of intervention and varies between 21 and 58%. Overuse of antibiotic prophylaxis is at least twice as frequent in colonoscopy and therapeutic endoscopy than in gastroscopy.

CONCLUSIONS

Guidelines for antibiotic prophylaxis are not well applied and do not lead to uniform management despite a high degree of professed adherence to them. This phenomenon can be explained by "cognitive dissonance" and "reactance." We conclude that guidelines based on unconvincing data may even prove harmful.

Epinephrine versus epinephrine plus fibrin glue injection in peptic ulcer bleeding: a prospective randomized trial

BACKGROUND

Peptic ulcer bleeding remains a disease with considerable morbidity and mortality. Epinephrine is the most widely used endoscopic injection agent, but bleeding recurs in 20% of high-risk cases. Fibrin glue might be an ideal injection agent, based on its physiologic properties, despite its demanding injection technique and high cost. The aim of this study was to determine whether the injection of fibrin glue in combination with epinephrine improves outcome for patients at high risk of recurrent bleeding.

METHODS

Patients were prospectively randomized to injection of epinephrine alone (n = 70) or epinephrine plus fibrin glue (n = 65). Endoscopy was repeated daily until the ulcer base was clean. All patients were treated with high-dose omeprazole.

RESULTS

Initial hemostasis was 100% in both groups. There was no significant overall difference in rates of recurrent bleeding (24.3% and 21.5%, respectively, for epinephrine and epinephrine plus fibrin). When patients were stratified according to Forrest criteria, no significant difference could be found, although there was a trend toward less recurrent bleeding after fibrin injection of actively bleeding ulcers. There was no significant difference in the proportions of patients who required surgery (10% and 6%, respectively, for epinephrine and epinephrine plus fibrin). Mortality was the same (3%) in each group.

CONCLUSIONS

Adding fibrin glue to epinephrine for injection treatment of bleeding peptic ulcers does not improve outcome. Fibrin glue might be of some value in selected cases.

Cisapride does not improve precolonoscopy bowel preparation with either sodium phosphate or polyethylene glycol electrolyte lavage

BACKGROUND

Oral sodium phosphate solution (NAP) and polyethylene glycol-electrolyte lavage (PEG-EL) are used for precolonoscopy bowel preparation. The benefit of adding cisapride to PEG-EL is controversial, and its influence on the effectiveness of NAP has not been investigated. The primary aim of this study was to determine whether cisapride improves the effectiveness and/or tolerableness of bowel preparation with either NAP or PEG-EL.

METHODS

In 187 patients undergoing colonoscopy, a randomized, double-blind, placebo-controlled trial with a Latin square design was conducted to compare 4 different bowel preparations: NAP plus either cisapride (10 mg; 2 doses) or placebo, or PEG-EL plus either cisapride (10 mg; 1 dose) or placebo. Quality of the bowel preparation was graded by the endoscopist according to the amount of stool present in the colon (excellent, satisfactory, unsatisfactory). To assess tolerability, patients rated 8 symptoms, the taste of the lavage solution, and the ease of preparation on a 5-point scale (1: easy; 5: distressing).

RESULTS

Endoscopists scored the bowel preparation as either excellent or satisfactory as follows: NAP: cisapride 50% versus placebo 61% (p = 0.3); PEG-EL: cisapride 80% versus placebo 78% (p = 1.0). Cisapride did not improve tolerability or the frequency of adverse symptoms associated with either solution. The ease of bowel preparation was significantly better in the NAP group versus PEG-EL group (mean score 1.8 versus 2.8; p < 0.0001).

CONCLUSIONS

Cisapride does not improve the quality of bowel preparation with either NAP or PEG-EL. NAP is better tolerated by patients than PEG-EL; however, PEG-EL results in better bowel preparation.

Patient satisfaction after biofeedback for constipation and pelvic floor dyssynergia

BACKGROUND

Patients referred for chronic constipation frequently report symptoms of straining, feeling of incomplete evacuation, or the need to facilitate defecation digitally (dyschezia). When such patients show manometric evidence of inappropriate contraction or failure to relax the pelvic floor muscles during attempts to defecate, they are diagnosed as having pelvic floor dyssynergia (Rome I).

AIMS

To evaluate long-term satisfaction of patients with pelvic floor dyssynergia after biofeedback.

PATIENTS

Forty-one consecutive patients referred for chronic constipation at an outpatient gastrointestinal unit and diagnosed as having pelvic floor dyssynergia who completed a full course of biofeedback.

METHODS

Data have been collected using a standardised questionnaire. A questionnaire survey of patients' satisfaction rate and requirement of aperients was undertaken.

RESULTS

Mean age and symptom duration were respectively 41 and 20 years. Half of patients reported fewer than 3 bowel motions per week. Patients were treated with a mean of 5 biofeedback sessions. At the end of the therapy pelvic floor dyssynergia was alleviated in 85% of patients and 49% were able to stop all aperients. Satisfaction was maintained at follow-up telephone interviews undertaken after a mean period of 2 years, as biofeedback was helpful for 79% of patients and 47% still abstained from intake of aperients.

CONCLUSIONS

Satisfaction after biofeedback is high for patients referred for chronic constipation and diagnosed with pelvic floor dyssynergia. Biofeedback improves symptoms related to dyschezia and reduces use of aperients.

Patient satisfaction after biofeedback for constipation and pelvic floor dyssynergia

BACKGROUND

Patients referred for chronic constipation frequently report symptoms of straining, feeling of incomplete evacuation, or the need to facilitate defecation digitally (dyschezia). When such patients show manometric evidence of inappropriate contraction or failure to relax the pelvic floor muscles during attempts to defecate, they are diagnosed as having pelvic floor dyssynergia (Rome I).

AIMS

To evaluate long-term satisfaction of patients with pelvic floor dyssynergia after biofeedback.

PATIENTS

Forty-one consecutive patients referred for chronic constipation at an outpatient gastrointestinal unit and diagnosed as having pelvic floor dyssynergia who completed a full course of biofeedback.

METHODS

Data have been collected using a standardised questionnaire. A questionnaire survey of patients' satisfaction rate and requirement of aperients was undertaken.

RESULTS

Mean age and symptom duration were respectively 41 and 20 years. Half of patients reported fewer than 3 bowel motions per week. Patients were treated with a mean of 5 biofeedback sessions. At the end of the therapy pelvic floor dyssynergia was alleviated in 85% of patients and 49% were able to stop all aperients. Satisfaction was maintained at follow-up telephone interviews undertaken after a mean period of 2 years, as biofeedback was helpful for 79% of patients and 47% still abstained from intake of aperients.

CONCLUSIONS

Satisfaction after biofeedback is high for patients referred for chronic constipation and diagnosed with pelvic floor dyssynergia. Biofeedback improves symptoms related to dyschezia and reduces use of aperients.

[Long-term results of conservative management of reflux esophagitis]

Reflux esophagitis is a frequent and chronic disease. Impairment of the quality of life by the reflux symptoms and the risk of complications are the most important indications for a long-term treatment. The base of the treatment of reflux esophagitis is the inhibition of the gastric acid secretion with proton pump inhibitors (PPI) or by H2-receptor antagonist. In general, PPI's are more efficient in the treatment of refluxesophagitis as compared to H2-receptor antagonists blockers regarding the relieve of symptoms and the healing of erosive esophageal lesions. The use of an antacids and procinetics in the long-term treatment is not indicated. The treatment strategy depends on the severity of the symptoms and the esophageal lesions. Patient with mild esophagitis can be treated either with H2-receptor antagonists or with PPI's on demand or continuous. In the case of severe esophagitis, a long-term treatment with PPI's is indicated to avoid complications. Recurrence of esophagitis during a long-term therapy should be treated by PPI's. After healing the long-term treatment should be adapted either by increasing the given dose of the medicament or by a switch to more effective medicaments in acid suppression.

Cushing's syndrome in an 81-year-old patient treated with budesonide and amiodarone

This is the first report of Cushing's syndrome under oral budesonide treatment. An 81-year-old man known for paroxysmal atrial fibrillation and chronic renal insufficiency, treated with 6 mg budesonide for collagenous colitis, developed Cushing's syndrome under co-administration of amiodarone. The Cushing's syndrome disappeared after discontinuation of the amiodarone treatment. Metabolism of the two medications by hepatic cytochrome P 450 3A may explain the development of Cushing's syndrome.

Role of octreotide and somatostatin in the treatment of intestinal fistulae

Intestinal fistulae usually arise as a complication of abdominal surgery. Its treatment is complex and intestinal fistula-related morbidity and mortality is high. Fistula closure rates under conservative medical treatment vary between 24 and 72%. Octreotide and somatostatin reduce gastrointestinal, biliary and pancreatic secretion and increase intestinal water and electrolyte absorption. In recent years, octreotide and somatostatin have been associated with conservative medical treatment for patients with intestinal fistulae. Four placebo-controlled studies have been published within the past 6 years. The interpretation of their results is difficult because patient collectives were small and heterogeneous. In one study, somatostatin decreased fistula-related complications when compared to placebo, and in another study, octreotide decreased the healing time of intestinal fistulae and the time patients required total parenteral nutrition when compared to placebo. In contrast, the fistula closure rate, hospitalization time and mortality were not influenced by the use of octreotide or somatostatin in conservative medical treatment. In conclusion, octreotide and somatostatin actually cannot be recommended in the treatment of intestinal fistulae in settings outside of controlled trials.

Effect of whey-based culture supernatant of Lactobacillus acidophilus (johnsonii) La1 on Helicobacter pylori infection in humans

BACKGROUND

Specific strains of Lactobacillus acidophilus are known to inhibit intestinal cell adhesion and invasion by enterovirulent bacteria. As L. acidophilus can survive transiently in the human stomach, it may downregulate Helicobacter pylori infection.

METHODS

The ability of L. acidophilus (johnsonii) La1 supernatant to interfere with H. pylori bacterial growth, urease activity, and adhesion to epithelial cells was tested in vitro. Its effect on H. pylori infection in volunteers was monitored in a randomized, double-blind, controlled clinical trial, using a drinkable, whey-based, La1 culture supernatant. H. pylori infected volunteers were treated 14 days with 50 ml of La1 supernatant four times a day combined with either omeprazole 20 mg four times a day or with placebo. Infection was assessed by breath test, endoscopy, and biopsy sampling, performed at inclusion, immediately at the end of the treatment (breath test only), and 4 weeks after the end of the treatment.

RESULTS

La1 supernatant inhibited H. pylori growth in vitro, regardless of previous binding of H. pylori to epithelial cells. In 20 subjects (8 females, 12 males, mean age 33.1 years) a marked decrease in breath test values was observed immediately after treatment with La1 supernatant, both in the omeprazole and in the placebo group (median 12.3 vs. 28.8 and 9.4 vs. 20.4, respectively; p < 0.03). In both treatment groups, breath test values remained low 6 weeks after treatment (omeprazole treated 19.2, placebo treated 8. 3; p < 0.03 vs. pretreatment), but the persistence of H. pylori infection was confirmed in gastric biopsies.

CONCLUSION

La1 culture supernatant shown to be effective in vitro has a partial, acid-independent long-term suppressive effect on H. pylori in humans.

Diagnostic accuracy and interobserver agreement of CT colonography (virtual colonoscopy)

BACKGROUND AND AIMS

Computed tomographic (CT) colonography or virtual colonoscopy (VC) is a non-invasive imaging method proposed for screening patients with colorectal neoplasias. Our aims were to study the diagnostic accuracy and interobserver agreement of VC for correct patient identification compared with conventional colonoscopy (CC).

METHODS

This was a prospective study of 50 patients successively undergoing VC and CC. Multiplanar two dimensional CT images and three dimensional VC were constructed using surface rendering software and interpreted by two independent investigator teams. VC findings were compared with those of CC. Interobserver agreement was determined using kappa statistics.

RESULTS

CC found 65 polyps in 24 patients. For identification of patients with polyps > or =10 mm, the sensitivity of VC was 38% and 63%, and specificity was 74% and 74% for teams 1 and team 2. Interobserver agreement was good (kappa 0.72). For patients with polyps of any size, the sensitivity of VC was 75% and 71%, and specificity was 62% and 69% for teams 1 and 2. Interobserver agreement was fair (kappa 0.56). Accuracy improved when comparing the results of the first 24 with the last 26 patients.

CONCLUSIONS

In our experience, VC had a low diagnostic value for identification of patients with colorectal neoplasias. Interobserver agreement for VC interpretation was fair. These results may be explained by software imperfections and a learning curve effect.

The effects of omeprazole on healing and appearance of small gastric and duodenal lesions during dosing with diclofenac in healthy subjects

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are associated with gastrointestinal mucosal damage. Omeprazole prevents the formation, and accelerates the healing, of NSAID-induced ulcers.

AIM

To test whether omeprazole accelerates healing of standardized gastroduodenal lesions in the presence of diclofenac.

METHODS

In a double-blind, double-dummy, placebo-controlled, crossover study, 12 healthy volunteers received consecutive, 2-week courses of omeprazole (40 mg o.d.) and placebo, in random order, with an intervening, 4-week washout period; diclofenac (50 mg t.d.s.), was given for the second week of each course. Five endoscopies were performed, one at the outset and the others before and after each course of diclofenac. Biopsies were taken from the endoscopically normal mucosa of the corpus, antrum and duodenum and also from any new mucosal lesion that developed after diclofenac. The sites of biopsies taken before each course of diclofenac were evaluated endoscopically after each course to assess the extent of healing according to a predetermined healing score scale.

RESULTS

The healing scores observed after administration of placebo/diclofenac (median=0; range 0-6) and after omeprazole/diclofenac (median=0; range 0-6; P=0.17) did not differ. Small gastroduodenal lesions developed de novo in six subjects during placebo/diclofenac and in seven during omeprazole/diclofenac. Focal chemical gastropathy was observed only in close proximity to macroscopic lesions.

CONCLUSIONS

In healthy subjects, omeprazole does not accelerate the healing of pre-existing mucosal lesions or prevent the development of small diclofenac-induced mucosal lesions.

Effects of pumaprazole (BY841), a novel reversible proton pump antagonist, and of omeprazole, on intragastric acidity before and after cure of Helicobacter pylori infection

BACKGROUND

Omeprazole produces a higher intragastric pH in the presence of Helicobacter pylori infection than after cure.

AIM

To investigate whether this effect also occurs with pumaprazole (BY841), a reversible proton pump antagonist which, in contrast to omeprazole, does not require activation in the acid compartment of the parietal cell.

METHODS

In a randomized, crossover, double-blind study, 24-h intragastric pH was measured in 13 H. pylori-positive subjects before and after a 1-week course of omeprazole (20 mg o.d.) or of pumaprazole (100 mg b.d.). The studies were repeated after the infection was cured.

RESULTS

In the absence of drug administration, the median 24-h pH values before cure (median 2.0, 90% CI: 1.2-3.2) did not differ from those after cure (median 1.5, 90% CI: 1.3-2.2; P = 0.115). The 24-h pH values were higher before cure of the infection than after during both pumaprazole (6.0, 4.8-6.7 vs. 4.3, 2.6-5.7; P = 0.002) and omeprazole (5.8, 4.0-6.2 vs. 3.6, 2.8-5; P = 0.004). Both before and after cure, there were no significant differences between the two drugs with respect to acid inhibition over the 24-h period. The median decrease in acid inhibition after cure of the infection (calculated as the difference in H+ activity in mmol/L) during pumaprazole (median 0.05, 90% CI: 6 x 10-4- 2.3) was no different from that during omeprazole (median 0.2, 90% CI: 3 x 10-3-1.5; P = 0.6).

CONCLUSIONS

Both before and after cure of H. pylori infection, pumaprazole raised the intragastric pH over a 24-h period to a similar degree as omeprazole. H. pylori infection similarly augments the pH-increasing effect of both drugs. This effect is related to H. pylori infection and not to an increased activation of acid inhibitory agents in the parietal cell compartment.

Differential expression of laminin-5 subunits and integrin receptors in human colorectal neoplasia

Cell-matrix interactions contribute to regulating the adhesion, growth, migration, and differentiation of epithelial intestinal cells. Alterations in matrix components and their cellular receptors have been found in tumours but their specific roles remain unclear. The tissue patterns of laminin-5 and alpha 3, beta 3 and gamma 2 subunits, as well as those of the alpha 3, alpha 6, beta 1, and beta 4 integrin chains, were determined by immunofluorescence on frozen sections of 12 colorectal mucosal samples from four patients, 15 adenomas, 29 adenocarcinomas, and eight metastases. Distinct patterns of laminin-5 and integrin expression were found along the mucosa-adenoma, and adenoma-carcinoma transitions. Expression of basement membrane laminin-5 and subunits was continuous and gradient-like in normal mucosa, enhanced at the periphery of adenomas, and discontinuous in places in carcinomas and metastases. Decrease of the alpha 3 integrin chain was found in adenomas, together with that of alpha 6 and beta 4 chains in carcinomas. A subpopulation of carcinoma cells dissociating (budding) from neoplastic tubules was found to accumulate the laminin-5 beta 3 gamma 2 heterodimer in the cytoplasm, with progressive loss of surface integrin expression. These results suggest that in colorectal cancer, an abnormal expression of laminin-5 subunits and integrin chains may identify a subset of carcinoma cells prone to invade focally and to contribute to disease aggressiveness.

Budesonide in the treatment of collagenous colitis

Collagenous colitis is characterized by watery diarrhea and inflammatory infiltration associated with a subepithelial collagen deposit on colonic biopsies despite a normal or subnormal endoscopic appearance. We here describe 5 patients treated with the locally active steroid budesonide. Complete and partial response was observed in 3 and 2 patients, respectively. Budesonide thus seems to be of therapeutic benefit in collagenous colitis. Prospective randomized long-term studies are needed to support this hypothesis.

Differential expression of laminin-5 subunits and integrin receptors in human colorectal neoplasia

Cell-matrix interactions contribute to regulating the adhesion, growth, migration, and differentiation of epithelial intestinal cells. Alterations in matrix components and their cellular receptors have been found in tumours but their specific roles remain unclear. The tissue patterns of laminin-5 and alpha 3, beta 3 and gamma 2 subunits, as well as those of the alpha 3, alpha 6, beta 1, and beta 4 integrin chains, were determined by immunofluorescence on frozen sections of 12 colorectal mucosal samples from four patients, 15 adenomas, 29 adenocarcinomas, and eight metastases. Distinct patterns of laminin-5 and integrin expression were found along the mucosa-adenoma, and adenoma-carcinoma transitions. Expression of basement membrane laminin-5 and subunits was continuous and gradient-like in normal mucosa, enhanced at the periphery of adenomas, and discontinuous in places in carcinomas and metastases. Decrease of the alpha 3 integrin chain was found in adenomas, together with that of alpha 6 and beta 4 chains in carcinomas. A subpopulation of carcinoma cells dissociating (budding) from neoplastic tubules was found to accumulate the laminin-5 beta 3 gamma 2 heterodimer in the cytoplasm, with progressive loss of surface integrin expression. These results suggest that in colorectal cancer, an abnormal expression of laminin-5 subunits and integrin chains may identify a subset of carcinoma cells prone to invade focally and to contribute to disease aggressiveness.

Alterations in plasminogen activation correlate with epithelial cell dysplasia grading in colorectal adenomas

Proteases are important for neoplastic invasion but a specific role for the plasminogen activator system in the progression of colorectal epithelial dysplasia to adenomatous lesions remains unclear. Consecutive tissue cryosections of 51 adenomas, 49 distant mucosa samples and five mucosa samples from control subjects were histopathologically analysed for dysplasia grade and tissue type, urokinase plasminogen activator levels and plasminogen activator inhibitor type 1 (PAI-1) using immunosorbent methods. Plasminogen activation and urokinase-mediated proteolytic activity levels were assessed using in situ zymography. Plasminogen activation and tissue-type activator levels were lower in adenomas than in mucosae (P < 0.001). PAI-1 concentration and urokinase levels were higher in adenomas than in mucosae (P < 0.001 and P < 0.001 respectively). In adenomas, urokinase concentration increased in parallel with PAI-1, but only the urokinase levels correlated with the dysplasia grade (P < 0.01). Thus, the alterations in plasminogen activation correlated with epithelial cell dysplasia grading. In the mucosa to adenoma transition, a marked decrease in tissue-type plasminogen activator occurred. In adenomas, this decrease was accompanied by a concomitant increase in urokinase and PAI-1. The urokinase level only continued to rise in parallel with the dysplasia grade. Resulting protease-antiprotease imbalance in high-grade dysplasia may represent the phenotypic change associated with malignant transformation and invasive behaviour.

Genetic heterogeneity in sporadic colorectal adenomas

The majority of colorectal cancers develop from adenomatous polyps under the influence of factors that are still poorly understood. Tumourigenesis is generally considered a multistep process in which multiple genetic alterations occur, eventually reflected in abnormalities of the cellular DNA content. Macroscopical features such as tumour size and tumour architecture (tubular, tubulovillous, or villous) are correlated wit the chance of malignancy in the lesion. Grade of dysplasia can be considered an indicator for the level of progression of the adenoma towards invasive carcinoma. These characteristics were correlated with the presence or absence of K-ras mutations and the DNA ploidy in a prospective study performed on 46 large sporadic colorectal adenomas resected by endoscopy. DNA ploidy and K-ras mutations were analysed in two samples taken at distant sites in the adenomas. Aneuploidy was present in 12 adenomas (26 per cent) and K-ras mutations occurred in 26 (57 per cent). A highly significant correlation was found between aneuploidy and adenoma size, architecture, and grade of dysplasia. The presence of K-ras mutations was significantly correlated only with the size of the adenomas. The proportion of adenomas with aneuploidy and/or a K-ras mutation increased when two samples were analysed instead of one. This observation suggests that the prevalence of genetic mutations and of aneuploidy is probably underestimated, as generally only one sample is investigated. No correlation was observed between K-ras mutations and ploidy. This study demonstrates the presence of genetic heterogeneity in colorectal adenomas and supports the notion that K-ras mutation is an early event, while aneuploidy is a late event in the adenoma-carcinoma sequence.

Comparison between esophageal Wallstent and Ultraflex stents in the treatment of malignant stenoses of the esophagus and cardia

BACKGROUND AND STUDY AIMS

Several published studies have examined various self-expanding metal esophageal stents for use in the palliative treatment of esophageal or cardiac neoplasia, but few have compared different self-expanding metal stents. The aim of this study was to evaluate non-covered Wallstent and Ultraflex prostheses in the treatment of malignancies in the esophagus and the cardiac region.

MATERIALS AND METHODS

In a retrospective study, the effectiveness of non-covered Wallstents (46 patients) and Ultraflex stents (36 patients) was compared in the treatment of malignancies in the esophageal and cardiac regions.

RESULTS

Reintervention procedures were necessary in 16 of the 46 Wallstent patients (six patients during an early phase) and in 22 of the 36 Ultraflex patients (13 during an early phase) (overall P = 0.022; early P = 0.018). The major complication in the Wallstent group was tumor ingrowth (12 of 35 complications), while in the Ultraflex group, it was incomplete deployment (18 of 49 complications). Incomplete stent deployment occurred more often in patients treated with Ultraflex (P = 0.01), and food impaction was more often observed in the Wallstent group (P = 0.001). In addition, in patients with Ultraflex stents, more complex reinterventions were necessary than those required with Wallstents (four vs. 13 complex reinterventions, P = 0.0046). Wallstents tended to improve dysphagia better than Ultraflex stents.

CONCLUSION

Compared to Ultraflex stents, Wallstents have several significant short-term and long-term advantages in the palliative treatment of malignancy of the esophagus and cardia.

Meglumine gadoterate: a new safe radiocontrast medium for endoscopic retrograde cholangiopancreatography?

The radiocontrast substance meglumine gadoterate (MG) is used in magnetic resonance imaging. It is characterized by its low rate of adverse drug reactions. In an open study we tested whether MG is useful in endoscopic retrograde cholangiopancreatography. The patients received in sequence MG and ioxotalamate. MG, in contrast to ioxotalamate, failed to visualize the proximal pancreatic and peripheral intrahepatic ducts. Thus, MG is not useful in routine endoscopic retrograde cholangiopancreatography. However, in patients with a history of severe allergic reactions to conventional contrast media, MG may be recommended when pathological findings of the extrahepatic bile duct or the area of the pancreatic head are suspected.

In situ stromal expression of the urokinase/plasmin system correlates with epithelial dysplasia in colorectal adenomas

An increase of urokinase-type plasminogen activator (uPA) and a decrease of tissue-type PA (tPA) have been associated with the transition from normal to adenomatous colorectal mucosa. Serial sections from 25 adenomas were used to identify PA-related caseinolytic activities by in situ zymography, blocking selectively uPA or tPA. The distribution of uPA, tPA, and type 1 PA inhibitor mRNAs was investigated by nonradioactive in situ hybridization, and the receptor for uPA was detected by immunostaining. Low- and high-grade epithelial cell dysplasia was mapped histologically. Results show that 23 of 25 adenomas expressed uPA-related lytic activity located predominantly in the periphery whereas tPA-related activity was mainly in central areas of adenomas. In 15 of 25 adenomas, uPA mRNA was expressed in stromal cells clustered in foci that coincided with areas of uPA lytic activity. The probability of finding uPA mRNA-reactive cells was significantly higher in areas with high-grade epithelial dysplasia. uPA receptor was mainly stromal and expressed at the periphery. Type 1 PA inhibitor mRNA cellular expression was diffuse in the stroma, in endothelial cells, and in a subpopulation of alpha-smooth muscle cell actin-reactive cells. These results show that a stromal up-regulation of the uPA/plasmin system is associated with foci of severe dysplasia in a subset of colorectal adenomas.

Effects of misoprostol on healing and prevention of biopsy-induced gastroduodenal lesions occurring during the administration of diclofenac to volunteers

AIM

To determine whether misoprostol promotes the healing of non-steroidal anti-inflammatory drug-induced gastroduodenal lesions in a human experimental model.

METHODS

Mucosal damage and healing of mucosal biopsy sites were assessed endoscopically in 10 healthy, Helicobacter pylori-negative volunteers with a normal initial endoscopy: they were enrolled in a double-blind, double-dummy, placebo-controlled cross-over study. They received 2-week courses of misoprostol (200 micrograms b.d.) or placebo; a water-soluble non-steroidal antiinflammatory drug diclofenac 50 mg t.d.s., was given during the second week of each dosage regimen after three endoscopic biopsies had been taken from each of the duodenum, antrum and corpus.

RESULTS

The number of unhealed biopsy sites was not different after misoprostol or placebo, although the number of healed biopsy sites was greater in the corpus and duodenum than in the antrum. Misoprostol did not prevent the appearance of diclofenac-induced erosions and petechiae. Epigastric discomfort was related to the intake of diclofenac and was reduced by misoprostol. Bloating and flatulence occurred more frequently with misoprostol alone and with misoprostol plus diclofenac, than with placebo alone or placebo plus diclofenac.

CONCLUSION

Misoprostol does not prevent new mucosal lesions induced by diclofenac in healthy volunteers and it does not accelerate the healing of the biopsy sites. Misoprostol decreases the frequency of diclofenac-induced epigastric discomfort, but it increases gas bloating and flatulence.

Effect of curing Helicobacter pylori infection on intragastric pH during treatment with omeprazole

It has been shown that omeprazole treatment produces higher intragastric pH values in Helicobacter pylori positive subjects than in H pylori negative subjects. This study aimed to investigate the effect of curing H pylori on the intragastric pH in both the presence and absence of omeprazole therapy. Twenty four hour intragastric pH recordings were performed before and after a one week course of omeprazole (20 mg once daily) in 18 H pylori positive subjects and were repeated after the infection had been cured. In the absence of omeprazole, the total 24 hour pH values before cure did not differ from those afterwards. During omeprazole treatment the 24 hour pH values were much higher before (median (95% CI) 5.4: 4.3, 6.0), than after cure of infection (3.6: 2.1, 4.4; p < 0.001). The omeprazole induced fall in H+ activity before cure of H pylori did not, however, differ from that afterwards. It is concluded that the apparently greater antisecretory effect of omeprazole during H pylori infection may be a result of the production of acid neutralising compounds by the H pylori. Although a direct interaction between H pylori and omeprazole cannot be excluded, it seems unlikely.

Endoscopic features of Helicobacter pylori-related gastritis

BACKGROUND AND STUDY AIMS

It is still controversial whether certain endoscopic features can be used to diagnose Helicobacter pylori (Hp)-related gastritis. To clarify this issue, we performed two consecutive prospective studies.

PATIENTS AND METHODS

In the first study, we tried to identify endoscopic criteria associated with Hp-related gastritis from a total of 66 predefined gastric features on endoscopy. These features were selected by a stepwise logistic regression analysis in 101 patients. The validity of these features gained from this first study was then evaluated in a second study in 86 patients (40 with Hp gastritis, 8 with Hp-unrelated gastritis and 38 with normal gastric mucosa).

RESULTS

Three features, namely an abnormal antral surface texture, a mammillated corpus surface, and white antral erosions, were identified in the first study as independent predictors of Hp-related gastritis. However, the sensitivity and specificity of these three criteria, as assessed in the second study, were only 75% and 63% respectively.

CONCLUSIONS

We conclude that it is not possible to diagnose Hp-related gastritis on the basis of the endoscopic appearance alone. The diagnosis should be based on other criteria, such as a rapid urease test, or a histological examination of gastric biopsies, or both.

Effect of cisapride on gallbladder motility after extracorporeal shock-wave lithotripsy

BACKGROUND/AIMS

Altered gallbladder motility is regarded as one of the important factors involved in the formation and recurrence of gallstones. Previous studies have suggested that cisapride increases postprandial gallbladder contraction and may therefore be theoretically useful in preventing stone recurrence. The aim of our study was therefore to investigate the effect of cisapride on gallbladder motility in stone-free patients after extracorporeal shock-wave lithotripsy, as compared to healthy volunteers pair-matched for age and sex.

METHODS

Each subject received cisapride or placebo in a double-blind, cross-over, random order. Gallbladder volumes were measured by ultrasonography in the fasting state and after intake of a standard liquid meal. Plasma cholecystokinin levels were determined by radioimmunoassay.

RESULTS

Fasting gallbladder volumes were smaller in patients as compared to volunteers (20.7 +/- 1.3 ml vs. 46.0 +/- 9.2 ml; p < 0.05) but were not modified by cisapride (21.1 +/- 1.7 ml vs. 58.6 +/- 11.3 ml). The maximal postprandial decrease in gallbladder volume was similar in patients and volunteers (64.5 +/- 12% vs. 62 +/- 10%; NS) and was not significantly altered by cisapride (59 +/- 9.4% vs. 54 +/- 9%; NS). In patients, cisapride increased integrated postprandial gallbladder volume by accelerating gallbladder refilling as compared to placebo by 37 +/- 15% (p < 0.05). Integrated cholecystokinin plasma levels were similar in patients and volunteers and were 13.4 +/- 4.7% higher after cisapride as compared to placebo (p < 0.05).

CONCLUSIONS

The results of this study suggest that cisapride does not alter postprandial gallbladder contraction but accelerates gallbladder refilling in patients free from gallstones after extracorporeal shock-wave lithotripsy. This effect of cisapride is probably due to an acceleration of gastric emptying also causing a secondary enhanced cholecystokinin release.

[Dieulafoy's simple stomach ulcer: apropos of 5 cases]

Dieulafoy's ulcer is a probably congenital arterial malformation which may produce severe upper gastrointestinal haemorrhage. It represents about 1% of all cases of acute upper gastrointestinal haemorrhage (3/249 in our department during 1989). We report 5 cases in whom haemostatic endoscopic treatment was successful and propose therefore that this therapy should be the initial treatment of choice. Surgical intervention should be considered only if endoscopic therapy fails.

[Clozapine-induced cholestatic jaundice: a case report]

We report on a patient who became jaundiced during treatment with clozapine (Leponex). Histologically, cholestatic hepatitis with single-cell necroses of hepatocytes and infiltration of the portal zones with eosinophilic granulocytes were found. The patient recovered after discontinuation of clozapine, and liver function tests returned to normal within 4 weeks. This adverse effect of clozapine suggests that this "atypical" tricyclic neuroleptic resembles the phenothiazines both with regard to therapeutic spectrum and side effects.