Short report: zinc sulphate supplementation corrects abnormal erythrocyte membrane long-chain fatty acid composition in patients with Crohn's disease

Patients with Crohn's disease may become zinc-deficient and, in such patients, an altered metabolism of radiolabelled long-chain fatty acids has been reported. We have investigated the possible reversal by zinc supplementation of altered long-chain fatty acid profiles of red cells in Crohn's disease. Twenty patients with long-standing Crohn's disease in clinical remission received 200 mg of zinc sulphate daily for 6 weeks. Phospholipid fatty acid profiles of washed red cells were analysed before and after zinc treatment and compared to those of 20 unsupplemented healthy controls. Plasma zinc levels in Crohn's were 72 +/- 8 micrograms/dL before zinc treatment and increased to 114 +/- 10 micrograms/dl after the therapy. Prior to zinc supplementation, the percentage of palmitic, stearic and oleic acids was significantly higher in Crohn's disease, while linoleic, arachidonic and n-3 fatty acids were reduced in Crohn's disease compared to healthy controls. Zinc supplementation abolished these pre-treatment differences in red-cell long-chain fatty acid profiles but did not affect plasma fatty acid values. Further studies are needed to clarify whether these fatty acid changes can be related to the clinical course of the disease.

Flow cytometry and in vitro tritiated thymidine labeling in normal rectal mucosa of patients at high risk of colorectal cancer

OBJECTIVES

To compare two different methods to evaluate rectal epithelial cell proliferation as a biomarker of risk of developing colon cancer.

METHODS

Samples of normal rectal mucosa from 26 patients at increased risk for colorectal cancer (22 patients with adenoma, three with adenocarcinoma of the large bowel, and one with longstanding ulcerative colitis) were examined by means of in vitro labeling with tritiated thymidine and flow cytometry.

RESULTS

We found a significant correlation between thymidine-labeling index and the percentage of cells in S-phase, measured by flow cytometry both in formalin-fixed, paraffin-embedded specimens and in frozen specimens (respectively, r = 0.7647, p < 0.001, and r = 0.4503, p < 0.01). However, using flow cytometry, the percentage of cells in S-phase was significantly higher than the thymidine-labeling index in both fixed-embedded and frozen specimens (p < 0.01). Proliferative parameters were not higher in patients with colon carcinoma, and were not related to the degree of dysplasia, the number of adenomas, or familial occurrence of colorectal cancer. Two specimens taken from normal rectal mucosa of two patients with adenomas showed aneuploidy. No aneuploidy was found in normal rectal specimens of patients with adenocarcinoma.

CONCLUSIONS

These results show that the calculation of cells in S-phase with in vitro tritiated thymidine labeling or by flow cytometry produces different results. However, the significant correlation between corresponding parameters obtained with these techniques support the use of either method as "intermediate biomarkers" of colorectal cancer risk and prognosis.

The relationship of endoscopy, portal Doppler ultrasound flowmetry, and clinical and biochemical tests in cirrhosis

The relationship of the endoscopic aspect of esophageal varices, portal quantitative Doppler ultrasound parameters and clinical and biochemical findings was assessed in 149 patients with cirrhosis stratified according to the presence of esophageal varices (n = 115) and the absence of previous bleeding (n = 96). In this series of patients the presence of esophageal varices and red signs proved to be significantly correlated with the severity of cirrhosis. However, in the group of patients with varices, no correlation was found between variceal size and the degree of liver failure. Portal blood flow velocity was significantly different in the endoscopic subgroups, but not in the clinical and biochemical subgroups. Furthermore, portal blood flow velocity was found to correlate only with the presence and size of esophageal varices. The Congestion Index of the portal vein (derived from the ratio between the cross-sectional area of the portal vein and the mean velocity of portal flow) was significantly different in most clinical, biochemical and endoscopic subgroups and was correlated with liver function, presence and size of varices, and presence and degree of red signs. We conclude that the Congestion Index of the portal vein, the clinical status and the endoscopic aspect of varices are not independent features in patients with cirrhosis. As for liver function and endoscopic findings, portal Doppler ultrasound parameters, in particular the Congestion Index, may contribute to a better clinical assessment in patients with cirrhosis.

Effects of acute cold pressor test on vagally stimulated gastric acid secretion and circulating levels of human pancreatic polypeptide and gastrin

The aims of our study were 3-fold: (1) to determine the effect of an acute cold pressor test on vagally stimulated gastric acid secretion, (2) to evaluate whether adrenergic blockers are able to prevent the stress-induced alterations of vagally stimulated gastric acid secretion, and (3) to assess the effect of stress and adrenergic blockers on serum levels of vagally stimulated pancreatic polypeptide and gastrin. Twenty-eight studies were carried out on 7 healthy subjects, each one of them being evaluated on four separate occasions. Active (4 degrees C) or control (37 degrees C) cold pressor tests were applied in random order after an interval of 15 min following completion of a vagal stimulation represented by modified sham feeding. Each stressful stimulus was preceded by an intravenous bolus plus an infusion of either adrenergic blockers (propranolol and phentolamine) or placebo. Modified sham feeding significantly stimulated gastric acid secretion and circulating hormonal levels, compared to basal values. Cold pressor test significantly stimulated gastric acid secretion 30 min after the beginning of the stressful stimulus. This stress-induced secretory response was completely prevented by infusions of adrenergic blockers. No effect was induced by stressful stimuli or by adrenergic blockers on human pancreatic polypeptide and gastrin circulating levels. The present study demonstrates that the cold pressor test induces a late increase of vagally stimulated gastric acid secretion suggesting a possible role mediated by adrenergic neural pathways.

[Calcium polycarbophil in clinical practice. The therapy of constipation]

The clinical efficacy of polycarbophil calcium was assessed in 57 patients of both sexes aged between 18 and 77 years old affected by chronic non-organic constipation. The multicentre study was performed using a single blind and cross-over protocol for 8 weeks, 4 with placebo and 4 with the drug (2 c.p.s 3 t.i.d). Thirteen patients failed to complete the study, 8 of them for reasons not related to the drug. In comparison to placebo, the drug caused a significant reduction in the consistency of stool and evacuatory force during the first week of stool therapy. Medical judgement was that efficacy was "very good" in 73% and "good" in 18%, whereas the drug was thought to be "non efficacious" in 9% of cases. The statistical analysis of data confirmed the efficacy of the drug. The hematochemical parameters evaluated before, during and after treatment only showed a slight increase in calcemia and calciuria which did not reach statistical significance. The therapeutic efficacy and lack of undesired effects confirm the value of polycarbophyl calcium in the treatment of chronic constipation.

Gastric retention of sucralfate gel and suspension in upper gastrointestinal diseases

This study was designed to compare by scintigraphy the gastric retention of a new dosage form of sucralfate as gel (Gastrogel) with that of sucralfate suspension in 25 patients with upper gastrointestinal symptoms referred for routine endoscopy. After endoscopy 4 subgroups were defined: macroscopically normal mucosa (n = 7), antral gastritis and/or erosions (n = 6), gastric ulcer (n = 6) and duodenal ulcer (n = 6). Each patient received either sucralfate gel or sucralfate suspension in equivalent doses (5 ml containing 1 g sucralfate). Both formulations were labelled with 111 MBq 99mTc-DTPA before administration. The mean value of t1/2 in the total group was significantly longer when patients were taking sucralfate gel (61.6 min) compared to sucralfate suspension (33.8 min) (P < 0.001). The mean values of t1/2 were significantly longer for sucralfate gel compared to sucralfate suspension also among the subgroups (macroscopically normal P < 0.02, antral gastritis P < 0.05, gastric ulcer P < 0.02 and duodenal ulcer P < 0.05). After 2 and 3 hours, the percentage residual activity in the gastric area was significantly higher following administration of sucralfate gel compared to sucralfate suspension. This study has shown that, compared to sucralfate suspension, sucralfate gel persists longer in the stomach of patients with gastritis and peptic ulcer.

Better quality of therapy with 5-ASA colonic foam in active ulcerative colitis. A multicenter comparative trial with 5-ASA enema

We evaluated the efficacy, tolerance, and acceptance of a new 5-ASA colonic foam versus 5-ASA liquid enema in the short-term treatment of active ulcerative colitis in a three-week prospective, randomized, investigator-blind study, enrolling 233 patients from 12 outpatient clinics in Italy. In arm 1 of the study, 117 patients with mild attacks received 2 g of 5-ASA as foam or enema at bedtime. In arm 2, 116 patients with moderate attacks were given 4 g of 5-ASA as foam or enema at bedtime. End points were defined as complete relief of symptoms, and endoscopic and histological evidence of remission or improvement. In patients with mild relapse, 34 of 63 (54%) treated with foam were in clinical remission after only 10 days compared with 17 of 51 (31%) treated with enemas (P < 0.05). However, there was no statistically significant difference between foam (83%) and enema (74%) after three weeks. In patients with moderate relapse, a higher proportion of patients achieved complete clinical remission in the foam group (63%) compared with enema group (52%) after three weeks (difference 11%, 95% CI -7 to 29). No significant differences were observed in endoscopic and histological evaluation of colonic mucosa between treatment groups in either arm. 5-ASA foam was well tolerated. No unexpected adverse events were reported. Patient evaluation of therapy showed that foam was much better accepted than enema because foam was more comfortable, more practical, easier to retain, and interfered less with daily living.(ABSTRACT TRUNCATED AT 250 WORDS)

Home parenteral nutrition for the management of chronic intestinal failure: a 34 patient-year experience

Home parenteral nutrition (HPN) was used for the treatment of 18 patients with chronic intestinal failure (CIF): short bowel syndrome (9), extensive intestinal disease (4), motility disorder (4), entero-enteric fistulas (1). The underlying diseases were: chronic inflammatory (7), mesenteric vascular (4), scleroderma (2), pseudo-obstruction (2), malignancy (2), radiation enteritis (1). HPN was more effective on protein-calorie nutritional status than on fluid and electrolyte balances. About two-thirds of the patients achieved full or partial social rehabilitation. During the 6 months before HPN, there were 20 hospitalizations (mean stay: 55 days). During HPN (mean length of treatment: 22 months/patient) there were 16 hospitalizations (mean stay: 22 days), 8 of which were caused by HPN complications (sepsis and deep vein thrombosis; overall incidence of catheter-related complications: 0.411 per patient-year). Bone demineralization, liver abnormalities and biliary stones developed, respectively, in 57%, 28% and 11% of the cases. The underlying intestinal condition played a role in their pathogenesis. The annual cost of HPN ranged from 40 (Hospital Pharmacy Service) to 80 (commercial firm) million lire per patient. To sum up, HPN improves the nutritional status and the quality of life of patients with CIF, and the risk of complications is acceptable. The medical and social advantages are considered to offset the cost of the technique.

Beta-endorphin response to exogenous corticotrophin-releasing hormone in obese women with different patterns of body fat distribution

Obese individuals may be characterized by higher than normal basal and stimulated beta-endorphin plasma concentrations, which suggests an increased activity of the opioid system. This study was carried out to investigate whether the regulation of beta-endorphin secretion may be different in different phenotypes of obesity. Twenty-two obese women (body mass index greater than 30 kg/m2) without other endocrine and metabolic abnormalities were investigated. A group of seven normal weight healthy women matched for age served as controls. According to the protocol, obese women included in the study had a waist-to-hip ratio higher than 0.85 (n = 9) or lower than 0.80 (n = 13). The former were defined as having abdominal type and the latter peripheral type body fat distribution. Both groups were matched for body mass index. All women randomly underwent a corticotrophin-releasing hormone test (human CRF, 1 microgram/kg body weight) and a control saline study, with blood samples for beta-endorphin determination taken at regular intervals. Basal beta-endorphin levels were not significantly different between the three groups. No significant variation in the hormone levels occurred during the control study in either group. After CRF injection, however, beta-endorphin rose significantly in all women, but the hormone concentrations were significantly higher in obese women with abdominal fat distribution than in those with peripheral fat distribution and in controls. These results indicate that, among obese women, only those with the abdominal phenotype seem to have increased opioid activity.

Abnormal rectal cell proliferation and p52/p35 protein expression in patients with ulcerative colitis

We evaluated the presence of cell proliferation and antigenic abnormalities in rectal biopsies from 37 patients affected by ulcerative colitis and 15 controls. The study was carried out by thymidine labeling and immunochemistry, using antibodies against specific cytoskeletal-associated proteins (p52, p35, alpha-actinin). Among ulcerative colitis patients, 24 had an immunofluorescence pattern similar to that of controls, while 13 showed an abnormal distribution of one or more proteins (p52 alone or p52 and either p35 or alpha-actinin) within the rectal crypts. Patients showed a shift of the proliferative compartment towards the top of the rectal crypts compared with controls. This finding was more evident in patients with p52 or p35 abnormalities. Proliferative and antigenic defects were not related either to age or the duration of colitis. These phenotypic changes might be a biomarker of increased risk of colon cancer in ulcerative colitis.

[Clinical evaluation of calcium-polycarbophil in the treatment of non-specific diarrhea]

We performed a study on 10 patients aged between 26 and 54 males and females, affected by non-specific diarrhea. A single-blind clinical trial has been developed where Calcium-Polycarbophil was administered (2 cps t.i.d.) for a period of 8 weeks, half with placebo and half with drug in cross-over. No drop-out occurred. Number of evaluations, cramps and consistency of stools, have been evaluated before and after treatment. A definite decrease of evacuations per day and of cramps, when present, together with a higher consistency of stools, are reported when Calcium-Polycarbophil is administered, according to the favourable medical judgement. Haematochemical parameters, evaluated before, during and after the treatment didn't show any relevant variation, apart from slight increase (not statistically significant) of calcium both in blood and in urine). No other unwanted event has been detected. Hence, the high therapeutic index of Calcium-Polycarbophil makes it highly desirable in the treatment of diarrhea.

One-day therapy for treatment of Helicobacter pylori infection

The present study evaluated the effect of a one-day high-dose combined therapy on Helicobacter pylori infection. Thirty-two consecutive patients (suffering from either peptic ulcer or nonulcer dyspepsia) with Helicobacter pylori infection received omeprazole (40 mg) + bismuth subcitrate (240 mg x 4) + amoxicillin suspension (2000 mg x 4) + metronidazole (500 mg x 4), for only one day. Endoscopy, histology, culture, and susceptibility studies were done at entry and 30 and 90 days after the treatment day. Successful eradication was obtained in 23/32 (72%) patients and gastritis had resolved in 95% of these. Side effects were induced by the treatment in 6/32 (19%) patients, but these were all self-limiting, short-lasting, and did not require any specific treatment. Development of bacterial resistance to metronidazole occurred in 6/9 (67%) non-eradicated patients. These data suggest that one-day treatment with high doses of amoxicillin, metronidazole, bismuth, and omeprazole represents an effective, safe, and inexpensive therapeutic approach for the treatment of H. pylori infection.

Serum pepsinogen I and II concentrations and IgG antibody to Helicobacter pylori in dyspeptic patients

AIMS

To investigate the association between histologically confirmed gastritis, carriage of Helicobacter pylori and pepsinogen (PG) I and PG II concentrations.

METHODS

Prospective study of 81 dyspeptic patients undergoing upper gastrointestinal endoscopy was made. The extent of gastric mucosal inflammation and the presence of H pylori was determined, and serology to evaluate PG I and II concentrations and IgG titres to H pylori was carried out.

RESULTS

The presence of H pylori was strongly correlated with high IgG antibody titres to H pylori and gastritis. Patients who were H pylori positive had significantly higher PG I and PG II concentrations and a significantly lower PG I:PG II ratio than patients who were negative for H pylori. In 13 patients with duodenal ulcer and H pylori positive gastritis serum PG I concentrations were significantly higher than in H pylori positive patients without duodenal ulcer. Significant correlations were found between the age of patients and serum PG II, the PG I:PG II ratio, IgG antibodies to H pylori, the severity of body gastritis and H pylori infection, and between the degree of gastritis in the body of the stomach and the PG II concentration.

CONCLUSIONS

Serum PG I and II concentrations, together with a fall in the PG I:PG II ratio, could be used as predictors of H pylori infection as well as serum IgG antibody response to H pylori.

The hypothalamic-pituitary-adrenal axis in obese women with different patterns of body fat distribution

To investigate whether obese subjects with abdominal obesity may be characterized by hyperactivity of the hypothalamic-pituitary-adrenal axis, we examined two groups of obese women with a waist to hip ratio (WHR) lower than 0.80 (n = 13), therefore having peripheral body fat distribution (P-BFD), or a WHR higher than 0.85 (n = 12), thus having abdominal body fat distribution (A-BFD). A group of seven normal weight healthy women served as controls. All subjects underwent the following protocol study that included 1) measurement of daily urinary free cortisol excretion rate; 2) a CRF test (human CRF, 1 microgram/kg BW, as iv bolus), with blood samples taken at regular intervals for ACTH and cortisol determination; and 3) an ACTH test, performed by administering two boli of ACTH (Synacthen, 0.2 microgram/kg BW, iv), at 90-min intervals, with blood samples taken for cortisol determination. Each woman also had a control saline study. Basal levels of both ACTH and cortisol rose significantly after CRF administration in all groups, but this increase was significantly higher in A-BFD than in P-BFD and control women. A significant correlation was found between the incremental area of cortisol and that of ACTH during the CRF test (r = 0.502), but not between these parameters and WHR values. Although the cortisol increase after the ACTH test was higher in A-BFD than in the other groups, these differences were only significant at 60 min during the test and when the analysis for repeated measures was applied. On the contrary, the incremental cortisol area after the ACTH test was not significantly different in the three groups. Moreover, it was not significantly correlated with the incremental cortisol area after CRF test or WHR values. Daily urinary free cortisol excretion rates (per g creatinine), however, were significantly higher in A-BFD than in P-BFD and control women. These results, therefore, suggest that obese women with A-BFD may have hyperactivity of the hypothalamic-pituitary-adrenal axis. This abnormality could be central in origin, due to hypersecretion of CRF or ACTH; alternatively, it could represent an adaptive phenomenon secondary to a state of functional cortisol resistance.

Persistent hepatitis C viraemia without liver disease

In viral infections persistence of the virus is not always associated with virus-induced disease. To find out if active hepatitis C virus (HCV) infection can persist without liver disease we selected four symptom-free individuals with antibodies to HCV but normal aminotransferase levels. They were followed up for 3 years by monthly serology and a liver biopsy was done. At presentation, all four had both antibodies to HCV and circulating HCV RNA. During follow-up their sera remained persistently positive for all HCV antibodies and RNA yet aminotransferase levels did not increase and liver biopsy was normal. These findings indicate that persistent hepatitis C viraemia is not invariably associated with liver damage.

Evaluation of Helicobacter pylori sensitivity to amoxycillin and metronidazole in dyspeptic patients

We evaluated the "in vitro" sensitivity to amoxycillin and metronidazole of 193 Helicobacter pylori strains isolated from the gastric mucosa of dyspeptic patients. Susceptibility was determined by disc diffusion on agar plates. All the isolates were found to be sensitive to amoxycillin. On the contrary, 12% of the strains isolated from patients never treated for Helicobacter pylori infection and 73% of those isolated from patients who had previously received unsuccessful treatment for Helicobacter pylori infection were found to be resistant to metronidazole. Resistance was more common in women (17%) than in men (4%: p < 0.01) and was not correlated with age. The occurrence of Helicobacter pylori resistance to metronidazole is relatively common in Italy. In vitro testing of Helicobacter pylori sensitivity seems to be important before embarking on treatments aimed at eradicating the bacterium.

Biliary surgery without the surgeon!

Since the introduction of endoscopic retrograde cholangiopancreatography in the 1970s and of endoscopic sphincterotomy (EST) in 1974, endoscopic techniques for the diagnosis and therapy of biliary and pancreatic disorders have proliferated. Although some procedures have become part of routine practice, for example EST for postcholecystectomy bile duct stones and stent insertion for inoperable biliary strictures, the place of others is unclear at present and should be evaluated by prospective randomized clinical trials. The choice of either an endoscopic or a transhepatic approach for biliary disease is usually dictated by local expertise, but these should be regarded as complementary rather than competing techniques, and complex biliary problems should be managed jointly by the endoscopist, interventional radiologist and hepatobiliary surgeon.

Serum IgM antibodies to hepatitis C virus in acute and chronic hepatitis C

A standardized commercially available immunoassay is not available for detection of IgM antibodies against hepatitis C virus antigens (IgM anti-HCV). Therefore, different "in-house" enzyme immunoassays have been assessed. These assays vary greatly in sensitivity, but specificity seems satisfactory in all of them. A typical IgM antibody response to HCV antigens is usually found in nearly all patients with acute hepatitis C. This antibody response rarely precedes the appearance of IgG anti-HCV, and it persists for a few months at high titer. Low titers of IgM anti-HCV are detectable in 50-80% of cases with chronic hepatitis C. IgM anti-HCV reactivity is typically found during acute exacerbation of chronic hepatitis C. Furthermore, many patients with chronic active hepatitis C without acute exacerbation also have IgM anti-HCV. In these patients a correlation exists between the titer of IgM anti-HCV and the biochemical parameters of liver disease. When alpha interferon therapy induces a sustained remission of liver disease activity, positivity for IgM anti-HCV disappears in more than 70% of cases. In contrast, patients who do not respond to therapy rarely loose IgM anti-HCV. In conclusion, serum IgM antibodies to HCV antigens are reliable markers of active HCV-induced liver disease both in acute and in chronic HCV infection.

The effect of different dosage schedules of cisapride on gastric emptying in idiopathic gastroparesis

The aim of this study was to determine the optimal dosage regimen of cisapride for the treatment of idiopathic gastroparesis. We studied 17 patients with documented idiopathic gastroparesis in a three-way, cross-over, double-blind study with three 4-day treatment periods separated by at least 3 days without treatment. In each period, the patients were preloaded with cisapride (10 mg tid) for three days. On the fourth day (the test day) they took either 10 mg or 20 mg before breakfast and placebo before lunch (1 x 10 mg), (1 x 20 mg), or 10 mg before breakfast and 10 mg before lunch (2 x 10 mg). The medications were taken 30 min before meals. Gastric emptying of solids (99mTc-sulphur colloid) was measured at lunch time under basal conditions and during each treatment period. Plasma concentrations of cisapride were determined before the breakfast dose, before the lunch dose, and at 1, 2, 3, 4 and 5 h after. The greatest acceleration in gastric emptying occurred with the 2 x 10 mg regimen. Although the single morning dose of 20 mg also significantly accelerated gastric emptying (P = 0.05), the reduction was not as substantial. Plasma concentrations of cisapride were significantly higher after 2 x 10 mg than after 1 x 20 mg or 1 x 10 mg. There was a significant relation between cisapride plasma concentrations and changes in gastric emptying. Peak concentrations of cisapride greater than 60 ng.ml-1 were invariably associated with acceleration of gastric emptying. We conclude that cisapride 10 mg tid before meals is the optimal dose for the treatment of idiopathic gastroparesis.

Accuracy of endoscopic ultrasonography in the diagnosis and staging of gastric cancer and lymphoma

BACKGROUND

There is a need to assess the sensitivity, specificity, and predictive value of endoscopic ultrasonography (EUS) in the diagnosis and staging of gastric cancer and lymphoma.

METHODS

A prospective study was performed on 86 patients with endoscopic gross appearance suspicious for cancer or lymphoma. Biopsies with endoscopic forceps were always carried out before EUS. All patients underwent laparotomy for final diagnosis, staging, and eventually treatment. The results of EUS were correlated with the histologic findings of the resected specimens, when possible, or with the surgical findings. There were 42 gastric cancers and 44 primary gastric lymphomas.

RESULTS

EUS made a correct diagnosis of cancer in 35 of 42 patients, with a sensitivity of 83%. Positive predictability was 87%, specificity was 97%, and negative predictability was 96%. Diagnostic accuracy was 95%. In the evaluation of cancer depth invasion, EUS was correct in 91% of cases. EUS displayed perigastric metastatic lymph nodes in 14 of 25 patients, with a sensitivity of 56%. Positive predictive value was 93%, specificity was 93%, and negative predictive value was 54%. Diagnostic accuracy was 69%. EUS made a correct diagnosis of lymphoma in 39 of 44 patients, with a sensitivity of 89%. Positive predictability was 87%, specificity was 97%, and negative predictability was 97%. Diagnostic accuracy was 95%. In the evaluation of lymphoma depth invasion, EUS was correct in 92% of cases. EUS displayed metastatic perigastric lymph nodes in 8 of 18 patients, with a sensitivity of 44%. Positive predictability was 100%, specificity was 100%, and negative predictability was 72%. Diagnostic accuracy was 77%.

CONCLUSIONS

From these data it appears that in these diseases EUS has demonstrated specific ultrasonographic features that allow correct diagnosis and staging in the majority of patients. In difficult cases EUS may help to achieve the correct diagnosis. EUS also appear to be a useful tool for staging of gastric cancer and lymphoma. It shows not only tumor depth and local spread but also the passage from a pathologic to a normal wall and lymph node metastasis. With this accurate noninvasive staging procedure, in the near future many patients will no longer undergo exploratory laparotomy for surgical staging. Thanks to EUS, the choice of conservative or surgical treatment can be strongly affected. In case of surgery, EUS can orient the kind of surgical approach. Moreover, the use of EUS for evaluation of therapy during follow-up will probably become of major importance.

Spread and distribution of 5-ASA colonic foam and 5-ASA enema in patients with ulcerative colitis

Rectal treatment with enemas, foams, and suppositories is the most efficient method of delivering an adequate quantity of locally active drugs to the distal colon. In a pilot study carried out by colonoscopy in four patients, it was observed that 4 g 5-ASA in 20 ml foam spread up or beyond the splenic flexure and more extensively than 2 g 5-ASA in 10 ml foam. Therefore we have undertaken a study in order to compare by scintigraphy the colonic distribution of 4 g 5-ASA foam versus 4 g 5-ASA in 100 ml liquid enemas in 10 patients with ulcerative colitis using a crossover randomized design. Both preparations were labeled with 100 MBq [99mTc]sulfur colloid before administration. Anterior scans were taken at intervals for 4 hr. Activity, expressed as a percentage of total radioactivity, was measured in the rectum, sigmoid, descending, transverse, and ascending colon. Six patients had the same extent of spread with the two formulations; in three patients with foam and in one patient with enema a greater spread was observed. The foam reached the upper limit of disease in all cases, while enema failed in two cases. The maximum spread with foam was observed within 30 min in nine of 10 patients compared with seven of 10 after enema. Compared to enema, foam distributes more uniformly and seems to persist longer in the descending and sigmoid colon. The 5-ASA colonic foam shows some more favorable characteristics than enema for the local treatment of left-sided ulcerative colitis.

Value of measurement of mean portal flow velocity by Doppler flowmetry in the diagnosis of portal hypertension

To establish the sensitivity and specificity of the mean portal flow velocity in the diagnosis of portal hypertension, a population of 304 consecutive cirrhotic patients, in whom 246 abdominal Doppler examinations were performed, was prospectively analysed between June 1988 and December 1990. To avoid equipment-related variability only examinations performed using the same equipment were considered. Further inclusion criteria were the absence of portal vein thrombosis or reversed flow in the portal vessels and the absence of spontaneous, ultrasonographically detectable, portosystemic shunts. The parameter evaluated was mean portal flow velocity calculated directly from the Doppler trace by specific, operator-independent, software. 123 patients satisfied the inclusion criteria. As a control group 60 healthy age- and sex-matched subjects were examined. Mean portal flow velocity was significantly lower in cirrhotic patients than healthy subjects (13.0 +/- 3.2 cm/s vs. 19.6 +/- 2.6 cm/s; p < 0.001). There was also a decrease in mean portal flow velocity in cirrhotics in each Child-Pugh category (13.8 +/- 2.8 cm/s in Child-Pugh A class; 12.1 +/- 3.5 cm/s in Child-Pugh B class and 11.0 +/- 2.4 cm/s in Child-Pugh C class) with a statistically significant difference between each Child-Pugh category and healthy subjects (p < 0.001), between Child-Pugh A and B (p < 0.01) and between Child-Pugh A and C (p < 0.005). The sensitivity and specificity of mean portal flow velocity in the detection of portal hypertension was then analyzed with the receiver operating characteristic curve.(ABSTRACT TRUNCATED AT 250 WORDS)

"Oesophageal angina" in patients with angina pectoris: a possible side effect of chronic therapy with nitroderivates and Ca-antagonists

The study was carried out on 18 patients with angina pectoris in whom the usual treatment with nitroderivatives and/or Ca-antagonists did not improve or prevent the angina-like chest pain in the absence of unstable angina. The patients underwent the following oesophageal examinations: X-ray, endoscopy-biopsy, manometry, acid perfusion test and 24-hour oesophageal pH ambulatory monitoring, the latter two being made in association with dynamic ECG. The presence of coronary insufficiency had been previously determined by means of ECG and scintigraphic stress tests and, when necessary, coronary arteriography was performed. In 10/18 patients severe oesophageal motor disorders were observed, the most frequent being diffuse oesophageal spasm. In the entire group the lower oesophageal sphincter basal tone was significantly lower than normal. In 14/18 patients a pathologic gastroesophageal reflux was detected: in 2 of these patients a temporal correlation between pain attacks and episodes of gastroesophageal reflux were observed in the absence of ECG modifications. Acid perfusion test induced the angina-like chest pain in another 2 patients without ECG modifications. In conclusion, the angina-like chest pain of these patients is not due to a failure of the antianginal therapy in relieving the coronary insufficiency, but is most probably related to gastroesophageal reflux. This oesophageal disorder may be considered a side effect caused by prolonged therapy with nitroderivatives and Ca-antagonists. In fact, these drugs decrease the lower oesophageal sphincter tone which is the main barrier against the reflux of gastric contents into the oesophagus so favoring gastroesophageal reflux and related disorders, including oesophageal pain.

Hepatitis C viraemia rebound after "successful" interferon therapy in patients with chronic non-A, non-B hepatitis

A quantitative polymerase chain reaction (PCR) assay for hepatitis C viral RNA (HCV-RNA) was used to monitor viraemia levels in six patients at multiple time points before, during, and after interferon therapy for chronic non-A, non-B hepatitis (NANBH). Prior to therapy, serum HCV-RNA was detected in all patients at approximately 10(4)-10(5) HCV genomes/ml. HCV viraemia became undetectable within 1 month of commencing interferon in three of the five patients whose alanine aminotransferase (ALT) levels decreased to normal on therapy. In the remaining two responder patients, viraemia levels declined more slowly, becoming undetectable after a period of several months. Recurrence of viraemia during therapy was observed in two cases. The one patient whose serum ALT levels remained elevated throughout therapy showed no decline in viraemia. On stopping interferon after a 6 months course, HCV genome titres climbed rapidly in all patients, reaching higher levels than had been observed prior to therapy. Biochemical relapse occurred within 7 months of ending interferon treatment in all but one of the patients who demonstrated this viraemia "rebound" phenomenon.

Natural history of small untreated hepatocellular carcinoma in cirrhosis: a multivariate analysis of prognostic factors of tumor growth rate and patient survival

We analyzed the growth pattern of tumor masses and the survival of 39 asymptomatic Italian patients with a total of 59 small (less than or equal to 5 cm in diameter) hepatocellular carcinomas arising from cirrhosis. The total length of the observation period ranged from 90 to 962 days, with an average of 364 +/- 229 (mean +/- S.D.). Doubling time ranged from 27.2 to 605.6 days (mean +/- S.D., 204.2 +/- 135; median = 171.6 days). Three different growth patterns were recognized: (a) tumors with no or very slow initial growth pattern (doubling time greater than 200 days), 10 cases (37%); (b) tumors with declining growth rate over time, 9 cases (33.4%); and (c) tumors with almost constant growth rate, 8 cases (29.6%). Using the stepwise discriminant analysis, we found a score based on albumin, alcohol intake, number of nodules, echo pattern and histological type that allowed a correct prediction of short doubling time (less than or equal to 150 days) in 55.6%, medium doubling time (151 to 300 days) in 60% and long doubling time (greater than 300 days) in 100% of cases. The estimated survival rate of the 39 patients, calculated by the Kaplan-Meier method was 81% at 1 yr, 55.7% at 2 yr and 21% at 3 yr. Stepwise discriminant analysis showed that a score based on sex, HBsAg status, alcohol consumption, ascites, gamma-glutamyltranspeptidase, prothrombin time, Child-Pugh class and all the sonographical parameters could predict 2-yr survival in 100% of cases. We conclude that great variability of growth patterns exists among and within small hepatocellular carcinomas. Prediction of subsequent growth rate is unreliable in most cases.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of the opioid peptides in the development of hyperinsulinemia in obese women with abdominal body fat distribution

In this study, we investigated the hypothesis that increased opioid activity may be involved in the development of hyperinsulinemia in women with obesity and abdominal body fat distribution. Two groups of nine obese body (body mass index [BMI], 30 to 40 kg/m2) women with abdominal (A-ob) (waist to hip ratio [WHR] greater than 0.85) or gluteo-femoral (F-ob) (WHR greater than or equal to 0.80) fat distribution were examined and compared with eight normal-weight controls. Basal beta-endorphin levels were higher in the A-ob group than in the other groups. Each woman underwent two oral glucose tolerance tests (OGTT, 75 g glucose). A bolus of naloxone (0.8 mg) followed by a constant infusion of naloxone (0.04 mg/kg/h) or saline was also administered during the glucose challenge in random order, and blood samples for glucose, insulin, and C-peptide were collected at regular times after glucose administration. No difference was observed in basal or stimulated glucose concentrations between the three groups, nor between the saline or naloxone study. However, basal and stimulated insulin levels were significantly higher in obese women (particularly in the A-ob group) than in controls. Naloxone administration, however, did not significantly modify insulin and C-peptide glucose-stimulated concentrations in controls and in the F-ob group, whereas it significantly reduced (by approximately 47%) insulin levels in the A-ob group. Partial correlation coefficients showed a significant negative correlation between percent variation of glucose-stimulated insulin incremental areas during the naloxone study and the WHR in all women considered together (r = .544, P less than .025).(ABSTRACT TRUNCATED AT 250 WORDS)

Neurotensin: a physiological regulator of exocrine pancreatic secretion?

The aim of the present review was to evaluate the effects of neurotensin on the exocrine pancreatic secretion. Neurotensin immunoreactivity has been identified in the central nervous system and also in the digestive system, where it is found in specific endocrine cells of the intestinal mucosa (N cells), in nerve fibers of the enteric nervous system and in intrapancreatic ganglia (both in nerves and cell bodies). Studies in laboratory animals and in humans have demonstrated that the ingestion of a meal causes a significant release of neurotensin into the circulation and that exogenous administration of low doses of the peptide strongly stimulates exocrine pancreatic secretion. These findings, together with the demonstration that the immunoneutralization of circulating neurotensin significantly reduces the pancreatic secretory response to a meal, suggest that neurotensin is a physiological regulator of exocrine pancreatic secretion.

Lipid, lipoprotein, and apolipoprotein assessment during an 8-wk very-low-calorie diet

The influence of a very-low-calorie diet (VLCD) on lipid pattern is controversial. To evaluate the long-term effect of semistarvation on lipid patterns, a group of severely obese patients [aged 37 +/- 12 y, body mass index (BMI) 40.0 +/- 0.9] underwent a VLCD for 8 wk. Total cholesterol (TC), LDL cholesterol (LDL-C), and HDL cholesterol (HDL-C), triglycerides (TGs), apolipoproteins A1 (apo A1) and B (apo B) were analyzed every week. TC (6.07 +/- 0.23 vs 5.53 +/- 0.25 mmol/L, P less than 0.0008), HDL-C (mmol/L 1.26 +/- 0.06 vs 1.04 +/- 0.05 mmol/L, P less than 0.0001), TGs (1.46 +/- 0.19 vs 1.06 +/- 0.10 mmol/L, P less than 0.0008), and apo A1 (1.57 +/- 0.06 vs 1.32 +/- 0.06 g/L, P less than 0.0002) decreased, whereas LDL-C and apo B showed a biphasic behavior: they significantly fell during the first 3 wk, but during the last weeks returned to their initial values.

[Natural history of asymptomatic lithiasis]

The natural history of asymptomatic gallstones, according to the best published studies, indicates that seventy per cent of the patients remain symptom-free. Nonetheless there are no clinical or morphological findings which can predict the occurrence of symptoms on a individual basis.

Changes in splanchnic hemodynamics in inflammatory bowel disease. Non-invasive assessment by Doppler ultrasound flowmetry

An increase in splanchnic blood flow in both arterial and venous beds has been demonstrated in inflammatory bowel disease (IBD) by means of angiographic and scintigraphic studies. Doppler ultrasound (US) enables a non-invasive evaluation of splanchnic arterial inflow in the superior mesenteric artery (SMA) and of venous outflow in the portal vein. The aim of this study was to assess the role of Doppler US in detecting changes in the hemodynamic variables measured in patients with IBD. Forty-five patients with IBD were studied, including 22 with Crohn's disease (CD) and 23 with ulcerative colitis (UC), and compared with 45 matched normal subjects. The mean velocity of portal flow (Vmean) and the resistance index (RI) of the SMA were evaluated by Doppler US. In CD the Vmean of portal flow was significantly higher in patients with active disease than in controls (p less than 0.001) and patients with inactive disease (p less than 0.001). The RI of the SMA was significantly lower in active disease than in controls (p less than 0.005), but no significant difference was noted between active and inactive CD. Also in UC, the Vmean of portal flow was significantly higher in patients with active disease than in controls (p less than 0.01) and patients with inactive disease (p less than 0.05). The RI of the SMA was significantly lower in active disease than in controls (p less than 0.005) and in patients with inactive disease (p less than 0.005). Doppler follow-up studies were carried out in 10 patients after initiation of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Significance of IgM antibody to hepatitis C virus in patients with chronic hepatitis C

We assessed the correlation between the positivity for serum IgM antibody to hepatitis C virus and the activity of liver disease in patients with chronic hepatitis C virus infection. Serum samples were taken from 10 antibody to hepatitis C virus-positive asymptomatic patients with normal serum ALT levels, from 14 untreated patients with clinically and histologically proven chronic hepatitis C and from 26 patients with clinically and histologically proven chronic hepatitis C assigned to receive recombinant interferon alpha-2a (6 million IU three times a week for 6 mo). Each serum specimen was tested for IgM antibody to hepatitis C virus-associated C100-3 antigen by enzyme-linked immunosorbent assay. Patients were observed for at least 12 mo. All 10 patients with normal ALT values tested negative for IgM antibody to hepatitis C virus. In contrast, 33 of 40 (82%) patients with chronic hepatitis C had IgM antibody to hepatitis C virus, and a positive correlation was seen between the ALT level and the level of IgM antibody to hepatitis C virus (r = 0.803, p less than 0.001). During interferon treatment, ALT levels declined into the normal range in 18 of 26 treated patients (69%) and remained normal after stopping treatment in 8 patients (31%). In untreated patients, in treated patients who did not respond to interferon treatment and in responder patients who relapsed, no significant changes in IgM antibody to hepatitis C virus levels were seen during the study period. In contrast, IgM antibody to hepatitis C virus became undetectable by the end of interferon treatment in seven of eight patients with a sustained response.(ABSTRACT TRUNCATED AT 250 WORDS)

Changes in mesenteric venous flow due to celiac sprue

Villus atrophy in celiac sprue determines not only a great reduction of the intestinal absorptive surface, but also destroys the underlying microcirculation which depends on the small artery of the villus and the rich network of capillaries. This may result in a significant shortening of the mesenteric vascular bed. We describe three cases of celiac sprue in which duplex Doppler ultrasound flowmetry revealed a high blood flow velocity in the superior mesenteric vein during the acute stage of the disease. A gluten withdrawal diet produced in all cases a restoration of the normal thickness of the mucosa, together with a significant decrease of blood flow velocity in the superior mesenteric vein.

Value of endoscopic ultrasonography in the management of portal hypertension

Using endoscopic ultrasonography (EUS) a large part of the portal venous system can be visualized. In 40 patients with portal hypertension (PH) and in 48 control subjects EUS displayed the azygos, splenic, mesenteric and portal veins in both groups. However, esophageal and gastric varices, peri- esophageal and peri-gastric collateral veins and submucosal gastric venules were displayed only in patients with PH. EUS was inferior to endoscopy for detecting and grading esophageal varices (p less than 0.0005), but superior in the detection of varices in the fundus of the stomach (p less than 0.0005). EUS cannot be considered a reliable method for the study of esophageal varices: it has an overall sensitivity of 50%, does not permit flow measurements, and does not provide information that could be used to estimate the risk of bleeding. EUS has been demonstrated to be superior to endoscopy in the diagnosis of gastric varices. This finding is extremely important for the optimal selection of treatment of patients with portal hypertension. EUS can detect portal hypertensive gastropathy; thus inflammatory gastritis can be more easily distinguished from congestive gastropathy and therapeutic decisions are strongly influenced.

The role of liver transplantation in the treatment of hepatocellular carcinoma

The role of liver transplantation in the treatment of hepatocellular carcinoma (HCC) is still debated. Overall survival is poor because of the high recurrence rate. Negative prognostic factors are the presence of large, multiple lesions, lymph node involvement, gross vascular invasion and extrahepatic metastases. On the other hand a long term survival (5 yrs), can be achieved in about 30 to 48% of transplanted patients. In the case of incidental tumours, the survival rate can be as high as 90%. Fibrolamellar HCC have a better prognosis than non fibrolamellar HCC. Due to the short supply of donor livers, OLT should be offered to those patients who have the highest probability of surviving.

Fasting and postprandial gastrointestinal motility in ulcer and non-ulcer dyspepsia

This study aimed to compare fasting and postprandial gastrointestinal motor patterns in patients with ulcer and non-ulcer dyspepsia. Forty five subjects were studied: 10 with uncomplicated gastric ulcer, eight with uncomplicated duodenal ulcer, 18 with chronic idiopathic dyspepsia, and nine healthy asymptomatic controls. Gastrointestinal fasting and postprandial motor patterns were recorded using a low compliance perfusion technique. The interdigestive antral cumulative motility index, computed for 30 minutes before the appearance of duodenal activity fronts, and the number of activity fronts with an antral component were significantly less in patients with ulcers and those with non-ulcer dyspepsia compared with asymptomatic controls. The patient groups also had a reduced antral motor response to a solid-liquid test meal compared with healthy controls. Intestinal motor abnormalities (bursts of non-propagated phasic pressure activity and discrete clustered contractions) were recorded in a minority of patients, all with associated irritable bowel symptoms. In conclusion, antral hypomotility is a frequent but nonspecific motor abnormality in dyspepsia; abnormal motor patterns of the small bowel are less frequent and seem to be confined to patients with concomitant irritable bowel syndrome.