Management of antithrombotic agents for colonoscopic polypectomies in Israeli gastroenterologists relative to published guidelines

BACKGROUND

Endoscopic procedures are commonly performed in patients taking antithrombotic agents.

OBJECTIVE

To examine the correlation between the management of antithrombotic drugs for colonoscopic polypectomies and the published guidelines.

DESIGN AND SETTINGS

A structured survey delivered to gastroenterologists in 15 major Israeli hospitals and three central HMO clinics.

RESULTS

We collected 100 filled out surveys. Polypectomies on aspirin were performed by 78%. Most physicians did not perform polypectomies on clopidogrel. None of the physicians performed polypectomies on warfarin. Cessation of aspirin for ≥ 3 days post-polypectomy was recommended by 60%. Renewal of LMWH or warfarin was recommended ≥ 2 days post-polepectomy in 91% and 71%, respectively. The greatest variation in recommendations was found for clopidogrel, where the majority of gastroenterologists advised renewal after 1-2 days (38%). Years in practice and increasing colonoscopy volume work had no significant association with management of antithrombotic agents. Working in a HMO clinic was associated with lower rates of polypectomies on aspirin (P=0.036).

DISCUSSION

When the guidelines are clear, most gastroenterologists practice according to the existing recommendation. However, lack of prospective studies limits the ability to publish evidence-based recommendation and guidelines. We found that the practice of our cohort study varies in these situations.

Prevalence and predictive factors for gastrointestinal pathology in young men evaluated for iron deficiency anemia

BACKGROUND

The prevalence of gastrointestinal lesions in young men with iron deficiency anemia (IDA) is unknown, and there are no evidence-based recommendations for the evaluation of the gastrointestinal tract in this population.

AIMS

The purpose of this study was to assess the prevalence of significant GI lesions among young males with IDA, and to shed light on potential predictors of their presence.

METHODS

Clinical, endoscopic, and histological data was retrospectively collected from medical records of 347 young males with IDA.

RESULTS

Clinically significant GI lesions were diagnosed in 62 %. Upper GI lesions were found in 35 %. Peptic disease was the most common finding, diagnosed in 30 %. Celiac disease was diagnosed in 4 %. Lower GI tract lesions were diagnosed in 34 %. The most common findings were hemorrhoids (17 %) and inflammatory bowel disease (16 %). Malignant lesions were not detected. GI lesions were encountered more frequently when respective symptoms were obtained. Multivariate analysis showed that the presence of GI symptoms and the use of proton pump inhibitors were associated with an increased likelihood of significant GI lesions.

CONCLUSIONS

GI lesions are common among young men with IDA. GI evaluation is mandatory in symptomatic men and in asymptomatic men when the anemia is resistant to iron therapy. Symptoms may dictate the order of evaluation.

Double balloon enteroscopy: a 2 year experience

BACKGROUND

Double balloon enteroscopy is a new technique that enables deep intubation of the endoscope into the small bowel lumen. Through a channel in the endoscope, invasive procedures such as biopsy, polypectomy and hemostasis can be performed, avoiding the need for surgery.

OBJECTIVES

To prospectively analyze our results of the first 124 DBEs performed since February 2007.

METHODS

The study group comprised all patients who underwent DBE at the Sheba Medical Center between February 2007 and February 2009. Recorded were the patients' demographic data, comorbidities, indications for the examination, results of previous non-invasive small bowel imaging (computed tomography enterography, capsule endoscopy, etc), investigation time, and results of the procedure including findings, endoscopic interventions, complications and pathological report.

RESULTS

A total of 124 procedures were performed in 109 patients. Of the 124 examinations, 57 (46%) were normal and 67 (54%) showed pathology. The main pathologies detected on DBE were polyps (14%), vascular lesions (17.6%) and inflammation (12%). Endoscopic biopsies and therapeutic interventions were required in 58 examinations (46%). A new diagnosis was established in 15% of patients, diagnosis was confirmed in 29% and excluded or corrected in 12%. One complication was observed: a post-polypectomy syndrome that was treated conservatively.

CONCLUSIONS

DBE is a safe procedure and has a high diagnostic and therapeutic yield. Most of the examinations were performed under conscious sedation, and only a minority of patients required deeper sedation.

Patient satisfaction with endoscopy measurement and assessment

BACKGROUND

Several factors could influence patient satisfaction with endoscopy including technical quality of care, comfort and tolerability of the procedure, whether informed consent has been obtained, the level of communication with staff before and after the procedure, and delays in appointments.

AIM

To assess what factors should be measured in assessing patient satisfaction by using a 16-point questionnaire based on the informed consent recommendations of the first workshop at Kos, and of the criteria of the American Society for Gastrointestinal Endoscopy (ASGE), and to compare the response of patients with gastroenterologists and the support staff.

METHOD

The questionnaire was answered by 81 patients, 71 gastroenterologists and 36 support staff (nurses and receptionists). It graded the relative importance of different factors which influenced the perception of satisfaction in those undergoing endoscopy. These factors included: the waiting time for appointment, the explanation received at various stages before and after the procedure, the reception process, the importance of premedication against pain and discomfort, privacy and satisfaction related to findings at the procedure.

RESULTS

Thirteen of the 16 factors were generally graded as important for patient satisfaction. The finding at endoscopy, a written explanation and the alternatives to the endoscopic procedure were regarded as of lesser importance. Gastroenterologists tended to rate the importance of a written explanation and the explanations from the nurses before and after the procedure lower than did the patients and nursing staff.

CONCLUSIONS

The courtesy and personal manner of the entire medical staff, as evidenced by the explanation of the procedure by the various physicians before and after and the process of admission, were generally rated of the highest importance. The nurses' ranking of the various factors was closer to that of the patients than of the gastroenterologists.

Interleukin-18 and its binding protein in patients with inflammatory bowel disease during remission and exacerbation

BACKGROUND

Crohn's disease and ulcerative colitis are inflammatory bowel diseases with an unknown etiology. Interleukin-18 is a pro-inflammatory cytokine that is up-regulated in Crohn's disease. IL-18 binding protein neutralizes IL-18. The relationship of IL-18 and IL-18BP and disease activity in these diseases is not fully understood.

OBJECTIVES

To investigate the correlation of IL-18 and IL-18BP with disease activity and other disease parameters in inflammatory bowel disease.

METHODS

IL-18 and IL-18BP isoform a were measured in 129 patients and 10 healthy individuals. Patients' mean age was 40.5 (range 15-70 years) and 43 were women; 58 Crohn's and 28 colitis patients were in remission and 52 and 14, respectively, were in exacerbation. Twenty-three (19 and 4 respectively) were studied in both remission and exacerbation.

RESULTS

The mean level of free IL-18 was significantly different between healthy individuals and Crohn patients, and between Crohn patients during exacerbation and remission (167 +/- 32 vs. 471 +/- 88 and 325 +/- 24 pg/ml, respectively, P < 0.05). Mean level of IL-18BP was significantly different between healthy individuals and Crohn patients, and between Crohn patients during exacerbation and remission (2.1 +/- 1.1, 7.5 +/- 4 and 5.23 +/- 2.8 ng/ml, respectively, P < 0.01). In the colitis patients, mean free IL-18 level and IL-18BP were significantly different between healthy individuals and patients, but not between disease remission and exacerbation (167 +/- 32, 492 +/- 247 and 451 +/- 69 pg/ml for IL-18, and 2.1 +/- 1.1, 7.69 +/- 4 and 6.8 +/- 7 ng/ml for IL-18BP, respectively, P= 0.05).

CONCLUSIONS

IL-18 and IL-18BP levels are higher in patients with inflammatory bowel disease compared to healthy individuals. In Crohn's disease, but not in ulcerative colitis, IL-18 (but not free IL-18) and IL-18BP levels are significantly higher during exacerbation compared to remission. This observation highlights the importance of IL-18 in the pathogenesis of inflammatory bowel diseases, especially in Crohn's disease.

Nonsurgical management of asymptomatic incidental pancreatic cysts

BACKGROUND & AIMS

Cystic lesions of the pancreas are detected more often nowadays. Many are considered premalignant and pancreatic resection is recommended. This study was undertaken to assess the natural course of asymptomatic pancreatic cysts and their malignant potential.

METHODS

All patients referred for endoscopic ultrasound (EUS) between 1994 and 2003 because of pancreatic cystic lesions were included.

RESULTS

A total of 135 patients underwent EUS because of pancreatic cysts. Twenty-three patients were excluded because they were symptomatic or had pancreatic pseudocysts. The other 112 patients were diagnosed as having true pancreatic cysts. Fourteen of the 112 patients were referred for surgery based on either unfavorable EUS morphology or fine-needle aspiration results. In 4 (29%) of 14 surgical specimens, the histology was that of malignancy. An additional 8 patients with serous cystadenoma and pseudocysts were excluded from the analysis. The remaining 90 patients were defined as having indeterminate or mucinous cysts and were managed conservatively. The follow-up period lasted between 12 and 180 months (mean, 48 +/- 33 mo). Malignancy was diagnosed in only 1 patient after 7 years of follow-up evaluation. None of the 57 patients available for clinical follow-up evaluation became symptomatic. The size of the cyst remained unchanged in 45 patients, increased in 2, and resolved in 9. Thirty-three patients were followed up through the Israel Registry: 31 were alive and 2 died from unrelated causes.

CONCLUSIONS

Our data suggest that a considerable number of asymptomatic pancreatic cystic lesions can be managed conservatively, at least for a mean period of 4 years. Malignant transformation in pancreatic cystic lesions probably is less frequent than previously reported.

[ERCP for benign disease in the elderly: a good prognosis]

BACKGROUND

biliary disease in the elderly (over 80) are common and can be a diagnostic and therapeutic challenge.

METHODS

medical records of patients age 80 and older who underwent endoscopic retrograde cholangiopancreatography (ERCP) for benign biliary disease from January 2000 to April 2005 were studied retrospectively.

RESULTS

100 patients of whom data was obtainable underwent 133 procedures. The indications for the procedure included suspicion of common bile duct stones (94.4%), biliary stend insertion and replacement (4%), non-malignant obstructive jaundice (0.8%) and echinococcal cyst (0.9%). Midaozolam (100%) and fentanyl (100%) were used for conscious sedation. Patient tolerance was good in 100% of procedures. Therapeutic procedures (endoscopic sphincterotomy, stent insertion or replacement) were indicated in 88% of procedures, and successful in 96.8% of cases. Short term complications (up to 30 days after procedure) occurred in 4/5% of ERCP procedures. There was no early mortality.

CONCLUSIONS

ERCP is a safe procedure in the elderly with a low complication rate and good therapeutic efficacy.

High levels of glucocorticoid receptors in patients with active Crohn's disease may predict steroid resistance

Up to 20% of Crohn's disease (CD) patients respond poorly to glucocorticoids (GC). A product of an alternative splicing of the glucocorticoid receptor (GR) premRNA, GRbeta, may play a role as a dominant inhibitor of the glucocorticoid response. Increasing evidence suggests that inflammatory cytokines such as interleukin (IL)-18 alternate the splicing of the primary transcript between the two isoforms GRbeta and GRalpha in hGR gene of CD patients. The aim of this study is to assess the expression of GRalpha and GRbeta in patients with CD and to look for a possible correlation between these receptors and the response to glucocorticoid treatment. Forty-two CD patients and 17 healthy volunteers were studied. Quantitative reverse transcription-polymerase chain reaction (RT-PCR) was performed using real-time PCR techniques. Serum IL-18 protein levels were measured by enzyme-linked immunosorbent assay (ELISA). The amount of hGRalpha-mRNA in patients in remission was significantly lower than in controls (P < 0.05). The amount of hGRbeta-mRNA was significantly higher in GC-resistant patients in the active stage of disease compared with all other groups (P < 0.05). Patients in the active stage of the disease had higher levels of IL-18 than patients in remission and both had higher levels than controls (P < 0.05). The amounts of IL-18 were directly correlated with the amount of hGRbeta mRNA in GC-resistant patients with an active disease. High levels of hGRbeta might be connected to GC resistance. IL-18 might participate in the alternative splicing of the hGR preliminary mRNA of CD patients. The results support the theory that augmented hGRbeta mRNA expression level in PBMC is connected with GC-resistance of CD patients.

Electrogastrography in patients with Parkinson's disease

BACKGROUND

Impaired gastrointestinal motility in Parkinson's disease may affect absorption of levodopa and contribute to the disabling response fluctuations (RF). In this study gastric myoelectric activity was recorded with electrogastrography in patients with PD and correlated with the duration, severity and the presence of RF.

METHOD

Electrogastrography (EGG) was performed in 36 patients with PD of which 22 were men. The mean age was 67 years (48-81), mean duration of disease was 7.07 years (1-20), and mean duration of treatment with levodopa was 5.07 years (1-20). Gastric dysrhythmia was diagnosed when either preprandial or postprandial dysrhythmia for more than 30% of the recording period was detected.

RESULTS

The EGG was abnormal in 24 of 36 patients. Significant association was found between preprandial dysrhythmia and duration of disease (P=0.002); duration of levodopa treatment (P=0.003), severity of 86RF (P=0.001), but not with age (P=0.076). Out of 18 patients with RF, 17 had at least one pattern of dysrhythmia. In 11 out of the 18 patients without RF, the EGG was normal while the remaining seven had at least one pattern of dysrhythmia.

CONCLUSION

Abnormal EGG was quite common in this group of patients with PD, particularly in those with RF. The most common pattern of abnormality was preprandial dysrhythmia, which was positively associated with disease duration and length of levodopa treatment. Although frequently asymptomatic, preprandial dysrhythmia leading to impaired gastric emptying may contribute to irregular absorption of levodopa from the small intestine and contribute to disabling response fluctuations.

Iron deficiency anemia in patients without gastrointestinal symptoms--a prospective study

BACKGROUND AND OBJECTIVES

Chronic gastrointestinal (GI) bleeding is the leading cause of iron deficiency anaemia (IDA) in men older than 50 years and post-menopausal women. There is a scarcity of data regarding IDA patients without GI symptoms or signs. We conducted a prospective study to determine the prevalence and the locations of the GI tract lesions in patients with asymptomatic IDA.

METHODS

Forty-eight patients with asymptomatic IDA (25 men older than 50 years and 23 post-menopausal women) underwent colonoscopy, gastroscopy and abdominal computed tomography (CT) with contrast agent.

RESULTS

An anaemia-causing lesion was found in 14 (29%) and 16 (33%) patients in the upper and the lower GI tract, respectively. The prevalence of dual lesions (in both the upper and lower GI tract) was low (6%). In 14 (29%) patients, a malignancy, predominantly right-sided colon carcinoma, was responsible for the IDA. Only one patient had a lesion in the small bowel. In 14 (29%) patients, the work-up was negative.

CONCLUSION

Our prospective study demonstrates a high rate of malignancy, predominantly right-sided colon carcinoma, in men older than 50 years and post-menopausal women with asymptomatic IDA. This finding obligates a complete and rigorous GI tract examination in this group of patients, especially of the right colon.

[Pseudomembranous colitis: clinical, endoscopic and radiological correlation--a 2-year experience]

The incidence rates of pseudomembranous colitis are rising. Early diagnosis and treatment are required for management of this potentially life-threatening disease. This report outlines our 2-year experience (1997-1998) at the gastrointestinal institute with 43 patients diagnosed with pseudomembranous colitis and describes the clinical course and imaging studies. The group consisted of 25 women and 18 men, aged 34-93 years (mean: 67). Thirty-nine patients were treated with antibiotics. Twelve patients were referred directly to an endoscopic examination with a presumed clinical diagnosis of pseudomembranous colitis (diarrhea, fever and abdominal pain) that was confirmed by colonoscopy. Thirty-one were referred to colonoscopy following abdominal imaging performed to clarify cause of fever and abdominal pain. Twenty-nine patients had an abdominal CT, one had an US and one a barium follow-through. The CT finding suggesting pseudomembranous colitis included colonic mural thickening in 28 patients (71% diffuse versus 29% segmental colitis), with an average wall thickness of 16 mm. Sixteen patients (59%) had pericolonic fat changes and 15 patients (51%) had ascites. All of these patients, except one, had endoscopic findings consistent with pseudomembranous colitis. Five patients (11.6%) died due to the severe PMC. To conclude, as an abdominal CT is often performed in the acutely ill patient, it may arouse the diagnosis of pseudomembranous colitis in the proper clinical setting. Such a suspected diagnosis justifies endoscopic evaluation, which is the most reliable diagnostic examination.

Cyclosporin for severe ulcerative colitis

BACKGROUND

About one-third of patients with severe ulcerative colitis do not respond to conventional therapy and require urgent colectomy. It was recently shown that cyclosporin is effective in some of these patients.

OBJECTIVES

To review the current experience of six hospitals in central Israel that used cyclosporin in patients with severe ulcerative colitis.

METHODS

The files of all 32 patients treated with cyclosporin for corticosteroid-resistant ulcerative colitis were reviewed. Activity of disease was measured by a clinical activity, index colonoscopy and laboratory tests.

RESULTS

The average duration of treatment with intravenous cyclosporin was 12.7 days (range 9-28) after which the disease activity index dropped from an average of 14.22 to 4.74. The mean time for response was 7.5 days (4-14). Twelve patients (40%) required surgery within 6 months and another 6 patients (18.8%) were operated on after more than 6 months. Twelve patients (37%) maintained remission for at least 6 months and did not require surgery. In one patient treatment was stopped because of non-compliance and one was lost to follow-up. There were numerous side effects, but in only one case with neurotoxicity was treatment withdrawn.

CONCLUSIONS

Cyclosporin is a relatively safe and effective treatment for severe ulcerative colitis. It induced long-term remission in 37% of the patients, and in those who required surgery the treatment resulted in an improved clinical condition before the operation.

Retroperitoneal perforation during endoscopic sphincterotomy: imaging findings

BACKGROUND

Endoscopic retrograde cholangiopancreatography with sphincterotomy has become an important technique in the diagnosis and treatment of biliary and pancreatic diseases. Serious complications, although rare, may occur, and their early recognition and treatment are of the utmost importance. We encountered several such cases. This study reviews the imaging findings in patients with retroperitoneal perforation detected after the procedure.

METHODS

Of 796 patients who had endoscopic sphincterotomy at our institution during a 9-year period, retroperitoneal perforation occurred in nine (1.13%). Imaging findings and clinical outcome were assessed.

RESULTS

In eight patients, routine abdominal radiographs taken during the procedure disclosed retroperitoneal air, associated with extravasation of contrast material in six patients. This was further confirmed on computed tomography (CT) in three patients. In the ninth patient, the diagnosis was established by an emergent abdominal CT performed a day after the sphincterotomy, because of severe abdominal pain. Two patients died of overwhelming sepsis.

CONCLUSIONS

Retroperitoneal perforation during endoscopic sphincterotomy is a rare complication, which occurred in 1.13% of our patients. It can be usually clearly recognized radiographically by an abdominal film and in doubtful cases by CT. We emphasize the importance of recognizing this potentially serious complication with imaging studies.

Expression of cytokeratin 20 in the blood of patients with disseminated carcinoma of the pancreas, colon, stomach, and lung

BACKGROUND

Cytokeratins are constituents of the intermediate filaments of epithelial cells that are expressed in various combinations depending on the epithelial type and the degree of differentiation. The recently identified cytokeratin 20 (CK-20) was found to be expressed in colonic, gastric, and pancreatic carcinoma tumor tissues. A low rate of incidence of expression of CK-20 was found in tumor tissue from lung carcinoma but no expression was found in blood even with the sensitive reverse transcriptase-polymerase chain reaction (RT-PCR) method. The objective of the current study was to examine whether CK-20 expression in the blood can be used as a biomarker for the detection of dissemination in patients with carcinoma of the colon, stomach, and pancreas.

METHODS

In the current study, RT-PCR was used to determine the expression of CK-20 in the blood cells from patients with metastatic colon carcinoma (n = 22), metastatic pancreatic carcinoma (n = 28), metastatic gastric carcinoma (n = 18), metastatic lung carcinoma (n = 13), no metastatic colon carcinoma (n = 13) and no known malignant diseases (n = 22). RNA was extracted from cell pellets and analyzed by RT-PCR using primers for CK-20.

RESULTS

In the group of 22 patients with metastatic colon carcinoma, 14 were found to be CK-20 positive (sensitivity of 63.6% and specificity of 92.3%), 22 of the 28 pancreatic carcinoma patients showed positive CK-20 expression, and 12 of 18 patients with gastric carcinoma showed positive CK-20 expression. All patients with metastatic lung carcinoma except 1 were negative (12 of 13 patients), and 12 of 13 patients with colonic carcinoma with no known metastases also were negative. Negative CK-20 results were obtained in all 22 patients with no known malignant diseases.

CONCLUSIONS

The results of the current study indicate that because of its high sensitivity, RT-PCR of CK-20 is a potential biomarker for detecting metastases in blood samples from patients with carcinoma of the colon, stomach, and pancreas.

Expression of cytokeratin 20 in the blood of patients with disseminated carcinoma of the pancreas, colon, stomach, and lung

BACKGROUND

Cytokeratins are constituents of the intermediate filaments of epithelial cells that are expressed in various combinations depending on the epithelial type and the degree of differentiation. The recently identified cytokeratin 20 (CK-20) was found to be expressed in colonic, gastric, and pancreatic carcinoma tumor tissues. A low rate of incidence of expression of CK-20 was found in tumor tissue from lung carcinoma but no expression was found in blood even with the sensitive reverse transcriptase-polymerase chain reaction (RT-PCR) method. The objective of the current study was to examine whether CK-20 expression in the blood can be used as a biomarker for the detection of dissemination in patients with carcinoma of the colon, stomach, and pancreas.

METHODS

In the current study, RT-PCR was used to determine the expression of CK-20 in the blood cells from patients with metastatic colon carcinoma (n = 22), metastatic pancreatic carcinoma (n = 28), metastatic gastric carcinoma (n = 18), metastatic lung carcinoma (n = 13), no metastatic colon carcinoma (n = 13) and no known malignant diseases (n = 22). RNA was extracted from cell pellets and analyzed by RT-PCR using primers for CK-20.

RESULTS

In the group of 22 patients with metastatic colon carcinoma, 14 were found to be CK-20 positive (sensitivity of 63.6% and specificity of 92.3%), 22 of the 28 pancreatic carcinoma patients showed positive CK-20 expression, and 12 of 18 patients with gastric carcinoma showed positive CK-20 expression. All patients with metastatic lung carcinoma except 1 were negative (12 of 13 patients), and 12 of 13 patients with colonic carcinoma with no known metastases also were negative. Negative CK-20 results were obtained in all 22 patients with no known malignant diseases.

CONCLUSIONS

The results of the current study indicate that because of its high sensitivity, RT-PCR of CK-20 is a potential biomarker for detecting metastases in blood samples from patients with carcinoma of the colon, stomach, and pancreas.

Expression of cytokeratin 20 in the blood of patients with disseminated carcinoma of the pancreas, colon, stomach, and lung

BACKGROUND

Cytokeratins are constituents of the intermediate filaments of epithelial cells that are expressed in various combinations depending on the epithelial type and the degree of differentiation. The recently identified cytokeratin 20 (CK-20) was found to be expressed in colonic, gastric, and pancreatic carcinoma tumor tissues. A low rate of incidence of expression of CK-20 was found in tumor tissue from lung carcinoma but no expression was found in blood even with the sensitive reverse transcriptase-polymerase chain reaction (RT-PCR) method. The objective of the current study was to examine whether CK-20 expression in the blood can be used as a biomarker for the detection of dissemination in patients with carcinoma of the colon, stomach, and pancreas.

METHODS

In the current study, RT-PCR was used to determine the expression of CK-20 in the blood cells from patients with metastatic colon carcinoma (n = 22), metastatic pancreatic carcinoma (n = 28), metastatic gastric carcinoma (n = 18), metastatic lung carcinoma (n = 13), no metastatic colon carcinoma (n = 13) and no known malignant diseases (n = 22). RNA was extracted from cell pellets and analyzed by RT-PCR using primers for CK-20.

RESULTS

In the group of 22 patients with metastatic colon carcinoma, 14 were found to be CK-20 positive (sensitivity of 63.6% and specificity of 92.3%), 22 of the 28 pancreatic carcinoma patients showed positive CK-20 expression, and 12 of 18 patients with gastric carcinoma showed positive CK-20 expression. All patients with metastatic lung carcinoma except 1 were negative (12 of 13 patients), and 12 of 13 patients with colonic carcinoma with no known metastases also were negative. Negative CK-20 results were obtained in all 22 patients with no known malignant diseases.

CONCLUSIONS

The results of the current study indicate that because of its high sensitivity, RT-PCR of CK-20 is a potential biomarker for detecting metastases in blood samples from patients with carcinoma of the colon, stomach, and pancreas.

The education and training of gastroenterologists for the 21st century: a paradigm for the education of medical specialists in technology-intensive fields - an international and Israeli perspective

Gastroenterology in the developed world as a paradigm for technologically intensive medical specialties has undergone dramatic changes during the last half-century with expansion, proliferation and affluence followed by serious reactions on the part of cost-conscious and demanding governments, insurers and consumers. A review of events in several regions within the developed world reveals tremendous technological progress but inadequate attention to professional, economic and ethical issues, which are crucial for the education of a model gastroenterologist who will embody the qualities that will enable him/her to function well clinically, technologically, scientifically, professionally and ethically and thus enable him/her to cope with the increasingly complex challenges that are likely to arise during the next decades. The possibility and need for defining a specific ethic for technology-intensive medical specialists is discussed.

Expression of bcl-2 in autoimmune and Helicobacter pylori-associated atrophic gastritis

Chronic atrophic gastritis can be induced either by H. pylori or by an autoimmune process. The protein product of bcl-2, which is a protooncogene, blocks apoptosis. Aberrant bcl-2 expression has been found in 68% of atrophic gastritis patients. The aim of this study was to compare bcl-2 expression in 20 autoimmune atrophic gastritis patients to that in 20 H. pylori-associated atrophic gastritis patients. Twenty patients with H. pylori antral gastritis but without atrophy served as controls. The bcl-2 expression was assessed by immunohistochemical staining of gastric biopsies, using mouse anti-human bcl-2 monoclonal antibodies. Autoimmune atrophic gastritis patients were younger, mainly females, with a significantly higher serum gastrin level than the H. pylori-associated atrophic gastritis group (P < 0.001). The bcl-2 was expressed in 10/20 (50%) of autoimmune atrophic gastritis patients, in 9/20 (45%) of H. pylori-associated atrophic gastritis patients (P = 0.73), and in 2/20 (10%) of controls. There was no correlation between bcl-2 expression and the presence of intestinal metaplasia (P = 0.35). Our findings confirm that H. pylori-associated atrophic gastritis and autoimmune atrophic gastritis are two different conditions, but with equal expression of bcl-2. Excessive expression of bcl-2 is found only in atrophic gastritis, but not in H. pylori antral gastritis without atrophy.

Idiopathic non-obstructive hypertrophic cardiomyopathy, vitamin B12 deficiency and gastric adenocarcinoma: an unreported association in a teenager

A 14-year-old boy presented with anorexia and weakness whereon the diagnosis of dimorphic anaemia was made. An excellent response to iron and vitamin B12 was observed. In addition, the patient had non-obstructive hypertrophic cardiomyopathy. At endoscopy 2.5 years later, an adenocarcinoma was diagnosed and the patient underwent a high subtotal gastrectomy. To the best of our knowledge, this rare association has never been reported in children.

CONCLUSION

We report a youngster with pernicious anaemia, associated with nonobstructive hypertrophic cardiomyopathy in whom gastric adenocarcinoma was found. Patients with pernicious anaemia are at greater risk of developing gastric carcinoma than the general population, therefore we recommend routine periodic gastroscopic surveillance in the paediatric population with pernicious anaemia.

Cerebral venous thrombosis and chronic active hepatitis as part of the antiphospholipid syndrome

A case of antiphospholipid syndrome, presenting as sinus vein thrombosis together with chronic active hepatitis, is reported in a 35-year-old woman.

Helicobacter pylori infection in rural settlements (Kibbutzim) in Israel

BACKGROUND

Helicobacter pylori (HP) is accepted as a major cause of type B gastritis, which is strongly associated with peptic ulcer disease. Epidemiological studies have indicated a correlation of HP infection and socioeconomic class.

METHODS

To determine the prevalence of HP infection and to evaluate symptoms and risk factors associated with HP infection in a rural population, 377 asymptomatic individuals were studied out of a random sample of 453 people. Subjects were randomly chosen in a ratio of 1:4 of all the adults over 30 years, living in eight communal settlements in Israel. Blood samples were taken and subjects answered a questionnaire in which sociodemographic information, clinical gastrointestinal background and the use of medication were included. A sensitive enzyme-linked immunoassay was used to determine antibodies to HP in serum.

RESULTS

The overall prevalence of HP infection was 72%. In a multivariant discriminant analysis: age, country of origin and ethnic group were found to be the most closely associated variables for HP infection and the discriminant analysis succeeded in predicting correctly, in 62% of the population, whether they had or did not have HP infection. There was no significant difference with gender, occupation, educational level, blood group, smoking, gastrointestinal symptoms and use of medication.

CONCLUSIONS

The prevalence of HP infection was higher than that in industrialized countries, but lower than in developing countries. The prevalence in a rural population was slightly higher than that of an urban population in Israel (65%). The country of origin and ethnic group influenced the prevalence of HP infection and not birth and growing up on the Kibbutz.

Achalasia in central Israel, 1973-83: clinical aspects

In the framework of an epidemiologic study we collected data on all the 162 patients with achalasia in central Israel. The mean (+/- SD) follow-up was 9.9 +/- 8.7 years (range 1-52). At the last, as compared to the initial examination, the clinical condition of the patients had improved: 38% were without dysphagia as compared to 0% initially, 67% did not vomit and 92% did not complain of aspiration as compared to 17% and 68% initially, and 67% did not complain of chest pain as against 36% initially. In contrast, X-ray examinations, endoscopy as well as manometry did not show major changes. Esophageal retention of a semisolid radiolabeled meal 10 min after ingestion was 46 +/- 25% initially and 34 +/- 26% at last examination (NS). Medical therapy was given to 99 patients and a beneficial response was initially noted in 65% of them. About 88.7% had a beneficial response to surgery and 82.7% to pneumatic dilatations which were associated with a 7.3% perforation rate. Overall the clinical course of this unselected, regional group of patients was better than expected.

[Widespread gastrointestinal CMV infection as the presenting manifestation of AIDS]

A 53-year-old man is reported who developed a widespread gastrointestinal infection due to cytomegalic (CMV) virus and was found to be suffering from AIDS. He died of overwhelming pulmonary infection. There is need for awareness of the rapid increase of AIDS in our local population, particularly in groups not regarded as at high risk. It is imperative to keep this diagnosis in mind when dealing with patients with gastroenterocolitis not responding to standard treatments. CMV has a broad spectrum of clinical manifestations, from carrier state to life-threatening infection. In the gastrointestinal system it causes inflammation and ulcers in the mucosa that may bleed or perforate. There are increasing numbers of reports of CMV ileocolitis in homosexuals with AIDS. The rate of sero-positive CMV in healthy homosexual populations is 94-100% and in 14% there is active infection. CMV is the main infective agent in patients suffering from AIDS; 90% will develop an infection with this virus and in most cases it will be fatal.

Seasonal pattern in the incidence of bleeding caused by peptic ulcer in Israel

We have reviewed all endoscopies performed in our hospital between 1977 and 1986. During that period, 1337 endoscopies were performed to identify bleeding from peptic ulcers. Excluded were cases in which a predisposing factor was found, such as the use of ulcerogenic drugs. Also excluded were chronic or critically ill patients. The remaining 540 cases were reviewed. In 447 of those cases, the bleeding lesion was a duodenal ulcer, whereas, in 93 cases, a gastric ulcer was found (a ratio of 5:1). The seasonal variation in the incidence of bleeding from peptic ulcers was evaluated. We found a significant difference in bleeding in the cold and hot seasons, the incidence being significantly greater during the cold season (November until February). A similar pattern was found for bleeding from both duodenal and gastric ulcers.

Case report: broken intracholedochal stent

Decompression of biliary obstruction by an internal stent is well accepted in patients with malignant strictures. Less frequent is the use of this technique for the management of benign disorders. In the latter situation the biliary stent may be left in place for a very long period. We report a rare complication of a broken intracholedochal stent which had been inserted for a benign post-operative stricture.

Epidemiology of ulcerative colitis in the Jewish population of central Israel 1970-1980

The epidemiology of ulcerative colitis (UC) was studied in the Jewish population of central Israel in a densely populated urban area of more than 1,400,000 inhabitants. The mean annual incidence for the years 1970-80 was 3.86/100,000, 3.94 in males, and 3.79 in females. The incidence rose from 2.67 in 1970 to 5.09 in 1979, the rise being similar in both sexes. This rise in incidence was found in 3 separate localities in the study area inhabited by communities of different extraction and age composition. The disease started most frequently between the ages of 25 and 29. The crude prevalence of UC in 1980 was 55.2/100,000. The age-adjusted prevalence in Israel-born Jews was 45.8, in Asia-Africa-born 48.5 and in Europe-America-born 52.7/100,000. Compared with our previous study in 1960-70 in the city of Tel Aviv-Yafo, the prevalence of UC was increased and the differences between the community groups have narrowed. This suggests an effect of environmental factors in the causation of ulcerative colitis.

Endoscopic treatment of suture line bleeding ulcer caused by nonabsorbable suture material in postvagotomy patients

Two postvagotomy patients with upper gastrointestinal bleeding, which appeared several months after operation, are reported. Endoscopy showed the pyloroplasty suture line to be ulcerated and bleeding, with a few strands of silk protruding from edematous mucosa. The history of suture line ulceration and the contribution of endoscopy to its diagnosis and treatment are reviewed.

Bile composition and bile acid pool size. Comparison after truncal, selective, and highly selective vagotomy

We studied biliary lipid composition and bile acid pool size in 29 patients surgically treated for duodenal ulcer. Fourteen were examined both before and after surgery, the rest postsurgically only. They were divided into three groups according to type of vagotomy. With duodenal fluid obtained via nasogastric tube, we determined bile acid pool size, bile concentrations, and lithogenic index. We found no significant differences in bile composition and bile acid pool size among the three types of vagotomy, postsurgically. However, patients studied before surgery, compared with the entire post-vagotomy group, had a significant increase in relative cholesterol content and lithogenic index, most pronounced in the truncal vagotomy group. Bile acid pool size was also increased postsurgically. Vagotomy may predispose to gallstone development by increasing the bile's relative cholesterol concentration and thus the lithogenic index. However, the slightly expanded bile acid pool size may improve cholesterol solubility in certain patients.

Value of the 14C-D-xylose breath test in patients with intestinal bacterial overgrowth

18 control subjects and 18 patients, with a variety of gastrointestinal conditions were investigated using a 10-muCi 14C-D-xylose breath test. The latter also underwent quantitative bacterial studies of fluid obtained by intestinal intubation. In 14 patients a smaller dose of 3 muCi 14C-D-xylose was compared to the standard dose and there was a good correlation between the two doses. The peak value of the 14C-D-xylose test provided the best discrimination between patients with and without bacterial overgrowth. The 14C-glycocholic acid test performed in 15 patients, although as sensitive, was less discriminating. The 14C-D-xylose breath test is reliable and more specific in confirming the diagnosis of small intestinal bacterial overgrowth without having to resort to direct bacterial studies.