Could JC virus be linked to chronic idiopathic intestinal pseudo-obstruction?

JC virus is a member of the Polyomavirus family, infects humans worldwide, and 90% of the population carry antibodies to the virus by adult life. The initial infection is asymptomatic, but it may become persistent. JC virus DNA is frequently present in the upper and lower gastrointestinal tracts of healthy adults. Chronic idiopathic intestinal pseudo-obstruction, one of the most severe gastrointestinal motility disorders, is a condition characterized by a clinical picture mimicking small bowel occlusion with related symptoms and signs in the absence of demonstrable mechanical obstruction. Because of the known neuropathic capability of this virus, and its frequent presence in the gut, it has been proposed that JCV might be detectable in tissues of patients with chronic idiopathic intestinal pseudo-obstruction, and possibly be involved in the pathogenesis of this disease, because the virus may actively infect the enteroglial cells of the myenteric plexuses of the patients with chronic idiopathic intestinal pseudo-obstruction. We report two cases of upper idiopathic intestinal pseudo-obstruction associated with JCV infection.

Single versus two-operator endoscopic biliary cannulation technique: a multicenter matched-case analysis

BACKGROUND

The aim of this study was to compare the outcomes of physician-controlled, using both long and short endoscopic-retrograde-cholangiopancreatography wire systems, and assistant-controlled guide-wire biliary cannulation techniques, and to perform a literature review on this topic.

METHODS

The endoscopic databases of three Endoscopic Centers were reviewed to identify all consecutive patients with an intact papilla who, between July 2013 and December 2014, underwent an endoscopic-retrograde-cholangiopancreatography. A total of 240 patients (80 for each group) were matched 1:1, by gender, age and indications for procedure and were included in the analysis. All articles of physician-controlled vs. assistant-controlled guide-wire biliary cannulation techniques, were extracted up to December 2016, and included in the review.

RESULTS

There were no statistically significant differences in primary and final (using rescue technique) cannulation rate between the three groups. The mean primary cannulation time and overall cannulation time were shorter in the two groups of physician-controlled guide-wire compared to the assistant-controlled guide-wire group, but the difference was not statistically significant. The total procedure time did not differ significantly between the three groups, but the physician-controlled guide-wire using short wire system was associated with a trend toward a shorter time compared to the other two techniques. There were no statistically significant differences in complication rates between the three groups. Three pertinent articles were included in the review. The mean procedure success and complication rates were 92% and 7%, respectively.

CONCLUSIONS

The literature review and our results show that all these techniques have equally efficacy and safety for guide-wire cannulation.

An unusual presentation of zollinger-ellison syndrome

Zollinger-Ellison syndrome is an often progressive, persistent and frequently life-threatening disease, described for the first time as characterized by ulceration of the upper jejunum, hypersecretion of gastric acid and non-beta islet cell tumors of the pancreas; this syndrome is due to the hypersecretion of gastrin. We report a case of Zollinger-Ellison syndrome presenting as severe esophagitis evolving in stenosis, which demonstrates how a delayed diagnosis may induce risk of disease spreading. In this setting new diagnostic approaches, such as somatostatin receptor scanning and positron emission tomography with 68 Ga-labeled octreotide, could be particularly useful, as well as further new therapeutic options, such as molecular targeted treatments and peptide receptor radionuclide therapy, though surgery is currently the only form of curative treatment, and the role of the therapeutic options mentioned needs to be clarified by forthcoming studies.

Delayed-onset superior mesenteric artery syndrome presenting as oesophageal peptic stricture

Superior mesenteric artery (SMA) syndrome is an infrequent cause of vomiting and weight loss due to compression of the third part of the duodenum by the SMA. We describe the case of a 17-year-old woman, admitted to our department for progressive dysphagia and severe weight loss due to an oesophageal peptic stricture, caused by chronic acid reflux secondary to duodenal compression by the SMA. Symptoms improved after (par)enteral nutrition and repeated oesophageal dilatation, thus supporting the role of intensive medical and endoscopic intervention as an alternative to surgery, at least in some cases.

Acquired double pylorus, due to penetrating gastric ulcer, presenting with melena

Acquired double pylorus (DP) is an uncommon condition consisting of two communicating channels between the gastric antrum and the first part of duodedum. Little is known about the origin of DP. As there is no specific gastrointestinal symptom due to DP, most often it is diagnosed by gastroscopy while performing for other indicationsFew data are also known about the clinical course of DP. In the patients with peptic ulcer symptoms, the pyloroplasty-like drainage effect, improving gastric emptying after the estabilishment of the fistula, could relieve these symptoms. This represents an unresolved issues about the necessity of repeating endoscopy to document in the patients with DP its final outcome, as the risk of ulcer recurrence. We describe a case of a 76-years-old woman admitted to our department for hyposideremic anemia associated to a recent history of melena.

Music for colonoscopy: A single-blind randomized controlled trial

BACKGROUND

Several methods have been reported to minimize patient discomfort during colonoscopy, none are currently recommended by clinical practice guidelines. We performed a single-blind randomized controlled trial to assess the efficacy of music for colonoscopy.

METHODS

109 patients were randomized to music-delivering or mute headphones before and during colonoscopy. Physicians were blinded to the trial. Sedation was given on demand. Primary outcome was pain measured on linear analogue scale from 0 to 10. Secondary endpoints were the difficulty of the procedure, need of sedation, overall patient satisfaction and willingness to repeat the procedure.

RESULTS

Mean pain score was 5.9±2.2 in the control group vs. 3.8±1.9 in the music group (p<0.00001); correspondingly overall satisfaction and willingness to repeat the procedure were significantly improved by music and the difficulty perceived by physicians was significantly reduced. Total administered midazolam was 36mg in the control group vs. 13 in the music group (p<0.007), pethidine was 860mg vs. 465mg (p=0.07) and patients requiring sedation were 22 vs. 9, respectively (p=0.003). A multivariable analysis to adjust treatment effect for potential confounding factors confirmed the significant beneficial effect of music.

CONCLUSIONS

Music significantly reduces discomfort and should be routinely offered to patients undergoing colonoscopy.

Management and long-term follow-up of early stage H. pylori-associated gastric MALT-lymphoma in clinical practice: an Italian, multicentre study

BACKGROUND/AIM

Data on management and long-term follow-up of Helicobacter pylori-associated MALT-lymphoma in clinical practice are scanty. We evaluate the long-term efficacy of H. pylori eradication on low-grade MALT-lymphoma, and the efficacy of further therapies in refractory patients.

METHODS

This study enrolled patients with stages I-II(1) MALT-lymphoma and H. pylori infection. H. pylori eradication was attempted in all patients. Patients with lymphoma persistence or progression following H. pylori treatments received further lymphoma treatments. Both 5-year and disease-free survivals were calculated.

RESULTS

Sixty patients (stage I/II(1): 50/10) were followed up for a median time of 65 months (range 7-156). H. pylori infection was successfully eradicated in 53 (88.3%) patients following three consecutive therapeutic attempts, and lymphoma regressed in 42 (79.2%) of these patients. Sixteen patients received anti-neoplastic treatments due to either lymphoma persistence or progression, and lymphoma was cured in 14 (87.5%) cases. At follow-up, lymphoma relapsed in 13/42 (30.9%) patients within a median time of 19 months (range 3-41), and all but 1 patient were cured with further therapies. Overall, lymphoma regression was achieved in 56 patients (93.3%). The 5-year and disease-free survivals were 94.7% and 74.6%, respectively.

CONCLUSIONS

In clinical practice, a conservative approach with antibiotic eradication seems to be appropriate management for early-stage MALT-lymphoma, with oncologic therapy being reserved for those patients who fail to respond to H. pylori therapy.

Clinical and endoscopic presentation of primary gastric lymphoma: a multicentre study

BACKGROUND

Although the stomach is the most frequent site of intestinal lymphomas, few data are available on both clinical endoscopic presentation of gastric lymphoma and possible differences between low-grade and high-grade lymphomas.

METHODS

Clinical, histological and endoscopic records of consecutive patients with primary low-grade or high-grade lymphoma diagnosed were retrieved. Symptoms were categorized as 'alarm' or 'not alarm'. The endoscopic findings were classified as 'normal' or 'abnormal'.

RESULTS

Overall, 144 patients with primary gastric lymphoma were detected, including 74 low-grade and 70 high-grade lymphoma. Alarm symptoms, particularly persistent vomiting and weight loss, were more frequently present in patients with high-grade lymphoma than in those with low-grade lymphoma (54% vs. 28%; P = 0.002). Low-grade lymphomas presented as 'normal' appearing mucosa (20% vs. 0%; P = 0.0004) or petechial haemorrhage in the fundus (9% vs. 0%; P = 0.02) more frequently than high-grade lymphomas, being also more often confined to the antrum (47% vs. 27%, P = 0.03) and associated with Helicobacter pylori infection (88% vs. 52%, P < 0.0001). On the contrary, high-grade lymphomas presented more commonly as ulcerative type (70% vs. 52%; P = 0.03), being also more frequently diagnosed in stage >I when compared with low-grade lymphomas (70% vs. 21%, P < 0.0001).

CONCLUSIONS

The overall prevalence of alarm symptoms is quite low and may be absent in more than 70% of patients with low-grade lymphoma.

Natural history of chronic hepatitis C

BACKGROUND AND AIMS

A comprehensive overview on the course of hepatitis C is not available despite the many studies published. The aim was to review the course and prognostic variables of untreated hepatitis C.

METHODS

English-language articles published between January 1989 and December 1997 were identified and data extracted to answer predefined relevant questions.

RESULTS

Median chronicization rate, mostly assessed in transfusion-associated hepatitis, was 67%. In retrospective studies, the interval between date of infection and diagnosis of cirrhosis or hepatocellular carcinoma was 20-40 years. Median progression rate from chronic hepatitis to cirrhosis was 27.9% after 8-12 years. Studies obtaining this figure included selected groups of patients and could reflect the worst prognostic segment of the disease. The course of hepatitis C virus infection may be more favourable: cirrhosis rarely or never occurred in young females infected by con-taminated anti-D-immunglobulins; hepatitis was histologically mild in most hepatitis C virus-RNA positive subjects with normal or near normal transminases, predicting non-progressive or very slowly progressive disease; in a population survey from Italy, among 170 infected subjects only 4% had raised transaminases, and none overt liver disease. Increasing age, histological severity, alcohol, possibly male sex and liver iron content were predictors of cirrhosis or increased fibrosis.

CONCLUSIONS

Chronicization rate of hepatitis C virus infection is very high. Hepatitis C virus infection can result in a wide prognostic spectrum of liver disease, ranging from cirrhosis and hepatocellular carcinoma to subclinical, nonprogressive disease. Cofactors such as alcohol excess are important in determining the outcome of hepatitis C virus-related chronic liver disease.

The effect of interferon on the liver in chronic hepatitis C: a quantitative evaluation of histology by meta-analysis

BACKGROUND/AIMS

Several randomized clinical trials of interferon in chronic hepatitis C have examined the histological changes in paired biopsy specimens. We have attempted a quantitative evaluation by meta-analysis.

METHODS

Randomized Clinical Trials found by MEDLINE search were included if: a) they compared different IFN regimens with non-active treatment or with each other, b) they obtained biopsies before starting and at the time of stopping IFN in a sizable proportion of the treated and control patients, and c) they assessed the biopsy-specimens semi-quantitatively according to Scheuer's numerical scoring system or Knodell's Histological Activity Index, with quantitation of fibrosis and of lobular, portal and periportal necroinflammation.

RESULTS

Seventeen trials were identified, in which 1223 adult patients had been studied. All trials homogeneously pointed towards a favorable interferon effect. The pooled data show a statistically significant histological improvement in treated patients as compared with controls for each of the four Histological Activity Index components and for the total Histological Activity Index score (overall improvement was -0.82 in favor of interferon, p<0.0001, 95% Confidence Interval -1.25 to -0.40). In the ten trials reporting histological changes separately in biochemical responders (primary and sustained responders) and non-responders, histological improvement was confined to the subset of biochemical responders. No change or very little change occurred in non-responders.

CONCLUSIONS

Interferon treatment in chronic hepatitis C significantly improves liver histology. The effect of interferon is closely related to biochemical response. Studies assessing histological outcome 1 year or more after interferon treatment in long-term responders and comparatively in non-responders or relapsers would be important to confirm the regression of the necroinflammatory process in the former, as suggested by the normal serum alanine aminotransferase levels.

Host and viral features in chronic HCV infection: relevance to interferon responsiveness

Host and viral variables interact in determining the course and responsiveness to therapy of any viral infection. Presence of cirrhosis, serum levels of hepatitis C virus (HCV) RNA and the genotype of infecting virus are considered predictive of response to interferon (IFN) in chronic HCV infection. We evaluated these parameters in relation to IFN therapy in a cohort of anti-HCV-positive subjects with chronic hepatitis or cirrhosis. HCV RNA was detected by polymerase chain reaction (PCR) and by the branched DNA assay (bDNA), to quantify viraemia. HCV typing was performed by reverse-hybridization line probe assay. HCV RNA was detected in almost all anti-HCV-positive subjects with liver disease, PCR being more sensitive than bDNA. Hepatitis C viraemia was lowest in cirrhosis. Low pretreatment viraemia selected for those patients with chronic hepatitis obtaining a high rate of sustained response to IFN. The role of HCV type was less clearcut, due to the high prevalence in our population of type 1 (especially subtype 1b, accounting for 80% of cases). A trend towards a better response of non-1b genotypes was confirmed. This may be related to higher HCV RNA levels in type 1b-infected subjects. Cirrhosis remains however, independently from virological features, the strongest predictor of non-response to IFN.