Chlamydia Trachomatis and Inflammatory Bowel Disease - a Coincidence?

Serological tests of 35 patients suffering from inflammatory bowel disease were compared to those of 35 healthy controls. The tests were performed using the indirect immunoperoxidase assay. Ninety-three per cent of 15 patients with Crohn's disease had IgG antibodies against Chlamydia, compared to 26% in the control group. In the 20 patients with ulcerative colitis, 45% had IgG antibodies against Chlamydia, compared to 10% in the control group. High serum titres of IgG antibodies were found in most of the patients with inflammatory bowel disease, mainly with Crohn's disease, while weak reactions appeared in most of the controls in which antibodies were detected. These results suggest a high incidence of Chlamydia infection in the studied patients with inflammatory bowel disease, especially in those with Crohn's disease. The possible association between Chlamydia trachomatis and inflammatory bowel disease is discussed.

Comparison of central and intraesophageal factors between gastroesophageal reflux disease (GERD) patients and those with GERD-related noncardiac chest pain

Gastroesophageal reflux disease (GERD) causes a wide range of symptoms. Some patients present with typical symptoms such as heartburn and regurgitation and others with atypical symptoms such as chest pain. The mechanism responsible for the varying clinical presentation of GERD is still not fully elucidated. The aim of this study was to prospectively evaluate differences in central and local intraesophageal factors between patients with typical GERD symptoms and those with noncardiac chest pain (NCCP). Patients presenting with typical and atypical symptoms suspicious of GERD underwent upper endoscopy and 24-hour pH monitoring with four sensors, each positioned at a different esophageal level. All patients completed GERD symptom, Hospital Anxiety and Depression Scale, and Symptom Stress Rating questionnaires. From January 2006 to December 2009, 50 patients were recruited, 29 with typical symptoms, and 21 with NCCP. Patients with proven GERD and NCCP had higher proximal extension of acid during reflux episodes than patients with typical symptoms. They were found to be older, had a shorter history of symptom onset, worse anxiety scores, and more endoscopic findings compatible with gastritis. Proximal extension of acid during the reflux episodes in patients with GERD presenting with NCCP may play a role in symptom generation.

Comparison of central and intraesophageal factors between gastroesophageal reflux disease (GERD) patients and those with GERD-related noncardiac chest pain

Gastroesophageal reflux disease (GERD) causes a wide range of symptoms. Some patients present with typical symptoms such as heartburn and regurgitation and others with atypical symptoms such as chest pain. The mechanism responsible for the varying clinical presentation of GERD is still not fully elucidated. The aim of this study was to prospectively evaluate differences in central and local intraesophageal factors between patients with typical GERD symptoms and those with noncardiac chest pain (NCCP). Patients presenting with typical and atypical symptoms suspicious of GERD underwent upper endoscopy and 24-hour pH monitoring with four sensors, each positioned at a different esophageal level. All patients completed GERD symptom, Hospital Anxiety and Depression Scale, and Symptom Stress Rating questionnaires. From January 2006 to December 2009, 50 patients were recruited, 29 with typical symptoms, and 21 with NCCP. Patients with proven GERD and NCCP had higher proximal extension of acid during reflux episodes than patients with typical symptoms. They were found to be older, had a shorter history of symptom onset, worse anxiety scores, and more endoscopic findings compatible with gastritis. Proximal extension of acid during the reflux episodes in patients with GERD presenting with NCCP may play a role in symptom generation.

Validation of the Capsule Endoscopy Crohn's Disease Activity Index (CECDAI or Niv score): a multicenter prospective study

BACKGROUND AND STUDY AIMS

The Capsule Endoscopy Crohn's Disease Activity Index (CECDAI or Niv score) was devised to measure mucosal disease activity using video capsule endoscopy (VCE). The aim of the current study was to prospectively validate the use of the scoring system in daily practice.

METHODS

This was a multicenter, double-blind, prospective, controlled study of VCE videos from 62 consecutive patients with isolated small-bowel Crohn's disease. The CECDAI was designed to evaluate three main parameters of Crohn's disease: inflammation (A), extent of disease (B), and stricture (C), in both the proximal and distal segments of the small bowel. The final score was calculated by adding the two segmental scores: CECDAI = ([A1 × B1] + C1) + ([A2 × B2] + C2). Each examiner in every site interpreted 6 - 10 videos and calculated the CECDAI. The de-identified CD-ROMs were then coded and sent to the principal investigator for CECDAI calculation.

RESULTS

The cecum was reached in 72 % and 86 % of examinations, and proximal small-bowel involvement was found in 56 % and 62 % of the patients, according to the site investigators and principal investigator, respectively. Significant correlation was demonstrated between the calculation of the CECDAI by the individual site investigators and that performed by the principal investigator. Overall correlation between endoscopists from the different study centers was good, with r = 0.767 (range 0.717 - 0.985; Kappa 0.66; P < 0.001). There was no correlation between the CECDAI and the Crohn's Disease Activity Index or the Inflammatory Bowel Disease Quality of Life Questionnaire or any of their components.

CONCLUSION

A new scoring system of mucosal injury in Crohn's disease of the small intestine, the CECDAI, was validated. Its use in controlled trials and/or regular follow-up of these patients is advocated.

Evidence for aberrant regulation of MAP kinase signal transduction pathway in peripheral blood mononuclear cells in patients with active celiac disease

BACKGROUND

Aberrant signaling via the p21/mitogen-activated proteins (MAP) kinase pathway has been described in lymphocytes of patients with various autoimmune diseases. There is little published data about the intracellular mediators and signals that regulate expression and activity of transcription factors and their effect on celiac disease induction and progression.

AIM

To investigate the possible involvement of MAP kinase pathway in peripheral blood mononuclear cells (PBMC) in celiac disease and its correlation with disease activity.

METHODS

Expression of the total and activated forms of two MAP kinases [extracellular response kinase (ERK) and c-Jun amino terminal kinase (JNK)] were studied by Western blots in PBMC of 17 untreated and 19 treated celiac patients, and 17 controls. Seven of these untreated celiac patients were studies before and after 6 months of gluten-free diet.

RESULTS

Phosphorylated ERK of active celiac disease patients was significantly lower compared with controls (P < 0.01) and was increased towards normal after 6 month of gluten-free diet (P < 0.01). Phosphorylated JNK was increased significantly in the untreated celiac group (P < 0.01) and normalized towards the control level after 6 months of gluten-free diet (P < 0.04).

CONCLUSIONS

Aberrant MAP-kinase pathway activity is associated with active celiac disease (CD). Further studies should examine the potential role of this aberration in pathogenesis of CD.

Antiplatelet therapy and the risk of bleeding induced by gastrointestinal endoscopic procedures. A systematic review of the literature and recommendations

Antiplatelet drugs may increase the risk of bleeding induced by gastrointestinal endoscopic procedures. The antiplatelet effect of cyclooxygenase-1 inhibitors lasts less than 4 h. Skin and colonic bleeding times are prolonged for 3 and 5 days after aspirin and ticlopidine withdrawal respectively. Major bleeding from endoscopic biopsies is extremely rare. In the four recent largest series, the general incidence of polypectomy-induced major bleeding was 0.11-0.42%. In more than half of the cases the bleeding was delayed, usually up to 2 weeks after the endoscopy. Although three retrospective studies suggested that aspirin does not increase the risk of polypectomy-induced bleeding, the power of these studies is limited. Similarly, it is difficult to draw conclusions from the two studies that assessed the risk of aspirin use during sphincterotomy. Aspirin withdrawal may be harmful in susceptible patients, mainly if it is for more than 7 days. There is no indication to stop aspirin before esophagogastroduodenoscopy, which may reveal aspirin-induced lesions. We recommend discontinuation of aspirin 4-7 days (according to the cardiovascular risk) before other endoscopic procedures. When aspirin is indicated for primary prevention, it can be resumed 14 and 10 days after polypectomy and sphincterotomy respectively. In cases of secondary prevention, it should be resumed after 1 week.

Chronic hepatitis C infection in children

Hepatitis C virus infection may differ in the pediatric age group with respect to transmission, natural history and response to treatment. Most infected children develop chronic hepatitis but with a relatively mild course of the disease. The most efficient transmission of hepatitis C virus is through direct percutaneous exposure to infected blood or blood products. However, the major risk factor for acquisition of hepatitis C virus in children at present is maternal-infant transmission. The rate of progression to advanced liver disease seems to be more rapid in post transfusional and vertically acquired hepatitis C virus infection than in sporadic hepatitis C virus infection acquired postnatally, or in those without known risk factors. There is a wide variety of histopathological expression, depending on the geographical distribution of the different countries. Treatment for hepatitis C virus in children has not yet been approved. However, combination treatment with peginterferon-alpha-2b with ribavirin shows encouraging results and is generally well tolerated. More randomized controlled trials are needed in the future to optimize the approach to hepatitis C virus infection in children.

Comparison of capsule endoscopy with ileocolonoscopy for detecting small-bowel lesions in patients with seronegative spondyloarthropathies

BACKGROUND AND STUDY AIMS

Patients with spondyloarthropathies are often found to have signs of small-bowel inflammation when examined by ileocolonoscopy. Because capsule endoscopy has been found to be superior to other endoscopic and radiological modalities in the detection of small-bowel inflammation, we aimed to compare the diagnostic yield of capsule endoscopy with that of ileocolonoscopy in the detection of small-bowel lesions in patients with spondyloarthropathies.

PATIENTS AND METHODS

Twenty patients with documented seronegative peripheral arthritis, ankylosing spondylitis, or sacroiliitis, who had not taken nonsteroidal anti-inflammatory drugs (NSAIDs) in the preceding 2 months, participated in the study. The patients underwent capsule endoscopy, followed by ileocolonoscopy within 7 days, with blinded assessment of both examinations. Biopsies were taken when indicated and adverse events were monitored. Patients completed a questionnaire on their satisfaction with the two procedures.

RESULTS

A total of 20 patients (11 men, 9 women; mean age 41+/-13 years) with seronegative inflammatory spondyloarthropathies but without abdominal complaints completed the study. No adverse effects were reported and all the capsules were excreted. Of these 20 patients, 11 (55%) had a normal small bowel on both examinations. Significant small-bowel findings (erythema, mucosal breaks, aphthous or linear ulcers, erosions) were detected by capsule endoscopy in six patients (30%) and by ileocolonoscopy in only one patient. In addition, capsule endoscopy detected significant upper gastrointestinal pathology in 40% of patients. The patients preferred capsule endoscopy to ileocolonoscopy.

CONCLUSIONS

Capsule endoscopy detected more small-bowel lesions than ileocolonoscopy, and provided additional potentially relevant information on upper gastrointestinal pathology in patients with spondyloarthropathies.

Levels of muscle enzymes in the serum after esophageal pneumatic dilation in patients with achalasia

The success rate of pneumatic dilation of the esophagus in patients with achalasia is variable. We aim to assess whether levels of muscle enzymes in the serum are useful for predicting the efficacy of this procedure. Consecutive adults with symptomatic achalasia treated with pneumatic dilation were included. Blood samples were taken immediately before the procedure and after 12, 24 and 32 h. Clinical efficacy of the pneumatic dilation was evaluated on the basis of a symptom score defined prior to, and 2 months after the procedure. Eleven patients underwent 13 pneumatic dilations. In nine patients this was the first dilation attempt. Ten dilations were clinically effective. The study was discontinued after enzyme levels did not show a trend of increase in any of our patients. Moreover, a statistically significant unexpected decrease in creatine phosphokinase values was found 12 h after the procedure, among the 10 successful dilations. We believe that levels of muscle enzymes in the serum cannot predict the efficacy of pneumatic dilation in patients with achalasia.

Enhanced glucose-dependent glucagon-like peptide-1 and insulin secretion in Crohn patients with terminal ileum disease is unrelated to disease activity or ileal resection

BACKGROUND

Enhanced secretion of glucagon-like peptide-1 (GLP-1) has been reported in patients with Crohn disease (CD). However, the correlation between the enteropancreatic axis and the activity of CD remains unclear.

METHODS

Plasma glucose, insulin, GLP-1 levels and insulin sensitivity were determined before and after oral glucose tolerance tests in 13 patients with CD of the terminal ileum, in 13 patients after resection of the terminal ileum and in 7 healthy controls. Basal and stimulated insulin sensitivities were determined using the homeostasis model assessment (HOMA) and the insulin sensitivity index (ISI) methods, respectively.

RESULTS

Basal and stimulated glucose levels were comparable in patients and controls. The peak stimulated GLP-1 secretion was significantly higher in the patient group compared to controls: 12.2 +/- 1.24 pM/L and 8.1 +/- 1.72 pM/L, respectively, P=0.03. This was associated with 52% increased overall insulin secretion in the patients' group as compared to controls (P=0.007) and a higher peak insulin response: 63.5 +/- 9.69 mU/L and 41.5 +/- 6.85 mU/L for patients and controls, respectively, P=0.04. Operated patients had similar GLP-1 levels but higher peak and overall insulin secretions compared with those in non-operated patients (P=0.01). Fasting and stimulated insulin sensitivities were reduced only in patients with ileal resection as compared to controls: P=0.01 and P=0.05, respectively. No correlation was found between the CD activity index and GLP-1 or insulin secretion.

CONCLUSIONS

CD of the terminal ileum is associated with enhanced glucose-dependent GLP-1 secretion, which is unrelated to disease activity or ileal resection.

Diagnosing small bowel Crohn's disease with wireless capsule endoscopy

BACKGROUND

The small bowel is the most commonly affected site of Crohn's disease (CD) although it may involve any part of the gastrointestinal tract. The current methodologies for examining the small bowel are x ray and endoscopy.

AIMS

To evaluate, for the first time, the effectiveness of wireless capsule endoscopy in patients with suspected CD of the small bowel undetected by conventional modalities, and to determine the diagnostic yield of the M2A Given Capsule.

PATIENTS

Seventeen patients (eight males, mean age 40 (15) years) with suspected CD fulfilled study entry criteria: nine had iron deficiency anaemia (mean haemoglobin 10.5 (SD 1.8) g%), eight had abdominal pain, seven had diarrhoea, and three had weight loss. Small bowel x ray and upper and lower gastrointestinal endoscopic findings were normal. Mean duration of symptoms before diagnosis was 6.3 (SD 2.2) years.

METHODS

Each subject swallowed an M2A Given Capsule containing a miniature video camera, batteries, a transmitter, and an antenna. Recording time was approximately eight hours. The capsule was excreted naturally in the patient's bowel movement, and the data it contained were retrieved and interpreted the next day.

RESULTS

Of the 17 study participants, 12 (70.6%, six males, mean age 34.5 (12) years) were diagnosed as having CD of the small bowel according to the findings of the M2A Given Capsule.

CONCLUSIONS

Wireless capsule endoscopy diagnosed CD of the small bowel (diagnostic yield of 71%). It was demonstrated as being an effective modality for diagnosing patients with suspected CD undetected by conventional diagnostic methodologies.

Effect of grapefruit juice on the pharmacokinetics of losartan and its active metabolite E3174 in healthy volunteers

Grapefruit juice (GJ), a cytochrome P450 (CYP) 3A4 inhibitor, may affect the pharmacokinetics of drugs metabolized through CYP 3A4. Losartan, an angiotensin II antagonist, is converted into its main active metabolite E3174 by CYP 3A4 and CYP 2C9. The effect of GJ on losartan pharmacokinetics was assessed in a randomized crossover trial. Losartan was given to 9 volunteers with and without GJ. Concentrations of losartan and its E3174 metabolite were determined in serum by a high-performance liquid chromatography method (HPLC). Significant differences were observed in some of the pharmacokinetic parameters of losartan and its metabolite E3174 after losartan administration with and without co-administered GJ. The lag time (time to drug appearance in serum) of losartan increased significantly with co-administered GJ. The mean residence time (MRT) and half-life (t(1/2)) of the E3174 metabolite were significantly longer and the area under the concentration--time curve (AUC) of the E3174 metabolite was significantly smaller after concomitant GJ administration. The ratio AUC(losartan)/AUC(E3174) was significantly increased after concurrent grapefruit juice intake. The increased lag time of losartan and the increased MRT and t1/2 and decreased AUC of E3174 were considered indicative of simultaneous CYP 3A4 inhibition and P-glycoprotein activation. The significantly increased AUC(losartan)/AUC(E3174) ratio, however, indicates reduced losartan conversion to E3174 by CYP 3A4 metabolism as a result of co-administered GJ.

Effectiveness of acupuncture for treatment of childhood constipation

The aim of the present study was to examine the influence of acupuncture on chronic constipation in children and to investigate their basal plasma panopioid level and the changes of this treatment. Seventeen children constipated for at least six months were treated by five weekly placebo acupuncture sessions, followed by 10 weekly true acupuncture sessions. Their parents filled a bowel habit questionnaire. Panopioid activity was measured at time 0 and after 5, 10, and 15 acupuncture sessions. The frequency of bowel movements in males increased more gradually compared to females and reached a maximal improvement only after 10 true acupuncture sessions, from 1.4 +/- 0.6/week to 4.4 +/- 0.6/week and females from 1.4 +/- 0.3/week up to 5.6 +/- 1.2/week. The basal panopioid activity was lower in constipated children as compared to the control population and increased gradually up to control level after 10 true acupuncture sessions. This study is the first to describe a successful treatment by acupuncture of constipated children.

A randomized trial comparing wireless capsule endoscopy with push enteroscopy for the detection of small-bowel lesions

BACKGROUND & AIMS

Wireless capsule endoscopy is a new, painless method of imaging the entire small bowel. It has not been compared with push enteroscopy. We compared the sensitivity, specificity, and safety of capsule and push enteroscopy in detecting small-bowel lesions.

METHODS

Nine to 13 radiopaque, colored beads (3-6 mm diameter) were sewn in random order inside 9 canine small bowels, half within the first meter, and confirmed on x-ray. After recovery, the number, order, and color of beads were assessed in 23 capsule enteroscopies and 9 push enteroscopies in a random order. The surgeons, push enteroscopists, capsule video interpreters, and pathologist were blinded to the others' findings.

RESULTS

The capsules identified more beads than push enteroscopy (median, 6 [range, 2-9] vs. 3 [range, 2-6 beads]; P < 0.001). The sensitivity of the capsule was 64% compared with 37% for push enteroscopy. The specificity was 92% for capsule enteroscopy and 97% for push enteroscopy. The capsules identified significantly more beads beyond the reach of the push enteroscope (median, 4 [range, 2-7] vs. 0; P < 0.0001). Hair, ingested plastic, ulceration, submucosal swelling, and worms were clearly identified by the capsule. The capsules passed safely through the animals with no significant histologic findings.

CONCLUSIONS

Wireless capsule endoscopy detected more abnormalities in the small bowel than push enteroscopy.

Prevalence of celiac antibodies in children with neurologic disorders

Neurologic complications are a recognized but unusual manifestation of celiac disease (CD) in adults and children. The use of antigliadin and antiendomysial antibodies in screening has revealed the frequency of CD among symptom-free individuals to be high. Recently, a high frequency (57%) of antigliadin antibodies was demonstrated in adult patients with neurologic dysfunctions of unknown cause. We investigated the yield of screening for CD in children with common neurologic disorders. One hundred sixty-seven children, 1-16 years of age, were included in the study: 41 with migraine headaches, 39 with attention-deficit disorder with or without hyperactivity, 36 with epileptic disorders, and 51 with hypotonia and motor abnormalities. Positive IgG antigliadin antibodies were evident in 22 children (13%) in the study group compared with three children (9%) in the control group. However, in all children, negative IgA and endomysial antibodies were observed; thus duodenal biopsies were not performed. Contrary to studies performed in adults, these results did not demonstrate any relationship between common neurologic disorders without a specific diagnosis during childhood and CD. Thus screening for CD does not need to be routinely included in the diagnostic evaluation of children with these disorders.

Superoxide dismutase activity in children with chronic liver diseases

BACKGROUND/AIMS

Liver disease in infancy has multiple etiologies. As reactive oxygen intermediates are involved in several types of tissue damage, we have investigated whether different forms of liver disease in infancy are associated with increased free radical generation, using an indirect approach in which superoxide dismutase (a free radical scavenger) activity is determined in the liver tissue.

METHODS

A total of 48 liver biopsies performed at diagnosis were evaluated retrospectively. Nine infants had biliary atresia, eight Alagille syndrome, seven alantitrypsin deficiency and 12 cryptogenic hepatitis. As controls we studied 12 biopsies with normal histology obtained from seven children with portal vein thrombosis and five children who underwent biopsy for management reason but had no liver disease. Superoxide dismutase activity in liver biopsy specimens was measured using the cytochrome C method by spectrophotometry and expressed as U SOD/mg protein.

RESULTS

Superoxide dismutase activity was significantly increased in biliary atresia (1.25 +/- 0.56 U SOD/mg protein, p<0.0001) and Alagille syndrome (1.31 +/- 0.56 U SOD/mg protein, p<0.0001) as compared with al-antitrypsin deficiency (0.75 +/- 0.3 U SOD/mg protein), neonatal hepatitis (0.72 +/- 0.37 U. SOD/mg protein) and normal controls (0.4 +/- 0.7 U. SOD/mg protein). The highest level of SOD activity was found, however, in control children with portal vein thrombosis (2.09 +/- 0.96 U SOD/mg protein; p<0.0001 as compared to the other groups).

CONCLUSION

Superoxide dismutase, a key enzyme in free radical protection, is increased significantly in the liver tissue of infants with cholestatic liver disease due to bile duct damage and in children with portal vein thrombosis, suggesting that products of free radical reactions are involved in the pathogenesis of these disorders.

Elevated carcinoembryonic antigen (CEA) levels in a patient with no malignancy

Carcinoembryonic antigen rarely exceeds serum levels of 10-12 ng/mL in benign diseases and has never been found above 24 ng/ml. We report a case in which carcinoembryonic antigen serum levels reached the value of 44.9 ng/ml without any overt reason (after 22 months of follow-up). A decline of the carcinoembryonic antigen to normal ranges was noticed after a radiolabeled anti-carcinoembryonic antigen monoclonal antibody scan was performed. The reason for this phenomenon is unclear.

Does laparoscopic cholecystectomy influence peri-sinusoidal cell activity?

BACKGROUND/AIMS

To investigate the influence of laparoscopic procedures on perisinusoidal cell function.

METHODOLOGY

In 31 patients who underwent laparoscopic cholecystectomy for symptomatic cholelithiasis, the serum levels of beta-N-acetyl hexosaminidase (beta-NAH) and hyaluronic acid (HA) were measured. Six female patients, who underwent other laparoscopic procedures, not involving the hepatobiliary system, served as controls.

RESULTS

HA serum levels increased significantly in both study and control groups, while beta-NAH serum levels remained within normal values. Post-operative AST and ALT serum levels increased significantly only in the study group. No elevation of serum ALP was noted in any of our patients, and post-operative bilirubin levels did not increase in patients with normal pre-operative levels.

CONCLUSIONS

Laparoscopic procedures caused detectable damage to Kupffer and endothelial cells as reflected by elevation of post-operative HA serum levels. The damage to the liver hepatocytes and perisinusoidal cells has no clinical significance and the laparoscopic procedure itself is the probable cause of the Kupffer and endothelial cells damage, while other mechanisms caused damage to the hepatocytes.

Gallbladder contraction in familial dysautonomia

The impaired function of the autonomic nervous system in patients with familial dysautonomia (FD) is frequently associated with gastrointestinal dysfunction. This study sought to determine whether gallbladder contraction is also affected in these patients. Nine consecutive patients with FD were assessed by real-time ultrasonography for gallbladder volume and calculated percentage of gallbladder contraction before and 45-60 min after a 50 g fatty meal, and compared with nine healthy control patients, matched for age and gender. Gallbladder volume before the fatty meal was found to be larger in healthy controls than in FD patients (25.4+/-9.5 and 15.4+/-7.4 ml3, respectively; p = 0.024). No significant difference was demonstrated between the groups after the fatty meal (controls: 12.1+/-6.0; FD: 9.0+/-6.6 ml, respectively) and the calculated percentage of gallbladder contraction was similar in both groups (controls: 53.4+/-16.6; FD: 44.8+/-18.8%). These results indicate that gallbladder function in FD patients does not differ from the general population and preventive measures for gallstone formation are not required.

Role of endothelin in obstructive jaundice

Mediators responsible for renal changes in obstructive jaundice are not specified. This study is designed to study the role of endothelin-1 (ET-1) in obstructive jaundice in rats. Animals were randomly placed into five experimental groups. Group 1 (N = 3) was the sham-operated group. Group 2 (N = 8) after common bile duct (CBD) ligation, received bosentan, which is a nonselective endothelin receptor blocker, 50 mg/kg/day for seven days. Group 3 (N = 7) received 1 microg/kg/day captopril. Group 4 (N = 7) was given both drugs orally for seven days. Group 5 (N = 6) after CBD ligation, received Arabic gum as the vehicle. Blood was drawn from the infrahepatic vena cava for the determination of ET-1, bilirubin, creatinine, protein oxidation products, hyaluronic acid, and beta-N-acetyl-hexosaminase. Liver tissue samples were obtained to determine glutathione levels. ET-1, protein oxidation products, hyaluronic acid, bilirubin, and creatinine levels increased significantly in the control group when compared with sham. Bosentan effectively prevented ET-1 elevation but could not reverse creatinine or bilirubin elevation. Captopril with or without bosentan was cytoprotective but did not reverse increased creatinine levels. It is concluded that increased ET-1 in obstructive jaundice may be one of the contributing factors of renal damage.

A comparison of new rapid urease tests for detection of Helicobacter pylori: test characteristics and factors affecting positivity and time to positivity

We assessed two new rapid urease tests, the Helicobacter Urease Test (HUT, Astra, Sweden) and the Polish test, for accuracy, reaction time, and the effect of biopsy site and bacterial density on test characteristics and time to positivity. A prospective study was conducted in two groups of patients: 64 consecutive patients undergoing upper endoscopy for dyspepsia and 61 consecutive patients with duodenal ulcer on upper endoscopy. In the first group, test accuracy, time to positivity, and possible associations with biopsy site and bacterial density were assessed between the tests. In the second group, the two new tests were compared with the CLOtest for time to positivity and effect of bacterial density on test outcome. The Polish and HUT test had similar specificities (97%), but the Polish test was more sensitive (90.3% vs. 80.7%). The Polish test was positive within 10 minutes in 55% of the positive patients compared with 10% for the HUT test. There was no association between bacterial density (by histologic count) and reaction time in either test or in the CLOtest in the second group. The Polish test was more accurate and had a quicker time interval to positivity than the HUT. There was no significant association between bacterial density and reaction time in any of the urease tests assessed, and the biopsy site did not affect test accuracy in the HUT test.

Does general anesthesia affect sinusoidal liver cells as measured by beta-N-acetyl hexosaminidase serum activity level?

BACKGROUND/AIMS

General anesthesia causes temporary hypoxia of liver tissue, resulting in several metabolic changes. The purpose of this study was to explore whether the function of hepatic sinusoidal cells, especially the Kupffer and endothelial cells, are damaged following general anesthesia.

METHODOLOGY

Liver sinusoidal cell (LSC) function was evaluated by means of measuring the serum level of activity of the lysosomal hydrolase beta-N-acetyl hexosaminidase before and 24 hours after general anesthesia in 20 patients who underwent orthopedic surgery.

RESULTS

The only change in liver function which might be of clinical significance was a mild decline in the serum albumin level.

CONCLUSIONS

Liver sinusoidal cells, especially Kupffer and endothelial cells, most probably remain undamaged after 1 to 5 hours of general anesthesia.

The contribution of endoscopy and biopsy to the diagnosis of periampullary tumors

BACKGROUND AND STUDY AIMS

Endoscopy and biopsy from a suspicious Vater's papilla may establish an early preoperative diagnosis of a periampullary tumor. However, information regarding the diagnostic accuracy of this procedure is limited and variable. The aim of the present study was to evaluate retrospectively the accuracy of this procedure compared to that of other diagnostic methods.

PATIENTS AND METHODS

Among 928 patients referred to our institute for endoscopic retrograde cholangiopancreatography (ERCP), a suspicious Vater's papilla was seen in 28. In each case comparison was made between the pre-ERCP clinical diagnosis, endoscopic appearance, histologic interpretation of endoscopic biopsies, and the final diagnosis. Two patients in whom a final diagnosis was not available were excluded from the study.

RESULTS

A final diagnosis of an ampullary or periampullary carcinoma was established in 17 patients (65%), a carcinoma within an adenoma of the papilla in three patients (12%), and adenoma and a metastatic gallbladder carcinoma in one patient each. The remaining four patients (15%) were finally diagnosed as having "pseudotumors" (due to choledocholithiasis). Eight (38%) of the 21 patients with ampullary or periampullary neoplasm also had gallstones. A pre-ERCP diagnosis (by clinical evaluation and non-invasive imaging) of tumor versus choledocholithiasis was accurate in only 65% of all 26 patients. In these, the diagnostic accuracy of endoscopic appearance and endoscopic biopsy was 77% and 85%, respectively. Regarding the 21 patients with carcinomas, the diagnosis by endoscopic appearance was more accurate than that by endoscopic biopsy (90% vs 81%). Unlike the positive predictive values, the negative predictive values for malignancy were weak: 33% for the endoscopic appearance and 50% for the endoscopic biopsy.

CONCLUSIONS

Because of a high incidence of concurrent cholelithiasis, many patients with a periampullary tumor seen during ERCP are misdiagnosed earlier (by clinical evaluation and non-invasive imaging) as having choledocholithiasis only. However, the accuracy of endoscopy and biopsy is also limited. This limitation must be considered when evaluating the optimal management of patients with suspected periampullary tumor.

[Acute liver damage after using ecstasy]

Ecstasy is a stimulant used mainly by youngsters to get 'high.' There are few reports of acute injury of the liver due to ecstasy. We describe a 37-year-old woman who presented with the clinical picture of recurrent hepatitis following ingestion of the drug. After several months she developed liver cirrhosis shown by biopsy and CT scanning. This case emphasizes the potential danger of ecstasy. Every patient with hepatitis of unknown origin must be questioned about ingestion of the drug.

The effect of colonoscopy on tumor markers

As preoperative elevated serum levels of carcinoembryonic antigen (CEA) and CA19.9 are markers for bad prognosis in colorectal cancer patients, it is important to decide whether preoperative total colonoscopy would make a significant change in their serum levels. CEA and CA 19.9 were evaluated in three groups of patients before and after colonoscopy. The groups comprised the following: Group A, 20 patients with colorectal cancer; Group B, 17 patients with colorectal polyp of > or = 1-cm diameter; Group C, 16 patients with no colorectal pathology. CEA serum levels were found to be significantly lower after colonoscopy in all groups. CA19.9 was found to be significantly lower after colonoscopy only in Group B; it did not reach significance in Group A and was found not to be significantly higher in Group C.

[Stromal uterine sarcoma arising from intestinal endometriosis after abdominal hysterectomy and salpingo-oophorectomy]

The incidence of ectopic endometriosis is 4% to 18%. The intestinal type is quite common with the rectosigmoid the most likely part of the bowel to be involved due to its pelvic location. A 43-year-old woman, whose symptoms, X-ray and endoscopic findings suggested malignancy of the rectosigmoid, is presented. Primary malignancy of the bowel was excluded by endoscopic biopsies. Histological examination at operation showed stromal sarcoma of the uterus with foci of endometriosis. There is no report in the English literature of transformation of intestinal endometriosis into malignancy, such as stromal sarcoma of the uterus, which imitates a primary malignancy with obstruction of the rectosigmoid.

Esophagogastric mucosal junction (EGMJ): its location as measured by endoscopy

The "esophageal" length, i.e., incisors-esophagogastric mucosal junction distance, was measured endoscopically in 758 patients, retrospectively. Two hundred twenty-five additional patients were evaluated prospectively and their height and weight were measured. All patients were analyzed according to their age and sex, indication for the procedure, and its endoscopic diagnosis. "Esophageal" length was found to be significantly longer in male patients. Fifty-three percent of the examined population had "esophageal" length shorter than 38 cm, whereas 99% of patients with normal endoscopy had "esophageal" length of 38-40 cm. Linear correlation was found between "esophageal" length and height, but not with weight. Patients with dyspepsia and esophagitis had a "shorter" esophagus, whereas those with tumors of the upper gastrointestinal tract and those with duodenal ulcer had a "longer" esophagus.

Treating gastrointestinal bleeding with endoscopic hemoclips

Seventeen patients were treated with endoscopic hemoclip placement in order to arrest or prevent active bleeding. Eight patients were investigated for lower gastrointestinal problems, and 9 patients for upper gastrointestinal indications. Success rate was 100%. Application was relatively easy. Comparative studies with other modes of endoscopic hemostasis are needed.

The role of endoscopic retrograde cholangiopancreatography in management of patients recovering from acute biliary pancreatitis in the laparoscopic era

BACKGROUND

Traditionally an episode of acute biliary pancreatitis (ABP) is an indication for direct imaging of the biliary tree. The optimal approach may vary according to local expertise, and endoscopic retrograde cholangiopancreatography (ERCP) is the most common. The fact that the incidence of choledocholithiasis in patients recovering from ABP varies between 3 and 33% raises a question about the necessity of visualizing the biliary tree in all patients recovering from ABP.

METHODS

In order to evaluate this policy, we reviewed 48 ERCPs performed on patients recovering from ABP who were scheduled for laparoscopic cholecystectomy (LC). We checked the correlations between ERCP findings and the severity of pancreatitis, biochemistry values (which were sampled during the acute phase), and ultrasonographic (US) findings.

RESULTS

The ERCP demonstrated common bile duct (CBD) stones in 11 (22.9%) patients. US finding of a dilated CBD and maximal aspartate transaminase (AST) values higher than 90 units/l were significantly correlated with CBD stones (a relative risk [RR] of 2.95 with a 95% confidence interval [CI] for a dilated CBD and RR of 3.89 with a 95% CI of 1.18-12.80 for an AST value higher than 90 units/l). No other parameters were significantly correlated with CBD stones.

CONCLUSION

We, therefore, recommend performing a preoperative ERCP only on patients who present with an ultrasonographic finding of CBD dilatation. The correlation to high AST is still to be proven.

Superoxide dismutase activity in Helicobacter pylori-positive antral gastritis in children

Reactive oxygen metabolites have been implicated in gastric mucosal injuries. Superoxide dismutase, a scavenger of superoxide radical, is a key enzyme in gastric mucosal protection against several damaging factors. This study was aimed at investigating the relationship of superoxide dismutase activity to Helicobacter pylori-induced antral gastritis in children. Two groups of 11 children each, one positive and the other negative for Helicobacter pylori, were studied. Biopsies from the antrum and corpus were obtained for evaluation of Helicobacter pylori by CLOtest and histology as well as for superoxide dismutase activity (cytochrome c method). Erythrocytic and serum superoxide dismutase levels were determined as well. Superoxide dismutase activity was significantly higher only in the antrum of children with Helicobacter pylori-induced antral gastritis. There was no significant difference in superoxide dismutase activity in the corpus, erythrocytes, or serum of both groups. These findings may suggest a pathogenic relationship between the presence of Helicobacter pylori and oxygen radicals in inducing antral mucosal injury.

Superoxide dismutase activity in duodenal ulcer patients

OBJECTIVE

To investigate whether duodenal ulcer (DU) is associated with increased free radical generation at the site of ulceration and to attempt, indirectly, to confirm the hypothesis by determining activity of free radical scavengers such as superoxide dismutase (SOD).

STUDY DESIGN

Prospective study comparing SOD activity in biopsies taken from the ulcer edge, and antrum in DU patients before and after one month of treatment to SOD activity in biopsies from the duodenal bulb and antrum in a control population.

SETTING

Institute of Gastroenterology of a university hospital.

STUDY POPULATION

Twenty-five patients with DU. The diagnosis was confirmed by endoscopy.

MEASUREMENTS

SOD activity in biopsy specimen, red blood cells (RBC) and serum was measured using the cytochrome c method by spectrophotometry and expressed as U SOD/mg protein. Helicobacter pylori was diagnosed by the rapid urease test (CLO test) from antral biopsies.

RESULTS

SOD activity was markedly depleted in the ulcer edge (2.78 +/- 0.9 U SOD/mg protein) as compared to the same patients after one month of treatment (4.59 +/- 2.2 U SOD/mg protein) (P = 0.05) and to biopsies from the duodenal bulb in control population (6.7 +/- 2.4 U.SOD/mg protein) (P = 0.05). SOD activity in the antrum of both groups was similar. There was no difference in SOD activity in RBC and serum of both groups.

CONCLUSION

Products of free radical reactions are implicated in the pathogenesis of DU disease. SOD, which is a key enzyme in gastric mucosal protection, is depleted significantly in the ulcer edge compared with controls and increases after healing. However, it is not clear whether this abnormality in oxygen free radical metabolism reflects, rather than causes, the condition which characterizes DU.

[Percutaneous choledochoscopic electrohydraulic lithotripsy]

Treatment of biliary stones impacted in the distal, common bile duct is a technical challenge. We report 2 consecutive patients, a woman aged 80 years and a man aged 64, in whom all operative attempts failed. In both, the stone was removed by percutaneous, choledochoscopic, electrohydraulic lithotripsy in a single session. To the best of our knowledge these are the first such cases reported in Israel.

Helicobacter pylori infection and blood groups

OBJECTIVES

Bacterial attachment is a prerequisite for colonization of the gastric epithelial surface. Recently, it was demonstrated that the receptor for Helicobacter pylori is the blood group antigen Lewis b, which is exposed only in blood group O. We prospectively examined the prevalence of blood groups in H. pylori-positive and -negative patients. To avoid a genetic bias, we compared blood group prevalence of our patients with the general population of Israel.

METHODS

In the 187 consecutive patients we studied, in addition to regular upper endoscopy, H. pylori status and blood group. Exposure to H. pylori was diagnosed when the results of two or more of three methods were found to be positive.

RESULTS

Exposure was found in 123 patients and 64 negative. The groups were similar in average age and origin, and no significant difference was demonstrated for blood group. Blood group distribution between any given origin was not significantly different in our patients and in a sample of 182,701 blood donors.

CONCLUSIONS

Positivity for H. pylori was not associated with blood group O. Our observation does not support the conclusion that the receptor for H. pylori in the gastric mucosa is the blood group antigen Lewis b.

Endoscopic retrograde cholangiopancreatography in octogenarians

Thirty patients > or = 80 years of age (mean 86) underwent diagnostic and/or therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The low mortality (6.6%) and complication (6.6%) rates lead us to believe that ERCP in octogenarians provides an acceptable route for diagnosis and treatment of biliary and pancreatic disorders.

To do or not to do an endoscopic retrograde cholangiopancreatography in acute biliary pancreatitis?

In 16 patients with acute biliary pancreatitis, we performed endoscopic retrograde cholangiopancreatography (ERCP) 10 to 14 days after onset of the attack. All patients had mild pancreatitis. In 10 patients with normal-appearing common bile duct (CBD) on ultrasonography, ERCP was normal also. In two patients with dilated CBD on ultrasonography, stones were found in the CBD on ERCP, sphincterotomy was performed, and the stones were extracted endoscopically. We think there is no need for preoperative ERCP in patients with mild attacks of biliary pancreatitis if the CBD appears undilated on ultrasonography.

Gastrointestinal patients in the emergency room

Of 4,839 patients who visited the Emergency Room (ER) of a 650-bed general hospital (serving a regional population of 220,000) over a period of 28 consecutive days, 436 were suffering from gastrointestinal (GI) problems. The patients, together with their 140 ER doctors, were interviewed by 40 trained interviewers and information concerning demographic data, tests performed, diagnosis, treatment and hospitalization was collected and evaluated. Most of the GI patients (39.9%) were aged 16 years or younger, were Israeli born and were suffering from infections of the GI system. Twenty percent of all GI patients were hospitalized. Most came to the ER on working days although their symptoms began at home. A total of 77.9% of the GI group expected to be treated in the ER and sent home without being hospitalized. The ER, which is open for 24 hours a day, is considered by the population as a kind of an outpatient clinic.

Gastric Mucosal Changes following Gastroplasty: A Comparative Study Between Vertical Banded Gastroplasty and Silastic Ring Vertical Gastroplasty

BACKGROUND: Long-term changes of gastric mucosa following surgery for morbid obesity have never been studied, to the best of our knowledge. As 31 patients in our series presented with various gastrointestinal complaints following surgery, we used this opportunity to study mucosal changes. METHODS: Thirty-seven gastroscopies were performed on 31 patients, 20 patients following Vertical Banded Gastroplasty (VBG) and 11 patients following Silastic Ring Vertical Gastroplasty (SRVG) with various gastrointestinal complaints. Macroscopic appearance of the gastric mucosa was examined and biopsies taken from the proximal gastric pouch, the transitional zone and distal stomach. RESULTS: In most patients, macroscopic appearance of the proximal and distal pouches was normal. Pathological findings were mainly located in the transitional zone and were found mainly in the VBG group. CONCLUSIONS: This study indicates that damage to the gastric mucosa is related to the surgical technique, and mainly to the strip of mesh used in the VBG patients. Since hyperplasia and metaplasia were among the microscopic findings, a question is raised about the possibility of malignant transformation. We suggest that routine post-operative gastroscopies be considered, especially following VBG.

[Groove pancreatitis and adenocarcinoma of the pancreatic head]

A mass within the head of the pancreas causing obstructive jaundice is frequently adenocarcinoma, or infrequently focal pancreatitis. Groove pancreatitis is an inflammation of the head of the pancreas which fills the anatomic space between the head of the pancreas on 1 side and the second part of the duodenum on the other. Obstruction from either cause may cause vomiting, abdominal pain, and loss of weight. It is sometimes impossible to differentiate between the 2 conditions clinically. We present 2 women, aged 41 and 42 years, respectively, with recent onset of diabetes mellitus, obstructive jaundice, abdominal pain and severe loss of weight in whom diagnosis was difficult. In 1 repeated fine needle biopsy directly from the mass did not show adenocarcinoma, but she died of the disease a few months later. The other, in whom malignancy was also suspected, recovered from what was retrospectively diagnosed as groove pancreatitis.

Are elevated liver enzymes and bilirubin levels significant after laparoscopic cholecystectomy in the absence of bile duct injury?

OBJECTIVE

Increased aspartate aminotransferase (AST), alanine aminotransferase (ALT), and bilirubin levels were noted incidentally after a laparoscopic cholecystectomy. The percentage in which such elevation occurs and its clinical significance in the absence of bile duct injury were investigated.

SUMMARY BACKGROUND DATA

Bile duct injury is the most feared complication of laparoscopic cholecystectomy. Some laboratory tests may be indicative of this complication, such as increases in liver enzyme (AST, ALT, and alkaline phosphatase [ALP]) and bilirubin. These parameters have not been investigated in patients who had laparoscopic cholecystectomy and in whom no damage to the bile duct was noted.

METHODS

Sixty-seven patients with normal results of preoperative liver function test were entered into the study. Blood was collected 24 hours after laparoscopic cholecystectomy, and AST, ALT, ALP, and bilirubin levels were measured.

RESULTS

A mean 1.8-fold increase in AST occurred in 73% of patients; 82% showed a 2.2-fold increase in ALT. A statistically nonsignificant increase was noted in 53% of patients (ALP remained within normal limits), and in 14% of patients bilirubin levels were increased (they were primarily of the unconjugated type).

CONCLUSIONS

In many patients a significant increase in AST and ALT levels occurred after laparoscopic cholecystectomy, but they returned to normal values within 72 hours. The cause of this is unclear, and these elevations appear to have no clinical significance.

"Rendez-vous" procedure (RVP) for obstructive jaundice

Seven patients with obstructive jaundice were palliatively treated with the "rendez-vous" procedure, which combines a percutaneous and an endoscopic approach to stent insertion into the biliary system. In six cases, pretreatment papillotomy was not needed. Endoscopy was also not really necessary for stenting in one patient. This procedure should be restricted for use in cases of endoscopic failure.

Colocutaneous fistula--a rare complication of percutaneous endoscopic gastrostomy

Although the percutaneous endoscopic gastrostomy technique for feeding is a fairly common procedure now, we have not come across a complication such as described below, a probable migration of the tube from the stomach to the colon, without any objective proof for this.