Combined Overview on Diverticular Assessment:a new score for the management of diverticular disease

Background

Diverticulosis is increasing worldwide as a public health problem. The Combined Overview on Diverticular Assessment (CODA) score, merging Diverticular Inflammation and Complication Assessment (DICA) and few clinical parameters, may reliably predict the occurrence of acute diverticulitis and surgery due to complications. Thus, the aim of the study is to confirm the value of DICA classification and to develop and validate the CODA endoscopic-clinical score.

Methods

A number of 2198 patients, at the first diagnosis of diverticulosis/diverticular disease were enrolled in a multicentre, prospective, international cohort study. Participants were scored according to DICA classifications. A 3-year follow-up was performed. Survival methods for censored observation were used to develop and validate the CODA score for predicting diverticulitis and surgery.

Results

The 3-year cumulative probability of diverticulitis and surgery was ≤4%, and ≤0.7% in CODA A; <10%and <2.5% in CODA B; >10%and >2.5% in CODA C, respectively. The 3-year cumulative probability of diverticulitis and surgery was of 3.3% (95% CI 2.5% to 4.5%) in DICA 1, 11.6% (95% CI 9.2% to 14.5%) in DICA 2 and 22.0% (95% CI 17.2% to 28.0%) in DICA 3 (p < 0.001), and 0.15% (95% CI 0.04% to 0.59%) in DICA 1, 3.0% (95% CI 1.9% to 4.7%) in DICA 2 and 11.0% (95% CI 7.5% to 16.0%) in DICA 3 (p < 0.001), respectively. The CODA score showed optimal discrimination capacity in predicting the risk of surgery in the development (cstatistic: 0.829; 95%CI 0.811 to 0.846) and validation cohort (c-statistic: 0.943; 95% CI 0.905 to 0.981).

Conclusions

DICA endoscopic classification was confirmed to have a significant predictive value in terms of acute diverticulitis occurence/recurrence and risk of surgery. CODA score could provide a new risk stratification tool useful for everyday clinical practice and also with a significant public health impact in terms of treatment effectiveness and decision making.

Key messages

• DICA endoscopic classification of diverticular disease is a clear predictor of the outcome of diverticulosis/diverticular disease.

• The CODA score, combining DICA and few clinical parameters, may reliably predict the occurence of acute diverticulitis and surgery due to complications.

Benchmarking between two different hospitals on health risk management in the covid-19 emergency

Iusse

The strategies adopted during COVID19 emergencies by two different hospitals in the Lazio Region are presented: S. Maria Goretti Hospital (SMGH) directly managed by the ASL Latina, hub and centre of the Emergency Department, and Cristo Re Classified Hospital (CRH), accredited in the territory of the ASL Roma1.

Description of the problem

SMGH has been identified as COVID19 Intervention Hospital. CRH initially was a No-COVID support structure, then included in the COVID19 network. During the COVID19 emergency, the directors of both hospitals had to simultaneously ensure activity as usual, COVID19 recovery and risk management.

Results

SMGH, while continuing the emergency, oncological, pregnancy, paediatrics and outpatient activities, COVID19 patients was isolated on 7 different floors/areas. Moreover was defined: chain of command; clinical admission criteria; COVID19 multi-professional and support teams, roles, skills and specific training; health surveillance; environmental hygiene, safety paths/procedures, vaccinal center and much more. CRH, while continuing minimum programmed activities to reduce waiting lists, in the first epidemic phase was created 4 tensile structures for Pre-triage and COVID pathways, respiratory isolation area for supsected patient; transfer admission for emergency networks, clean-dirty pathway. Moreover in the second phase, was activated beds of COVID19 network and 4 technical beds OBI; the ‘Walk-in' for antigenic testing, with molecular confirmation <24h and infectious counselling; multi-disciplinary and specialist support teams, training courses, health surveillance, vaccinal center and much more.

Lessons

During COVID19 pandemic, risk management skills linked to the technical-organisational strategy of hospital directors, making it possible to reprogramme their structure in a short period of time with flexibility and resilience of the whole organization.

Key messages

Specific skills and roles, both hygienic and organizational, are essential to risk management in hospitals during epidemic emergencies.

The multidisciplinarity, flexibility and modularity of the hospital structure are the organizational bases in cases of pandemics.

Assessment of the nutritional status in patients with acute diverticulitis

Background

The study evaluated the implementation of a screening strategy on all hospitalizations for diverticular disease (DD) of the colon with particular reference to acute diverticulitis (AD) regarding nutritional status.

Methods

The Nutritional Risk Security (NRS2002) system, was used, preselecting those with AD by the nurses of the nutrition team on the same day of admission from 1/01 to 31/12/2017 at the S. Eugenio Hospital in Rome. Patients (pts) with positive pre-screening were referred for additional evaluation performed by a dietician.

Results

AD was observed in 133 pts, 58% women, out of a total sample of 4667. The NRS2002 was applied to all, finding a positive screening test in 97 (72.9%) pts of whom a severely compromised nutritional status (NRS2002 score&gt;3) in 61 pts (62.9%). Each patient tested positive was given initial nutritional support: oral supplements (17 pts, 17.52%), enteral nutrition (22 pts 22.68%), total parenteral nutrition (58 pts 59.8%). The mean length of hospital stay was 6.9 days, although was significantly longer for pts with NRS2002 positive (mean of 18 day). NRS2002 score can be a significant predictor of disease severity and outcome, operating independently of BMI, since a total score ≥3 can predict length of hospital stay.

Conclusions

The study confirmed that NRS2002 is a useful screening tool for identifying nutritional risk AD pts in hospital wards and allowed to select pts who needed a more careful monitoring program, diet therapy and possibly nutrition artificial. Furthermore, it showed an increasing and underestimated risk of malnutrition in a large number of pts hospitalized and that NRS2002 screening is a good predictor of some socio-health indicators such as hospital stay.

Key messages

There is an increasing and underestimated risk of malnutrition in a large number of patients hospitalized. NRS2002 is a useful screening tool for identifying nutritional risk and a good predictor of some socio-health indicators such as hospital stay.

Azathioprine in the maintainance remission in inflammatory bowel disease patients: 7-year follow up

Background

Azathioprine (AZA) and thiopurine are widely used for induction and maintenance of remission in steroid dependent patients with inflammatory bowel disease (IBD).

Methods

Aim of this study has been to investigate its efficacy and safety in maintaining steroid-free remission in steroid dependent IBD patients seven year after the institution of treatment. Data from consecutive IBD outpatients referred in our Institution, between 1985-2016, were reviewed and all patients treated with AZA were included in this retrospective study. AZA was administered at the recommended dose of 2-2.5 mg/kg.

Results

Out of 2802 consecutive IBD outpatients visited in the index period, AZA was prescribed to 433 patients, 236 (54.5%) were affected by Crohn's disease (CD) and 197 (45.5%) by ulcerative colitis (UC). One hundred and seventy-nine patients with a follow-up &lt; 84 months were excluded from the study. Two hundred and fifty-four patients were evaluated, 141 (55.5%) with CD and 113 (44.5%) with UC. One hundred and thirty-nine (54.7%) were male and 115 (45.3%) female (average age of 35.62 ± 14.20 SD years, range 14-74 y.). Seven year after the institution of treatment, 127 (50%) patients still were in steroid-free remission (83 CD vs 44 UC, 58.8% and 38.9%, respectively, p = 0.0024), 71 (27.9%) had a relapse requiring retreatment with steroids (29 CD vs 42 UC, 20.6% and 37.2%, respectively, p = 0.0047), 56 (22.1%) discontinued the treatment due to side effects (29 CD vs 27 UC, 20.6% and 23.9%, respectively). Loss of response from 1st to 7th year of follow-up was low, about 20%.

Conclusions

Seven year after the onset of treatment 50% of patients did not require further steroid courses. After the first year loss of response was low in six subsequent years. In the present series the maintenance of steroid-free remission was significantly higher in CD than in UC patients. The occurrence of side effects leading to the withdrawal of AZA treatment has been low.

Key messages

An important therapeutic moment of IBD is mantaining remission in steroid dipendent patients. AZA can be a viable and inexpensive alternative to treath these patients.

DICA endoscopic classification: 2-year analysis from an international, multicenter prospective study

Background

Diverticulosis of the colon is the most frequent anatomical alteration detected during colonoscopy. The endoscopic classification “DICA”(Diverticular Inflammation and Complication Assessment) has been recently developed in order to have an objective endoscopic description of the colon harbouring diverticula. Aim of this multicentre, international, prospective study was to assess the predictive value of this classification in term of acute diverticulitis and surgery occurrence on a 2-year observational follow-up period.

Methods

2215 prospective patients at the first diagnosis of diverticular disease were enrolled after exclusion of radiological signs of acute diverticulitis; inflammatory bowel diseases; ischemic colitis; prior colonic resection; patients with severe liver failure (Child-Pugh C) or severe kidney failure; pregnant women; patients who are currently using or who have received any laxative agents or mesalazine or probiotics or antibiotics &lt; 2 weeks prior to the enrollment; inability to comply with study protocol; patients with or history of cancer, of any origin, within 5 years before enrollment; history of alcohol, drug, or chemical abuse.

Results

1377(62.15%) patients were classified as DICA 1, 599(27,04%) as DICA 2 and 239(10.80%) as DICA 3. The risk of acute diverticulitis occurrence/recurrence, as well as the risk of surgery, were significantly linked to the severity of DICA score at entry. Overall, acute diverticulitis occurred in 123 (5,5%) patients: it occurred in 32 (2,3%) DICA 1, 53 (8,9%) DICA 2 and 32 (16.4%) DICA 3 patients respectively (p &lt; 0,0001). Overall, surgery occurred in 35 (1,6%) patients: it occurred in 2 (0.1%) DICA1, 15 (2,5%) DICA 2 and 18 (7,6%) DICA 3 patients respectively (p &lt; 0,0001).

Conclusions

The 2-year results of this prospective study seems to confirm that DICA endoscopic classification has a significant prognostic role on the risk of acute diverticulitis occurrence/recurrence and surgery in these patients.

Key messages

DICA is the first endoscopic classification of diverticular disease. The risk of occurrence/recurrence of acute diverticulitis and the risk of surgery are strictly linked to the severity of DICA score.

Prognostic value of the Diverticular Inflammation and Complication Assessment (DICA) classification

Key messages

DICA classification was able to discriminate, based on endoscopic records, the patients that could develop complications for Diverticular Disease. DICA classification is a valid parameter to predict the outcome of the disease, with great impact on public health improving the effectiveness of treatment.

Impact of treatments on fecal microbiota and fecal metabolome in symptomatic uncomplicated diverticular disease of the colon: a pilot study

Symptomatic uncomplicated diverticular disease (SUDD) affects 50% of people having diverticulosis. We performed a pilot study assessing the effect of current treatments on fecal microbiota and metabolome in SUDD. Thirteen consecutive females with SUDD were treated with a 2-week therapeutic trial of 30 g/day fiber supplementation (3 patients), 1.6 g/day of mesalazine (3 patients), 900 billion/day of probiotic mixture VivoMixx® (3 patients), or 800 mg/day of rifaximin (4 patients). Stool samples were collected at entry (T0), at the end of the 2-week therapeutic course (T1), and 30 (T2) and 60 days (T3) after the end of the therapeutic course. Real-time PCR quantified targeted microorganisms. Fecal metabolome patterns were studied by high-resolution proton NMR spectroscopy. At cumulative analysis, symptoms significantly decreased at each time point during follow-up (p less than 0.0001), and only left-lower quadrant pain increased again at T3. The overall bacterial quantity was not altered by the treatments. The amount of Akkermansia muciniphila species was significantly reduced at T1 (p=0.017) and at T2 (p=0.026), while at T3 the reduction was not significant in comparison to enrollment (p=0.090). Fecal molecular profile showed significant changes at T1 and T2, while at T3 it became similar to that of T0. Differences were found for 18 of the quantified molecules (tryptophan, phenylalanine, tyrosine, 4-hydroxyphenylacetate, urocanate, X-6.363, X-5.779, uridylate, galactose, X-4.197, threonine, sarcosine, methionine, 2-oxoisocaproate, 5-aminolevulinate, alanine, leucine, valerate). Metabolome and microbiota changed in patients with SUDD under treatment, confirming a possible role of dysbiosis/dysmetabolome in the pathology.

Intermittent versus every-day mesalazine therapy in preventing complications of diverticular disease: a long-term follow-up study

BACKGROUND

Mesalazine seems to be effective in preventing recurrence of acute uncomplicated diverticulitis (AUD), but the optimal mesalazine scheme to achieve these results is still debated.

AIM

To assess the effectiveness of two different mesalazine-based treatments in preventing recurrence of AUD and the occurrence of other complications of diverticular disease (DD) during a long-term follow-up.

PATIENTS AND METHODS

We reviewed 311 patients suffer from recent episode of AUD and undergoing to mesalazine treatment: 207 (group A, 105 males, median age 63 years, range 47-74 years) were treated with mesalazine 1.6 g for 10 days each month, whilst 104 (group B, 55 males, median age 65 years, range 50-72 years) were treated with mesalazine 1.6 g every day. Patients were followed-up every 6 months (median 7.5 months, range 5-13 months).

RESULTS

Patients were followed-up for a mean time of 3 years (range 12-72 months). Overall, occurrence of complication recurred more frequently in group A than in group B (p = 0.030, log-rank test). Acute diverticulitis recurred in 17 (8.2%) patients in group A and in 3 (2.9%) in group B; diverticular bleeding occurred in 4 (1.9%) patients in group A and in 1 (0.96%) patient in group B; surgery was required in 3 (1.4%) patients in group A and in no (0%) patient in group B.

CONCLUSIONS

This is the first study showing that long-term mesalazine treatment is significantly better that intermittent mesalazine treatment in preventing occurrence of DD complications after an attack of acute diverticulitis.

Decreasing efficacy of the standard seven-day triple therapy containing amoxycillin and clarithromycin in curing Helicobacter pylori infection in clinical setting in Italy: a 10-year follow-up study

AIM

The aim of the present study was to assess the efficacy of the standard triple therapy containing PPI plus amoxycillin and clarithromycin in curing Helicobacter pylori (H. pylori) infection during a long-term period.

METHODS

A retrospective analysis was conducted on 1497 consecutive dyspeptic patients with proven H. pylori infection and enrolled from 1996 to 2006. Patients received a standard triple therapy with proton pump inhibitor (PPI) plus amoxicillin 1 g and clarithromycin 500 mg for 7 days (all twice daily) plus PPI every day for further 4 weeks in case of active peptic ulcer or severe gastritis detected at endoscopy. One month after conclusion of therapy, endoscopy was performed in those patients for whom the examinations were clinically relevant. The remaining patients were checked by ¹³C-urea breath test.

RESULTS

The overall H. pylori eradication rate was 70.41% (on intention-to-treat analysis). However, it decreased significantly during the observation period, ranging from 90% (95% CI 87.14% to 93.91%) in 1996 to 51.11% (95% CI 48.14% to 55.91%) in 2006 (on i-t-t analysis) (P=0.001). No difference in eradicating the was found infection between Puglia and Lazio (1996: P=0.39; 2006: P=0.64).

CONCLUSION

Standard triple therapy does not appear anymore a valid therapeutic strategy for the management of H. pylori infection in clinical practice.

Expression of basic fibroblastic growth factor, syndecan 1 and tumour necrosis factor α in resected acute colonic diverticulitis

AIM

Inflammation and fibrosis are present in both colonic diverticulitis and Crohn's disease (CD). The molecular pattern of basic fibroblastic growth factor (bFGF) and syndecan 1 (SD1) expression is altered in stenosing CD, but their expression in resected complicated colonic diverticulitis (ACD) is unknown.

METHOD

The expression of bFGF, SD1 and tumour necrosis factor α (TNF-α) in 20 patients after resection of ACD was compared with 15 patients having a resection for CD. Analysis was conducted using real-time reverse transcriptase polymerase chain reaction in biopsy samples.

RESULTS

Lymphocytic and neutrophil inflammation scores were similar in both groups (P = 0.771 and P = 0.562). TNF-α and bFGF expression was significantly higher in ACD than in CD (P < 0.0001 and P = 0.009). SD1 expression was similar in both groups (P = 0.841).

CONCLUSION

TNF-α and bFGF are significantly overexpressed in ACD with respect to CD, whilst SD1 levels do not differ. The findings confirm that inflammation and its association with altered molecular patterns of mucosal healing may play an important role in the phenotype of the diseases.

Randomised clinical trial: mesalazine and/or probiotics in maintaining remission of symptomatic uncomplicated diverticular disease--a double-blind, randomised, placebo-controlled study

BACKGROUND

Placebo-controlled studies in maintaining remission of symptomatic uncomplicated diverticular disease (SUDD) of the colon are lacking.

AIM

To assess the effectiveness of mesalazine and/or probiotics in maintaining remission in SUDD.

METHODS

A multicentre, double-blind, placebo-controlled study was conducted. Two hundred and ten patients were randomly enrolled in a double-blind fashion in four groups: Group M (active mesalazine 1.6 g/day plus Lactobacillus casei subsp. DG placebo), Group L (active Lactobacillus casei subsp. DG 24 billion/day plus mesalazine placebo), Group LM (active Lactobacillus casei subsp. DG 24 billion/day plus active mesalazine), Group P (Lactobacillus casei subsp. DG placebo plus mesalazine placebo). Patients received treatment for 10 days/month for 12 months. Recurrence of SUDD was defined as the reappearance of abdominal pain during follow-up, scored as ≥5 (0: best; 10: worst) for at least 24 consecutive hours.

RESULTS

Recurrence of SUDD occurred in no (0%) patient in group LM, in 7 (13.7%) patients in group M, in 8 (14.5%) patients in group L and in 23 (46.0%) patients in group P (LM group vs. M group, P = 0.015; LM group vs. L group, P = 0.011; LM group vs. P group, P = 0.000; M group vs. P group, P = 0.000; L group vs. P group, P = 0.000). Acute diverticulitis occurred in six group P cases and in one group L case (P = 0.003).

CONCLUSION

Both cyclic mesalazine and Lactobacillus casei subsp. DG treatments, particularly when given in combination, appear to be better than placebo for maintaining remission of symptomatic uncomplicated diverticular disease. (ClinicalTrials.gov: NCT01534754).

Effectiveness of different therapeutic strategies in preventing diverticulitis recurrence

BACKGROUND

Colonic diverticulitis shows a high recurrence rate.

AIMS

To assess the efficacy of three different therapeutic strategies in preventing diverticulitis recurrence.

MATERIALS AND METHODS

One hundred thirty patients suffering from Acute Uncomplicated Diverticulitis (AUD) (81 males, 49 females, mean age 64.71 years, range 40-85) were prospectively assessed. After obtaining remission, considered present when both endoscopic and histological damage were absent, the patients were treated with mesalazine 1.6 g/day (59 patients, group A), or rifaximin 800 mg/day for 7 days every month (52 patients, group B). Clinical, endoscopic and histological follow-up was performed after 6, 12 and thereafter every 12 months after diagnosis of AUD.

RESULTS

Seven patients were excluded from final evaluation because they were lost to follow-up. Fifty-five group A patients and 49 group B patients patients were available for the final assessment at the end of a 24-month follow-up. Sustained remission was significantly higher in group A with respect to group B.

CONCLUSIONS

Patients taking mesalazine have lower risk of diverticulitis recurrence than patients taking rifaximin because of the lower prevalence of persisting endoscopic and histological inflammation.

Mucosal expression of basic fibroblastic growth factor, Syndecan 1 and tumor necrosis factor-alpha in diverticular disease of the colon: a case-control study

BACKGROUND

Inflammation may be detected in diverticular disease (DD), and fibrosis may also develop. We assessed the mucosal expression of bFGF, SD1, and TNF-α in DD according to the severity of the disease. Moreover, we assessed the response to therapy of these cytokines in acute uncomplicated diverticulitis (AUD).

METHODS

Fifteen patients affected by AUD and seven patients affected by symptomatic uncomplicated diverticular disease (SUDD) were enrolled. Patients with asymptomatic diverticulosis (AD), segmental colitis associated with diverticulosis (SCAD), ulcerative colitis (UC), and healthy subjects (HC) served as control groups.

KEY RESULTS

The expression of bFGF, SD1, and TNF-α was significantly higher in diverticulitis than in healthy controls, in diverticulosis, and in uncomplicated diverticular disease. Cytokines were significantly higher in uncomplicated diverticular disease than in healthy controls. Cytokine expression in diverticulitis did not differ significantly from that of ulcerative colitis. After treatment, TNF-α expression dropped significantly.

CONCLUSIONS & INFERENCES

Mucosal TNF-α is overexpressed only in symptomatic DD, while SD1 and bFGF are already overexpressed in AD. Finally, TNF-α but not SD1 or bFGF expression seems to be influenced by the treatment in AUD.

Musosal tumour necrosis factor α in diverticular disease of the colon is overexpressed with disease severity

AIM

Inflammation occurs in diverticular disease (DD), but there is little information on inflammatory cytokines such as tumour necrosis factor α (TNF-α). The aim of this study was to assess TNF-α expression in DD and to see whether it is related to the severity of the disease.

METHOD

Twenty-four patients with symptomatic DD were divided into those with acute uncomplicated diverticulitis (AUD) (12 patients) and those with symptomatic uncomplicated diverticular disease (SUDD) (12 patients). Twelve further patients with asymptomatic diverticulosis (AD), six with segmental colitis associated with diverticulosis (SCAD), with ulcerative colitis (UC) and six healthy individuals (HC) were enrolled as controls. TNF-α expression in the colonic mucosa was assessed by the amount of mRNA codifying for the synthesis of TNF-α.

RESULTS

TNF-α expression was significantly higher in AUD than in HC (P=0.0007), in AD (P=0.0001) and in SUDD (P=0.0179). It was significantly higher also in SUDD than in HC (P=0.0007) and in AD (P=0.0001). TNF-α expression in AUD did not differ significantly from that in UC (P=0.0678) and SCAD (P=0.0610). It was significantly higher in UC, SCAD and AUD than in SUDD (P=0.0007, P=0.0001, P=0.0179).

CONCLUSION

TNF-α expression in DD seems to be related to the severity of the disease. In particular, it appears to be overexpressed in DD with inflammation (AUD and SUDD) compared with DD without (AD).

Role of fecal calprotectin in the diagnosis and treatment of segmental colitis associated with diverticulosis

AIM

Information about fecal calprotectin (FC) in segmental colitis associated with diverticulosis (SCAD) is lacking. We assessed FC in SCAD, comparing it healthy controls (HC), irritable bowel syndrome (IBS), diverticular disease (DD), ulcerative colitis (UC). Moreover, we compared FC levels in different degrees of SCAD and assessed FC SCAD before and after treatment.

METHODS

Twenty-seven consecutive patients with a new endoscopic diagnosis of SCAD, and 16 patients for each control group, underwent to FC assessment. FC was assessed by semi-quantitative method.

RESULTS

FC was not increased in HC and in IBS patients, whilst it was increased in DD, SCAD, and UC. FC concentration was higher in SCAD and UC than in DD (SCAD vs. DD, P=0.05). No difference was found in FC concentration between SCAD and UC (P=0.213), as well as between different degree of SCAD (P= 0.178). After treatment, FC values decreased to normal values in all patients obtaining remission (P<0.0005). Three patients experienced still symptoms (one SCAD type B and two SCAD type D patients), and in all of them FC was still detectable.

CONCLUSION

FC may be useful in differentiating SCAD from functional syndromes. Moreover, it may be useful in assessing response to therapy.

Inflammatory manifestations at colonoscopy in patients with colonic diverticular disease

BACKGROUND

Ulcerative colitis with diverticulosis (UCD), segmental colitis associated with diverticulosis (SCAD) and acute uncomplicated diverticulitis (AUD) may affect the same colonic regions, but the real incidence of these entities in clinical practice is unknown.

AIM

To assess the incidence and the endoscopic findings of UCD, SCAD and AUD.

METHODS

From January 2004 to June 2009, 8525 consecutive colonoscopies were performed. Diagnosis of the diseases was based on specific endoscopic and histological (UCD and SCAD), and on endoscopic and radiological (AUD) patterns.

RESULTS

Ulcerative colitis with diverticulosis was diagnosed in 25 patients (0.3%), SCAD was diagnosed in 129 patients (2%) and AUD was diagnosed in 130 patients (2%). In UCD, the inflammation in colonic area harbouring diverticula always affects the overall colonic mucosa in all cases, involving also diverticular orifices. The endoscopic characteristic of SCAD is that inflammation is mainly detected within the inter-diverticular mucosa without involvement of the diverticular orifices. In AUD, the inflammation affects primarily diverticular orifice and peri-diverticular mucosa.

CONCLUSIONS

In clinical practice, the incidence of mucosal inflammation in the presence of colonic diverticular disease is low and endoscopy is the mainstay of differential diagnosis.

Prevalence of celiac disease and symptoms in relatives of patients with celiac disease

BACKGROUND AND OBJECTIVES

We determined the prevalence and clinical features of celiac disease (CD) in family-members (FMs) of a population-based cohort of index cases.

MATERIALS AND METHODS

We recruited 108 CD index cases: mean age at diagnosis, 23.0 years (range, 1.5-45.2 years); 81 (75%) female. Three-hundred twelve (mean age, 41.6 years; 219 [70%] female) of FMs were analyzed. 153 (49%) were parents, 24 (7.7%) were children, 69 (22.2%) were siblings, 66 (21.1%) were second degree FMs.

RESULTS

CD was diagnosed in 63 subjects (20.1%, 21 males and 42 females, mean age 34.24 years, range 2-81 years). Classic, subclinical, and silent forms of CD were recognized in 18 [28.6% (6 siblings, 6 parents, 3 child, 3 second-degree FMs)], in 27 [45.8% (9 siblings, 3 parent, 15 second-degree FMs)], and in 18 [28.6% (6 siblings, 6 parents, 6 second-degree FMs)] cases, respectively. Most of patients suffering from "classical" (18/63 patients, 28.7%) and "subclinical" (27/63 patients, 42.9%) form of CD were older than patients suffering from "silent " CD (18/63 patients, 28.7%) (p=0.01). Most of patients suffering from subclinical disease showed autoimmune diseases (Hashimoto's thyroiditis, and psoriasis), and other atypical symptoms, as gastroesophageal reflux disease (GERD), were also recorded.

CONCLUSIONS

We found an high-prevalence of CD between CD FMs, and most of them were olygo- or asymptomatic.

The endoscopic spectrum of segmental colitis associated with diverticulosis

OBJECTIVE

An endoscopic classification of 'Segmental colitis associated with diverticulosis' (SCAD) is lacking. Our aim was therefore to assess the endoscopic spectrum of SCAD, comparing it with the histological and clinical features.

METHOD

A prospective study was performed from January 2004 to October 2007. Diagnosis of SCAD was made on the basis of specific endoscopic and histological patterns.

RESULTS

A total of 6230 consecutive colonoscopies were performed during the study period. SCAD was diagnosed in 92 (1.48%) patients, with four endoscopic patterns: pattern A, 'crescentic fold disease' (52.20%); pattern B, 'Mild-to moderate ulcerative colitis-like' pattern (30.40%); pattern C, 'Crohn's disease colitis-like' pattern (10.90%); pattern D, 'Severe ulcerative colitis-like' pattern (6.50%). Most patients with patterns A (58.33%, P < 0.018) and B (89.29%, P < 0.00001) showed histological alterations resembling moderate ulcerative colitis (UC). In pattern C, larger histological variability was found (P < 0.01). All patients showing pattern D showed the typical histological alteration changes of severe UC (P < 0.0001). In pattern A (60.42%, P = n.s.) and pattern B (46.43%, P = n.s.), diarrhoea was the most common symptom whilst abdominal pain was the most frequent in pattern C (50%, P = n.s.) and pattern D (83.33%, P = n.s.) patients.

CONCLUSIONS

Endoscopic patterns of SCAD may range from mild to severe inflammation. The histopathological findings but not clinical features showed a statistically significant association with the degree of endoscopic severity.

Safety and effectiveness of infliximab for inflammatory bowel diseases in clinical practice

BACKGROUND AND OBJECTIVES

Our aim was to assess the efficacy and safety of infliximab (IFX) in clinical practice in three Primary Care, Hospital Centers.

MATERIAL AND METHODS

From September 2004 to December 2008 62 patients (28 males, 34 females, mean age 30.25 years, range 15-55 years), affected by ulcerative colitis (UC) (23 pts) or by Crohn's disease (CD) (39 patients) were treated. Clinical efficacy, safety, mucosal healing and quality of life were assessed both in UC and CD.

RESULTS

A total of 746 infusions were performed. IFX was administered for a mean of 26 months (range 8-44 months). 33/39 (84.61%) pts with CD were in remission under treatment with IFX for a mean time of 19 months (range 12-44 months). Mean Crohn Disease Activity Index (CDAI) score decreased from 295 (range 258-346) to 136 (range 98-136) (p < 0.005). Inflammatory Bowel Disease Quality of Life (IBDQL) improved from 48 (at entry) to 198 (at the end of the study) (p < 0.005). 20/23 (86.95%) patients with UC were in remission under treatment with IFX for a mean of 18 months (range 8-34 months). Mean Disease Activity Index (DAI) decreased from 11 (range 9-12) to < 3 (range 2-3) (p < 0.05). Mean Mayo Subscore for Endoscopy decreased from 3 to < 1 (range 0-1). IBDQL improved from 56 (at entry) to 194 (at the end of the study) (p < 0.005). Only 5 patients (8.06%) experienced side-effects.

CONCLUSIONS

Long-term outpatients treatment with IFX seems to be safe and effective in managing patients affected by IBD in clinical practice.

Effect of mesalazine on epithelial cell proliferation in colonic diverticular disease

BACKGROUND AND AIMS

Increased epithelial cell proliferation may be detected in diverticular disease, but antibiotics have failed in reducing it. We assess therefore the effect of mesalazine on epithelial cell proliferation in diverticular disease.

METHODS

A prospective study was conducted on 20 consecutive patients with a new endoscopic diagnosis of symptomatic uncomplicated diverticular disease. The patients were treated with mesalazine 1.6 mg/day for 1 year. The Ki-67 antigen index of the whole crypt and in the upper third was separately evaluated before and after starting the treatment.

RESULTS

Cell proliferation index was higher in diverticular disease patients than healthy controls both in the whole crypt (median 6.7%, range 2-9% vs. median 1.6%, range 1-3%, p=0.001) and in the upper third of the crypt (median 6.8%, range 2-8% vs. median 1.8%, range 1-3%, p=0.001). Cell proliferation decreased throughout the follow-up. In the whole crypt it was 6.7% at entry and 3.8% at the end of treatment (p<0.005), whereas it was 6.8% at entry and 2.9% at the end of treatment in the upper third of the crypt (p<0.005).

CONCLUSIONS

We found mesalazine effective in reducing the colonic cell proliferation in long-term treatment for colonic diverticular disease.

Endoscopic and histological findings in the duodenum of adults with celiac disease before and after changing to a gluten-free diet: a 2-year prospective study

BACKGROUND AND STUDY AIMS

Published follow-up data on small-intestinal recovery in patients with celiac disease are scarce and contradictory. This is especially the case for adult patients, who often show incomplete histological recovery after starting a gluten-free diet (GFD). We conducted a 2-year prospective study to evaluate the effectiveness of a GFD in improving the endoscopic and histological duodenal findings in adults with celiac disease.

PATIENTS AND METHODS

We studied 42 consecutive adults with newly diagnosed celiac disease (13 men, 29 women; mean age 32.7 years, range 15 - 72 years). All the patients underwent esophagogastroduodenoscopy and small-bowel biopsy. We devised our own grading system for the endoscopic appearance of the duodenum, which ranged from "normal" appearance to "mild", "moderate", or "severe" alterations. Small-bowel biopsies were obtained from the second part of the duodenum (and from the duodenal bulb when it had a micronodular appearance). The histopathological appearances were described according to modified Marsh criteria.

RESULTS

A normal endoscopic appearance in the duodenum was found in 5/42 patients (11.9 %) at entry and in 32/42 patients (76.2 %) after 2 years on a GFD. Subdividing the patients according to age, patients aged from 15 years to 60 years showed significant improvement within 12 months ( P < 0.0001 for patients aged from 15 years to 45 years; P < 0.003 for patients in the 46 years to 60 years group), whereas the improvement in endoscopic findings in patients older than 60 years was not statistically significant, even 24 months after starting the GFD. "Normal" histology was reported in none of the patients at entry, but in 25 patients (59.5 %) after 24 months on a GFD, but this parameter did not show a significant improvement until the patients had been on the GFD for 12 months ( P < 0.0001). Only the younger patients (5 - 30 years) showed significant improvement of histology within 12 months ( P < 0.034); older patients (>30 years) showed histological improvement but this was not statistically significant, even after 24 months on a GFD.

CONCLUSIONS

This study shows for the first time that endoscopic recovery is faster than histological recovery in adults with celiac disease who go on a GFD. Moreover, older patients showed incomplete endoscopic and histological recovery even 24 months after starting a GFD. We therefore advise, as a minimum recommendation, that follow-up biopsies should be taken 1 - 2 years after starting a GFD in adults with celiac disease.

Crohn's disease and celiac disease: association or epiphenomenon?

Recent literature data show a certain relation between Crohn's disease and celiac disease. We describe herein what are the pro and the cons about a possible association between Crohn's disease and celiac disease.

Symptomatic gastric leiomyoma mimicking giant gastric polyp: endoscopic diagnosis and removal

Gastric leiomyoma is an uncommonly found benign submucosal neoplasm which may cause hemorrhage in rare cases. A 67-years-old patient was admitted to our attention due to two episodes of hematemesis and melena occurred in the previous two days. Esophagogastroduodenoscopy showed a giant semi-pedunculated gastric polyp (diameter of 4 centimeters) located at the distal body. A large ulcer with a clot was seen on the polyp. We treated endoscopically the giant polyp using the new two-steps-technique recently described by us for the treatment of the large pedunculated gastric and colorectal polyps, and the polypectomy was successfully performed without immediate or delayed complications. Histological evaluation of the transected polyp revealed morphology according to a gastric submucosal leiomyoma. Endoscopic control, performed one and four weeks and 12 months later, showed complete reepithelization of the gastric mucosa, without any sign of endoscopic, endosonographic and histological recurrence of the disease. This case report shows that our endoscopic approach may be successfully used also for giant semi-pedunculated gastric polyps.

Effectiveness of the sorbitol H2 breath test in detecting histological damage among relatives of coeliacs

BACKGROUND

Small intestinal lesions have a wide severity in coeliac disease (CD), and early diagnosis is important in preventing neoplastic and non-neoplastic disorders related to CD. The aim of this study was to compare the effectiveness of the sorbitol H2 breath test (H2-BT) and serological tests (antigliadin (AGA), antiendomysium (EMA) and anti-tissue transglutaminase (anti-tTG)) as screening tests in the detection and estimation of CD prevalence in 1st-degree relatives.

METHODS

Screening was performed in 111 1st-degree relatives of 37 coeliac families. Sorbitol H2-BT, AGA, EMA and anti-tTG antibodies were used to select the candidates for small-bowel biopsy. Relatives with abnormal serological tests and/or with sorbitol H2-BT positivity underwent a small-bowel biopsy. Small-bowel biopsy was also performed in relatives negative in all tests but with clinical complaints or suspected of having CD, and intestinal lesions were expressed according to the Marsh classification.

RESULTS

CD was diagnosed in 49/111 screened relatives (44.14%): 5 showed Marsh IIIc, 8 Marsh IIIb, 16 Marsh IIIa, 13 Marsh II and 7 Marsh I lesions. Nineteen relatives showed the classical form of the disease, while the subclinical and silent forms were recorded in 20 and 10, respectively. AGA, EMA and anti-tTG showed strong positivity only in severe intestinal damage (Marsh IIIb-c lesions) (but overall positivity was 36.73%, 38.78% and 44.89% for AGA, EMA and anti-tTG, respectively), while sorbitol H2-BT showed strong positivity also in patients with slight histological damage (Marsh I-IIIa) (overall positivity was 83.67%).

CONCLUSIONS

A significant proportion of coeliacs may be missed if relatives are screened by serology only, while the efficacy of sorbitol H2-BT in screening relatives is confirmed. This study confirms that neither a breath test nor serology can replace intestinal biopsy, which remains the gold standard for the diagnosis of CD.

Sorbitol H2-breath test versus anti-endomysium antibodies to assess histological recovery after gluten-free diet in coeliac disease

BACKGROUND

Gluten-free diet plays a key role in treatment of coeliac disease, but it is difficult to evaluate its effect on improvement of villous architecture using sensitive non-invasive tests.

AIMS

To compare sorbitol H2-Breath Test with antiendomysial antibodies in the follow-up of coeliac disease to detect histological recovery

METHODS

A total of 38 consecutive patients with coeliac disease were studied. All underwent Sorbitol H2-Breath Test, antiendomysial and oesophagogastroduodenoscopy with multiple bioptic samples before diet and then 6, 12 and 18 months after gluten-free diet. Expiratory samples were collected before patients drank the test solution (5 g sorbitol in 150 ml tap water) and thereafter every 30 min for 4 hours. An increase in H2 concentration of > or = 20 ppm above fasting baseline was considered positive for sorbitol malabsorption. Antiendomysial antibodies were evaluated by the indirect immunofluorescent method.

RESULTS

Antiendomysial antibodies were positive in 32/38 patients before gluten-free diet (84.21%), while they were positive in 20/34 (54.82%), 2/16 (12.5%) and 0/2 (0%) cases after 6, 12 and 18 months of gluten-free diet, respectively, no correlation being found with improvement of histological lesions (p = ns). As far as concerns sorbitol H2-Breath Test, maximal cut-off value (in ppm) decreased progressively and parallel to histological recovery during follow-up. Indeed, it decreased from a mean 63 ppm before diet to 35, 19 and 12 ppm, after 6, 12 and 18 months of gluten-free diet, with a stetistical difference being found before and after (p < 0.001). Likewise, the peak value (in minutes) appeared progressively later during follow-up, parallel to histological recovery. In fact, it appeared at a mean of 119 minutes before gluten-free diet, while it appears at a mean of 164, 195 and 219 minutes after 6, 12 and 18 months on gluten-free diet. A statistical difference before and after start of gluten-free diet was found also in this case (p < 0.001).

CONCLUSIONS

Sorbitol H2-Breath Test is better than antiendomysial antibodies in revealing histological recovery in the follow-up of coeliac patients after the start of gluten-free diet due to its good correlation with histological damage. Moreover, it also appears to be able to detect dietary mistakes of the patients on gluten-free diet.

Small bowel adenocarcinoma as first presentation of coeliac disease

Coeliac disease is a chronic inflammatory disease of the gut with increased risk of gastrointestinal malignancy. Although enteropathy T-cell lymphoma is the most common neoplasm in coeliacs, an increased frequency of small bowel carcinoma has been described. A case is described of jejunal carcinoma as first presentation of coeliac disease, in which gastrointestinal and extraintestinal symptoms of disease developed only after surgical resection and disappeared after gluten withdrawal.

Endoscopic features of celiac disease in adults and their correlation with age, histological damage, and clinical form of the disease

BACKGROUND AND STUDY AIMS

Although earlier studies have focused on endoscopic markers as predictors of celiac disease, there are still no certainties about the value of these markers. The aim of this study was to consider first, specific endoscopic features as predictors of specific histological damage; secondly, whether there is an association between the endoscopic features of celiac disease and the age of patients at the time of diagnosis; and thirdly, whether particular endoscopic features of celiac disease are associated with the clinical form of the disease.

PATIENTS AND METHODS

We studied the endoscopic features of celiac disease in 144 consecutive adult patients (52 had the classical form of the disease, 64 the subclinical and 28 the silent form). The histopathological findings were expressed according to the Marsh classification.

RESULTS

Slight/mild damage seen at endoscopy was associated with a Marsh II-IIIa grading (P < 0.005), while severe endoscopic damage was related to a Marsh IIIb-IIIc grading (P < 0.0005). Younger patients showed slighter damage at endoscopy (P < 0.001), while older patients showed more severe damage (P < 0.005). Finally, the classical form of celiac disease showed more severe damage at endoscopy, while the subclinical/silent forms of celiac disease showed slighter damage endoscopically (P < 0.001).

CONCLUSIONS

This study showed that the endoscopic appearance of the duodenum may be predictive of histological damage grading. Moreover, we showed that in young patients with subclinical/silent celiac disease there is a greater probability of finding slight/mild endoscopic abnormalities associated with slight/mild histological damage.

Long-term treatment with mesalazine and rifaximin versus rifaximin alone for patients with recurrent attacks of acute diverticulitis of colon

BACKGROUND/AIMS

To compare efficacy of combined therapy with rifaximin and mesalazine versus rifaximin alone in treatment of patients with recurrent diverticulitis in order to evaluate: 1) rapidity in improvement of symptoms, 2) regulation of bowel attacks, 3) prevention of recurrence of diverticulitis.

METHODS

A total of 218 consecutive eligible patients (131 males, 87 females age 64.3 years, range 51-79), affected by diverticulitis were monitored. Of these, 109 patients were treated with rifaximin 400 mg bid plus mesalazine 800 mg tid for 7 days, followed by rifaximin 400 mg bid plus mesalazine 800 mg bid for 7 days/month (group A); 109 patients were treated with rifaximin 400 mg bid for 7 days, followed by rifaximin 400 mg bid for 7 days/month (group B). Colonoscopy was performed after 3, 6 and 12 months of therapy.

RESULTS

At end of follow-up, 193 patients were fully compliant to therapy Two patients died during study (1 in group A, 1 in group B), while four patients were lost to follow-up [1 in group A (0.91%) and 3 in group B (2.75%)]. The only side-effects recorded were transient urticaria (1 in group B, 0.91%) and epigastric pain (9 in group A, 8.25%). Severity of symptoms improved significantly in group A vs group B within 3 months (p < 0.005, p < 0.001 and p < 0.0001 and p < 0.0005 at 3, 6, 9 and 12 months, respectively). Bowel habits inproved significantly in group A vs group B within 3 months (p < 0.005, p < 0.0005, p < 0.001 and p < 0.0001 at 3,6,9 and 12 months respectively). Symptomatic recurrence of diverticulitis occurred in 3 patients in group A, while 13 patients showed recurrence of diverticulitis in group B (p < 0.005) during follow-up.

CONCLUSIONS

This study clearly shows that rifaximin plus mesalazine are more effective than rifaximin alone in resolution of symptoms and prevention of recurrence of diverticulitis.

Changing trends in clinical form of celiac disease. Which is now the main form of celiac disease in clinical practice?

BACKGROUND

In recent years an increased incidence of subclinical/silent celiac disease (CD) has been reported. The prevalence and clinical presentation of classical and subclinical/silent CD in 298 consecutive diagnosed celiac patients are described.

METHODS

From 1988 to 2000 we diagnosed 298 celiac patients (81 M and 217 F, mean age 27.9 yrs, range 15-65 yrs, F/M ratio: 2.4). 167 patients were referred to us due to gastrointestinal symptoms, while 131 from other specialists due to unexplained or unresponsive disease. In most of the patients (266/298) we performed sorbitol H2-breath test, while all patients underwent both total IgA and AGA/EMA evaluation, followed by gastrointestinal endoscopy with duodenal histological examination.

RESULTS

155 (52.01%) and 143 (47.98%) patients showed classical and subclinical/silent CD respectively. The prevalence of the classical form decreased from 100% (7/7 patients) in 1988 to 26.19% (14/49 patients) in 2000, while the subclinical/silent form increased from 0% (0/7 patients) in 1988 to 76.08% (35/49 patients) in 2000. The most frequent extraintestinal marker of subclinical CD were iron-deficiency anemia (25.21%), alopecia and dermatitis herpetiformis (9.56%), while first-degree relatives (35.71%), Hyperthyroidism (21.42%) and insulin-dependent diabetes (17.85%) were the most frequent in silent CD. As for malabsorption concern, it was present in 81.93% of patients with classical form, while it was present in 33.91% and in 14.28% of patients with subclinical and silent form of celiac disease respectively.

CONCLUSIONS

This study confirms the increasing occurrence of the subclinical/silent form of CD in clinical practice, which can now be considered the main form of CD. However, it is not understood what is the cause of this changing appearance in clinical practice.

Endoscopic treatment of benign anastomotic esophageal stenosis with electrocautery

BACKGROUND AND STUDY AIMS

Stricture of the esophagus following surgical resection is uncommon. Several methods have been described for treatment of this entity, but the therapeutic success may be impaired either by poor long-term results or by poor acceptance by patients. Even the high cost of the therapeutic management may represent a problem. We describe the use of electrocautery to treat benign anastomotic esophageal stenosis.

PATIENTS AND METHODS

Six unselected consecutive patients (four men, two women; mean age 68.3, range 54 - 82) with stenosis following esophagojejunostomy were enrolled in this trial. Postoperative stenoses were shown endoscopically (four patients) or radiographically (two patients). We performed endoscopic dilation of the strictures using electrocautery.

RESULTS

In all patients we obtained dilation of the strictures, without any immediate or delayed procedure-related complication. No recurrence of the stenosis was demonstrated during a mean 24-month follow-up (range 8 - 33 months).

CONCLUSIONS

This study showed that endoscopic electrocautery is a safe and effective treatment for benign anastomotic esophageal stenosis.

[Non-invasive diagnosis of celiac disease in clinical practice]

Coeliac disease is a permanent intolerance to gluten which requests a quick diagnosis as soon as possible to prevent neoplastic and non-neoplastic complications of the disease, since frequently coeliac disease shows pauci- or asymptomatic forms. We describe herein the most common non invasive diagnostic methods used in clinical practice to diagnose coeliac disease, as well as we describe non invasive methods poorly used or which will play a key role in the non invasive diagnosis of coeliac disease in the future.

Sorbitol H2-breath test versus anti-endomysium antibodies for the diagnosis of subclinical/silent coeliac disease

BACKGROUND

Recent studies have shown that the prevalence of anti-endomysial antibodies (EMAs) in clinical practice is lower than expected; the aim of our study was therefore to compare the sorbitol H2-breath test (BT) with EMAs in the diagnosis of subclinical/silent coeliac disease and to compare with histologic lesions.

METHODS

We studied 123 consecutive patients with subclinical (96) and silent (27) coeliac disease. Expiratory samples were collected before the patients drank the test solution (5 g of sorbitol in 150 ml of tap water) and every 30 min for 4 h. An increase in H2 concentration of at least 20 ppm over fasting baseline was considered positive for sorbitol malabsorption. EMAs were screened by the indirect immunofluorescence method.

RESULTS

EMAs were positive in 77/96 (80.80%) and sorbitol H2-BT in 94/96 (97.91%) patients with subclinical coeliac disease, while EMAs were positive in 17/27 (62.96%) and sorbitol H2-BT in 26/27 (96.29%) patients with silent coeliac disease (P < 0.001 in both forms of coeliac disease). The best cut-off values in ppm and minutes are higher and shorter in the severe form than in the minor form of intestinal damage, respectively (P < 0.001 in both forms).

CONCLUSIONS

This study indicates that almost all subclinical/silent coeliac patients show abnormal sorbitol H2-BT and that there is a strict correlation between cut-off value (in ppm and minutes) and histologic lesions. In particular, the maximal cut-off value (in ppm and in minutes) correlates statistically with the more severe the grade of intestinal damage. Finally, the prevalence of EMA in subclinical/silent disease is lower than expected.

Endoscopic snare excision of large pedunculated colorectal polyps: a new, safe, and effective technique

BACKGROUND AND STUDY AIMS

The endoscopic polypectomy of large pedunculated polyps can have serious complications, such as hemorrhage, which has an incidence of about 2 %. We describe here a new, safe, and effective technique of endoscopic polypectomy for the treatment of large pedunculated colorectal polyps using a standard detachable diathermic snare.

PATIENTS AND METHODS

35 patients (18 men, 12 women; mean age 67.3, range 35 - 82), with 43 pedunculated colorectal polyps, of benign appearance and of size 3 cm or larger (range 3 - 5 cm) on colonoscopy, were included in our study. The polypectomy was performed in two steps: a) we first placed a polypectomy snare round the middle of the stalk, as a prophylactic measure to prevent postpolypectomy bleeding, and we then took out the colonoscope without removing the snare after dismantling it and blocking with a clip; b) endoscopic polypectomy was done using a second polypectomy snare, and transecting the stalk of the polyps at 2 mm above the first snare. The first polypectomy snare was left in place, and the patients were discharged within 3 hours of endoscopic polypectomy. The first polypectomy snare sloughed off spontaneously and slipped down the anus, being evacuated within 4 days following the endoscopic polypectomy.

RESULTS

The ensnared polyps were located in the rectosigmoid region (n = 27), and the descending (n = 13) and transverse colon (n = 3). Complete ensnarement of the head of the polyp with a single endoscopic treatment was obtained in all cases. In addition, no procedural or delayed bleeding was noted during a 6-month follow-up.

CONCLUSIONS

Our technique allows us to overcome the risk of bleeding, since the use of a standard diathermic snare makes it easier to obtain optimal tightness. Moreover, this technique is cheaper than the use of the standard detachable snare currently available (the cost of the snares being $50.52 compared with $189.47).

Low prevalence of antigliadin and anti-endomysium antibodies in subclinical/silent celiac disease

OBJECTIVE

Endomysial antibodies (EMA) are a well-known hallmark of celiac disease, but some recent studies showed that the prevalence of these antibodies in clinical practice is lower than expected. The aim of our study was to determine the prevalence of antigliadin (AGA) and EMA antibodies on a consecutive series of subclinical/silent celiac patients.

METHODS

We studied 115 consecutive patients with subclinical (92 patients) or silent (23 patients) forms of celiac disease. AGA and EMA were screened in all patients. Histopathology of celiac disease was expressed according to the Marsh classification.

RESULTS

The overall AGA in subclinical form were positive in 77% (14 of 18) of patients with partial villous atrophy (VA), in 84% (21 of 25) of patients with subtotal VA, and in 90% (27 of 30) of patients with total VA, whereas EMA were positive in 88.88% (16 of 18) of patients with partial VA, in 92% (23 of 25) of patients with subtotal VA, and 96.66% (29 of 30) of patients with total VA. On the other hand, AGA were positive in 0% (zero of two) of patients with Marsh I and in 30% (three of 10) of patients with Marsh II, whereas EMA were positive in 0% (zero of two) of patients with Marsh I and in 40% (four of 10) of patients with Marsh II (Marsh I-IIIa vs Marsh IIIb-c, p = < 0.005 in overall AGA-positive patients and p = < 0.0001 in EMA-positive patients). At the same time the overall AGA in silent form were positive in 60% (three of five) of patients with partial VA, in 66.66% (four of six) of patients with subtotal VA, and in 77.77% (seven of nine) of patients with total VA, whereas EMA were positive in 80% (four of five) of patients with partial VA, in 83.33% (five of six) of patients with subtotal VA, and in 88.88% (eight of nine) of patients with total VA. On the other hand, overall AGA were positive in 0% of patients with both Marsh I (zero of one) and Marsh II (zero of two), as well as EMA were positive in 0% with both Marsh I (zero of one) and Marsh II (zero of two) (Marsh I-IIIa vs Marsh IIIb-c, p = < 0.001 in overall AGA-positive patients and p = < 0.007 in EMA-positive patients).

CONCLUSIONS

At this time small bowel biopsy seems to be the only correct procedure to diagnose a case of suspected celiac disease, especially in patients with mild symptoms or suspected for celiac disease, because they belong to high-risk groups.

Prevalence and clinical presentation of subclinical/silent celiac disease in adults: an analysis on a 12-year observation

BACKGROUND/AIMS

In recent years, an increased incidence of subclinical/silent celiac disease has been reported. Thus, we herein describe the prevalence and the clinical presentation of subclinical/silent celiac disease in 252 consecutive diagnosed celiac patients.

METHODOLOGY

From 1988 to 1999 we diagnosed 252 celiac patients (74M and 178F, mean age: 27.9 yrs; range: 15-65 yrs, F/M ratio: 2.4). 144 patients were referred to us due to gastrointestinal symptoms, while 108 were referred to us from other specialists due to unexplained or unresponsive disease. All patients underwent both total immunoglobulin A and antigliadin antibodies antiendomysium antibody and evaluation, followed by gastrointestinal endoscopy with duodenal histological examination.

RESULTS

144 (57.14%) and 108 (42.86%) patients showed classical and subclinical/silent celiac disease, respectively. The most frequent extraintestinal marker of subclinical celiac disease were iron-deficiency anemia (27.77%), alopecia and dermatitis herpetiformis (11.36%), osteoporosis (6.81%) and recurrent aphtous stomatitis (5.68%), while first-degree relatives (30%), Basedow's disease (25%) and insulin-dependent diabetes (20%) were the most frequent in silent celiac disease.

CONCLUSIONS

This study confirms the extremely polymorphic nature of this condition that can affect several organs and apparatus without gastrointestinal symptoms. However, a more precise description of subclinical/silent celiac disease can only emerge from screening studies on general populations.

Granular cell tumour of the oesophagus: a rare cause of dysphagia with differential diagnosis of oesophageal neoplastic lesions

Granular cell tumour is a relatively uncommon, typically benign neoplasm of soft tissue. The macroscopic appearance of oesophageal granular cell tumour is a polypoid lesion, which is often asymptomatic and can be found incidentally, but, in some cases, is symptomatic and requires a correct differential diagnosis with malignant neoplasms of the oesophagus. We describe the case of a 28-year-old female who came to our attention due to a six-month history of heartburn and dysphagia. Oesophagogastroduodenoscopy showed the presence of a polypoid lesion 2 cm above the gastro-oesophageal junction. The overlying mucosa was normal and the lesion seemed to be an isolated submucosal nodule with a "submucosal pill" appearance. It was excised completely using a standard diathermic snare, and diagnosis of oesophageal granular cell tumour was made by histological and immunohistochemical staining. The patient's symptoms disappeared immediately after removal of the nodule by endoscopic polypectomy, and no macroscopic or microscopic recurrence of granular cell tumour was noted during follow-up. Likewise, the patient was symptom-free during follow-up. This case shows that endoscopy is very effective, not only in the diagnosis, but also in the treatment of oesophageal lesions which require careful differential diagnosis.

Bilo-pancreatic Ascaris Lumbricoides infestation. Endoscopic discovery and removal

Ascaris Lumbricoides infestation is relatively rare in industrialized countries, and it occurs mainly in conditions in which hygiene is lacking. We describe here a case of a 39-year-old female from ex-Jugoslavia affected by recurrent hepatic colic. At entry ultrasonography revealed microlithiasis in the gallbladder and widening of the pancreatic head. The subsequent ERCP showed slight filling defects in the choledochus and an inflammation-like stricture of the papilla of Vater, and after endoscopic sphincterotomy we saw an outflow of dense bile and microlitholits. Thus, a standard surgical cholecystectomy was carried out and the patient was dismissed on the 3rd postoperative day without any symptoms. However, the patient was admitted again after four days for a new coliky pain attack. An upper endoscopy showed a 23 cm long mobile parasite in the duodenum: it was caught with the polypectomy loap, extracted and identified as A. Lumbricoides. The patient's symptoms disappeared after the endoscopic removal of the worm and she was dismissed the day after the worm's removal. No recurrence of symptoms was noted during a 1-year follow-up. This case showed that A. Lumbricoides infestation of the biliary tree should be considered when biliary and/or pancreatic symptoms recur, especially in patients coming from undeveloped countries. At the same time we showed that endoscopic removal is a safe and effective treatment for this infestation.

Endoscopic treatment of benign anastomotic colorectal stenosis with electrocautery

BACKGROUND AND STUDY AIMS

Benign anastomotic colorectal stenosis can occur after surgery and can require surgical or endoscopic dilation. This study aimed to investigate the use of electrocautery in this area.

PATIENTS AND METHODS

We enrolled 39 consecutive patients (25 men, 14 women; mean age 61, range 48-77) suffering from anastomotic colorectal stenosis, demonstrated by colonoscopy (19 patients) or by barium enema (20 patients). We performed endoscopic dilation of the strictures with electrocautery once only in each patient.

RESULTS

In all patients we obtained dilation of the strictures without any immediate or delayed procedure-related complications. No recurrence of the stenosis was demonstrated during a follow-up of a mean of 25 months (range 8-43 months).

CONCLUSIONS

This study shows that endoscopic electrocautery is a safe and effective treatment of anastomotic colorectal stenosis.

Self-expanding metal stents as palliative treatment of stenotic relapsed gastric cancer after curative surgery in the elderly

Palliation of inoperable stenotic gastric and/or duodenal cancer remains an open problem due to high operative mortality and diffuse tumor growth. We describe here in 3 cases of stenotic recurrent gastric cancer in the elderly successful treated using self-expanding metal stents.

Antimicrobial treatment for peptic stenosis: a prospective study

OBJECTIVE

Peptic stenosis, a complication of peptic ulcer disease, is treated by endoscopic balloon dilation or surgery. However, recent reports showed that Helicobacter pylori eradication may resolve peptic stenosis. Thus, we carried out a prospective study on a cohort of patients with peptic stenosis and H. pylori infection to evaluate the efficacy of anti- H. pylori therapy in the treatment of peptic stenosis.

DESIGN/METHODS

From May 1995 to May 1998 we studied 22 consecutive patients with benign peptic stenosis (16 with duodenal stenosis and six with pyloric stenosis) and H. pylori infection. Searches for H. pylori were made at first diagnosis of peptic stenosis and at every endoscopic control. All patients were treated with an anti- H. pylori treatment (13 with omeprazole/clarithromycin/ metronidazole and nine with omeprazole/amoxycillin/ clarithromycin), followed by 8 weeks' therapy with a proton-pump inhibitor. Endoscopic controls were performed after the end of H. pylori-eradication therapy, at 2 and 6 months, and then every 6 months.

RESULTS

H. pylori eradication was achieved in all patients. Peptic stenosis disappeared completely in 20/22 cases (17/20 after 2 months and 3/20 after 6 months), and in all these patients the symptoms disappeared within 2 months. At the median follow-up of 12.4 months (range 2-24), the patients remained asymptomatic, without recurrence of the stenosis, and needed no medication. In one patient the stenosis disappeared partially and symptoms improved, and it was successfully treated with cisapride. In one patient the stenosis did not disappear despite H. pylori eradication and continuous proton-pump inhibitor treatment. The patient was treated with a liquid diet due to old age, but he died 4 months after H. pylori eradication due to stroke.

CONCLUSIONS

H. pylori eradication is a safe and effective therapy for peptic stenosis. Endoscopic balloon dilation or surgery should be used only after failure of this conservative treatment.