[Dyspepsia, Ulcer Disease – Helicobacter pylori, Gastroesophageal Reflux Disease]

Prevalence of H. pylori (HP) is declining, whereas reflux disease and the proportion of non-steroidal antiinflammatory drugs (NSAR) to HP-induced ulcers increase. Eradication heals HP-ulcer disease, interrupts cancerous progression and can improve dyspeptic symptoms. NSAR-ulcers heal under proton pump inhibitor (PPI) therapy but tend to recur after reexposition. Anticoagulants and antiplatlet agents increase the risk additionally. PPI reduces NSAR-ulcer recurrence. Reflux patients with severe inflammation and complications often need long-term therapy. Barrett’s esophagus patients are at risk of esophageal adenocarcinoma.

Different Pathophysiology of Gastritis in East and West? A Western Perspective

Background

Gastritis results from multifactorial gastric mucosal injury. Helicobacter pylori (Hp) is the main cause, and associated diseases have typical underlying patterns of gastritis. Gastric ulcer and gastric cancer (GC) develop from chronic atrophic corpus gastritis (CAG) which therefore represents the most important pattern. GC incidences in East Asia are substantially higher than elsewhere, and this should be also reflected by higher prevalences of CAG and characteristic differences in pathophysiology compared to the West.

Summary

The few available comparative studies of gastritis in Eastern and Western patients are summarized. The main pathogenic factors of gastritis are discussed together with their limitations to explain local differences in disease outcome. Emphasis was put to also include less well-established pathogenic host and environmental factors of possible impact.

Conclusions

CAG is more prevalent in East Asian areas with high GC incidences than the West. Geographic heterogeneity of associated diseases is due to differences in Hp prevalence and virulence as well as modulating host and environmental factors. The following may contribute to the higher burden of CAG in the East: ABD type of CagA with vacA s1 and babA2 alleles of Hp, host Lewis(b) expression in sej/sej nonsecretors, H. heilmannii, low parietal cell mass, high sodium and nitrate intake, preferences in vegetable and fruit consumption, cigarette smoking, air pollution, alcohol. Conversely, green tea, nonfermented soy products and rice may confer protective effects. Hp is on the decline, but also in a world cleared from this bacterium, differences in host genetics will continue to modify gastric disease outcome together with maintained customs as part of cultural diversity.

[Highlights in gastroenterology 2011]

«Gastro-Highlights», an annual symposium dedicated to continuing education, took place at the University Hospital Zürich for the sixteenth time this autumn. In this well-attended event, major new findings in the fields of gastroenterology and hepatology that were published in the past year or recently presented at the «Digestive Disease Week (DDW)» were summarized for practising gastroenterologists and internists.

Host Lewis phenotype-dependent Helicobacter pylori Lewis antigen expression in rhesus monkeys

Both human and H. pylori populations are polymorphic for the expression of Lewis antigens. Using an experimental H. pylori challenge of rhesus monkeys of differing Lewis phenotypes, we aimed to determine whether H. pylori populations adapt their Lewis phenotypes to those of their hosts. After inoculation of four monkeys with a mixture of seven strains identified by RAPD-polymerase chain reaction, H. pylori Lewis expression was followed in 86 isolates obtained over 40 wk. Host Lewis(a/b) secretion status was characterized by immunological assays. Fingerprints of the predominating strain (J166) were identical in all four animals after 40 wk, but its Lewis phenotype had substantial variability in individual hosts. At 40 wk, J166 populations from two Lewis(a-b+) animals predominantly expressed Lewis(y). In contrast, J166 populations had switched to a Lewis(x) dominant phenotype in the two Lewis(a+b-) animals; a frame shift in futC, regulating conversion of Lewis(x) to Lewis(y), accounted for the phenotypic switch. The results indicate that individual cells in H. pylori populations can change Lewis phenotypes during long-term colonization of natural hosts to resemble those of their hosts, providing evidence for host selection for bacterial phenotypes.

Helicobacter pylori modulates the T helper cell 1/T helper cell 2 balance through phase-variable interaction between lipopolysaccharide and DC-SIGN

The human gastric pathogen Helicobacter pylori spontaneously switches lipopolysaccharide (LPS) Lewis (Le) antigens on and off (phase-variable expression), but the biological significance of this is unclear. Here, we report that Le⁺H. pylori variants are able to bind to the C-type lectin DC-SIGN and present on gastric dendritic cells (DCs), and demonstrate that this interaction blocks T helper cell (Th)1 development. In contrast, Le⁻ variants escape binding to DCs and induce a strong Th1 cell response. In addition, in gastric biopsies challenged ex vivo with Le⁺ variants that bind DC-SIGN, interleukin 6 production is decreased, indicative of increased immune suppression. Our data indicate a role for LPS phase variation and Le antigen expression by H. pylori in suppressing immune responses through DC-SIGN.

Colonic Perforation after Preoperative Endoscopic Tattooing with India Ink

Die laparoskopische Kolonchirurgie benötigt oft als unterstützende Massnahme eine präoperative Markierung der Läsion, da dem Chirurgen die intraoperative orientierende Palpation fehlt. Die endoskopische Markierung mit Tusche ist aufgrund der Einfachheit und der langanhaltenden Markierung die Methode der Wahl. Nur wenige Komplikationen sind bei dieser Technik beschrieben. In unserem Fall traten im Anschluss an die Markierung einer idiopathischen ulzerösen Kolonveränderung progrediente Bauchschmerzen auf. Bei der Operation fand sich eine retroperitoneale gedeckte Perforation. Die entzündlichen Veränderungen waren derart, dass ein laparoskopisches Vorgehen unmöglich war und eine offene Hemikolektomie rechts notwendig war. Bei Fieber, Abdominalschmerzen und Zeichen der lokalen Peritonitis im Anschluss an eine endoskopische Tuschmarkierung muss an eine unerwünschte Reaktion auf die Tusche gedacht werden.

Helicobacter pylori strain-specific differences in genetic content, identified by microarray, influence host inflammatory responses

Helicobacter pylori enhances the risk for ulcer disease and gastric cancer, yet only a minority of H. pylori-colonized individuals develop disease. We examined the ability of two H. pylori isolates to induce differential host responses in vivo or in vitro, and then used an H. pylori whole genome microarray to identify bacterial determinants related to pathogenesis. Gastric ulcer strain B128 induced more severe gastritis, proliferation, and apoptosis in gerbil mucosa than did duodenal ulcer strain G1.1, and gastric ulceration and atrophy occurred only in B128+ gerbils. In vitro, gerbil-passaged B128 derivatives significantly increased IL-8 secretion and apoptosis compared with G1.1 strains. DNA hybridization to the microarray identified several strain-specific differences in gene composition including a large deletion of the cag pathogenicity island in strain G1.1. Partial and complete disruption of the cag island in strain B128 attenuated induction of IL-8 in vitro and significantly decreased gastric inflammation in vivo. These results indicate that the ability of H. pylori to regulate epithelial cell responses related to inflammation depends on the presence of an intact cag pathogenicity island. Use of an H pylori whole genome microarray is an effective method to identify differences in gene content between H. pylori strains that induce distinct pathological outcomes in a rodent model of H. pylori infection.

Trypsinogen gene mutations in patients with chronic or recurrent acute pancreatitis

Three-point mutations (R117H, N211, A16V) within the cationic trypsinogen gene have been identified in patients with hereditary pancreatitis (HP). A genetic background has also been discussed for idiopathic juvenile chronic pancreatitis (IJCP), which closely mimicks the clinical pattern of HP, and alcoholic chronic pancreatitis because only a small number of heavy drinkers develop pancreatitis. This prompted us to screen 104 patients in our well-defined pancreatitis cohort for the currently known cationic trypsinogen gene mutations. The R117H mutation was detected in seven patients (six patients of two clinically classified HP families, one patient with clinically classified IJCP) and the A16V mutation in one IJCP patient. No cationic trypsinogen gene mutations were found in the remaining 96 patients with chronic and recurrent acute pancreatitis of various etiologies. Our results demonstrate the need for genetic testing to exclude HP, particularly in the presence of an atypical or unknown family history. In addition, cationic trypsinogen gene mutations are no predisposing factor in patients with chronic and recurrent acute pancreatitis of different etiologies.

[Helicobacter pylori and skin diseases--a (still) intact myth?]

Helicobacter pylori plays a key role in the aetiology of peptic ulcer, gastric cancer and gastric MALT-lymphoma. Based on a number of reports, a possible relationship of Helicobacter pylori infection to a variety of different dermatoses has been suggested, including urticaria, rosacea, acne-rosacea, atopic dermatitis, alopecia areata, Sjögren's syndrome, Schönlein-Henoch purpura, and Sweet syndrome. Larger case-control studies, however, do not confirm this relationship. Therefore, Helicobacter pylori eradication therapy cannot be generally recommended in these dermatoses.

Quasispecies development of Helicobacter pylori observed in paired isolates obtained years apart from the same host

Helicobacter pylori isolates show greater genetic diversity than other bacterial species studied, but the basis for this phenomenon is unknown. Whether detectable genomic mutation appears within an H. pylori population during persistent colonization was investigated. Paired H. pylori populations obtained across 7- to 10-year intervals from 13 patients were characterized by use of methods including polymerase chain reaction (PCR) genotyping for cagA, vacA, iceA, recA, and IS605; random arbitrarily primed DNA (RAPD)-PCR and amplified fragment length polymorphism (AFLP) analysis; and ELISA, to determine Lewis phenotypes. Genotyping, including recA sequence analysis, revealed that initial and follow-up populations represented the same population in 11 patients (85%). Nevertheless, distinct dissimilarities were shown within each of these 11 pairs by both RAPD-PCR and AFLP analyses. During follow-up, Lewis-y levels, but not Lewis-x levels, decreased significantly. The changes detected by RAPD-PCR and AFLP indicate that genetic drift occurs within H. pylori populations over the course of years of colonization of a single host.

Helicobacter pylori alters gastric epithelial cell cycle events and gastrin secretion in Mongolian gerbils

BACKGROUND & AIMS

Human colonization with Helicobacter pylori increases the risk for distal gastric adenocarcinoma, possibly by altering gastric epithelial cell cycle events and/or gastrin secretion. This study aimed to determine whether H. pylori virulence-related characteristics affect apoptosis, proliferation, and gastrin levels in a rodent model of gastric adenocarcinoma.

METHODS

Mongolian gerbils were challenged with H. pylori wild-type or isogenic cagA(-) and vacA(-) mutants, and apoptotic and proliferating cells were identified by terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling and proliferating cell nuclear antigen immunohistochemistry, respectively. Serum gastrin levels were determined by radioimmunoassay.

RESULTS

Gastric epithelial cell turnover was no different after infection with the wild-type, cagA(-), or vacA(-) strains. H. pylori infection significantly increased antral apoptosis 2-4 weeks after challenge, before apoptotic indices decreased to baseline. In contrast, antral proliferation rates were significantly higher 16-20 weeks after inoculation, but then decreased by 40 weeks. Antral proliferation was significantly related to serum gastrin levels, whereas antral apoptosis was inversely related to acute inflammation and lymphoid follicles.

CONCLUSIONS

In H. pylori-infected gerbils, enhanced antral apoptosis is an early and transient cell cycle event. Epithelial cell proliferation peaks later and is significantly related to increased gastrin levels, suggesting that epithelial cell growth in H. pylori-colonized mucosa may be mediated by gastrin-dependent mechanisms.

Phenotypic diversity in Lewis expression of Helicobacter pylori isolates from the same host

Populations of Helicobacter pylori cells show a stable expression of Lewis surface antigens, although phase variation may occur among individual organisms grown in vitro. We searched for variation in Lewis phenotypes among H. pylori cells of minimally in vitro-passaged isolates. Lewis expression in 180 clonal H. pylori populations from the primary culture of 20 gastric biopsy samples from 12 patients, and that in 160 isolates from primary cultures from 16 experimentally infected rodents, were examined by enzyme immunoassays. Substantial differences in Lewis expression were found among the isolates from 9 (75%) of 12 patients. These differences were unrelated to overall genetic diversity as determined by polymerase chain reactions for random amplified polymorphic DNA or cagA status, and they persisted during subsequent in vitro passage. In contrast, Lewis expression was highly uniform in H. pylori isolates from different rodents infected for up to 20 weeks. Variation in H. pylori Lewis expression in genetically closely related organisms in human subjects may provide a pool of bacterial phenotypes for the continuous selection of optimally host-adapted populations suitable for persistence.

Host specificity of Helicobacter pylori strains and host responses in experimentally challenged nonhuman primates

BACKGROUND & AIMS

The specificity of colonization by Helicobacter pylori and complex host-bacterium interactions cannot be readily examined in humans. The aim of this study was to perform such analyses in rhesus monkeys.

METHODS

Four animals that had been cured of natural H. pylori colonization were challenged with a mixture of 7 strains of human origin, and bacteria recovered during periodic videogastroscopy were DNA fingerprinted.

RESULTS

Three animals carried mixtures of several strains for 4 months, after which strain J166 predominated. In the fourth animal, only strain J238 was isolated from the earliest phase of colonization through 7 months, but strain J166 again became predominant by 10 months after the challenge. Gastritis scores and plasma gastrin and anti-H. pylori immunoglobulin G titers reached levels observed in naturally colonized animals by 4 months after the challenge; however, no plasma immunoglobulin A response was observed up to 10 months.

CONCLUSIONS

These results show that (1) natural colonization does not elicit protective immunity against subsequent H. pylori challenge; (2) individuals differ in susceptibility to different H. pylori strains during initial stages of colonization; and (3) certain strains are better suited than others for long-term survival in different hosts. These observations show the complexity of H. pylori-host interactions.

Experimental infection of Mongolian gerbils with wild-type and mutant Helicobacter pylori strains

Experimental Helicobacter pylori infection was studied in Mongolian gerbils with fresh human isolates that carry or do not carry cagA (cagA-positive or cagA-negative, respectively), multiply passaged laboratory strains, wild-type strain G1.1, or isogenic ureA, cagA, or vacA mutants of G1.1. Animals were sacrificed 1 to 32 weeks after challenge, the stomach was removed from each animal for quantitative culture, urease test, and histologic testing, and blood was collected for antibody determinations. No colonization occurred after >/=20 in vitro passages of wild-type strain G1.1 or with the ureA mutant of G1.1. In contrast, infection occurred in animals challenged with wild-type G1.1 (99 of 101 animals) or the cagA (25 of 25) or vacA (25 of 29) mutant of G1.1. Infection with G1.1 persisted for at least 8 months. All 15 animals challenged with any of three fresh human cagA-positive isolates became infected, in contrast to only 6 (23%) of 26 animals challenged with one of four fresh human cagA-negative isolates (P < 0.001). Similar to infection in humans, H. pylori colonization of gerbils induced gastric inflammation and a systemic antibody response to H. pylori antigens. These data confirm the utility of gerbils as an animal model of H. pylori infection and indicate the importance of bacterial strain characteristics for successful infection.

Simultaneous expression of type 1 and type 2 Lewis blood group antigens by Helicobacter pylori lipopolysaccharides. Molecular mimicry between h. pylori lipopolysaccharides and human gastric epithelial cell surface glycoforms

Previous structural investigations performed on the lipopolysaccharides (LPSs) from the human gastric pathogen Helicobacter pylori have revealed that these cell surface glycan molecules express type 2 partially fucosylated, glucosylated, or galactosylated N-acetyllactosamine O antigen chains (O-chains) of various lengths, which may or may not be terminated at the nonreducing end by Lewis X (Lex) and/or Ley blood group epitopes in mimicry of human cell surface glycoconjugates and glycolipids. Subsequently, serological experiments with commercially available Lewis-specific monoclonal antibodies also have recognized the presence of Lex and Ley blood group antigens in H. pylori but, in addition, have indicated the presence of type 1 chain Lea, Leb, and Led (H-type 1) blood group epitopes in some H. pylori strains. To confirm their presence, structural studies and additional serological experiments were undertaken on H. pylori strains suspected of carrying type 1 chain epitopes. These investigations revealed that the O-chain region of H. pylori strain UA948 carried both Lea (type 1) and Lex (type 2) blood group determinants. The O-chain from H. pylori UA955 LPS expressed the terminal Lewis disaccharide (type 1 chain) and Lex and Ley antigens (type 2). The O-chain of H. pylori J223 LPS carried the type 1 chain precursor Lec, the H-1 epitope (Led, type 1 chain) and an elongated nonfucosylated type 2 N-acetyllactosamine chain (i antigen). Thus, O-chains from H. pylori LPSs can also express fucosylated type 1 sequences, and the LPS from a single H. pylori strain may carry O-chains with type 1 and 2 Lewis blood groups simultaneously. That monoclonal antibodies putatively specific for the Leb determinant can detect glycan substructures (Le disaccharide, Lec, and Led) of Leb indicates their nonspecificity. The expression of both type 1 and 2 Lewis antigens by H. pylori LPSs mimics the cell surface glycomolecules present in both the gastric superficial (which expresses mainly type 1 determinants) and the superficial and glandular epithelium regions (both of which express predominantly type 2 determinants). Therefore, each H. pylori strain may have a different niche within the gastric mucosa, and each individual LPS blood group antigen may have a dissimilar role in H. pylori adaptation.

Epithelial attachment alters the outcome of Helicobacter pylori infection

Genetically defined in vivo models are needed to assess the importance of target cell attachment in bacterial pathogenesis. Gastric colonization by Helicobacter pylori in human populations is common and persistent, and has various outcomes including peptic ulcers and cancer. The impact of attachment on the course of infection was examined in transgenic mice expressing a human receptor for H. pylori in their gastric epithelium. Persistent infection by a clinical isolate occurred at comparable microbial densities in transgenic and nontransgenic littermates. However, microbial attachment in transgenic mice resulted in production of autoantibodies to Lewisx carbohydrate epitopes shared by bacteria and acid-secreting parietal cells, chronic gastritis, and parietal cell loss. This model should help identify bacterial and host genes that produce attachment-related pathology.

[Peptic ulcer, Helicobacter pylori]

The etiology of gastric or duodenal ulcer defines the choice of treatment. In patients with H. pylori infection but without NSAID treatment of the acute ulcer is achieved by a one week eradication therapy. Prolonged treatment with acid inhibitors is usually not necessary. Eradication should be done by a triple therapy consisting of one acid inhibitor and two antibiotics. Success of the eradication should be controlled 4 weeks after end of the treatment by a C13-urea breath test. Serology is not useful for this matter. NSAID induced ulcers without H. pylori infection should be treated for 4-6 weeks with a potent acid inhibitor, preferably a proton pump inhibitor. If NSAID is continued afterwards prophylaxis against ulcer relapse is necessary. Prostaglandin analog Misoprostol is the only well established drug for that. Proton pump inhibitors seemed also to prevent NSAID ulcer, but solid publications are lacking. H. pylori and NSAID are independent risk factors. Thus. H. pylori eradication does not necessarily prevent relapse of NSAID induced Ulcers. Relapse prophylaxis by Misoprostol or possibly by PPI seems advisable. Ulcer without H. pylori infection and without NSAID is seldom. Other reasons, such as carcinoma, Whipple's disease or Zollinger-Ellison syndrome has to be ruled out. False negative H. pylori tests should be excluded by searching for H. pylori with other methods.

Helicobacter pylori Lewis expression is related to the host Lewis phenotype

BACKGROUND & AIMS

Lewis antigens occur in human gastric epithelium and in Helicobacter pylori lipopolysaccharide; their expression is polymorphic in both. Autoimmune mechanisms induced by bacterial Lewis expression have been proposed to cause gastritis. The aim of this study was to examine the relationship between bacterial and host gastric Lewis expression, as determined by the erythrocyte Lewis(a/b) phenotype, and between gastric histopathology and bacterial Lewis expression.

METHODS

H. pylori Lewis expression was determined by enzyme immunoassays, erythrocyte Lewis phenotype was assessed by agglutination tests, and gastric histopathology was scored blindly.

RESULTS

The host Lewis phenotype was (a+b-) in 15, (a-b+) in 34, and (a-b-) in 17 patients, therefore expressing Lewis x, y, or neither as their major gastric epithelial Lewis type 2 antigen. H. pylori from patients with Lewis(a+b-) expressed Lewis x more than y (1147 +/- 143 vs. 467 +/- 128 optical density units [ODU]; P = 0.006), isolates from patients with Lewis(a-b+) expressed Lewis x less than y (359 +/- 81 vs. 838 +/- 96 ODU; P = 0.0001), and isolates from Lewis(a-b-) patients expressed Lewis x and y approximately equally. Gastritis was unrelated to H. pylori Lewis expression.

CONCLUSIONS

In mimicking host gastric epithelium, H. pylori cells not only express Lewis x and y, but the relative proportion of expression corresponds to the host Lewis phenotype, suggesting selection for host-adapted organisms.

[Comparative effect of lansoprazole/amoxicillin with omeprazole/amoxicillin for the eradication of Helicobacter pylori in patients with duodenal ulcer]

Lansoprazole, a potent antisecretory drug, possesses on an equimolar basis a 4-fold higher in vitro anti-Helicobacter pylori activity than omeprazole. In a prospective randomized study we compared lansoprazole 30 mg b.i.d. and amoxicillin 1 g b.i.d. with omeprazole 40 mg b.i.d. and amoxicillin 1 g b.i.d. for 14 days followed by lansoprazole 30 mg q.d. or omeprazole 20 mg q.d. for 14 additional days in 50 H. pylori positive duodenal ulcer patients (14f, 36m, age 27-83 [mean 43] years). H. pylori infection was diagnosed by histology (3 antral biopsies and 2 from gastric body, H & E- and Giemsa stain), rapid urease test (CLO) and culture in 39 patients, or by histology and rapid urease test in 11 patients. Control endoscopy was performed 4-6 weeks after the end of treatment. For eradication, a negative result in all 3 diagnostic modalities was required. The eradication rate was 43% (9/21 patients) in both treatment groups. 8 patients were lost to follow-up. The ulcer healing rate was 100% in both groups. Nonsmokers had a significantly higher (p = 0.026) eradication rate than smokers. No relevant adverse effects of the therapy occurred. 24 patients with persistent H. pylori infection were subsequently treated with lansoprazole 60 mg b.i.d. and amoxicillin 1 g b.i.d. for 14 days. Eradication was achieved in 5/22 (23%) patients (3/14 smokers, 2/8 nonsmokers), while 2 patients were lost to follow-up. 17 patients with persistent H. pylori infection after the second treatment received quadruple therapy consisting of metronidazole 500 mg t.i.d., tetracycline 500 mg q.i.d. bismuth-subcitrate 120 mg q.i.d. and lansoprazole 30 mg for 10 days. H. pylori eradication was achieved in 12/15 patients (80%). In conclusion, lansoprazole plus amoxicillin was equal to omeprazole plus amoxicillin in the treatment of H. pylori infected duodenal ulcer patients. Patients with eradication failure after dual therapy were successfully treated by quadruple therapy. In contrast, high dose lansoprazole and amoxicillin therapy was effective in only 23% of patients with persistent infection after standard dual therapy.

Expression of the human cell surface glycoconjugates Lewis x and Lewis y by Helicobacter pylori isolates is related to cagA status

Monoclonal antibodies were used in an enzyme-linked immunosorbent assay for the detection of human Lewis immunodeterminants in the lipopolysaccharide of Helicobacter pylori. In 94 H. pylori isolates, expression of Lewis(x) (Le(x)) and Le(y) was a stable phenotypic marker independent of the growth medium and cell age; 46 (49%) of the isolates expressed both and 34 (36%) of the isolates expressed either Le(x) or Le(y); 14 (15%) were negative for both determinants. Twelve (13%) isolates expressed Le(b), 3 (3%) expressed Le(a), and 2 (2%) expressed sialyl-Le(x). H. pylori isolates positive for both Le(x) and Le(y) were predominantly cagA+ (P < 0.001) and possessed the s1 signal sequence (P < 0.05) and the m1 midregion type (P = 0.033) of vacA. Isogenic mutants of H. pylori CPY3401 were created by interruption of the cagA, picB, or ureA gene. The cagA-ablated strain (but not the picB- and ureA-ablated mutant strains) had significantly (P < 0.01) diminished expression of Le(y) compared with that of the wild-type strain; for all four strains, expression of Le(x) was similar. In conclusion, 89% of H. pylori isolates express Le determinants in their lipopolysaccharide, mimicking human cell surface glycoconjugates. Strong expression of Le(x) and Le(y) by cagA+ isolates could counterbalance their enhanced proinflammatory activities and thereby facilitate persistence.

Effect of growth phase and acid shock on Helicobacter pylori cagA expression

Helicobacter pylori strains possessing cagA are associated with peptic ulceration. To understand the regulation of expression of cagA, picB, associated with interleukin-8 induction, and ureA, encoding the small urease subunit, we created gene fusions of cagA, ureA, and picB of strain 3401, using a promoterless reporter (xylE). Expression of XylE after growth in broth culture revealed that basal levels of expression of cagA and urea in H. pylori were substantially greater than for picB. For cagA expression in stationary-phase cells, brief exposure to acid pH caused a significant increase in xylE expression compared with neutral pH. In contrast, expression of xylE in urea or picB decreased after parallel exposure to acid pH (pH 7 > 6 > 5 > 4), regardless of the growth phase. Expression of the CagA protein varied with growth phase and pH exposure in parallel with the observed transcriptional variation. The concentration of CagA in a cell membrane-enriched fraction after growth at pH 6 was significantly higher than after growth at pH 5 or 7. We conclude that the promoterless reporter xylE is useful for studying the regulation of gene expression in H. pylori and that regulation of CagA production occurs mainly at the transcriptional level.

Rapidly progressive portal hypertension 23 years after post-traumatic arterioportal fistula of the liver

Intrahepatic arterioportal fistulas may occur after blunt abdominal trauma and lead to severe portal hypertension, which can be prevented by early diagnosis and treatment. The diagnostic workup of an asymptomatic young male with elevated transaminases revealed an arterioportal fistula secondary to a traumatic liver rupture during childhood, 23 yr earlier. Three years after initial diagnosis, the patient presented with gastrointestinal hemorrhage. Progression of portal hypertension had resulted in esophageal varices and ascites. After ligation of the right hepatic artery, the esophageal varices and ascites disappeared. Twelve months after surgery, the patient is asymptomatic without any signs of liver decompensation or recurrence of gastrointestinal hemorrhage. Our case demonstrates that rapid progression of portal hypertension with severe complication can occur in patients with arterioportal fistula after a long-lasting asymptomatic course of 23 yr. Simultaneous chronic hepatitis C may have a contributory role.

Long-term follow-up after treatment of common bile duct stones by extracorporeal shock-wave lithotripsy

BACKGROUND AND STUDY AIMS

The efficacy of extracorporeal shock-wave lithotripsy (ESWL) of difficult bile duct stones that were not amenable to routine endoscopic extraction was assessed, with evaluation of the long-term follow-up after successful treatment.

PATIENTS AND METHODS

Fifty-four patients (mean age 74 years, range 33-92) were treated with ESWL for difficult bile duct stones. Treatment was performed either with the Dornier HM3 kidney lithotriptor (49 patients) or with the MPL 9000 lithotriptor (five patients).

RESULTS

Stone disintegration was achieved in 50 patients (93%), with complete stone clearance in 45 patients (83%) (mean 1.2 session). Patients with successful stone removal after one session had significantly smaller stones than patients with treatment failure (20 +/- 9 versus 27 +/- 8 mm; p < 0.05). An intrahepatic location of stones was significantly associated with treatment failure (p < 0.005). Serve complications occurred in 7% (procedure-related 5%), with a 30-day mortality rate of 0% (in-hospital mortality rate of 2%). Minor side effects such as fever, petechiae, and mild arrhythmias were frequent (37%), and microhematuria (95%) occurred in nearly all of the patients. Symptomatic recurrent bile duct stones were observed in two patients (5%) after three and four years, respectively (mean follow-up 5.3 years).

CONCLUSION

Extracorporeal shock wave lithotripsy represents a safe and effective treatment modality for difficult bile duct stones, with a low rate of symptomatic recurrences.

[Effectiveness of triple therapy to eradicate H. pylori in patients after failed therapy with omeprazole/amoxicillin]

Helicobacter pylori (H. pylori) eradication rates with omeperazole/amoxicillin range from 0-90%. The best regimen for retreatment after failure of omeprazole/amoxicillin has not been established so far. The aim of this prospective study was to evaluate the efficacy of triple therapy with bismuth, tetracycline and ornidazole in eradicating H. pylori after failure of omeprazole/amoxicillin. 79 duodenal ulcer patients with H. pylori infection were treated with oral omeprazole (40 mg bid) and amoxicillin solute (750 mg tid) for 10 days. Eradication rate was 28/79 (35%) and was distinctly lower in smokers (> 10 cigarettes/day) vs nonsmokers (10/49 [20%] vs 18/30 [60%], p < 0.001). 37 patients with persistent H. pylori infection in whom omeprazole/amoxicillin had failed agreed to retreatment with triple therapy. Persistence of H. pylori was confirmed by histology (3 antral and 2 gastric body biopsies; H&E, Giemsa), urease test (CLO) and/or H. pylori culture. Patients smoking > 10 cigarettes/day were classified as smokers. Retreatment consisted of oral bismuth-subcitrate 4 x 120 mg/d for 28 days (day 1-28), tetracycline 4 x 500 mg/d and ornidazole 3 x 500 mg/d for 10 days (day 1-10). Control endoscopy was done 30 days after the end of treatment. Criteria for H. pylori eradication was negative urease test, culture and histology. 34/37 patients (6 females/28 males; 39 [23-64] years) completed the study (24/34 smokers, 10/34 nonsmokers). 3/37 patients dropped out because of side effects (n = 1) or incompliance (n = 2). H. pylori subcultures for resistance testing were possible in 32/34 patients: H. pylori was metronidazole-sensitive in 11/32 (1 female, 10 males; 38 [24-55] years; 9 smokers, 2 nonsmokers) and metronidazole-resistant (minimal inhibitory concentration for metronidazole > 8 mg/ml) in 21/32 (5 females, 16 males; 40 [23-64] years; 13 smokers, 8 nonsmokers). The overall H. pylori eradication rate of the triple therapy was 27/34 (79%). H. pylori was eradicated in 19/24 (79%) smokers and in 8/10 (80%) nonsmokers. Eradication rate for metronidazole-sensitive H. pylori was 11/11 (100%) vs 14/21 (67%) for metronidazole-resistant H. pylori (p = 0.012). Triple therapy is effective and safe in eradicating H. pylori in patients after failure of omeprazole/amoxicillin. Smoking had no negative effect on the eradication rate of the triple therapy after failure of omeprazole/amoxicillin. Eradication failures were due to metronidazole-resistance.

[Clinical manifestations and course of cytomegalovirus colitis in AIDS patients]

The clinical findings and course in 10 HIV-positive patients with cytomegalovirus (CMV) colitis were analyzed. Homosexuality was the main risk factor for HIV infection. All patients had markedly reduced CD4 counts (mean 25 x 10(9)/l). Symptoms at presentation were chronic diarrhea, weight loss, fever and abdominal pain. One of the patients had an abdominal mass in the ileocecal region due to inflammation as the leading symptom. Endoscopically the colitis was more often segmental than diffuse. In 2 out of 9 patients who underwent colonoscopy, only the right hemicolon was affected. Concurrent intestinal infections with up to 4 different pathogens were found in 7 patients. 5 patients had chorioretinitis as an extraintestinal CMV symptom (2 before, 3 after the occurrence of CMV-colitis). In only one patient was there a partial response of CMV-colitis to therapy with ganciclovir and foscarnet. Even under therapy CMV colitis was complicated in 2 patients by perforation and inflammatory stenosis respectively. Both needed surgical treatment. Most of the patients died of generalized CMV infection or wasting syndrome.

[Initial personal experiences with alpha-1-antitrypsin determination in feces]

Fecal alpha-1-antitrypsin is recommended as a marker of enteric protein loss and in patients with Crohn's disease as an index of intestinal inflammatory activity. We describe our experience in 88 patients with chronic diarrhea or suspicion of protein-losing enteropathy. We measured alpha-1-antitrypsin concentration in random stool samples (n = 7), quantitative alpha-1-antitrypsin excretion in a 24 h feces collection (n = 59) and fecal alpha-1-antitrypsin clearance (n = 22). 13 of 88 patients with the following diagnoses had increased values: Crohn's disease (3/9), other inflammatory diseases of the small intestine (3/3, Whipple's disease, eosinophilic gastroenteritis, celiac disease), hypertrophic gastropathy (1/4), infectious diarrhea (2/6), irritable bowel syndrome (2/29), chronic pancreatitis (2/32) and diarrhea of other reasons (0/5). In patients with Crohn's disease, alpha-1-antitrypsin excretion correlated with the clinical disease activity. All 3 patients with other inflammatory diseases of the small intestine showed increased fecal alpha-1-antitrypsin. All but 2 of the 32 patients with diarrhea due to chronic pancreatitis had normal values. Of 29 patients with idiopathic diarrhea, only 2 showed slightly increased fecal alpha-1-antitrypsin. 10 of the 11 patients with increased alpha-1-antitrypsin excretion in 24 h stool collection had normal alpha-1-antitrypsin concentration in random stool samples. Of the 5 patients with increased alpha-1-antitrypsin clearance, 4 also had increased alpha-1-antitrypsin in 24 h stool collection, but only one had increased alpha-1-antitrypsin concentration in random stool sample. Fecal alpha-1-antitrypsin measurement proved helpful in differing between inflammatory and non-inflammatory diarrhea.(ABSTRACT TRUNCATED AT 250 WORDS)

[Gastroduodenal ulcer disease: update on pathogenesis]

Gastroduodenal ulcer disease comprises a heterogeneous group of different diseases resulting uniformly in a mucosal defect reaching beyond the muscularis mucosae. Consequently, a single unifying pathogenesis of ulcer disease does not exist but only a rather general concept that ulcers develop when mucosa-injuring factors outweigh the mucosa-protecting factors. According to this concept, ulcers develop within a broad range of different possibilities in the relation of mucosa-injuring factors to impaired mucosal protection. The main histological and physiological elements for the understanding of peptic ulcer disease are briefly summarized, followed by a short survey of the important known 'traditional' abnormalities of possible pathogenetic importance in duodenal and gastric ulcer patients. Gastroduodenal ulcer disease represents a typical example of a multifactorial disease, where different combinations of both hereditary and environmental factors produce the same morphological lesion. By far the most exciting data of the last ten years originate from the still increasing understanding of the role of Helicobacter pylori in gastroduodenal ulcer disease. The most important evidence and hypotheses are presented of how and where Helicobacter pylori is or could be involved in the complicated pathogenetic network of ulcer disease. The infection of gastric epithelium by Helicobacter pylori has become the second main factor besides acid/pepsin in the pathogenesis of ulcer disease. Beside the improved insights in ulcer pathogenesis, the translation of the new data into clinical medicine has led and will lead to remarkable progress. Most important: a causal therapy of ulcer disease has become available in contrast to the so far practiced sole symptomatic treatment of single ulcer episodes. What has treatment of single ulcer episodes. What has been a domain of ulcer surgery has come into reach of drug therapy.

[Abnormal increase in pancreatic polypeptide in the secretin-provocation test: hypoglycemia-induced?]

Pancreatic polypeptide (PP) can be used as a marker for endocrine active tumors originating from the pancreas. After intravenous administration of secretin, individually divergent increases in plasma PP concentration can be observed hampering interpretation of the stimulation test. Under certain circumstances elevated basal PP concentrations can be observed. Besides age, renal insufficiency and diabetes, hypoglycemia can cause high PP levels. We therefore inquired whether in patients with atypically high increase of PP after secretin this increase could be caused by hypoglycemia during the secretin stimulation test. In order to test this hypothesis we prospectively determined the plasma glucose and insulin concentrations in addition to the routinely measured gastro-intestinal hormones in 19 patients referred for secretin provocation test. In the 16 patients in whom the increase of PP was not due to an endocrine active tumor or renal insufficiency, PP rose to 170 +/- 57 pmol/l (+/- SEM) 2 minutes after secretin administration. In parallel, plasma insulin concentration increased to 365 +/- 51 pmol/l 2 minutes after secretin. The maximal insulin concentrations correlated significantly with the PP concentrations observed at the same time (R = 0.73, p < 0.01). The mean glucose concentration, however, remained constantly between 4.8 +/- 0.3 and 5.2 +/- 0.3 mmol/l and there was no correlation between the peak plasma PP concentrations after secretin and the plasma glucose concentrations (R = 0.07). The minimal glucose concentrations observed were 3.3 mmol/l in three patients (30 minutes after secretin in 2 patients and 45 minutes after secretin in one). The mean plasma glucagon concentration rose to 22.5 +/- 4.1 pmol/l 10 minutes after secretin.(ABSTRACT TRUNCATED AT 250 WORDS)

[Significance of subtype pattern of antimitochondrial antibodies in primary biliary cirrhosis for prognostic parameters and response to ursodeoxycholic acid]

Antimitochondrial antibodies are of considerable importance for the diagnosis of primary biliary cirrhosis. Several subtypes of antimitochondrial antibodies have been identified and the pattern has been associated with prognosis of the disease in the long term course. 22 patients with primary biliary cirrhosis (19 female, 3 male; age 29-66, mean 49 years) were examined for the occurrence of the subtypes of antimitochondrial antibodies anti M2, anti M4 and anti M9. Diagnosis of primary biliary cirrhosis was based on elevated cholestatic enzymes, antimitochondrial antibodies, histology and exclusion of other chronic liver disease in all patients and elevated serum IgM concentration in 18/22 patients. Most patients were included in a study protocol of the Swiss Association for the Study of the Liver and treated with 10 mg/kg/day oral ursodeoxycholic acid. According to the subtype pattern of antimitochondrial antibodies, patients were divided into 4 groups A to D (A: anti M2-, anti M4-, anti M9+; B: anti M2+, anti M4-, anti M9+; C: anti M2+, anti M4-, anti M9- and D: anti M2+, anti M4+, anti M9-). The groups were compared with respect to the prognostically relevant parameters age, bilirubin, albumin, prothrombin time and peripheral edema, as well as the occurrence of granulomas in liver biopsy, galactose elimination capacity and response to treatment with ursodeoxycholic acid during one year. Treatment response was expressed as decrease of the serum concentration of IgM, GPT, alkaline phosphatase, gamma glutamyl transpeptidase and bilirubin. No significant differences between the four groups were found with respect to the prognostically relevant parameters, histology and galactose elimination capacity at study entry.(ABSTRACT TRUNCATED AT 250 WORDS)

Prospective evaluation of interferon-alpha in treatment of chronic active Crohn's disease

Several case reports suggested good effects of interferon-alpha in patients with Crohn's disease. In addition, a decreased production of interferon-alpha in Crohn's disease has been shown in vitro. Treatment with interferon-alpha may activate intestinal natural killer cells and down-regulate the overproduction of inflammatory cytokines like interleukin-6 in Crohn's disease. To evaluate the clinical efficacy of interferon-alpha, we treated 12 patients with a chronic active course of Crohn's disease with recombinant human interferon-alpha prospectively for 24 weeks. Prednisolone was continuously tapered and discontinued at week 12. The end point of the study was the prevention of worsening of clinical symptoms defined with the Crohn's disease activity index and was monitored by acute-phase proteins, interleukin-6 serum concentrations, and endoscopy. The biochemical activity of interferon-alpha was measured by 2',5'-oligo adenylate serum levels. The end point of the study was reached in four patients (33%). In these patients the final Crohn's disease activity index was above 150, which means that they did not achieve clinical remission. All other patients (66%) did not respond to interferon-alpha and had to be withdrawn prematurely. Interferon-alpha did not show any beneficial effect on interleukin-6 or acute-phase protein concentrations and on endoscopic activity. The 2',5'-oligo adenylate levels continuously increased during interferon therapy. Considerable side effects were noted. These results fail to demonstrate a therapeutic role of interferon-alpha in chronic active Crohn's disease.

[Omeprazole/amoxicillin: improved eradication of Helicobacter pylori in smokers because of N-acetylcysteine]

Colonization of Helicobacter pylori (HP) beneath the protective film of gastric mucus enables the organism to survive in the hostile environment of the gastric mucosa. N-acetylcysteine (NAC), a sulfhydryl compound with potent mucolytic activity, induces a reduction of gastric barrier mucus thickness of about 75% and reduces mucus viscoelasticity. We therefore tested the hypothesis whether better eradication results could be achieved by addition of NAC to omeprazole/amoxicillin (OME/AMOX). 34 HP positive outpatients with endoscopically documented recurrent duodenal ulcer were included in an ongoing, prospective, randomized trial. Exclusion criteria were: alcoholism, previous gastric surgery, or intake of antibiotics, OME, bismuth salts, corticosteroids or NSAIDs within 4 weeks before study entry. Patients currently smoking > 10 cigarettes/day were classified as smokers. HP infection was confirmed by histology (3 biopsy specimens from gastric antrum and 2 from gastric body; H&E, Giemsa) and at least positive rapid urease test or culture. All 34 patients underwent ulcer therapy with OME (20 mg per day) for 20 days (d 1-20). Group A: in 17 patients (5 females, 12 males, mean age 46 [29-74] years; 8 smokers, 9 nonsmokers) the subsequent eradication therapy, consisting of oral OME (40 mg bid) and AMOX solute (750 mg tid) for 10 days, was combined with NAC solute (2 x 600 mg bid (d 21-30). Group B: 17 patients (2 females, 15 males, mean age 39 [19-70] years; 11 smokers, 6 nonsmokers) underwent eradication therapy without NAC (d 21-30). Control endoscopy was done after a minimal interval of 30 days from the end of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

[Omeprazole/amoxicillin: impaired eradication of Helicobacter pylori in smoking but not in premedication with omeprazole]

The efficacy of high dose omeprazole/amoxicillin (OME/AMOX) for eradication of Helicobacter pylori (HP) is controversial. Reported eradication rates range from 0% to 90%. Different therapy schedules and unknown factors may be crucial; in particular, pretreatment with OME has been thought to endanger HP eradication by subsequent OME/AMOX. Preliminary findings suggested that smoking may impair eradication with OME/AMOX. The aims of this study were (1) to establish whether HP eradication rates differ depending on whether eradication with OME/AMOX was performed before or after ulcer therapy with OME, (2) to determine whether smoking impairs HP eradication by OME/AMOX and (3) to evaluate the efficacy of OME/AMOX in our population. 52 HP positive outpatients with endoscopically documented recurrent duodenal ulcer were included. Exclusion criteria were: alcoholism, previous gastric surgery, or intake of antibiotics, OME, bismuth salts, corticosteroids and NSAIDs within four weeks before study entry. Patients currently smoking > 10 cigarettes/day were classified as smokers. HP infection was confirmed by histology (3 biopsy specimens from the gastric antrum and 2 from the gastric body; H&E, Giemsa) and at least positive rapid urease test (CLO) or culture. Eradication therapy consisted of oral OME (40 mg bid) and AMOX solute (750 mg tid) for 10 days (OME/AMOX). This therapy preceded (group A) or followed (group B) ulcer therapy with OME (20 mg per day for 20 days). In group A 17 patients (2 females, 15 males, mean age 39 [19-70]; 11 smokers, 6 nonsmokers) underwent ulcer therapy with OME (d 1-20) before OME/AMOX d 21-30).(ABSTRACT TRUNCATED AT 250 WORDS)

[Eradication of metronidazole-resistant Helicobacter pylori: is omeprazole/amoxicillin a therapeutic alternative?]

Recommended therapies with the highest eradication rates for Helicobacter pylori (HP) are triple therapies comprising bismuth salts, nitroimidazole and amoxicillin or tetracycline. Primary and secondary resistance of HP to nitroimidazole, however, represents a major problem of this treatment since it is the main cause of eradication failure. In these cases therapeutic regimes without nitroimidazole could prove more successful. High dose omeprazole/amoxicillin has been suggested as a simple and effective therapy with few side effects. The effectiveness of this combination in eradicating metronidazole resistant HP has not been established so far. The aim of this study was to evaluate high dose omeprazole/amoxicillin in eradicating metronidazole resistant HP in our population. 33 patients (6 women, 27 men, mean age 39 [range 21-68]) with recurrent duodenal ulcer and gastric colonization by metronidazole resistant HP were examined. Smokers were defined as patients currently smoking > 10 cigarettes/day. Exclusion criteria were: gastric surgery or intake of antibiotics, omeprazole bismuth salts and NSAIDs within four weeks before study entry endoscopy. Biopsy specimens were obtained in a standardized manner: 5 from the gastric antrum (1 CLO, 1 culture, 3 histology: H & E, Giemsa) and 2 from the gastric body (histology). Resistance testing for penicillin, amoxicillin and metronidazole was performed using a disk diffusion test (E-test, AB Biodisk, Sweden). Metronidazole resistance was defined as a minimal inhibitory concentration (MIC) of metronidazole of > 8 micrograms/ml. Eradication therapy consisted of oral omeprazole (40 mg bid) and amoxicillin solute (750 mg tid) for 10 days. Subsequently, for ulcer treatment, patients were given omeprazole (20 mg per day) for 20 days.(ABSTRACT TRUNCATED AT 250 WORDS)

[Gastrointestinal hormone profile in medullary thyroid carcinoma]

Medullary thyroid carcinoma (MTC) can be important for gastroenterologists because 20-30% of patients with MTC suffer from chronic diarrhea and the tumor is capable of producing--besides other bioactive substances--a multitude of gastroenteropancreatic hormones. Gastrointestinal hormone profiles of 5 patients with MTC were determined both basally and after intravenous stimulation with secretin and calcium respectively. Diagnosis of MTC was confirmed histologically or cytologically and by demonstration of elevated serum concentration of calcitonin both basally and after calcium stimulation. 4/5 patients had chronic diarrhea. Normal values or only borderline increases were found for the following hormones: vasoactive intestinal polypeptide (VIP), neurotensin, substance P, growth hormone releasing hormone (GRH), glucagon, neurokinin A, peptide YY, and pancreatic polypeptide. Somatostatin was elevated after calcium stimulation in 1/5 patients only. The main findings were increased basal concentrations for GAWK in 5/5 patients and elevated concentrations for gastrin-releasing peptide (GRP, human bombesin) after calcium stimulation in 4/5. Probably as a consequence of the GRP increase, an increase in gastrin occurred in parallel, indicating bioactivity of the GRP released from the tumor. Besides calcitonin as the main tumor marker for MTC, determination of GAWK and GRP seems to provide helpful additional markers in laboratory diagnosis of MTC. GRP determination after i.v. calcium infusion allowed identification of patients with normal basal plasma GRP concentration.

[Eosinophilia in primary biliary cirrhosis: regression under therapy with ursodeoxycholic acid]

Eosinophilia can be observed in up to 40% of patients with primary biliary cirrhosis (PBC). Eosinophilia is transient, tends to occur in the early stages of the disease and seems to be associated with episodes of florid bile duct destruction [42-45]. 14 Patients with PBC were examined before and during treatment with ursodeoxycholic acid (UDCA) (10 mg/kg/d) for episodes of eosinophilia and the number of eosinophilic granulocytes in differential white blood cell counts. Group A consisted of 5 patients with one or several episodes of eosinophilia before the start of UDCA. Group B included 9 patients without known episodes of eosinophilia. Observation time before and after start of treatment for group A was 3-96 (mean 25) months and 6-24 (mean 14) months, and for group B 3-108 (mean 34) months and 6-27 (mean 19) months respectively. During treatment with UDCA the mean counts of eosinophilic granulocytes decreased in both groups from 309 +/- 47/mm3 to 135 +/- 14/mm3 (p < 0.001). In group A there was a decrease from 529 +/- 89/mm3 to 157 +/- 17/mm3 (p < 0.001) and in group B from 151 +/- 15/mm3 to 128 +/- 15/mm3 B (n.s.). In group A 9/18 differential white blood cell counts showed eosinophilia before UDCA medication (3 x relative [> or = 6%], 6 x absolute [> or = 500/mm3]) and 0/24 after the onset of UDCA (p < 0.001). In group B 0/25 differential white blood cell counts showed eosinophilia before UDCA and 2/72 after start of the therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Parietal cell antibodies in primary biliary cirrhosis: pathogenetic or diagnostic significance?]

24 patients with primary biliary cirrhosis (21 female, 3 male; mean age 51 years) were examined for the occurrence of autoantibodies to gastric parietal cells (APA). APA-titers were correlated with several hematological, chemical and immunological parameters. The results of upper GI-endoscopy were available from 12 patients. APA were positive in 24/24 PBC patients. None of the endoscopies revealed evidence for type A gastritis. No pathological decrease in serum vitamin B12 was found (n = 21). Hemoglobin was either normal (n = 18) or the anemia was microcytic with low serum ferritin (n = 6). Erythrocyte MCV was < or = 97 fl in all patients. No positive correlation was found between APA and erythrocyte sedimentation rate (r = 0.13, n = 24) or the titer of antinuclear antibodies (r = -0.18, n = 24) by linear regression. Correlation coefficient between APA and total serum-Ig was 0.67 (n = 24), 0.74 between APA and serum IgM (n = 24) and 0.13 between total serum-Ig minus IgM (n = 24), indicating that APA found in PBC patients belong to the IgM-isotype. Correlation between APA and anti-M2 was 0.65 (n = 21) and between APA and antimitochondrial antibodies (AMA) 0.96 (n = 24), suggesting recognition of identical epitope(s) by APA and AMA in PBC patients. APA were consistently negative in a control group of 40 patients with various forms of chronic liver disease. We conclude that parietal cell antibodies (APA) in PBC patients seem to be of diagnostic rather than pathogenic importance. Sensitivity for PBC appears comparable to that of AMA.(ABSTRACT TRUNCATED AT 250 WORDS)

[Dilatation of the common bile duct: what does endoscopic sonography contribute?]

In a prospective study 20 patients (14 women, 6 men; mean age 62 [31-81] years) with extrahepatic obstructive jaundice (n = 15) or common bile duct dilatation (CBD) without cholestasis (n = 5) were investigated by endoscopic ultrasound (EUS). All these patients underwent negative transabdominal ultrasonography (US) (n = 20) and computed tomography (CT) (n = 16). Inclusion criterion was a dilatation of the CBD of > 7 mm or > 10 mm in patients with previous cholecystectomy. The definitive diagnosis of a tumor (n = 8), choledocholithiasis (n = 7), stone migration (n = 1), choledochocele (n = 2) or slight dilatation of the CBD without obstruction (n = 2) was confirmed by endoscopic retrograde cholangiopancreatography (ERCP) (n = 13), percutaneous transhepatic cholangiography (PTC) (n = 2), intraoperative cholangiography (n = 1) and follow up (n = 4; mean 21 [3-36] mo.). Dilatation of the CBD could be demonstrated in all cases by EUS. Common bile duct stones (2-15 mm) were demonstrated by EUS in every case. CBD dilatation without underlying obstruction was correctly identified by EUS in all patients and confirmed by further clinical and laboratory findings as well as EUS and ERCP (n = 1). EUS correctly described the localization of a malignant obstruction (n = 8) as confirmed by ERCP/PTC. All tumors (pancreatic head carcinoma n = 3, periampullary tumor (n = 5) could be visualized by EUS. The diagnosis was confirmed by surgery (n = 5) or ultrasound guided fine needle puncture (FNP) after a bile duct prosthesis had been placed (n = 3).(ABSTRACT TRUNCATED AT 250 WORDS)

[Duodenal ulcer disease: a defect in the secretory immune response to Helicobacter pylori?]

In a prospective study we examined 20 Helicobacter pylori (HP)-positive duodenal ulcer patients (5 female, 15 male; age 26-70 [mean 43] years), 20 HP-positive patients with non-ulcer dyspepsia (10 female, 10 male; age 26-79 [mean 48] years) and 10 HP-negative patients with non-ulcer dyspepsia (5 female, 5 male; age 21-76 [mean 45] years) during upper GI-endoscopy. HP was detected by histology (H&E, Giemsa), rapid urease test (CLO) and serology (Cobas Core Anti-H. pylori EIA). IgA anti-HP in gastric juice was determined by ELISA. HP-positivity included positivity in all methods, and HP-negativity failure to detect HP-infection by all methods used. Of the 20 duodenal ulcer patients, 10 patients (2 female, 8 male; age 26-70 [mean 42] years) had an endoscopically documented duodenal ulcer at an earlier endoscopy with no current ulcer, 10 patients had florid duodenal ulcer disease at the time of examination. Duodenal ulcer patients compared with non-ulcer dyspepsia patients were tended to have higher serum IgG anti-HP (551 +/- 240 vs. 338 +/- 159 U/ml) and significantly higher gastric juice IgA anti-HP (50.0 +/- 7.3 vs. 26.5 +/- 4.3 relative units). Concentrations of both serum IgG anti-HP and gastric juice IgA anti-HP tended to be higher in patients with positive ulcer history but no present ulcer compared with patients with florid ulcer disease (934 +/- 456 vs. 170 +/- 63 U/ml and 60.0 +/- 8.6 vs. 40.8 +/- 10.4 relative units).(ABSTRACT TRUNCATED AT 250 WORDS)

[Suppression of Helicobacter pylori by local secretory immune response?]

54 patients (22 females, 32 males, age 21-79, mean 45 years) referred for upper gastrointestinal endoscopy were investigated. Helicobacter pylori (HP) infection was determined using histology (H&E and Giemsa stain), rapid urease test (CLO) and serology (Cobas Core Anti-H. pylori EIA). Density of HP colonization was determined in gastric antral (3 biopsy specimens) and body mucosa (2 biopsy specimens) and semiquantitatively graded on a scale of 0 to 3. Gastric colonization was obtained by addition of the two scores. IgA anti-HP concentration was determined by ELISA using the same FPLC purified HP-antigen mixture as for serology. Gastric juice IgA anti-HP concentration in HP-positive patients (n = 40) was significantly higher than in HP-negative (n = 14) patients (38.3 +/- 4.6 vs. 5.4 +/- 1.2 relative units, p < 0.001). Comparison of HP-colonization density of gastric mucosa with gastric juice IgA anti-HP concentration of the 54 patients by binominal regression analysis yielded a correlation coefficient of 0.65 (p < 0.01). The biphasic course of the curve suggests a mutual relationship of HP-colonization density and IgA immune response. Increasing colonization densities seemed to induce increasing secretory immune responses. Half-maximal and higher immune responses, however, seemed to suppress further HP colonization in vivo without eradicating the infection.

[Thoracic pain, shock-inducing gastrointestinal bleeding]

A 65-year-old patient was referred to hospital with suspected myocardial infarction because of left-sided thoracic pain. A paresis of the left recurrent nerve of unknown etiology has been known for three years. Because of shock with anemia, upper gastrointestinal endoscopy was performed. A diverticulum-like lesion in the proximal esophagus was found to be the source of the bleeding. A contrast X-ray examination showed a cavity of approximately 2 x 2 cm originating from the proximal esophagus. Computerized tomography revealed a large mediastinal mass reaching from the thyroid to the diaphragm. An ultrasound-guided fine-needle puncture of this tumor, together with the endoscopical snare biopsies of the esophageal lesion, allowed the diagnosis of an anaplastic thyroid carcinoma with erosion of the esophagus. The patient responded well to palliative radiotherapy. The defect in the proximal esophagus refilled quickly. Nine months after radiotherapy the patient is doing well.

[Chronic vitamin A poisoning with musculoskeletal symptoms and morphological changes of the liver: a case report]

The case of a 69-year-old woman with a chronic vitamin A intoxication syndrome after self-administration of vitamin A is presented. The clinical picture included musculoskeletal disorders, headache and hepatomegaly. The diagnosis of chronic vitamin A intoxication was based on a history of excessive vitamin A ingestion, clinical chemistry and needle biopsy of the liver. Besides retinol and retinyl ester, the serum concentration of retinol-binding protein (RBP) should be determined. Whereas the serum retinol concentration in chronic vitamin A intoxication often does not correlate with toxicity, the ratio between retinol and RBP and the concentration of retinyl ester is more sensitive. Morphological alterations are associated with the cumulative dosage of ingested vitamin A, whereas the daily amount of vitamin A determines the latency until pathological changes occur. The hormone-like, retinoid-receptor mediated molecular mechanism of action seems to be responsible for the multisystemic manifestations in chronic vitamin A intoxication syndrome.

[Abdominal pain, fresh blood in the anus]

A 60-year-old lady with type II diabetes, arterial hypertension and 'melancholia' was treated with Lithium, a neuroleptic (Leponex) and an ACE inhibitor (Reniten). She was referred to our hospital because of abdominal pain, subfebrile temperatures, diarrhea and hematochezia. The radiological and sonographic examinations showed a thickened wall of the left hemicolon. Colonoscopy revealed a sharply delineated segment with pronounced inflammation in the descending colon and the proximal sigmoid colon, suggestive for an ischemic colitis. Histology of the inflamed colon was compatible with this diagnosis. Under suspended enteral feeding and antibiotic therapy the symptoms disappeared within two weeks, and a control colonoscopy six weeks later was completely normal. 1 1/2 years later the patient suffered from a second episode of ischemic colitis exactly a the same site. Again, complete cure was achieved by conservative treatment.

[Transient eosinophilia in primary biliary cirrhosis]

We reviewed 144 differential white blood cell counts from 23 patients with primary biliary cirrhosis (PBC, 21 females, 2 males) for occurrence of eosinophilia. Over an average observation time of 43 +/- 9 months, 9/23 (39%, 9 female) patients were found to have transient absolute (> 500/mm3, n = 5) or relative (> or = 6%, n = 4) blood eosinophilia. The maximum value of eosinophilic granulocytes observed was 1385/mm3 (19%). Other causes of eosinophilia had been ruled out. Eosinophilia was transient, disappearing without treatment. Significantly younger patients with eosinophilia also had a tendency to prognostically more favourable values for serum albumin, prothrombin time, bilirubin and galactose elimination capacity. None had edema, compared to two patients with edema in the group without eosinophilia. Two patients died during the observation period; both were from the group without eosinophilia. The average 5- and 7-year survival probability, calculated on the Mayo survival model, tended to be higher for patients with eosinophilia (92% and 87%) compared to patients without eosinophilia (79% and 72%). In patients with eosinophilia, disease stage I (5/6 vs 1/9) and epitheloid cell granuloma (4/6 vs 1/9) were significantly more frequent. Blood eosinophilia in PBC seems to be an indicator of an early disease state with florid bile duct lesions. Primary biliary cirrhosis should therefore be considered--with other hepatopathies--as a possible cause of eosinophilia of otherwise unknown origin. These observations could be of importance for future therapeutic concepts, at least for patients in early disease states.

[Hepatosplenic schistosomiasis: case report and clinical review]

Although seen rarely in Switzerland, schistosomiasis is a parasitosis affecting 200 to 250 million people round the world, mainly in tropical and subtropical regions of Africa, Asia, Central and South America. Depending on the parasitic species, the ureters and the bladder (S. haematobium) or the intestine and the liver (S. mansoni, S. japonicum, S. mekongi) are primarily involved. Other organs may be affected (lung, kidneys and central nervous system). Hepatosplenic schistosomiasis represents a special form of chronic infection by S. mansoni, S. japonicum or S. mekongi predominantly occurring in adolescents heavily and repeatedly infected during childhood, together with an additional genetic predisposition for the disease. Hepatosplenic schistosomiasis on a worldwide scale is one of the most prevalent causes of portal hypertension in man. We describe a 33-year-old Portuguese female with mansonian hepatosplenic schistosomiasis 12 years after leaving Africa, who had hepatosplenomegaly, portal hypertension, esophageal varices and hypersplenism. Splenomegaly and slight anemia had been known for years without prompting further work-up. Two months before diagnosis she had been delivered of a normal child after pregnancy without portal-hypertensive complications, namely esophageal hemorrhage. Because of placenta accreta, however, erythrocyte transfusion had been performed after delivery and was possibly responsible for hepatitis C found later on. Pathophysiology, clinical findings and therapy of the disease are discussed.

[A trial of modified triple therapy for the eradication of H. pylori in recurrent duodenal ulcer]

In a prospective trial we examined the efficacy and acceptability of a modified triple therapy in H. pylori (HP)-positive patients with recurrent duodenal ulcer disease. Oral administration of amoxicillin for two weeks was substituted for one single injection of intramuscular depot penicillin (benzathine penicillin G). Additionally, patients were given ornidazole 500 mg tid for 14 days and 120 mg colloidal bismuth sub-citrate qid for 28 days. The patients were investigated for H. pylori colonization using a rapid urease test (CLO), histology (H&E-, Giemsa stain), culture (including determination of the minimal inhibitory concentrations for metronidazole, penicillin G and amoxicillin) and H. pylori serology (Cobas Core Anti-H. pylori EIA, F. Hoffmann-La Roche). Control endoscopies using the same methods were performed 1 and 6 months after eradication therapy. The eradication rate was 50% and the ulcer healing rate 90% 1 month after therapy. Ulcers recurred in 2/3 of patients with persistent infection vs 0/5 of HP-eradicated patients after 6 months. Both successfully HP-eradicated patients and patients with treatment failure exhibited comparable decreases in mean serum IgG anti-HP concentration within 2 months. Discrimination between the two groups and hence identification of the eradication success by serology was not possible within a time period of 2 months. After 6 months, serum IgG anti-HP concentrations in non-HP-eradicated patients returned to pre-therapy values, in HP-eradicated patients the concentrations further decreased. The above-described modified triple therapy against HP cannot be recommended as a standard therapy, mainly because of the insufficient eradication effect.(ABSTRACT TRUNCATED AT 250 WORDS)