The syndrome of gastric carcinoid and hyperparathyroidism: a family study and literature review

OBJECTIVE

To present evidence supporting the hypothesis that the coexistence of gastric carcinoids (GCs) and hyperparathyroidism may represent a distinct clinical entity, not related to multiple endocrine neoplasia type 1 (MEN1).

METHODS

We studied a cohort of five young siblings (age range 26-42 years), one of whom had been found to have GC and hyperparathyroidism. All siblings underwent serial gastroscopies for the assessment of gastric neuroendocrine cell proliferations over a mean follow-up period of 31.2 months. Imaging, biochemical and hormonal as well as molecular genetic investigations were performed in the direction of MEN1 syndrome. The literature was searched for cases with coexistence of GCs and hyperparathyroidism not associated with MEN1.

RESULTS

Four of the siblings, all male, were found to have GCs in a background of Helicobacter pylori-associated chronic atrophic gastritis and pernicious anaemia, with no serological evidence of gastric autoimmunity. In two of them, asymptomatic hyperparathyroidism was also present. Screening for MEN1 gene mutations or large deletions was negative, and hormone and imaging investigations did not support a diagnosis of familial MEN1 syndrome. A literature search revealed sporadic reports of cases with GC and hyperparathyroidism not attributable to MEN1.

CONCLUSIONS

The association of GCs and hyperparathyroidism appears to constitute a distinct syndrome that can be encountered in genetically predisposed individuals, and should not be regarded as 'atypical' or 'incomplete' expression of MEN1. Its prevalence and aetiology should be the subject of future studies. Screening for hyperparathyroidism seems to be justified in patients with GC of any type.

Pelvic floor study in patients with obstructive defecation: influence of biofeedback

The aim of this study was to evaluate the pathophysiologic abnormalities in patients with obstructive defecation or dyssynergia and to assess the role of biofeedback treatment. Three groups were studied. Group A had 24 patients with obstructive defecation; B, 25 patients with constipation; and C, 22 healthy volunteers. Rectosigmoid segmental transit time of group A was 28.5 hours (SD +/- 13.4); B, 17.2 hours (SD +/- 11.5); and C, 8.5 hours (SD +/- 6.3) (p < 0.05). There was no statistical difference in resting and squeezing anal pressure among the three groups. Anorectal angle at rest revealed no difference among the three groups. At strain, a statistically significant difference between groups A and C (p < 0.05) and a marginal difference between groups A and B was noted. Rectocele of the anterior rectal wall was present at strain in 17/24 patients of group A and 7/22 patients of group C (p < 0.05). Electromyography during strain revealed abnormal contractions of puborectalis muscle and external anal sphincter, in 13 and 14 patients of group A, respectively, which differed from that observed in groups B and C (p < 0.001). Biofeedback treatment was applied with good results in 7 of 11 patients of group A. At six months, constipation relapsed in only one of treated patients. Patients suffering from obstructive defecation seem to have slower rectosigmoid transit time than the others. Defecography shows smaller anorectal angle at strain and rectocele of the anterior rectal wall more often. Abnormal pelvic floor contraction at strain is often noted in anal electromyography. Some of these patients seem to respond favorably to biofeedback treatment.

"Reappearance" of Helicobacter pylori after eradication: implications on duodenal ulcer recurrence: a prospective 6 year study

We estimated the rate of Helicobacter pylori "reappearance" and of duodenal ulcer relapse up to 6 years after eradication of H. pylori. Of 220 patients in whom H. pylori was eradicated, 165 were eligible at 12 months to follow-up. Endoscopy was scheduled every 12 months or whenever symptoms appeared. Baseline H. pylori eradication was confirmed by CLO test, histology (hematoxylin-eosin and Giemsa stain), and culture. H. pylori was tested for by the three methods at 12 months and subsequently by 2 methods (CLO, histology) on biopsies obtained from the gastric antrum and body. We reviewed 90 patients after 1 year, 32 after 2 years, 13 after 3 years, 12 after 4 years, 2 after 5 years, and 16 after 6 years (range, 12 to 72 months; average, 25.23 months; patient-years, 347). At 12 months after eradication, 16 of 165 patients (9.7%) were H. pylori positive and 5 had ulcer relapse. Of 75 patients evaluated at 24 months, 7 (9.3%) were H. pylori positive and 1 (1.3%) had ulcer relapse. At 36 months, 43 patients were seen and 1 (2.3%) was H. pylori positive and had ulcer relapse (2.3%). Thirty, 18, and 16 patients were seen at 48, 60, and 72 months, respectively. None was H. pylori positive and none had ulcer relapse. Overall, 24 H. pylori-positive patients were found, two thirds of them in the first year after eradication. In 7 of 24 (29%, 6 smokers), ulcer recurred. None of the H. pylori-negative patients had ulcer relapse. The H. pylori reappearance rate was 7% and the ulcer relapse rate was 2% per patient-year. If the 16 H. pylori-positive patients who were found the first year are considered as recrudescence, then the reinfection rate will be 2.3% per patient-year.

One-week therapy with omeprazole, clarithromycin and metronidazole or ornidazole, followed by 3 weeks' treatment with omeprazole, eradicates Helicobacter pylori equally and heals duodenal ulcer

OBJECTIVE

To estimate and compare the efficacy of 'triple' 1-week regimens--omeprazole, clarithromycin and a nitroimidazole (metronidazole or ornidazole)--followed by omeprazole, for an additional 3 weeks, on Helicobacter pylori eradication and duodenal ulcer (DU) healing, in a country with a high resistance rate of H. pylori to metronidazole.

DESIGN

Open, prospective, two-centre study.

METHODS

Patients older than 18 years with active duodenal ulcer (DU), diagnosed by endoscopy and found to be infected with H. pylori (modified Giemsa stain and CLO test, Delta West, Australia), were included in the study. Three triple-drug regimens, given for 7 days, were used. (1) omeprazole (Om) 20 mg once a day, plus clarithromycin (Cl) 250 mg twice daily, plus ornidazole (Or) 500 mg twice daily (O1COr); (2) Om 20 mg twice daily, plus Cl 250 mg twice daily, plus Or 500 mg twice daily (OCOr); and (3) Om 20 mg twice daily, plus Cl 250 mg twice daily, plus metronidazole (M) 500 mg twice daily (OCM). Two hundred and three consecutive H. pylori-positive patients were included in the study, randomly assigned as follows: 50 patients (group A1: 32 men, 18 women, age 23-77 years) on O1COr; 47 patients (group A2: 29 men, 18 women, age 27-77 years) on OCOr; and 106 (group B: 71 men, 35 women, age 18-83 years) on OCM. Ulcer healing and H. pylori eradication were assessed endoscopically, 8-9 weeks after the start of treatment. H. pylori was considered eradicated if both histology and rapid urease test (six biopsies, antrum-body) were negative.

RESULTS

Eleven patients were lost to follow-up; 192 patients were analysed. Group A1: 48; group A2: 44; group B: 100. 'Per-protocol' analysis: H. pylori eradication, 90-93% (P = 0.901); ulcer healing, 90-98% (P = 0.300). 'Intention to treat' analysis: H. pylori eradication, 85-88% (P = 0.887); ulcer healing, 86-91% (P = 0.657). Compliance was excellent, no serious side effects were observed and no patients withdrew due to side effects.

CONCLUSIONS

No differences were observed in the H. pylori eradication and the healing rate among the groups. It seems that twice daily omeprazole is no better than single daily dosage and that ornidazole is as effective as metronidazole. In addition, in the studied population which is believed to have a high prevalence of metronidazole resistance, all the regimens used were effective.

Short-course therapy with amoxycillin-clarithromycin triple therapy for 10 days (ACT-10) eradicates Helicobacter pylori and heals duodenal ulcer. ACT-10 Study Group

BACKGROUND

Whilst the role of Helicobacter pylori eradication in managing duodenal ulcers has been established, consensus regarding the ideal regimen has not been achieved.

METHODS

Patients with H. pylori-positive active duodenal ulcer were randomly assigned to receive triple therapy with amoxycillin 1000 mg b.d. + clarithromycin 500 mg b.d. + omeprazole 20 mg daily for 10 days (ACT-10) or dual therapy with clarithromycin 500 mg t.d.s. + omeprazole 40 mg daily for 14 days (Dual). No additional acid suppression was provided following eradication therapy. Endoscopy, with biopsy for culture and histology, as well as 13C-urea breath testing (13C-UBT) were performed pre-treatment to assess H. pylori infection. H. pylori eradication was established at 4-6 weeks follow-up with culture (2 antral, 1 corpus biopsies), histology (2 antral biopsies), and 13C-UBT. Ulcer healing by endoscopy and change in clinical symptoms were also assessed at 4-6 weeks.

RESULTS

Two hundred and sixty-seven (267) patients were randomized to ACT-10 (n = 137) or Dual therapy (n = 130). By per-protocol and intention-to-treat analyses, H. pylori eradication at 4-6 weeks follow-up was 91% (115/127) and 88% (120/136), respectively, for ACT-10 patients and 59% (68/115) and 55% (72/130), respectively, for Dual therapy patients (P < 0.001 for both analyses). Ulcer healing was high in both treatment groups: ACT-10, 93% (118/127) and 90% (122/136), respectively; and Dual therapy, 91% (104/114) and 85% (111/130), respectively. Pre-treatment resistance to clarithromycin was low (4%, 8/214) as compared to metronidazole resistance which was over 40%. Emergence of resistance to clarithromycin was observed in 2% of patients receiving ACT-10 and in 25% of those receiving Dual therapy. ACT-10 and Dual therapy patients experienced similar rates of drug-related adverse events (33% vs. 32%, respectively) and discontinuation from therapy due to an adverse event (1.5% vs. 5%, respectively). More than 90% of patients were compliant with each prescribed medication.

CONCLUSION

In patients with active duodenal ulcer, a 10-day course of amoxycillin-clarithromycin-based triple therapy without additional acid suppression is highly effective in eradicating H. pylori and healing duodenal ulcer.

High eradication rate of Helicobacter pylori using a four-drug regimen in patients previously treated unsuccessfully

The objective of this study was to assess the efficacy of a new regimen in eradicating Helicobacter pylori (Hp) in patients with duodenal ulcer (DU) who were previously treated unsuccessfully with standard triple therapy (tripotassium dicitratobismuthate [TDB] 120 mg QID, metronidazole 500 mg TID, and tetracycline 500 mg QID) or proton-pump inhibitor (PPI) dual therapy (omeprazole 20 mg BID and amoxicillin 500 mg QID). The study included 133 consecutive patients aged 17 to 83 years with endoscopically diagnosed DU (diameter > or = 5 mm) in whom standard triple therapy or PPI dual therapy had failed to eradicate Hp. A rapid urease (CLO) test was performed on four biopsy specimens at study entry and at least 1 month after the end of treatment to confirm Hp colonization and eradication, respectively. Patients were considered to be Hp positive if any CLO test was positive within 2 hours, and Hp was considered to be eradicated if all CLO tests were still negative after 24 hours. In 31 randomly selected patients, Hp eradication was confirmed histologically as well. Patients were given omeprazole 60 mg/d (20 mg in the morning and 40 mg in the evening) plus amoxicillin 500 mg QID for 10 days and subsequently were given metronidazole 500 mg TID for 10 days plus TDB 120 mg QID for 6 weeks. One hundred and twenty-four patients were followed up; five (4%) withdrew because of side effects (protracted diarrhea, stomatitis, skin rashes). Per-protocol analysis showed Hp eradication in 113 of 119 patients (95%) and ulcer healing in 118 of 119 (99%). Intent-to-treat analysis showed an Hp eradication rate of 85% (113 of 133 patients) and an ulcer healing rate of 89% (118 of 133 patients). In per-therapy analysis, the Hp eradication rate was 91% (113 of 124 patients), and the ulcer healing rate was 95% (118 of 124 patients). Side effects were observed in 39 of 119 patients (33%) and were generally mild. The four-drug regimen used in this study, when given to patients previously treated unsuccessfully with standard triple therapy or PPI dual therapy, was highly effective in eradicating Hp and healing DUs and had no major side effects.

Helicobacter pylori infection in spouses of patients with duodenal ulcers and comparison of ribosomal RNA gene patterns

BACKGROUND

In recent studies, familial coinfection with the same Helicobacter pylori strains has been indicated, but more data are necessary to confirm intra-familial spread of the micro-organism.

AIMS

The aim of this study was (a) to assess the frequency of H pylori infection in spouses of patients with duodenal ulcers and (b) to investigate the possibility of intraspousal typing of the respective strains.

PATIENTS

Sixty four patients with duodenal ulcer and their spouses were included in the study.

METHODS

The H pylori infection was confirmed after endoscopy by culture and histological examination of biopsy specimens, and CLO test. The isolates were compared on the basis of their rRNA gene patterns (ribopatterns) after digestion of chromosomal DNA by the restriction endonucleases HaeIII or HindIII.

RESULTS

Of the patients, 54 were found to be H pylori positive. Of the respective spouses, 42 (78%) were also H pylori positive. In contrast, only two out of 10 (20%) partners of H pylori negative patients were infected. Ribopatterns of H pylori strains derived from 18 patients and their spouses showed that in each of eight couples a single strain had colonised both partners, while in the remaining 10 couples each partner was colonised by a distinct H pylori strain.

CONCLUSIONS

These data suggest person to person transmission within couples or exposure to a common source of infection.

The use of ERCP in the study of patients with hepatic echinococcosis before and after surgical intervention

BACKGROUND

Biliary tree involvement is the most common complication of hydatid liver disease, which is difficult to detect and manage.

METHODS

During the last 7 years, we examined by ERCP 26 cases with echinococcal liver involvement. Indications in the preoperative group included cholangitis in 6 cases, right-sided hypochondralgia involving 4, preoperative assessment in 4, and icterus in 1 case. In the postoperative group, the indications for ERCP were cholangitis in 5 cases, external biliary fistulas in 5, and biliary colic in 1 case.

RESULTS

ERCP findings in the preoperative group included external bile duct compression in 11 cases (73.3%), biliary fistula affecting 3 (20%), and echinococcal remnants within the common bile duct in 1 case (6.6%). With regard to the postoperative group, biliary fistula formation was detected in 6 cases (54.5%), echinococcal remnants within the common bile duct in 4 (36.3%), and external bile duct compression involving 1 case (9%). Endoscopic sphincterotomy was successfully performed in 13 patients in both groups. No serious complications were encountered.

CONCLUSION

ERCP is a safe and helpful preoperative or postoperative tool that aids in the diagnosis and often the treatment of echinococcal liver disease with involvement of the bile ducts.

Intraluminal duodenal diverticulum

A 76-year-old man with an iron deficiency anemia during the previous 4 years and recent melena was presented. Gastroscopy showed a sessile polypoid lesion in the area of the papilla of Vater and histology was normal. Barium swallow follow-through and CT scan revealed a round intraluminal filling defect. ERCP demonstrated extrinsic compression of both ducts. Emergency laparotomy was performed because of upper GI bleeding and because attempts at endoscopic haemostasis of the oozing polypoid mass were unsuccessful. A soft compressible polypoid mass was found, which on palpation excreted a viscous milky liquid through a tiny opening. Histology showed normal duodenal mucosa bilaterally, a diagnostic finding of intraluminal duodenal diverticulum. The atypical age of presentation as well as gastroscopic and roentgenographic findings of this rare entity are illustrated.

ABO blood group, secretor status and detection of Helicobacter pylori among patients with gastric or duodenal ulcers

Patients (454) referred for gastroscopy to the General Hospital of Athens were examined to determine (1) if non-secretors were over-represented among patients with ulcers and (2) if there was an association with ABO blood group or secretor status and carriage of Helicobacter pylori. Compared with the local population, among patients with either gastric ulcer (51) or duodenal ulcer (96) there was a significant increase in the proportion of those who were blood group O (P less than 0.025); however, there were no significant differences in the proportions of non-secretors. H. pylori was identified in 62% of the 454 patients: 59.5% of those without evidence of ulcers; 62.5% of those with gastric ulcer; 88% of those with duodenal ulcer (P less than 0.0005). These bacteria were cultured more often and in higher numbers from patients with duodenal ulcer (P less than 0.025). There was no association between ABO blood group and prevalence of H. pylori. The prevalence of H. pylori among non-secretors with gastric ulcer (12.5%) was significantly lower than that for non-secretors with duodenal ulcer (100%) (P less than 0.0005). This was not observed for secretors.

Seroepidemiology of Helicobacter pylori infection in Greece

Helicobacter pylori infection is strongly associated with chronic gastritis and peptic ulceration. As the prevalence of H. pylori infection in southern European populations is not known, a serological survey of 1069 samples from three different age groups in the Greek population was carried out with an enzyme-linked immunosorbent assay (ELISA) for antibodies to these bacteria. The antigen was an ultracentrifuged supernate of whole cell sonicates of 5 isolates of H. pylori assessed by electrophoresis and by immunoblotting with negative and positive sera. The sensitivity of the test was 97.43% and the specificity 100% for IgG antibodies; IgA and IgM antibodies to the antigen preparation were not found. Antibodies to H. pylori were detected among 39.4% of children aged 1-10 years, 67.1% of recruits (20-27 years) and 70% of blood donors (20-50 years). The prevalence of antibodies did not differ with sex in each of the age groups. The proportion of individuals with antibodies to H. pylori was higher in the younger age groups than those reported for similar age groups in western Europe.