Determination of alpha-1 antitrypsin genetic deficiency in duodenal ulcer by polymerase chain reaction

OBJECTIVE

To confirm alpha-1-AT deficiency status in duodenal ulcer using a combination of PCR and restricted enzyme digestion.

METHODS

Fifty patients with endoscopically proven duodenal ulcer and hundred controls with no signs of the disease were included. Alpha-1-AT phenotypes were confirmed by polymerase chain reaction followed by restriction enzyme digestion.

RESULTS

Alpha-1-AT concentration in duodenal ulcer patients showed a mean value of 2.12 +/- 0.11 g/l (range: 0.52-3.95 g/l, p < 0.05). In controls this was 2.47 +/- 0.08 g/l (range: 0.52-5.0 g/l). Among the controls 70% had the MM phenotype, 28% M1 M2 and 2% FM. In duodenal ulcer, MM predominates (70%), followed by M1 M2 (18%), SS (4%), SZ (4%), ZZ (2%) and MZ (2%).

CONCLUSION

Alpha-1 AT deficiency was found in 10% of duodenal ulcer patients. DNA analysis more accurately resolved the phenotypes as S and Z mutations.

Efficacy of albendazole in giardiasis

Albendazole and metronidazole were compared in 68 patients diagnosed positive for giardiasis. Albendazole 1200 mg, one dose was given to 24 patients, albendazole 400 mg twice a day for 3 days was given to 23 patients, and metronidazole 400 mg 3 times a day for 5 days to 21 patients. Response to therapy was monitored by clinical examination and analysis of fresh faecal samples on days 0, 3, 7 and 10. Response to the single dose of albendazole was 55%, to the divided dose of albendazole 70%, and to metronidazole 84%. The results show that albendazole, originally recommended for helminthic infection, can also be used in patients with mixed protozoal infection or for infections resistant to metronidazole.

Phenotypes of alpha 1 antitrypsin in Karachi, Pakistan

OBJECTIVE

To determine serum level of the protease inhibitor, to identify phenotypes and determine their frequencies.

STUDY DESIGN

A prospective study.

SETTING

PMRC, Research Centre, JPMC and the Aga Khan University Hospital, Karachi.

SUBJECTS

Healthy adults without history of peptic ulcer disease and a normal endoscopy.

METHODOLOGY

Quantitative measurement of serum alpha 1 AT was carried out by radial immunodiffusion, phenotyping by iso-electric focusing and confirmation of phenotypes by immuno-fixation and DNA analysis technique.

RESULTS

Serum alpha 1 AT was low in 13.4% of the subjects. MM phenotype predominated followed by SZ, SS,MZ and ZZ. DNA diagnosis accurately resolved the phenotypes as S and Z.

CONCLUSION

Frequency of phenotype associated with total and intermediate deficiency is less in the population.

Genetic markers and duodenal ulcer

Serum pepsinogen, alpha 1-antitrypsin (alpha 1-AT) and blood groups were studied as genetic markers in 32 patients with endoscopically proven duodenal ulcer and 44 control subjects with no family history of ulcer disease. Serum pepsinogen was determined by the modified method of Edward et al, alpha 1-AT by single radial immunodiffusion (RID) and phenotyping was carried out by isoelectric focusing (IEF). Duodenal ulcer patients with hyper- pepsinogenemia (28%) and low serum alpha 1-AT (35%) had a dominant blood group O, lower mean age, an early onset of disease, a higher frequency of gastrointestinal (GI) bleeding and ulcer perforation. These parameters were found considerably different in patients with normal serum pepsinogen and alpha 1-AT. Phenotype analysis of alpha 1-AT revealed that four duodenal ulcer patients had partial deficiency of the protease inhibitor and none of the normal exhibited the deficiency pattern. The etiology of the disease appears to be genetic anomaly in 28% of patients while the rest (72%) had ulcers as a result of neuroendocrinological or environmental factors.

Roxatidine versus ranitidine in the treatment of patients with duodenal ulcer: a randomized, double-masked, multicenter study

The comparative efficacy of roxatidine and ranitidine in the treatment of patients with acute duodenal ulcer was assessed at 4 and 6 weeks in this multicenter study. Ninety-four of 192 patients were given roxatidine in a single nightly dose of 150 mg, and 98 patients were given ranitidine in a single nightly dose of 300 mg. All the patients had endoscopically proven duodenal ulcer. Of the 171 assessable patients, ulcers were healed in 88% of the roxatidine group (73 of 83) and in 84% of the ranitidine group (74 of 88). No serious adverse events were reported in either group. We conclude that roxatidine 150 mg once daily is as effective and safe for the treatment of acute duodenal ulcer as ranitidine 300 mg once daily.

Triple therapy in duodenal ulcer healing--a follow up study

Thirty-nine Helicobacter pylori (HP) positive chronic duodenal ulcer patients completed the 4 weeks treatment of triple therapy (Denol, Metronidazole and Amoxil). Of these 29 showed healed duodenal ulcer and negative CLO test at 8 weeks (eradication). They were followed at 3,6 and 12 months and at each follow-up, endoscopy and CLO testing were repeated. At 12 weeks, 54% showed a healed ulcer and negative CLO and these figures reached to 69 and 66% at 6 and 12 months respectively. Thirty percent relapsed within 1 year. The present study indicates a prolonged remission of duodenal ulcer following HP eradication.

Endoscopic re-evaluation of Visick grading

Correlation of Visick grading was done with serial endoscopies in 19 patients operated for duodenal ulceration. Deeper mucosal lesions like ulceration showed good association with Visick grading (100%), while superficial mucosal lesions were mostly asymptomatic and therefore, caused disparity in grading. Moreover, as symptoms and endoscopic findings changed with passage of time, it was concluded that in the light of endoscopic findings the grading need re-evaluation.

Serum alpha 1 antitrypsin and pulmonary emphysema

Using isoelectric focusing (IEF) and radial immunodiffusion (RID) techniques, serum samples from 100 normal healthy adults and 21 patients with pulmonary emphysema were analysed to identify various alpha 1 antitrypsin phenotypes and the serum concentrations. Ten percent of the patients had low serum values. The normal or most common genetic form, MM, is the predominant phenotype in both controls and patients.

Famotidine 40mg B.I.D. in the treatment of reflux oesophagitis

To assess the efficacy of famotidine in the healing of reflux oesophagitis, 25 endoscopically proven cases were treated with famotidine 40 mg B.I.D. for 6 to 12 weeks. Six patients were lost to follow-up, of the 19 cases analysed, 16 (84.2%) healed at 6 weeks and 17 (89.5%) at 12 weeks. Twelve cases (63%) became asymptomatic within six weeks of treatment. In conclusion famotidine 40 mg B.I.D. is effective in the healing of reflux oesophagitis.

Genetic variants of serum alpha 1 antitrypsin

Complete absence of data on alpha 1 antitrypsin in this country prompted us to determine serum levels using radial immunodiffusion (RID) and phenotypes by isoelectric focusing (IEF) in 100 healthy adults (52 males and 48 females). Mean serum alpha 1 antitrypsin concentration in healthy subjects was 2.47 +/- 0.08 g/l and the main phenotypes MM (70%), M1 M2 (28%) and FM 3 (2%) are infrequent in our population.

Healing and relapse rates of duodenal ulcer with omeprazole vs ranitidine

The efficacy of omeprazole 20 mg a day was assessed against ranitidine 150 mg twice a day in the healing and relapse of duodenal ulcer. Forty three endoscopically verified cases were allocated to 2 weeks of treatment, which was extended to 4 weeks, if the ulcer persisted on day 15. Two cases were excluded due to deviation from the protocol. Of 41 evaluable cases, 21 received omeprazole and 20 ranitidine. Healing rates with omeprazole and ranitidine at 2 weeks were 71% and 70% respectively which rose to 100% and 90% at 4 weeks (N.S). There was no significant difference in pain relief in two groups. Follow-up endoscopies, in 33 healed cases revealed 100% relapse at 3 months in omeprazole and 79% in ranitidine treated cases (P < 0.05).

Helicobacter pylori clearance and eradication with triple therapy in duodenal ulcer patients

Triple therapy was given to 49 chronic helicobacter pylori positive chronic duodenal ulcer cases to see its efficacy in H. pylori clearance, eradication and ulcer healing. H. pylori clearance and eradication rates at week 5 and 8 were 87.8% and 81.5% while ulcer healing rates 68.2% and 81.5% respectively. Seven (18%) cases failed to clear H. pylori and were classified as non-responders. Histologically 60% showed post-treatment regression of gastritis. Tolerance to drugs was excellent with a good compliance rate.

Serum alpha 1-antitrypsin and duodenal ulcer

Evaluation of serum alpha 1-antitrypsin levels in the South Asian population and its possible involvement in disease conditions such as duodenal ulcer has not been given due consideration. This is mainly because reports from European and North American countries indicate that the genetic deficiency of this protease inhibitor is rare among Asians of the subcontinent. Using isoelectric focusing (IEF) and radial immunodiffusion (RID) techniques, we analysed serum samples from 100 normal, healthy adults and 50 patients with endoscopically proven duodenal ulcers to determine if there is a possible relationship between alpha 1-antitrypsin phenotype and this disease. Five duodenal ulcer patients had low alpha 1-antitrypsin levels as well as SZ and S phenotype. None of the controls showed presence of S or SZ phenotypes. The normal or most common genetic form, MM, is the predominant phenotype in both controls and patients.

Association of upper gastrointestinal lesions with addictions

The association of upper gastrointestinal (G.I.) lesions with various addictions was studied in 383 consecutive patients endoscoped over a year. Of the total, 179 (47%) had no addictions and 204 (53%) were addicted to either cigarette smoking (70%), tobacco chewing with pan (23%), pan alone (5%) or alcohol (2%). Overall, 78% cases with and 59% without addictions had an upper G.I. lesion on endoscopy (P < 0.001). Duodenal ulcer was commonest lesion in all types of addiction.

Omeprazole vs ranitidine in the healing of duodenal ulcer

To assess the comparative efficacy of omeprazole 20 mg in the morning versus ranitidine 150 mg twice a day, in the healing of duodenal ulcer, 43 endoscopically verified cases were randomly allocated to 2 or 4 weeks (if ulcer did not heal at 2 weeks) treatment. Two cases were excluded due to deviation from the protocol. Of 21 cases treated with omeprazole 15 (71%) healed at two weeks and all (100%) at 4 weeks. Similarly of 20 cases treated with ranitidine, 14 (70%) healed at 2 and 18 (90%) at 4 weeks (P = NS). Two patients who did not heal with ranitidine, when crossed over to omeprazole healed at 4 weeks. No significant difference in the rate of pain relief, clinical or laboratory parameters or adverse effects were noted in either group. Both the drugs were well tolerated and were potent healer of duodenal ulcer; but omeprazole appears to be superior in the healing of resistent ulcers.

Endoscopic lesions in chronic renal failure

To determine the frequency and type of upper gastrointestinal lesions in patients with chronic renal failure (CRF), upper G.I. endoscopy was done in 101 cases. Of the various mucosal lesions, inflammatory changes were seen maximally (40), followed by erosions (16) and ulcers (7). Other changes included atrophic gastro-duodenal folds (17), pale mucosa (11) and moniliasis (6) which was only seen in patients with end stage CRF. Lesions were more frequent in those who were in advanced stage of CRF (81%) and those undergoing dialysis (79%), reflecting a positive correlation of upper G.I. lesions with the severity of CRF.

Portal vein thrombosis following sclerotherapy

We present the case of a woman with idiopathic portal hypertension who underwent sclerotherapy for bleeding esophageal varices. She had a rebleed 27 months after complete eradication of esophageal varices. Endoscopy showed bleeding gastric varices. Ultrasonography, and later splenoportography, revealed a large thrombus in the right branch of the portal vein causing gross dilation of the portal and splenic vein. A proximal splenorenal shunt was done to decompress the portal system and hence gastric varices. Repeat endoscopy 4 weeks after surgery revealed complete disappearance of the gastric varices, while ultrasonography at 38 weeks showed marked decompression of the portal system with complete disappearance of the thrombus from the right branch of the portal vein. No new thrombus formation was seen.

Gastric ulcer in Karachi

Of 138 endoscopically or surgically confirmed cases of gastric ulcer, 102 (74%) were males and 36 (26%) females. Both sexes were affected most commonly in the 6th decade of life. Pain, vomiting and gastrointestinal bleeding were the major presenting symptoms, with a median duration of 6 months. Cigarette smoking was the most common (44%) addiction and 10% were on analgesics or nonsteroidal anti-inflammatory drugs (NSAID). Family history of ulcer was uncommon (2%) and no predilection for any blood group was noted. Among males 53% were skilled workers while 94% of females were housewives. Forty five percent patients were migrants from India and the rest belonged to different provinces of Pakistan. Presentation and behaviour of different sites of gastric ulcers though varied but the results were not significant. Healing rates with H2 receptor antagonists were 33% at 4 weeks and 78% at 8 weeks.

Oesophageal carcinoma in Karachi

Between January, 1979 to August, 1990, 107 histologically proven cases of oesophageal carcinoma were seen. The ages of the patients ranged from 19-85 years (mean 55 +/- 14 years) with a male to female ratio of 1.2:1. Majority (70%) of the cases belonged to lower socioeconomic group and 56% were migrants from India. History of tobacco chewing or smoking was present in 78% cases. In 54%, the lesion was located in the middle third of the oesophagus, followed by lower third in 44%. Histology showed squamous cell carcinoma in 86% and adenocarcinoma in 10% cases. Of the 19 cases followed, 16 underwent surgery and 3 received chemotherapy. Two cases died within 7 months following surgery and in 6 carcinomas recurred. All cases receiving chemotherapy died within 8 months of treatment.

H2 receptor antagonist or H. pylori eradication?

To assess the healing and relapse rate of duodenal ulcer (DU) treated with H2 receptor antagonists in helicobacter pylori (HP) positive vs negative cases, we analysed 95 cases of endoscopically proven duodenal ulcer. H. pylori colonization was found in 73 (77%) patients before treatment. No difference was observed in the pre-treatment characteristics between patients with HP positive and HP negative duodenal ulcers. Healing rates with H2 receptor antagonist at 8 weeks were 90% and 91% respectively (NS). No difference in HP colonization was found between patients with and without healed ulcerie, 77% and 78% respectively. Relapse rate within 1 year was 50% in patients with HP positive vs 73% with HP negative cases. We conclude that duodenal ulcer healing and relapse rate is related to acid inhibition rather than HP colonization.

Oesophageal changes in oral submucous fibrosis using fibreoptic endoscopy--a pilot study

Thirty patients with oral submucous fibrosis (OSMF) underwent fibreoptic upper G.I. endoscopy and oesophageal biopsy from 20 cms to see if any correlation is found between visual and histological changes in OSMF and oesophageal mucosa. On endoscopy, the colour of oesophageal mucosa was normal in 28 and whitish pale in 2 cases. On endoscopy mucosa felt stiff and fibrotic in 19, leathery in 4, firm/gritty in 2 and normal in 5 cases. The biopsies were difficult to take in most cases yielding small tissue samples on repeated attempts. On histology most of the samples consisted of only a few layers of hyperplastic epithelium with lamina propria and submucosa being absent in all samples. Good correlation was found between the grade of OSMF and oesophageal changes seen on endoscopy.

Is the vagotomy complete?

Incomplete vagotomy is the single most common cause of ulcer recurrence. Completeness of vagotomy was assessed postoperatively in 17 patients using the congo red test. Various types of vagotomies included truncal vagotomy and gastrojejenostomy in 6, highly selective vagotomy in 5, truncal vagotomy and pyloroplasty in 3 and selective vagotomy with gastrojejenostomy in 3 cases. Congo red test was positive in 13 cases, with 9 of these showing evidence of incomplete vagotomy manifesting as erosions, duodenitis, stomal ulceration or ulcer recurrence.

Misoprostol in the treatment of NSAID-induced gastroduodenal lesions

The cytoprotective effect of misoprostol co-administered with non-steroidal anti-inflammatory drugs (NSAIDs) was assessed in a double blind, placebo controlled study. Thirty-seven patients with rheumatoid arthritis receiving NSAIDs, having upper gastrointestinal symptoms and endoscopically confirmed gastric and/or duodenal lesions, were randomised to receive either misoprostol 200 micrograms or placebo tablets twice daily for 4 weeks. Of 31 evaluable cases, 13 of 16 (81%) patients receiving misoprostol showed endoscopic improvement as compared to 10 of 15 (67%) receiving placebo (P:NS). A significant decrease in mean (+/- SEM) mucosal lesion score was observed with misoprostol (from 3.38 +/- 0.32 to 1.32 +/- 0.44; P less than 0.001) but no change was seen with placebo (from 2.80 +/- 0.42 to 1.60 +/- 0.53; P:NS). Symptomatic relief was similar in both groups, being 44% and 40% respectively. Two patients complained of diarrhea in each group and one developed menorrhagia with misoprostol. It is concluded that though misoprostol decreased the number of NSAID-induced mucosal lesions, it was unable to relieve gastrointestinal symptoms.