The Importance of Artificial Intelligence in Upper Gastrointestinal Endoscopy

Recently, there has been a growing interest in the application of artificial intelligence (AI) in medicine, especially in specialties where visualization methods are applied. AI is defined as a computer's ability to achieve human cognitive performance, which is accomplished through enabling computer "learning". This can be conducted in two ways, as machine learning and deep learning. Deep learning is a complex learning system involving the application of artificial neural networks, whose algorithms imitate the human form of learning. Upper gastrointestinal endoscopy allows examination of the esophagus, stomach and duodenum. In addition to the quality of endoscopic equipment and patient preparation, the performance of upper endoscopy depends on the experience and knowledge of the endoscopist. The application of artificial intelligence in endoscopy refers to computer-aided detection and the more complex computer-aided diagnosis. The application of AI in upper endoscopy is aimed at improving the detection of premalignant and malignant lesions, with special attention on the early detection of dysplasia in Barrett's esophagus, the early detection of esophageal and stomach cancer and the detection of H. pylori infection. Artificial intelligence reduces the workload of endoscopists, is not influenced by human factors and increases the diagnostic accuracy and quality of endoscopic methods.

Current trends in the management of Helicobacter pylori infection in Serbia: preliminary results from the European registry on H. pylori management (Hp-EuReg)

BACKGROUND

Helicobacter pylori (H. pylori) is the most common chronic bacterial infection. Treatment effectiveness remains a subject of debate considering bacterial antimicrobial resistance. Our aim was to analyse the diagnostic methods and eradication treatments for H. pylori infection in Serbia.

METHODS

An observational multicentre prospective study was conducted in Serbia, as part of the European Registry on H. pylori Management (Hp-EuReg). Demographics, treatment indication, diagnostic methods, previous eradication attempts and treatment were collected at AEG-REDCap e-CRF. Modified intention-to-treat (mITT) and per protocol (PP) effectiveness analyses were performed. Safety, compliance and bacterial antimicrobial resistance rates were reported. Data was quality checked.

RESULTS

Overall 283 patients were included, with a mean age of 55±15 years. Dyspepsia (n=214, 77%) was the most frequent treatment indication, and histology (n=144, 51%) was the most used diagnostic method. Overall eradication rate was 95% (PP) and 94% (mITT). Most prevalent first-line therapy was quadruple PPI+clarithromycin+amoxicillin+metronidazole, with a 96% effectiveness (p<0.001). Second-line main treatment choice was triple-amoxicillin+levofloxacin, with a 95% effectiveness (p<0.05). Single-capsule Pylera ® was the most prescribed third-line therapy, with 100% effectiveness (p<0.05). Longer treatment duration was associated with a higher eradication rate in first-line therapy (p<0.05). Clarithromycin and quinolone resistance rates in first-line were 24% and 8.3%, respectively. The overall adverse events' incidence rate was 13.4%, and therapy compliance was 97%.

CONCLUSIONS

Considering the high eradication rate, 14-day non-bismuth quadruple concomitant therapy is a reasonable first-line choice, while quinolone-based therapy and single-capsule Pylera ® should be considered as rescue therapy options.

Dyspepsia Challenge in Primary Care Gastroenterology

BACKGROUND

The purpose of this review is to take a deep dive into general problems and challenges of diagnosis and treatment of patients with symptoms of dyspepsia in primary care practice.

SUMMARY

Primary care physicians become acquainted with a broad range of clinical problems and therefore require a wide span of knowledge in taking care of patients from their first medical examination within the health care system. Dyspepsia and Helicobacter pylori infection are two of the most frequent reasons of digestive-related health care issues, despite that in primary care practice, current recommendations for diagnosis and differential therapy are often not implemented. The "test-and-treat" strategy is the initial management of the condition, reserving gastroscopy for patients refractory to symptomatic treatment and for patients presenting with any of the following alarm signs: age of above 55, dysphagia, anemia, weight loss, frequent vomiting, family history of GI malignancy, or a physical examination with key pathological findings.

KEY MESSAGES

Examination and treatment of dyspepsia symptoms is the diagnostic and therapeutic challenge dictated by organizational and economic potentials of the health system, professional resources, and primary health care capabilities to accept and treat patients with dyspepsia and to properly refer those with alarm symptoms and findings indicative of organic disease to a gastroenterologist.

Chronic Constipation: Gastroenterohepatologist's Approach

BACKGROUND

Constipation is a common problem in gastroenterological practice. The prevalence of constipation is about 16%. Constipation can be primary or secondary.

SUMMARY

The diagnostic and therapeutic approach to patients with constipation begins with a detailed history and physical examination. In selected cases, the use of additional diagnostic procedures is very important. This includes the use of laboratory, endoscopic, and radiological examinations, as well as advanced physiological testing (anorectal manometry, balloon expulsion test, colonic transit studies, and defecography). Constipation therapy can be both nonoperative and operative. Nonoperative therapy includes the application of a lifestyle measures, pharmacotherapy and biofeedback therapy. Key Messages: Two key things when taking a medical history and physical examination are to rule out the existence of alarm symptoms/signs and to rule out secondary constipation (primarily drug-induced). Therapy begins with lifestyle modification, and in case of failure, bulk or osmotic laxatives are used. In case of failure, the use of lubiprostone is indicated, as well as linaclotide. Surgical treatment of constipation is reserved for cases of refractory constipation, with delayed intestinal transit.

Chronic Abdominal Pain: Gastroenterologist Approach

BACKGROUND

Abdominal pain is a common symptom of gastroenterology examination. Chronic abdominal pain is present for >3 months.

SUMMARY

Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal diseases encountered by both gastroenterologists and general practitioners. GERD is usually a chronic disease presented with a set of symptoms including heartburn and/or regurgitation, and less commonly epigastric pain. Epigastric pain syndrome is characterized by the following symptoms: epigastric pain and/or burning. It does not necessarily occur after meal ingestion, may occur during fasting, and can be even improved by meal ingestion. Duodenal ulcers tend to cause abdominal pain that is localized in the epigastric region and commence several hours after eating, often at night. Hunger provokes pain in most of the cases and decreases after meal. Gastric ulcer pain occurs immediately after eating, and consuming food increases pain. Pain is localized in the epigastrium and can radiate to the back. Abdominal pain in irritable bowel syndrome is related to defecation. A typical symptom of chronic pancreatitis is pain that radiates to the back. In Crohn's disease, inflammation causes pain. Key Messages: Pain can occur at different locations with diverse intensity and propagation and is often associated with other symptoms. For any gastroenterologist, abdominal pain is a big challenge.

Helicobacter pylori first-line and rescue treatments in patients allergic to penicillin: Experience from the European Registry on H pylori management (Hp-EuReg)

BACKGROUND

Experience in Helicobacter pylori eradication treatment of patients allergic to penicillin is very scarce. A triple combination with a PPI, clarithromycin (C), and metronidazole (M) is often prescribed as the first option, although more recently the use of a quadruple therapy with PPI, bismuth (B), tetracycline (T), and M has been recommended.

AIM

To evaluate the efficacy and safety of first-line and rescue treatments in patients allergic to penicillin in the "European Registry of H pylori management" (Hp-EuReg).

METHODS

A systematic prospective registry of the clinical practice of European gastroenterologists (27 countries, 300 investigators) on the management of H pylori infection. An e-CRF was created on AEG-REDCap. Patients with penicillin allergy were analyzed until June 2019.

RESULTS

One-thousand eighty-four patients allergic to penicillin were analyzed. The most frequently prescribed first-line treatments were as follows: PPI + C + M (n = 285) and PPI + B + T + M (classic or Pylera^® ; n = 250). In first line, the efficacy of PPI + C + M was 69%, while PPI + B + T + M reached 91% (P < .001). In second line, after the failure of PPI + C + M, two rescue options showed similar efficacy: PPI + B + T + M (78%) and PPI + C + levofloxacin (L) (71%) (P > .05). In third line, after the failure of PPI + C + M and PPI + C + L, PPI + B + T + M was successful in 75% of cases.

CONCLUSION

In patients allergic to penicillin, a triple combination with PPI + C + M should not be generally recommended as a first-line treatment, while a quadruple regimen with PPI + B + T + M seems to be a better option. As a rescue treatment, this quadruple regimen (if not previously prescribed) or a triple regimen with PPI + C + L could be used but achieved suboptimal (<80%) results.

Burden of Gastroduodenal Diseases from the Global Perspective

PURPOSE OF REVIEW

We reviewed the recent medical literature to show global burden of gastroduodenal disease, potential strategies, and further perspectives.

RECENT FINDINGS

Gastrointestinal and liver diseases are growing health problems, and cause more than 8 million deaths per year worldwide; encompass a range of long-term health conditions, such as digestive cancers, gastroesophageal reflux disease, Helicobacter pylori infection, peptic ulcer disease, liver diseases, inflammatory bowel disease, coeliac disease, and functional gastrointestinal disorders. Scientific knowledge demonstrates that the noncommunicable disease burden can be greatly reduced if cost-effective preventive and curative actions, along with interventions for prevention and control of noncommunicable diseases already available, are implemented in an effective and balanced manner.

SUMMARY

Future research will have to elaborate on simple methods for preselection of patients at high risk to allow their implementation in strategies and respect all demand of cost-effectiveness. Understanding trends in GI illnesses could be helpful to meet the needs of patients and decrease the disease burden.

Metabolic Syndrome in Inflammatory Bowel Disease: Association with Genetic Markers of Obesity and Inflammation

Background: This study analyzed poorly understood relationship of two overlapping conditions: metabolic syndrome (MeS) and inflammatory bowel disease (IBD), both associated with inflammation in the visceral adipose tissue. Methods: Newly diagnosed 104 IBD patients, of which 50 Crohn's disease (CD) and 54 ulcerative colitis (UC), and 45 non-IBD controls were examined for MeS-related obesity and lipid markers. Th-17 immune genes IL17A, IL17F, IL23A, and TLR9 mRNAs were measured in intestinal mucosa by qRT-PCR. Subjects were genotyped for obesity-associated FTO variant rs9939609 by polymerase chain reaction-amplification refractory mutation system. Results: CD was associated with MeS (P = 0.01), while both CD and UC were associated with central obesity (P = 10^-5, P = 0.002, respectively) and low levels of high-density lipoprotein (HDL) cholesterol (P = 5 × 10^-6, P = 6 × 10^-6, respectively). IBD lipid profile was characterized by decreased total and HDL cholesterol, while low-density lipoprotein cholesterol was reduced only in CD. Negative correlations were found between total cholesterol and CD activity index (P = 0.005), waist circumference and IL17A as well as IL17F mRNA levels in inflamed CD colon (P = 0.003, P = 0.001, respectively). Carriers of FTO rs9939609 AA genotype showed increased risk of CD (OR 2.6, P = 0.01). Conclusions: MeS, central obesity, and dyslipidemia could be important for IBD pathogenesis. This could influence therapeutic approaches and prevention strategies in high-risk groups.

Assessment of Duodenal Adenomas and Strategies for Curative Therapy

BACKGROUND

The increasing incidence of duodenal neoplasm has underlined different methods of resection depending on the clinical presentation, endoscopic features and histopathology. In this comprehensive review, we systematically describe the current knowledge concerning the diagnosis and management of duodenal adenomas (DAs) and discuss data considering all possible therapeutic approaches.

SUMMARY

Among a variety of duodenal lesions, including neuroendocrine tumors and gastrointestinal stromal tumors, DAs present precancerous lesions of the duodenal papilla or non-ampullary region necessitating removal. DAs can occur sporadically (SDA) as rare lesions or relatively common in polyposis syndromes. The endoscopic resections of DA are associated with an increased degree of complexity due to distinctive anatomical properties of the duodenal wall, luminal diameter and the presence of ampulla with pancreatic and biliary drainage. The endoscopic techniques including cold snare polypectomy (CSP), endoscopic mucosal resection (EMR), and argon plasma coagulation ablation are suggested to be less invasive than surgical treatment, associated with shorter hospital stay and lower cost. According to the current clinical practice, surgery has been accepted as standard therapeutic approach in familial adenomatous polyposis patients with severe polyposis or DA not amenable to endoscopic resection. Key Messages: The strategy for endoscopic resection of DAs depends on the lesion size, morphology, location, and histopathology findings. Small adenomas are most frequently diagnosed and removed by standard CSP techniques, while large laterally spreading lesions and ampullary adenoma are referred for EMR or endoscopic papillectomy respectively. Screening colonoscopy is indicated in patients with SDA. Additional studies for new endoscopic strategies and techniques for curative therapy of DAs are needed to refine future management decisions. Complete resection of DA is considered curative, but nevertheless, long-term endoscopic follow-up is still required to detect and treat any recurrent arising lesions.

Multiple Myeloma Associated Intestinal Amyloidosis: Intestinal Pseudoobstruction Falsely Considered as an Ascites

INTRODUCTION

Amyloidosis is a group of diseases pathohistologically diagnosed by characteristic extracellular deposition of an abnormal fibrillary protein (i.e. amyloid) into organs, leading to organ dysfunction secondary to destruction of normal tissue architecture.

METHODS

Case-report of a 44 year-old female, presenting with massive abdominal distension clinically suspected of ascites.

RESULTS

On admission, the patient was complaining of nausea, vomiting, abdominal pain, distension and bloating associated with weight loss and diarrhoea. Her prior medical history revealed a treatment naïve viral hepatitis C (HCV) infection with normal liver tests. She was on long term haemodialysis due to end-stage renal disease. Based on clinical, laboratory and radiology findings we established the diagnosis of light chain amyloidosis associated with multiple myeloma, complicated with amyloid bowel depositions and intestinal pseudo-obstruction. On imaging, diffuse liver enlargement was seen. Liver biopsy could have rendered the possible cause of hepatomegaly, but patient's noncompliance hindered the answer whether liver involvement was the consequence of a chronic hepatitis due to HCV infection or amyloid accumulation. Unfortunately, consequent patient's death prevented specific treatment implementation.

CONCLUSION

Patients with multiple myeloma and obscure abdominal complaints should be worked up for amyloidosis. Intestinal pseudo-obstruction due to amyloidosis can imitate in certain instances ascites hence complicating diagnostic algorithm. In such complex clinical cases, close collaboration between surgeon, gastroenterohepatologist and haematologist is necessary.

Gastrointestinal Tract Disorders in Older Age

Considering an increase in the life expectancy leading to a rise in the elderly population, it is important to recognize the changes that occur along the process of aging. Gastrointestinal (GI) changes in the elderly are common, and despite some GI disorders being more prevalent in the elderly, there is no GI disease that is limited to this age group. While some changes associated with aging GI system are physiologic, others are pathological and particularly more prevalent among those above age 65 years. This article reviews the most important GI disorders in the elderly that clinicians encounter on a daily basis. We highlight age-related changes of the oral cavity, esophagus, stomach, small and large bowels, and the clinical implications of these changes. We review epidemiology and pathophysiology of common diseases, especially as they relate to clinical manifestation in elderly. Details regarding management of specific disease are discussed in detail if they significantly differ from the management for younger groups or if they are associated with significant challenges due to side effects or polypharmacy. Cancers of GI tract are not included in the scope of this article.

Accuracy and Pitfalls in the Assessment of Early Gastrointestinal Lesions

Superficial neoplastic lesions of the digestive tract are usually asymptomatic, and often represent incidental findings on endoscopy. The Paris Classification was developed for the systematic evaluation of superficial lesions of the oesophagus, stomach and colon. The significance of this classification in clinical practice is that it allows the depth of invasion to be estimated. Chromoendoscopy is used to improve the visualization of gastrointestinal lesions. There are 2 types of chromoendoscopy: dye and virtual chromoendoscopy. In addition to chromoendoscopy, advanced endoscopy techniques have great importance in the detection of early gastrointestinal lesions. Although the depth of invasion can be estimated by endoscopy, the final decision regarding therapeutic approach is made on the basis of histopathological examination, as obtained by biopsy or endoscopic resection (ER). Polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection may be considered ER. For early gastrointestinal lesions with or without limited submucosal infiltration, ER can serve as therapy. In patients with neoplastic lesions localized deeper than the submucosa, or if the location of the lesion carries a high risk of perforation, a full-thickness resection can be performed. Guidelines for assessment and therapy of early oesophageal, gastric and colorectal lesions are currently available.

Importance of TLR9-IL23-IL17 axis in inflammatory bowel disease development: Gene expression profiling study

BACKGROUND AND AIMS

Mucosal gene expression have not been fully enlightened in inflammatory bowel disease (IBD). Aim of this study was to define IL23A, IL17A, IL17F and TLR9 expression in different IBD phenotypes.

METHODS

Evaluation of mRNA levels was performed in paired non-inflamed and inflamed mucosal biopsies of newly diagnosed 50 Crohn's disease (CD) and 54 ulcerative colitis (UC) patients by quantitative real-time PCR analysis.

RESULTS

IL17A and IL17F expression levels were significantly increased in inflamed IBD mucosa. Inflamed CD ileal and UC mucosa showed increased IL23A, while only inflamed CD ileal samples showed increased TLR9 mRNA level. Correlation between analysed mRNAs levels and endoscopic and clinical disease activity were found in UC, but only with clinical activity in CD.

CONCLUSION

Both CD and UC presented expression of Th17-associated genes. Nevertheless, expression profiles between different disease forms varies which should be taken into account for future research and therapeutics strategies.

Erythropoietin in Predicting Prognosis in Patients with Acute-on-Chronic Liver Failure

BACKGROUND AND AIMS

Acute-on-chronic liver failure (ACLF) is characterized by a rapid progression to multiple organ failure and is associated with a very high mortality rate of 50-90%. Novel therapies are being investigated such as Erythropoietin (EPO). The aim of this prospective cohort study was to analyse the value of EPO in predicting prognosis and determine which patients may benefit most from EPO therapy.

METHODS

According to the EASL-CLIF criteria, 104 consecutive patients were diagnosed with ACLF, and separated into two groups based on the type of insult: bleeding (Group A=31) or non-bleeding (Group B=73). In addition to a complete biochemical work-up and calculation of relevant prognostic scores, levels of EPO were measured on admission and correlated to the type of insult and final outcome.

RESULTS

Fifteen patients from Group A (mean age 60.32+/-9.29 years) had a lethal outcome and higher values of EPO on admission (319.26+/-326.58 mIU/ml) (p<0.005), compared to the 37 patients from Group B (mean age 59.9+/-10.19 years) with EPO levels at admission of 29.88+/-34.6 mIU/mL. In Group B, a cut-off EPO value of 30.65 mIU/mL had a sensitivity of 87.5% and a specificity 57.4% in predicting lethal outcome with an AUROC of 0.823. In Group A, a cut-off value of 229.95 mlU/mL had a sensitivity and specificity of 53.3% and 92.7%, respectively. The AUROC for this cut-off was 0.847.

CONCLUSIONS

Erythropoietin is superior to the standard prognostic scores in predicting 28-day mortality. Lower levels of EPO were detected in patients without bleeding as an insult indicating a possible therapeutic benefit in these patients.

Translation and validation of the Serbian primary biliary cholangitis-40 questionnaire

Background and aims

To translate into Serbian and validate the Primary Biliary Cholangitis–40 (PBC-40) and PBC-27 questionnaires.

Materials and methods

Ninety-four consecutive outpatients with the diagnosis of PBC from three departments across two tertiary care institutions in Belgrade were enrolled from February to October 2016. Standard methodology for cultural adaption of healthcare related quality of life questionnaires was used, and included: a forward translation, backward translation and a pilot test of the Serbian PBC-40 on five patients who gave suggestions and comments. For evaluation of the questionnaires, acceptance was shown by the proportion of missing items and the internal consistency was assessed using Cronbach’s α coefficient. The PBC-40 was self-administered under the supervision of an experienced hepatologist. The PBC-27 is a shorter version of the PBC-40.

Results

A total of 92 (97.9%) of the patients were females. The mean age was 59.26 ± 1.05 years and the average length of disease was 60.45 ± 48.314 months. The average PBC-40 score was 85.62 ± 30.46. The total time needed to complete the questionnaire ranged from 7 to 16 minutes. The proportion of missing items was 5.45% (205/3760). Cronbach’s α for the entire scale was 0.93. Reliability for all of the domains of the PBC-40 was above 0.70, except for the domain “Symptoms” (α = 0.52). Overall reliability of the PBC-27 was α = 0.90. Domains “Dryness”, “Symptoms” and “Fatigue” demonstrated reliability below α = 0.70.

Conclusions

The Serbian PBC-40 is a valid and reasonably adequate for use in Serbian PBC patients. The PBC-40 is preferred over the PBC-27.

Drug-induced liver injury: Do we know everything?

Interest in drug-induced liver injury (DILI) has dramatically increased over the past decade, and it has become a hot topic for clinicians, academics, pharmaceutical companies and regulatory bodies. By investigating the current state of the art, the latest scientific findings, controversies, and guidelines, this review will attempt to answer the question: Do we know everything? Since the first descriptions of hepatotoxicity over 70 years ago, more than 1000 drugs have been identified to date, however, much of our knowledge of diagnostic and pathophysiologic principles remains unchanged. Clinically ranging from asymptomatic transaminitis and acute or chronic hepatitis, to acute liver failure, DILI remains a leading causes of emergent liver transplant. The consumption of unregulated herbal and dietary supplements has introduced new challenges in epidemiological assessment and clinician management. As such, numerous registries have been created, including the United States Drug-Induced Liver Injury Network, to further our understanding of all aspects of DILI. The launch of LiverTox and other online hepatotoxicity resources has increased our awareness of DILI. In 2013, the first guidelines for the diagnosis and management of DILI, were offered by the Practice Parameters Committee of the American College of Gastroenterology, and along with the identification of risk factors and predictors of injury, novel mechanisms of injury, refined causality assessment tools, and targeted treatment options have come to define the current state of the art, however, gaps in our knowledge still undoubtedly remain.

Doppler ultrasonography combined with transient elastography improves the non-invasive assessment of fibrosis in patients with chronic liver diseases

AIMS

Accurate clinical assessment of liver fibrosis is essential and the aim of our study was to compare and combine hemodynamic Doppler ultrasonography, liver stiffness by transient elastography, and non-invasive serum biomarkers with the degree of fibrosis confirmed by liver biopsy, and thereby to determine the value of combining non-invasive method in the prediction significant liver fibrosis.

MATERIAL AND METHODS

We included 102 patients with chronic liver disease of various etiology. Each patient was evaluated using Doppler ultrasonography measurements of the velocity and flow pattern at portal trunk, hepatic and splenic artery, serum fibrosis biomarkers, and transient elastography. These parameters were then input into a multilayer perceptron artificial neural network with two hidden layers, and used to create models for predicting significant fibrosis.

RESULTS

According to METAVIR score, clinically significant fibrosis (≥F2) was detected in 57.8% of patients. A model based only on Doppler parameters (hepatic artery diameter, hepatic artery systolic and diastolic velocity, splenic artery systolic velocity and splenic artery Resistance Index), predicted significant liver fibrosis with a sensitivity and specificity of75.0% and 60.0%. The addition of unrelated non-invasive tests improved the diagnostic accuracy of Doppler examination. The best model for prediction of significant fibrosis was obtained by combining Doppler parameters, non-invasive markers (APRI, ASPRI, and FIB-4) and transient elastography, with a sensitivity and specificity of 88.9% and 100%.

CONCLUSION

Doppler parameters alone predict the presence of ≥F2 fibrosis with fair accuracy. Better prediction rates are achieved by combining Doppler variables with non-invasive markers and liver stiffness by transient elastography.

Non-alcoholic fatty pancreas disease

Obesity is a growing problem worldwide and disorders associated with excess body fat including the metabolic syndrome, type 2 diabetes mellitus (T2DM), cardiovascular disease and malignant neoplasms are becoming a major cause of morbidity and mortality. Over the past decade, a vast amount of research has furthered our understanding of non-alcoholic fatty liver disease; however, only recently pancreatic fat infiltration is coming to the forefront of investigation. Termed non-alcoholic fatty pancreas disease (NAFPD), it is becoming evident that it has important associations with other diseases of obesity. It appears to arise as obesity progresses and after an initial phase of pancreatic hypertrophy and hyperplasia, fatty infiltration becomes apparent. Various studies have demonstrated that NAFPD may exacerbate the severity of acute pancreatitis, promote pancreatic dysfunction associated with insulin resistance and T2DM, and even have links to the development of pancreatic carcinoma, and therefore, it must be investigated in further detail.

Variations in inflammatory genes as molecular markers for prediction of inflammatory bowel disease occurrence

OBJECTIVE

Research on inflammatory bowel disease (IBD) has highlighted genes involved in the regulation of inflammatory responses as contributors to disease pathogenesis. This study aimed to evaluate the associations between IBD and variations in NOD2, TLR4, TNF-α, IL-6, IL-1β and IL-1RN genes, and to use the genetic data obtained in predictive modeling.

METHODS

A total of 167 IBD patients and 101 healthy controls were genotyped by polymerase chain reaction-restriction fragment length polymorphism. Using the genotype data attained as the input to various classification algorithms, IBD prediction models were designed. The area under the receiver operating characteristic curve (AUROC) was used to measure their performance.

RESULTS

Significant associations were found between Crohn's disease (CD) and minor NOD2 variants, as well as TLR4 299Gly, TNF-α G-308A, IL-6 G-174C and IL-1RN VNTR A2 variants, while ulcerative colitis (UC) was associated only with IL-1RN VNTR A2 variants. CD and UC showed highly significant difference in the allelic distribution of TNF-α G-308A, where the A allele was found to be related to CD, and the G allele to UC. A combined effect of patients' gender and TLR4 variants was observed among CD patients. When all analyzed genotype and gender data were used, prediction performance achieved a maximum AUROC of 0.690 for CD and 0.601 for UC dataset.

CONCLUSION

Variations in the genes involved in immune regulation are genetic factors of importance in IBD susceptibility that could potentially be used as predictors of disease development.

Role of Helicobacter pylori infection in gastric carcinogenesis: Current knowledge and future directions

Helicobacter pylori (H. pylori) plays a role in the pathogenesis of gastric cancer. The outcome of the infection depends on environmental factors and bacterial and host characteristics. Gastric carcinogenesis is a multistep process that is reversible in the early phase of mucosal damage, but the exact point of no return has not been identified. Therefore, two main therapeutic strategies could reduce gastric cancer incidence: (1) eradication of the already present infection; and (2) immunization (prior to or during the course of the infection). The success of a gastric cancer prevention strategy depends on timing because the prevention strategy must be introduced before the point of no return in gastric carcinogenesis. Although the exact point of no return has not been identified, infection should be eradicated before severe atrophy of the gastric mucosa develops. Eradication therapy rates remain suboptimal due to increasing H. pylori resistance to antibiotics and patient noncompliance. Vaccination against H. pylori would reduce the cost of eradication therapies and lower gastric cancer incidence. A vaccine against H. pylori is still a research challenge. An effective vaccine should have an adequate route of delivery, appropriate bacterial antigens and effective and safe adjuvants. Future research should focus on the development of rescue eradication therapy protocols until an efficacious vaccine against the bacterium becomes available.

The role of fecal calprotectin in assessment of hepatic encephalopathy in patients with liver cirrhosis

INTRODUCTION

Calprotectin is a cytoplasmatic protein of neutrophilic granulocytes and it is an established marker for the assessment of localized intestinal inflammation.

AIM

To explore correlation between values of fecal calprotectin and degree of liver cirrhosis and hepatic encephalopathy.

METHODS

We included 60 patients with liver cirrhosis and 37 healthy patients as controls. Patients revealing other causes of abnormal calprotectin results (gastrointestinal bleeding or inflammatory bowel disease) were excluded. The degree of liver insufficiency was assessed according to the Child-Pugh classification and Model of End Stage Liver Disease (MELD), and degree of hepatic enceph- alopathy by West-Haven criteria, serum concentration of ammonium ion and the number connection test.

RESULTS

The mean value of fecal calprotectin in patients with liver cirrhosis was 189.1 ± 168.0 μg/g, and 35.0 ± 26.0 μg/g in the control group, respectively. We have confirmed significantly higher fecal calprotectin in patients with cirrhosis (p < 0.001). There were no significant differences in values of fecal calprotectin between the patients with different stages of liver cirrhosis according to Child-Pugh classification and MELD score (p > 0.05). We observed statistically significant difference comparing fecal calprotectin by West-Haven criteria of hepatic encephalopathy (p < 0.001), while there were no correlation with the number connection test and serum concentration of ammonium ion (p > 0.05).

CONCLUSION

We confirmed significantly higher values of fecal calprotectin in patients with liver cirrhosis, especially in hepatic encephalopathy according to West-Haven criteria.

Expression and cellular distribution of glucose transporters and alpha subunits of Na+/K+-ATPase in the heart of fructose-fed female rats: the role of estradiol

Remarkable parallels are observed between glucose transporters (GLUT) and subunits of Na+/K+-ATPase, which deal with insulin regulation, tissue specificity, intracellular distribution and function of these proteins. To test our hypothesis that similarities also exist in alteration of cardiac GLUTs and alpha subunit isoforms of the pump in insulin resistance, animal model of fructose rich diet was exploited. The role of estradiol in regulation of GLUTs and Na+/K+-ATPase in insulin resistance context was studied as well. Cardiac protein expression, as well as insulin-regulated cellular localization of GLUT4, GLUT1, and α1 and α2 subunits of the pump were analyzed by Western blot. Fructose rich diet increased plasma insulin level and HOMA index, while estradiol treatment reversed both parameters to the control level. We did not observe obvious similarities in the pattern of alterations of GLUT1/α1 subunit of the pump, as well as GLUT4/α2 subunit, related to diet or hormone treatment. Considering alterations in expression and cellular localization of GLUTs and the pump subunits, fructose rich diet jeopardized cardiac glucose transport in some extent, but in contrast, stimulated Na+/K+-ATPase function. Estradiol treatment opposed the fructose diet biochemical action and the effect on cardiac GLUTs, but was inefficient concerning the changes of cardiac Na+/K+-ATPase subunits. Changes of the cardiac molecules can be mediated by alterations in the level of insulin and nonesterified fatty acids, induced by the diet and hormone treatment.

Extraintestinal manifestations of autoimmune pancreatitis

The term autoimmune pancreatitis (AIP) was first used in Japan in 1995 to describe a newly recognized form of chronic pancreatitis, after the description of Yoshida and colleagues. But Sarles in 1961, first described a form of idiopathic chronic inflammatory sclerosis of the pancreas, suspected to be due to an autoimmune process. AIP has become a widely accepted term because clinical, serologic, histologic, and immunohistochemical findings suggest an autoimmune mechanism. Most affected patients have hypergammaglobulinemia and increased serum levels of IgG, particularly IgG4. Recently published International Consensus Diagnostic Criteria for Autoimmune Pancreatitis include Guidelines of the International Association of Pancreatology, classifying AIP into types 1 and 2, using five cardinal features of AIP, namely imaging of pancreatic parenchyma and duct, serology, other organ involvement, pancreatic histology, and an optional criterion of response to steroid therapy. Extrapancreatic presentations can include sclerosing cholangitis, retroperitoneal fibrosis, sclerosing sialadenitis (Küttner tumor), lymphadenopathy, nephritis, and interstitial pneumonia. Increased IgG4+ plasma cell infiltrate has been reported in sclerosing lesions from other organ sites, including inflammatory pseudotumors of the liver, breast, mediastinum, orbit, and aorta, and it has been observed with hypophysitis and IgG4-associated prostatitis. Abundant IgG4+ plasma cells were also confirmed in Riedel thyroiditis, sclerosing mesenteritis, and inflammatory pseudotumor of the orbit and stomach. Extrapancreatic lesions could be synchronously or metachronously diagnosed with AIP, sharing the same pathological conditions, showing also a favorable result to corticosteroid therapy and distinct differentiation between IgG4-related diseases from the inherent lesions of the corresponding organs.

Complications of peptic ulcer disease

There are four major complications of peptic ulcer disease (PUD): bleeding, perforation, penetration, and obstruction. Complications can occur in patients with peptic ulcer of any etiology. Despite improvements in the medical management and the lower overall incidence of PUD, there are conflicting data about the incidence of potentially life-threatening ulcer complications. There are important time trends embedded within this stable overall rate of complications: the dramatic decline in the prevalence of Helicobacter pylori (comparing the cohort born from 1900 to 1920 to cohorts born after 1940); an increased use of nonsteroidal anti-inflammatory drugs, and an increased rate of ulcer complications related to such drug use, especially in the elderly. As a result of these trends, ulcer complications are on the rise in older patients but on the decline in younger individuals. Hemorrhage is the most frequent PUD complication and its incidence is increasing in comparison to perforation and stenosis. Therapeutic endoscopy is considered the treatment of choice for bleeding ulcers, reducing the need for emergent surgical procedures to 10-20% of the cases. In recent years, besides the success of angiographic embolization, the containment of massive hemorrhage must also be taken into account. Transcatheter arterial embolization is also an effective and safe treatment in patients with duodenal ulcers re-bleeding after therapeutic endoscopy or surgery.

Interaction between insulin and estradiol in regulation of cardiac glucose and free fatty acid transporters

The estrogen binding to specific extranuclear receptors (ER) activates several intracellular pathways that are activated by insulin as well. Moreover, insulin and estradiol (E2) influence cardiac energy substrates, blood glucose and free fatty acids (FFAs), and both hormones exert cardio-beneficial effects. In view of these facts, we suggest that cross-talk between their signaling pathways might have an important role in regulation of cardiac energy substrate transport. Ovariectomized rats were treated with insulin, estradiol (E2), or their combination 20, 30, or 40 min before analysis of blood glucose and FFA level, as well as cardiac plasma membranes (PM) and low density microsomes (LDM) content of glucose (GLUT4 and GLUT1) and FFA (CD36) transporters. Insulin, given alone, or in combination with E2, decreased plasma glucose level at all time points, but did not influence FFA level, while E2 treatment itself did not change glucose and FFA concentration. Insulin increased PM GLUT4 and GLUT1 content 30 and 40 min after treatment and the increases were partially accompanied by decrease in transporter LDM content. E2 increased PM content and decreased LDM content only of GLUT4 at 30 min. Insulin generally, and E2 at 20 min increased CD36 content in PM fraction. Both hormones decreased CD36 LDM content 20 min after administration. Effect of combined treatment mostly did not differ from single hormone treatment, but occasionally, particularly in distribution of GLUT4, combined treatment emphasized single hormone effect, suggesting that insulin and E2 act synergistically in regulation of energy substrate transporters in cardiac tissue.

Classification of chronic pancreatitis

Chronic pancreatitis (CP), defined as a continuing inflammatory disease of the pancreas characterized by irreversible morphological changes which typically cause abdominal pain and/or permanent impairment of pancreatic function, has proved resistant to categorization. The disease may present clinically either with an individual symptom or a combination of symptoms associated with loss of pancreatic function. The single most frequent symptom of CP is pain, either in the form of intermittent episodes or in a more chronic or persistent pattern. The natural history of CP is usually characterized by progression of tissue damage and various degrees of exocrine and endocrine pancreatic insufficiency, which will become apparent over time. The main reason for the lack of guided strategies in the therapeutic management of CP is the absence of a clinically applicable classification of CP. In the past, several classifications have certainly contributed to a better understanding of the pathogenesis and pathophysiology of CP. The meetings in Marseilles (1963 and 1984), Cambridge (1984) and in Rome (1985) added a great deal of information to our knowledge of the pathogenesis and evolution of CP. More recent work on understanding the temporal course of CP led to the Zurich international classification which has been used to define patient cohorts in recent studies of patients undergoing surgery for CP. In order to combine clinical experience in the field of CP with progress in diagnostic methods and new molecular technologies for the assessment of CP, a classification of CP based on key clinical aspects is crucial. A new classification should first be validated to determine whether it can be applied to the majority of patients with CP, and then the value of such a classification needs to be tested in our understanding of the natural course in different etiologies (progression, arrest, regression) and most importantly, to study the clinical outcome when different therapeutic strategies are applied.

Gastrointestinal and liver tumours and public health in Europe

STATE OF THE ART

Europe comprises only one eighth of the total world population but has around one quarter of the global total of cancer cases--some 3.2 million new patients per year. While the disproportionate cancer burden is readily apparent, the disease patterns in Europe cannot simply be generalized--overall cancer incidence and mortality rates vary at least two-fold between European countries and the differences are often far greater for specific cancers. With 1.7 million deaths each year, cancer currently represents the second most important cause of death in Europe. The range of survival rates is similarly wide. For individual cancers, the variation across Europe is even greater. This reflects a wide range of social and epidemiological factors in different countries: cancer prevention programmes; screening programmes; cancer control plans; individual lifestyles and occupational exposures; the existence and accessibility of health-care facilities and technological infrastructure; and the availability of human, financial and material resources for health and economic development. Europe has some of the richest countries in the world, but also some of the poorest. In 2002, 168 million people were living below the poverty line, about 46% of the European population. The time trends in cancer risk also vary between European countries and some cancers show different trends between men and women, or young and old, or poor and rich. The public health profile of cancer in Europe is complex. Trends in the incidence and mortality rates are also influenced by successes in health promotion (e.g. tobacco control), efficient screening (e.g. breast, bowel, cervix) and better treatment. These have been reflected in lower incidence, reduced mortality, higher survival, improved life expectancy and a better quality of life for cancer survivors.

CONCLUSIONS

Cancer of the gastrointestinal (GI) tract is the most common cancer in Europe. More than half of GI cancer cases arise from the colon. They can remain asymptomatic until late in the natural history of the disease, and as this is the stage at which they can be cured, screening has been advocated for well members of the population and surveillance for those with conditions predisposing to cancer.

Insulin signaling in the liver and uterus of ovariectomized rats treated with estradiol

We used rat hepatic and uterine tissues to examine the impact of estradiol (E2) on insulin (INS) signaling. Ovariectomized (OVX) female Wistar rats were treated with E2 (20 microg/kg b.wt., i.p.) and used for the experiment 6h after E2 administration. To highlight E2 effects on tyrosine phosphorylation of INS receptor (IR) and INS receptor substrates (IRSs) and IRSs association with p85 subunit of phosphatidylinositol 3-kinase (PI3-K) in the context of INS signaling, E2-treated OVX rats were also injected with INS (20 IU, i.p.), 30 min before the experiment. Treatment with E2 did not change the levels of plasma INS and glucose (Glu). However, it significantly decreased the free fatty acid (FFA) level and increased uterine weight. Furthermore, the results show that E2 had no effect on the content of hepatic IR protein, but significantly increased IR protein content in the uterus and decreased IR tyrosine phosphorylation in both the liver and uterus. Compared to the control, hepatic IRS-1 and IRS-2 were significantly decreased and increased, respectively, after E2 treatment. Protein content of both molecules, IRS-1 and IRS-2, was increased in uterine tissue after E2 administration. Protein content of the p85 subunit of PI3-K and that of protein kinase B (Akt) were increased in the uterus, with no changes in the liver. The results suggest that E2 treatment induces tissue-specific changes in INS signaling. The consequences of E2 treatment on INS signaling molecules are more apparent in the uterus, but their physiological relevance for INS action is probably greater in the liver.

Expression of cytokeratins in Helicobacter pylori –associated chronic gastritis of adult patients infected with cagA+ strains: An immunohistochemical study

AIM: To investigate the expression of different cytokeratins (CKs) in gastric epithelium of adult patients with chronic gastritis infected with Helicobacter pylori (H pylori) cagA+ strains.

METHODS: The expression of CK 7, 8, 18, 19 and 20 was studied immunohistochemically in antral gastric biopsies of 84 patients. All the CKs were immunostained in cagA+H pylori gastritis (57 cases), non-H pylori gastritis (17 cases) and normal gastric mucosa (10 cases).

RESULTS: In cagA+ H pylori gastritis, CK8 was expressed comparably to the normal antral mucosa from surface epithelium to deep glands. Distribution of CK18 and CK 19 was unchanged, i.e. transmucosal, but intensity of the expression was different in foveolar region in comparison to normal gastric mucosa. Cytokeratin 18 immunoreactivity was significantly higher in the foveolar epithelium of H pylori-positive gastritis compared to both H pylori-negative gastritis and controls. On the contrary, decrease in CK19 immunoreactivity occurred in foveolar epithelium of H pylori-positive gastritis. In both normal and inflamed antral mucosa without H pylori infection, CK20 was expressed strongly/moderately and homogenously in surface epithelium and upper foveolar region, but in H pylori -induced gastritis significant decrease of expression in foveolar region was noted. Generally, in both normal antral mucosa and H pylori-negative gastritis, expression of CK7 was not observed, while in about half cagA+ H pylori-infected patients, moderate focal CK7 immunoreactivity of the neck and coiled gland areas was registered, especially in areas with more severe inflammatory infiltrate.

CONCLUSION: Alterations in expression of CK 7, 18, 19 and 20 together with normal expression of CK8 occur in antral mucosa of H pylori-associated chronic gastritis in adult patients infected with cagA+ strains. Alterations in different cytokeratins expression might contribute to weakening of epithelial tight junctions observed in H pylori-infected gastric mucosa.

Gastrin and antral G cells in course of Helicobacter pylori eradication: Six months follow up study

AIM: To assess long-term effects of Helicobacter pylori (H pylori) eradication on antral G cell morphology and function in patients with and without duodenal ulcer (DU).

METHODS: Consecutive dyspeptic patients referred to the endoscopy entered the study. Out of 39 H pylori positive patients, 8 had DU (H pylori +DU) and 31 gastritis (H pylori +G). Control groups consisted of 11 uninfected dyspeptic patients (CG1) and 7 healthy volunteers (CG2). Basal plasma gastrin (PGL), antral tissue gastrin concentrations (ATGC), immunohistochemical and electron microscopic characteristics of G cells were determined, prior to and 6 mo after therapy.

RESULTS: We demonstrated elevated PGL in infected patients compared to uninfected controls prior to therapy. Elevated PGL were registered in all H pylori+patients (H pylori +DU: 106.78 ± 22.72 pg/mL, H pylori +G: 74.95 ± 15.63, CG1: 68.59 ± 17.97, CG2: 39.24 ± 5.59 pg/mL, P < 0.01). Successful eradication (e) therapy in H pylori+patients lead to significant decrease in PGL (H pylori+DU: 59.93 ± 9.40 and H pylori +Ge: 42.36 ± 10.28 pg/mL, P < 0.001). ATGC at the beginning of the study were similar in infected and uninfected patients and eradication therapy lead to significant decrease in ATGC in H pylori +gastritis, but not in DU patients. In the H pylori +DU patients, the mean number of antral G cells was significantly lower in comparison with all other groups (P < 0.01), but after successful eradication was close to normal values found in controls. By contrast, G cell number and volume density were significantly decreased (P < 0.01) in H pylori +Ge group after successful eradication therapy (294 ± 32 and 0.31 ± 0.02, respectively), in comparison to values before eradication (416 ± 40 and 0.48 ± 0.09). No significant change of the G cell/total endocrine cell ratio was observed during the 6 mo of follow up in any of the groups. A reversible increase in G cell secretory function was seen in all infected individuals, demonstrated by a more prominent secretory apparatus. However, differences between DU and gastritis group were identified.

CONCLUSION: H pylori infection induces antral G cell hyperfunction resulting in increased gastrin synthesis and secretion. After eradication therapy complete morphological and functional recovery is observed in patients with gastritis. In the DU patients some other factors unrelated to the H pylori infection influence antral G cell morphology and function.

Detection of gastrointestinal and abdominal infections by 99mTc-ciprofloxacin

BACKGROUND/AIMS

The aim of the study is detection and evaluation of the abdominal and gastrointestinal infective foci using 99mTc-ciprofloxacin (Laboratory for radioactive isotopes, Vinca).

METHODOLOGY

In total 21 patients with clinical suspicion on abdominal or gastrointestinal infection were investigated. In all the patients, planar liver/spleen scintigraphy was performed. Ciprofloxacin chloride (3.5 mg) was mixed with 555 MBq of 99mTc in 3 mL of physiological solution and incubated for 20 min. After slow i.v. injection in a cubital vein, dynamic acquisition (1 f/min) was performed during the first 60 min in the position of interest, followed by static acquisition (500,000 imp) anterior and posterior view, abdomen and pelvis after 1 h and 4 h in all patients. When necessary, additional scintigrams were acquired after 24 h. In all the patients with negative or equivocal findings of planar scintigraphy, emission computerized tomography (SPECT) was performed (60 positions, 6 degrees). Interpretation was made by three independent observers. Additional data were provided using clinical findings, ultrasonography, computed tomography and magnetic resonance imaging, laboratory analyses, and surgical or microbiological confirmation of infection.

RESULTS

There were eleven true-positive findings, seven true negative, two were false negative while one was false positive due to intestinal obstruction. Sensitivity was 79%, specificity 91%, positive predictive value 92%, negative predictive value 77%, accuracy 84%.

CONCLUSIONS

According to our results, scintigraphy with radiolabeled ciprofloxacin is a useful method for detection and assessment of exact localization of abdominal and gastrointestinal infections.

Anti-CagA and anti-VacA antibodies in Helicobacter pylori-infected patients with and without peptic ulcer disease in Serbia and Montenegro

BACKGROUND

The expression of two Helicobacter pylori proteins, CagA and VacA, is associated with more severe pathogenesis and clinical outcomes of the infection. However, this association varies among geographical regions and ethnic groups. We therefore evaluated CagA and VacA seroprevalence in H. pylori-positive dyspeptic patients in Serbia and Montenegro.

METHODS

In 173 consecutive dyspeptic patients referred to endoscopy (67M, mean age 49 +/- 15, 76 smokers), immunoblot assay was used to detect serum antibodies against CagA and VacA. Presence of H. pylori infection was assessed using a rapid urease test (RUT), routine histology and serology (anti-IgG ELISA). Duodenal ulcer (DU) was diagnosed in 28, gastric ulcer (GU) in 3 and non-ulcer dyspepsia (NUD) in the remaining 142 patients.

RESULTS

129 (74.6%) patients were H. pylori-positive, 27 (96.4%) with DU, 3 (100%) with GU and 99 (69.7%) with NUD (P < 0.01); 121 (93.8%) patients carried anti-CagA antibodies and there was no difference between the DU and NUD groups. VacA antibodies were detected in sera of 50 (38.75%) and were more prevalent in patients with DU compared to the NUD group (P < 0.05).

CONCLUSIONS

In Serbia and Montenegro there is high seroprevalence of CagA-positive H. pylori strains in dyspeptic patients with and without peptic ulcer, while VacA-positive strains are more closely related to peptic ulcer disease.

Down-regulation of secretory leukocyte protease inhibitor expression in gastric mucosa is a general phenomenon in Helicobacter pylori-related gastroduodenal diseases

BACKGROUND

Secretory leukocyte protease inhibitor (SLPI) represents a multifunctional protein of the gastric mucosa exerting anti-microbial and anti-inflammatory effects. Recently, a local down-regulation of antral SLPI expression in Helicobacter pylori (Hp)-infected healthy volunteers was demonstrated.

AIM

To analyze mucosal SLPI expression in patients with various gastroduodenal disorders.

METHODS

The prospective study included 90 patients with following gastroduodenal disorders diagnosed: gastric cancer (GC, n=22), duodenal ulcer (DU, n=17), Hp-positive dyspeptic patients (NUD, n=31) and Hp-negative NUD (n=20). During esophagogastroduodenoscopy, biopsies were taken each from antrum, corpus and tumor. SLPI expression was analyzed by quantitative RT-PCR and ELISA.

RESULTS

Antral SLPI levels were reduced in all Hp-infected patients (NUD, DU, GC) by about 75% (1,494-1,826 pg/50 microg protein) compared to Hp-negative NUD (6,563 pg/50 microg protein, p<0.001, ANOVA). Tumor tissue had twofold higher SLPI levels than surrounding tumor-free gastric mucosa (3,900 vs. 1,826 pg/50 microg protein, p=0.013), but revealed reduced SLPI levels compared to Hp-negative NUD patients (p=0.067). No differences were found between SLPI expression of intestinal and diffuse GC. SLPI transcript levels were unchanged throughout all groups and locations implying that transcriptional regulation of SLPI is not involved.

CONCLUSION

Local down-regulation of SLPI in antral mucosa is a general phenomenon of Hp-related diseases.

Somatostatin and D cells in patients with gastritis in the course of Helicobacter pylori eradication: a six-month, follow-up study

BACKGROUND/AIMS

As well as causing chronic gastritis, Helicobacter pylori predisposes patients to peptic ulcer disease and gastric cancer, and induces gastric functional disorders. The aim of our study was to investigate the effects of H. pylori eradication therapy on the morphological and functional recovery of gastric antral and corpus D cells in patients with chronic gastritis during 6 months of follow-up.

PATIENTS AND METHODS

Forty consecutive, dyspeptic patients referred for endoscopy (31 with H. pylori infection and nine controls; mean age 49 years; 17 men, 23 women) entered the study. All patients had histological signs of gastritis but no signs of peptic ulcer or gastric cancer. Antrum (n=8) and corpus (n=6) biopsy specimens were collected for routine histology, radioimmunoassay tissue somatostatin levels, immunohistochemistry and electron microscopy, prior to and 6 months after therapy. Basal plasma somatostatin levels were determined prior to eradication, plus 6 weeks and 6 months after therapy. Eradication therapy consisted of amoxicillin, metronidazole and omeprazole.

RESULTS

Basal somatostatin plasma values in antral and corpus tissue were lower in infected patients than in the H. pylori-negative controls at the beginning of the study. A significant increase occurred after successful eradication therapy, together with an increase in the number of D cells in both regions. Changes in the D-cell ultrastructure in antral and corpus mucosa after eradication therapy suggest an increase in somatostatin synthesis and secretion.

CONCLUSIONS

The structural and functional restoration of D cells following eradication therapy indicates possible recovery of the diseased mucosa.

Radioimmunodetection of colorectal carcinoma

BACKGROUND/AIMS

The aim of the study is detection of the recurrences and metastases of colorectal carcinomas using 111In-labeled antibodies B72.3.

METHODOLOGY

Fourteen patients underwent planar immunoscintigraphy and/or tomoscintigraphy.

RESULTS

With tomography in comparison to planar scintigraphy, we can access better distinction of tumor and estimation of its size. Other imaging methods (computed tomography, ultrasonography) have an advantage in detection of liver metastases, while immunoscintigraphy is more specific for the assessment of malignant abdominal tumors and extrahepatic metastases.

CONCLUSIONS

The first results point out that Oncoscint CR-103 can be useful in diagnosis of recurrences and metastases of colorectal carcinoma, viability assessment after radiotherapy and in the choice of the adequate surgical treatment in dependence of the spread of the disease.

Changing pattern of cytokeratin 7 and 20 expression from normal epithelium to intestinal metaplasia of the gastric mucosa and gastroesophageal junction

It is currently unclear whether intestinal metaplasia at the esophagogastric junction and in the distal esophagus represent a continuum of the same underlying disease process, i.e., gastroesophageal reflux, or constitute different entities with a different pathogenesis. Biopsies below the Z line might show specialized epithelium in some patients and the question is whether this is another form of short segment Barrett's esophagus or whether it is related to a generalized atrophic process of the stomach. Data from recent studies regarding the expression of cytokeratin CK7 and CK20 in intestinal metaplasia (IM) found at the gastroesophageal junction are conflicting. Prompted by these data we undertook the present study: a) to evaluate the expression of CK7 and CK20 in IM of the gastric cardia and to compare the findings with those in patients with Barrett's esophagus and IM of the gastric corpus and antrum mucosa; and b) to evaluate the immunophenotype of non-intestinalized cardiac mucosa and to compare it with that of normal gastric epithelium. We studied the expression of CK7 and CK20 on biopsy specimens from patients with long-segment Barrett's esophagus (n=17) and surgical resection and biopsy specimens of gastric cardia (n=15), corpus (n=14) and antrum (n=22) from patients with histological evidence of IM. Eighty-four biopsy specimens from 42 patients (antrum n=15, corpus n=20, cardia n=7) without evidence of IM were studied as a control group. We observed an immunophenotype characterised by diffuse moderate to strong CK7 staining on the surface and crypt epithelium combined with strong CK20 staining on the surface and superficial part of the crypts in 94.1% (16/17) of the cases with long-segment Barrett's esophagus, but in none of the 36 cases with IM in distal stomach (antrum and corpus). IM in the gastric cardia expressed the immunophenotype seen in IM of the gastric mucosa in 93.3% (14/15) of the cases. On the other hand, normal cardiac epithelium expressed patchy strong CK7 staining on the surface epithelium and on both, superficial and deep parts of the pits combined with patchy strong CK20 staining on the surface epithelium and superficial pits, a feature permitting distinction of the normal cardiac epithelium from those of the normal gastric antrum and corpus epithelium. We conclude that the expression of cytokeratins 7 and 20 can be used to distinguish the origin of IM of the gastroesophageal junction. The CK7/20 immunophenotype of IM in the gastric cardia closely resembles that of the IM in the gastric antrum and corpus and is different from IM in long-segment Barrett's esophagus. In contrast, the CK7/20 immunophenotype of the cardiac epithelium is different from that of the gastric antrum and corpus mucosa, suggesting that cardiac epithelium might not be a native normal gastric epithelium but one that is acquired as a consequence of longstanding inflammation. Changing pattern of CK7 and CK20 expression from normal to intestinalized epithelium suggests that IM arising from cardiac epithelium might have distinctive features.

Medical management of inflamatory bowel diseases--therapeutic options

Corticosteroids and the 5-aminosalicylate (5-ASA) drugs still constitute the mainstays of therapy, with azatioprine/mercaptopurine an established second-line agent for resistant disease. Primarily nutritional therapy has a place for some patients with Crohn's disease, and alternative immunosupressants are finding their own disease. The medical management of inflammatory bowel diseases is poised to enter to new era if the current promise shown by investigatory immunomodulatory regimes translates into confirmed effective therapy.

Rectal cancer--from genetics to the therapy

Cancer of the colon and rectum is major cause of cancer-associated morbidity and mortality. Globally, it is the third most common cancer in males and fourth most common in females. Colorectal cancer is primarily a genetic disease with lesions being either somatically induced by environmental agents or inherited through the germline. Familial adenomatous polyposis and hereditary non-polyposis colorectal cancer are the main types of inherited colorectal cancer. Sporadic colorectal cancer is though to involve several genes in a multistep pathway. Colorectal cancer occurs as a result of a series of genetic alterations in normal tissue that lead to disorganization in the molecular mechanisms that control growth. Most of the evidence incriminating diets as a major factor in the genesis of colorectal cancer. Case control studies and complex statistical analyses implicate both causative and protective dietary factors. The aim of screening is to detect neoplasia of the colon and rectum before it reaches an advanced stage, survival being directly related to the stage at presentation. The most sensitive evaluation of the whole colon is by colonoscopy. The way forward continues to rest with research into more sensitive occult fecal blood tests, more cost-effective endoscopic protocols and greater knowledge of the biological factors triggering dysplastic changes in large bowel mucosa.

Endoscopic biliary manometry in cholecystectomized patients with and without choledocholithiasis

BACKGROUND/AIMS

Direct study of the function of the sphincter of Oddi became possible recently with the advent of endoscopic manometry. A dysfunction of the bilio-pancreatic sphincter apparatus has been implicated in some bilio-pancreatic disorders. The purpose of this study was to examine the relation between dysfunction of the sphincter of Oddi and the formation of common bile duct stones.

METHODOLOGY

Endoscopic biliary manometry was performed on 45 cholecystectomized patients. Endoscopic retrograde cholangiography showed choledocholithiasis in 26 patients while 19 patients were free of common bile duct stones. Nine healthy subjects served as controls.

RESULTS

Manometric investigation showed a significant increase in the percentage of retrograde phasic contractions of the sphincter of Oddi (SO) in patients with choledocholithiasis compared to the control group (p < 0.05). Also, a significantly higher frequency of SO phasic contractions was found in the group of patients with choledocholithiasis when compared to the cholecystectomized group without common bile duct stones (p < 0.05), but there was no difference when compared with the control group. Markedly increased SO basal pressure was found in 5 patients with choledocholithiasis as well as in one cholecystectomized patient without choledocholithiasis (greater than x + 3SD). However, the SO basal pressure, phasic SO pressure, amplitude and duration of the phasic contractions as well as the choledochal pressure did not differ significantly between the groups.

CONCLUSIONS

This study demonstrates manometric abnormalities in the SO of patients with choledocholithiasis which suggests that SO dysfunction and pathophysiological mechanisms are related to the formation of common bile duct stones.