[Cholangitis and cholecystitis: diagnostic criteria and management]

In developed countries, diseases of the gallbladder and the biliary tract count as some of the most frequent gastrointestinal disorders. The inflammation of the gallbladder/biliary tree is a potentially severe, even lethal condition that requires rapid diagnosis and early multidisciplinary approach to be treated. Although the frequency of these diseases is high, the treatment is not unified in Hungary yet. The aim of the evidence-based recommendation is to clarify the diagnostic criteria and severity grading of these diseases and to highlight the indications and rules of proper application of the numerous available therapeutic interventions. The recent guideline is based on the consensus of the Board members of the Endoscopic Section of the Hungarian Gastroenterology Society in contribution with renown experts of surgery, infectology as well as interventional radiology and it counts as a clear and easy applicable guide during the all-day healthcare practice. Our guidelines are based on Tokyo guidelines established on the basis of the consensus reached in the International Consensus Meeting held in Tokyo which were revised in 2013 (TG13) and in 2018 (TG18). Orv Hetil. 2023; 164(20): 770-787.

Az endoszkópos retrográd cholangiopancreatographia szövődményei

Az endoszkópos retrográd cholangiopancreatographia (ERCP) a több mint 50 éves története során diagnosztikus módszerből szinte kizárólag terápiás beavatkozássá vált. Köszönhető ez a kevésbé invazív vizsgálati módszerek kialakulásának, illetve annak a felismerésnek is, hogy számos szövődmény kialakulásának veszélyét hordozza magában. Ezek ismerete manapság alapvető fontosságú. Az eltelt évtizedek során a szövődmények hajlamosító tényezőiről, illetve a megelőzés lehetőségeiről jelentős ismeretanyag gyűlt össze, melyhez magyar szakemberek komoly eredményekkel járultak hozzá. Jelen közleményünkben az ERCP szövődményeit, azok definícióját, súlyossági osztályozásukat, kockázati tényezőiket, a profilaktikus lehetőségeket és az endoszkópos ellátás módjait foglaljuk össze. Orv Hetil. 2022; 163(23): 911–919.

First prospective European study for the feasibility and safety of magnetically controlled capsule endoscopy in gastric mucosal abnormalities

BACKGROUND

While capsule endoscopy (CE) is the gold standard diagnostic method of detecting small bowel (SB) diseases and disorders, a novel magnetically controlled capsule endoscopy (MCCE) system provides non-invasive evaluation of the gastric mucosal surface, which can be performed without sedation or discomfort. During standard SBCE, passive movement of the CE may cause areas of the complex anatomy of the gastric mucosa to remain unexplored, whereas the precision of MCCE capsule movements inside the stomach promises better visualization of the entire mucosa.

AIM

To evaluate the Ankon MCCE system’s feasibility, safety, and diagnostic yield in patients with gastric or SB disorders.

METHODS

Of outpatients who were referred for SBCE, 284 (male/female: 149/135) were prospectively enrolled and evaluated by MCCE. The stomach was examined in the supine, left, and right lateral decubitus positions without sedation. Next, all patients underwent a complete SBCE study protocol. The gastric mucosa was explored with the Ankon MCCE system with active magnetic control of the capsule endoscope in the stomach, applying three standardized pre-programmed computerized algorithms in combination with manual control of the magnetic movements.

RESULTS

The urea breath test revealed Helicobacter pylori positivity in 32.7% of patients. The mean gastric and SB transit times with MCCE were 0 h 47 min 40 s and 3 h 46 min 22 s, respectively. The average total time of upper gastrointestinal MCCE examination was 5 h 48 min 35 s. Active magnetic movement of the Ankon capsule through the pylorus was successful in 41.9% of patients. Overall diagnostic yield for detecting abnormalities in the stomach and SB was 81.9% (68.6% minor; 13.3% major pathologies); 25.8% of abnormalities were in the SB; 74.2% were in the stomach. The diagnostic yield for stomach/SB was 55.9%/12.7% for minor and 4.9%/8.4% for major pathologies.

CONCLUSION

MCCE is a feasible, safe diagnostic method for evaluating gastric mucosal lesions and is a promising non-invasive screening tool to decrease morbidity and mortality in upper gastro-intestinal diseases.

Az endoszkópos ultrahangvizsgálat diagnosztikus érzékenysége epeúti kövesség gyanúja esetén

Összefoglaló. Bevezetés: Az epeúti kövesség meglétének valószínűsége különböző klinikai prediktorok alapján megbecsülhető, e faktorok szenzitivitása és specificitása azonban nem kielégítő. Az endoszkópos ultrahangvizsgálat az epeúti kövesség diagnosztizálásának szemiinvazív precíz eszköze. Célkitűzés: Célunk az endoszkópos ultrahangvizsgálat diagnosztikus érzékenységének vizsgálata gyanított epeúti kövesség esetén. Módszer: A prospektív vizsgálat során a betegeket az Amerikai Emésztőszervi Endoszkópos Társaság (ASGE) ajánlása szerint meghatározott prediktorok alapján közepes és magas valószínűségi csoportokba osztottuk, és endoszkópos ultrahangvizsgálatot, valamint amennyiben szükséges volt, endoszkópos retrográd kolangiopankreatográfiát (ERCP) végeztünk. Eredmények: Összesen 95 beteget vizsgáltunk. Az endoszkópos ultrahangvizsgálat 53 (56%) beteg esetében írt le epeúti kövességet: 55%-ban (39/71) a közepes valószínűségi és 58%-ban (14/24) a magas valószínűségi csoportban. Az ERCP mindegyik choledocholithiasisos esetet megerősítette. A két valószínűségi csoport között nem volt szignifikáns különbség (p = 0,56) az ERCP által igazolt epeúti kövesség tekintetében. Az ERCP csupán 1 esetben detektált epeúti kövességet a negatív endoszkópos ultrahangvizsgálat ellenére. Az endoszkópos ultrahangvizsgálat specificitása 100%, szenzitivitása 98%, míg pozitív és negatív prediktív értéke 100%, valamint 98% volt. Megbeszélés: Az epeúti kövesség meglétének becslése különböző klinikai prediktorok alapján kihívást jelenthet. Következtetés: Az endoszkópos ultrahangvizsgálat szenzitív és pontos diagnosztikus eszköz a choledocholithiasis kimutatására és értékelésére, olyan esetekben is, amelyeknél az előzetes képalkotók nem találtak kövességet. Orv Hetil. 2022; 163(10): 400–406.

Summary. Introduction: The likelihood of common bile duct stones can be prognosticated by various clinical predictors, however, the sensitivity and specificity of these factors are moderate. Endoscopic ultrasonography has been shown to be a semi-invasive precise test for the detection of common bile duct stones. Objective: Our aim was to assess the diagnostic accuracy of endoscopic ultrasonography in patients with suspected choledocholithiasis. Method: Patients of this prospective study were categorized and divided into intermediate likelihood and high likelihood groups according to the clinical predictors defined by the American Society of Gastrointestinal Endoscopy (ASGE) guidelines and referred for linear endosonography. Endoscopic retrograde cholangiopancreatography (ERCP) was performed if needed. Results: A total of 95 patients were assessed. Common bile duct stones were detected by endoscopic ultrasonography overall in 53 (56%) patients: 55% (39/71) in the intermediate likelihood and 58% (14/24) in the high likelihood group of patients. The detected common bile duct stones in all patients were confirmed by ERCP. There was no significant difference (p = 0.56) in the detection of stones by ERCP between the two likelihood groups. ERCP confirmed choledocholithiasis only in one patient whose preceding endosonography did not detect stone. The specificity and sensitivity of endoscopic ultrasonography were 100% and 98%, the positive predictive value and negative predictive value were 100% and 98%, respectively. Discussion: Estimating the likelihood of choledocholithiasis based on various clinical predictors might be challenging. Conclusion: Endoscopic ultrasonography is a highly sensitive and accurate diagnostic tool for the detection and evaluation of common bile duct stones also in patients with previous normal imaging findings. Orv Hetil. 2022; 163(10): 400–406.

Transitional elevation of anti-tissue transglutaminase antibodies in children with type 1 diabetes mellitus without coeliac disease

Összefoglaló. Bevezetés: Az 1-es típusú diabetes mellitus és a coeliakia gyakori társulása jól ismert. Néhány tanulmány beszámol átmeneti antitranszglutamináz-emelkedésről 1-es típusú diabeteses betegekben, akiknél az emelkedett antitestszint gluténmentes diéta bevezetése nélkül normalizálódik. Célkitűzés: Kutatásunk során az átmeneti antitranszglutamináz-emelkedés gyakoriságának meghatározását tűztük ki célul. További célunk volt a coeliakia gyakoriságának megállapítása 1-es típusú diabetesszel gondozott betegeink között. Módszer: A Semmelweis Egyetem I. Gyermekgyógyászati Klinikáján 1-es típusú diabetesszel gondozott betegeket vontuk be vizsgálatunkba (238 lány, 265 fiú, medián [IR] életkor az 1-es típusú diabetes diagnózisakor: 7,83 [4,67-11] év). Vizsgáltuk a jelenség időbeli megjelenését, az emelkedés mértékét, gyakoriságát és az antitest típusát. Leíró statisztikai módszereket és khi-négyzet-próbát alkalmaztunk. Eredmények: A vizsgált populációban a coeliakia gyakorisága 12,52%. Átmeneti antitranszglutamináztiter-emelkedést 48 gyermeknél (10,9%) észleltünk. Összesen 71-szer mértünk átmeneti antitranszglutamináz-emelkedést. A gyermekek közül 34 esetben (70,83%) egyszer fordult elő emelkedést mutató antitest, a többi betegnél 2-8 alkalommal. Gyakrabban tapasztaltunk izolált IgA-típusú emelkedést, mint izolált IgG-típusút (54 vs. 5). Következtetés: Az átmeneti antitranszglutamináz-emelkedés gyakorisága magas, összevethető a valódi coeliakiás csoporttal. Kutatásunk alátámasztja a nemzetközi ajánlást, miszerint mérsékelt mértékű antitranszglutamináz-emelkedés esetén, tünetmentes 1-es típusú diabetesszel gondozott betegben a gluténfogyasztás folytatása és az antitestszintek gyakori kontrollja javasolt. Orv Hetil. 2021; 162(48): 1924-1930.

SUMMARY

INTRODUCTION

The frequent association of type 1 diabetes mellitus with coeliac disease is well known. Development of transitional elevation of anti-tissue transglutaminase antibodies in the diagnosis of type 1 diabetes is reported in some studies. In these cases, the anti-tissue transglutaminase antibodies returned to normal without gluten-free diet.

OBJECTIVE

Our aim was to assess the frequency of transitional elevation of anti-tissue transglutaminase in our type 1 diabetes patients. We aimed to investigate the prevalence of coeliac disease in patients with type 1 diabetes.

METHOD

Patients with type 1 diabetes at the Ist Department of Paediatrics, Semmelweis University, were enrolled in the study (238 girls, 265 boys; the median age at the time of type 1 diabetes diagnosis was 7.83 [4.67-11] years). Descriptive statistical analysis was done and the time of appearance, extent, frequency and type of elevated anti-tissue transglutaminase antibodies were examined.

RESULTS

The proportion of children with diagnosed coeliac disease was 12.52%. We detected transitional anti-tissue transglutaminase elevation in 48 cases (10.9%). Temporarily elevated antibody levels were measured 71 times. In 34 children (70.83%), the temporary elevation occured once, while in the others, antibody levels became positive 2-8 times. The elevation of the IgA antibody was more frequent than the elevation of the IgG antibody (54 vs. 5).

CONCLUSION

The frequency of temporary elevated anti-tissue transglutaminase levels is considered high. Our study confirms the recommendation that in the case of moderate anti-tissue transglutaminase levels with lack of clinical symptoms, control antibody measurement is necessary with ongoing gluten consumption. Orv Hetil. 2021; 162(48): 1924-1930.

Network meta-analysis of prophylactic pancreatic stents and non-steroidal anti-inflammatory drugs in the prevention of moderate-to-severe post-ERCP pancreatitis

BACKGROUND

There is an ongoing debate that non-steroidal anti-inflammatory drugs (NSAID) or prophylactic pancreatic stents (PPS) are more beneficial in preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). In our present network meta-analysis, we aimed to compare PPSs to rectal NSAIDs in the prevention of moderate and severe PEP in average- and high-risk patients.

METHODS

We performed a systematic search for randomized controlled trials (RCT) from MEDLINE (via PubMed), Embase and Cochrane Central databases. RCTs using prophylactic rectal NSAIDs or PPSs in patients subjected to ERCP at average- and high-risk population were included. The main outcome was moderate and severe PEP defined by the Cotton criteria. Pairwise Bayesian network meta-analysis was performed, and interventions were ranked based on surface under cumulative ranking (SUCRA) values.

RESULTS

Seven NSAID RCTs (2593 patients), and 2 PPS RCTs (265 patients) in the average-risk, while 5 NSAID RCTs (1703 patients), and 8 PPS RCTs (974 patients) in the high-risk group were included in the final analysis. Compared to placebo, only PPS placement reduced the risk of moderate and severe PEP in both patient groups (average-risk: RR = 0.07, 95% CI [0.002-0.58], high-risk: RR = 0.20, 95% CI [0.051-0.56]) significantly. Rectal NSAID also reduced the risk, but this effect was not significant (average-risk: RR = 0.58, 95% CI [0.22-1.3], high-risk: RR = 0.58, 95% CI [0.18-2.3]). Based on SUCRA, PPS placement was ranked as the best preventive method.

CONCLUSION

Prophylactic pancreatic stent placement but not rectal NSAID seems to prevent moderate-to-severe PEP better both, in average- and high-risk patients.

Prophylactic stents in the prevention of pancreatitis following endoscopic retrograde cholangiopancreatography

Összefoglaló. Bevezetés: Az endoszkópos retrográd cholangiopancreatographiát (ERCP) követő pancreatitis (PEP) incidenciája a magas kockázatú betegcsoportban 14,7%. Célkitűzés: A munkacsoportunk által szerzett tapasztalatok elemzése. Módszerek: A profilaktikus pancreassztentes (PPS), magas kockázatú betegek adatait tartalmazó prospektív adatbázisunkat elemeztük retrospektív módon. Az adatokat a PEP-incidencia és a súlyosság tekintetében összehasonlítottuk a korábbi, hasonlóan magas kockázatú, sztent nélküli beteganyagunkkal, illetve a sztenteléssel kapcsolatos szövődményeket és a különböző sztenttípusokat is elemeztük. A Cotton-kritériumok szerint értékeltük a PEP-t. Eredmények: A 317, magas kockázatú betegből 288 esetben (90,9%) volt sikeres a PPS-implantáció. A sztent nélküli kontrollcsoportba 121, magas kockázatú beteget választottunk be. A sikeresen sztentelt betegekben a PEP incidenciája 10,0% volt. Ez és a PEP súlyossága (enyhe: 8,3%, középsúlyos: 1,4%, súlyos: 0,3%) is szignifikánsan alacsonyabb volt a PPS nélküli beteganyaghoz (PEP: 31,4%, enyhe: 15,7%, középsúlyos: 10,7%, súlyos: 5,0%) és a sikertelenül sztentelt betegekhez (PEP: 41,3%, enyhe: 24,1%, középsúlyos: 13,8%, súlyos: 3,4%) képest. Az utóbbi két csoport közötti különbség nem volt szignifikáns. A sztenttel kapcsolatos szövődmények közül a leggyakrabban a korai sztentkicsúszást (5/288 beteg, 1,74%) és a proximalis sztentmigrációt (3/288 beteg, 1,04%) észleltük. A sztenttípusok közül a legkedvezőbb mellékhatás-profilúnak a Freeman-típusú, belső füllel és külső "pigtail" véggel ellátott sztenteket találtuk. Következtetés: A profilaktikus pancreassztentelés hatékonyan csökkenti a PEP incidenciáját, és a súlyosságát az enyhébb esetek felé tolja el. Alkalmazása viszonylag egyszerű, azonban ismerni kell használatának megfelelő technikáját, időben történő eltávolításának és a szövődmények felismerésének fontosságát. Eredményeink és a nemzetközi ajánlások alapján magas PEP-rizikójú betegekben a PPS rutinszerű alkalmazása minden ERCP-laborban ajánlott. Orv Hetil. 2021; 162(1): 31-38.

SUMMARY

INTRODUCTION

The most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP) is post-ERCP pancreatitis (PEP). Its incidence in the high-risk patient population is 14.7%.

OBJECTIVE

To analyze 10 years experiences of our working group.

METHODS

We retrospectively analyzed our prospective database of high-risk patients treated with prophylactic pancreatic stents (PPS) including the period between 2009 and 2014. We compared PEP incidence and severity findings with our historical data of pre-PPS period of similarly high-risk patients (no-stent group), furthermore analyzed the complications of PPS insertion and different stent types. PEP was defined and categorized according to the Cotton criteria.

RESULTS

In 317 high-risk patients, PPS implantation was successful in 288 cases (90.9%). The no-stent group comprised of 121 patients. Incidence and the severity of PEP in the successfully stented group (all: 10.0%; mild: 8.3%, moderate: 1.4%, severe: 0.3%) were significantly lower compared to the no-stent group (all: 31.4%; mild: 15.7%, moderate: 10.7%, severe: 5.0%) and the unsuccessfully stented group (all: 41.3%; mild: 24.1%, moderate: 13.8%, severe: 3.4%). The difference between the latter two groups was not significant. Only early dislodgment (5/288 patients, 1.74%) and proximal migration (3/288 patients, 1.04%) were observed as stent-related complications. Freeman type (single inner flange, outer pigtail end) stent was the best based on the complication profile.

CONCLUSION

Prophylactic pancreatic stenting effectively lowers the incidence and severity of PEP. We should recognize the proper technic of its application and the importance of proper timing of its extraction and identification of complications. Utilization of PPSs in high-risk patients is strongly recommended in every ERCP center. Orv Hetil. 2021; 162(1): 31-38.

Improved adenoma detection with linked color imaging technology compared to white-light colonoscopy

OBJECTIVES

Linked color imaging (LCI) is a new endoscopic technology that may increase colorectal adenoma detection rate (ADR) and polyp detection rate (PDR) by virtual chromoendoscopy. Aim of the present study was to evaluate the effectiveness of LCI in ADR and PDR compared to the HD white-light colonoscopy (WLC) technique.

MATERIALS AND METHODS

Between October 2016 and June 2018, we enrolled consecutive outpatients prospectively. Eligible patients allocated randomly to undergo HD WLC or LCI colonoscopy technique during instrument withdrawal. Each colonoscopy was performed in a single center by the same three expert endoscopists (with expertise more than 5000 colonoscopies).

RESULTS

A total of 1278 patients underwent colonoscopy in the study period. ADR and PDR were significantly higher in the LCI group compared to the WLC group (34.4% vs. 26.8%; p = .007; and 53.3% vs 46.4%; p = .023, respectively). Similarly, the mean number of adenomas per patient (MAP) was significantly higher with the LCI than WLC (0.64 vs 0.44, respectively; p = .002). The mean age of patients at the time of colonoscopy was 51.95 years (SD = 13.861) in the LCI group and 51.96 years (SD = 14.028) in the WLC group. No significant differences observed in patient demographic characteristics (there was no difference in gender and age distribution, p = .986), quality of colonoscopy preparation and withdrawal times (WT) between the two groups (WLC and the LCI groups, 493.9 (SD: 143.5) and 514.0 (SD: 139.5) sec, respectively).

CONCLUSIONS

According to our results, LCI virtual chromoendoscopic technology was superior compared to conventional HD WLC in detecting colorectal polyps and adenomas.

Risk factors of post-ERCP pancreatitis in high-risk patients despite prevention with prophylactic pancreatic stents

Objectives: To analyze risk factors of post-ERCP pancreatitis (PEP) in high risk patients in whom prophylactic pancreatic stents (PPSs) were intended to use to prevent endoscopic retrograde cholangiography (ERCP)-related complications.Patients and methods: Three hundred and seventeen high-risk patients for developing PEP were considered for preventive pancreatic stent placement in our endoscopy unit over 5 years. 5 Fr, 3-5 cm long PPSs were used. All data were collected in a predefined database. Development of PEP despite PPS placement was analyzed.Results: PEP occurred in 29 of 288 successfully stented patients (10.07%; 24 mild, four moderate, one severe). PPS was protective against all risks factors except for sphincter of Oddi dysfunction (SOD). PPS related complication rate was 2.78% (n = 8). Unsuccessful stenting occurred in 29 patients (9.15%), PEP developed in 41.38% (n = 12; seven mild, four moderate, one severe). Those patients who had more patient related risk factors were more likely to develop PEP despite preventive measures with PPS. On the contrary, PPS placement was less successful in patients who had more procedure related risk factors.Conclusions: PPS is protective against all risks factors of PEP except for SOD in high-risk patients. More vulnerable patients who have more patient-related risk factors are more likely to develop PEP despite PPS is used, while more complex procedures predispose to unsuccessful PPS placement in patients with more procedure-related risk factors. PPS insertion in high-risk patients is effective and safe preventive method and the procedure related complication rate is reasonably low.

[Gardner's syndrome, a rare disease]

Introduction: Gardner's syndrome is a clinical subgroup of Familial Adenomatosus Polyposis, arare, autosomal disease. It is characterized by gastrointestinal polyps and extra-intestinal manifestations including multiple osteomas, skin and tissue tumours. The authors describe a case of a male patient, and discuss the diagnosis, treatment and follow-up of patients with Gardner's syndrome. We conclude that the knowledge of rare syndromes is very important for the correct treatment.

Preventive pancreatic stents in the management of acute biliary pancreatitis (PREPAST trial): pre-study protocol for a multicenter, prospective, randomized, interventional, controlled trial

BACKGROUND

The outcome of the most common biliary form of acute pancreatitis has not changed even with the better described indications for early endoscopic intervention. It may be due to the fact that this intrevention theoretically can cause further pancreatic injury or cannot always relieve the pancreatic duct obstruction. We hypothesize that maintaining the outflow of the pancreatic duct with preventive pancreatic stents at the early ERCP improves the outcome of acute biliary pancreatitis.

METHODS/DESIGN

PREPAST is a prospective, randomized, controlled, multicenter trial. Patients with acute biliary pancreatitis with coexisting cholangitis are randomized to undergo urgent endoscopic intervention with or without pancreatic stenting within 48 h from the onset of pain, and in addition patients without signs of cholangitis but cholestasis are randomly allocated to recieve conservative treatment or early endoscopic intervention with or without pancreatic stenting within 48 h from the onset of pain. Patients without acute cholangitis and signs of cholestasis recieve conservative treatment. 230 patients are planned to be enrolled during a 48 months period from different centers. The primary endpoint is the outcome of acute biliary pancreatitis as described by the latest guidelines. Secondary endpoints include mortality data, and other variables not analyzed as a primary endpoint but related to the pancreatitis or the pancreatic stenting.

DISCUSSION

The PREPAST trial is designed to show whether early endoscopic intervention with the usage of preventive pancreatic stenting improves the outcome of acute biliary pancreatitis. The study has been registered at the International Standard Randomised Controlled Trial Number (ISRCTN) Register (trial ID: ISRCTN13517695).

Association between visceral, cardiac and sensorimotor polyneuropathies in diabetes mellitus

AIMS

Gastrointestinal complaints are common in diabetes mellitus. However, its association to peripheral sensorimotor and autonomic neuropathies is not well investigated. The aim was to assess skin, muscle, bone and visceral sensitivity in diabetes patients with sensorimotor neuropathy, and correlate these with gastrointestinal symptoms and degree of cardiac autonomic neuropathy.

METHODS

Twenty patients with sensorimotor neuropathy (65% type 2 diabetes, aged 58.3±12.0 years, diabetes duration 15.8±10.0 years) and 16 healthy controls were recruited. Cutaneous sensitivity to von Frey filaments, mechanical allodynia, muscle/bone/rectosigmoid sensitivities, and heart rate variability were examined. Gastrointestinal symptom scores (PAGI-SYM) and health-related quality of life (SF-36) were also recorded.

RESULTS

Patients displayed hypesthesia to von Frey filaments (p=0.028), but no difference to muscle and bone pain sensitivities. Also, patients were hyposensitive to multimodal rectal stimulations (all p<0.05), although they suffered more gastrointestinal complaints. Heart rate variability was reduced in the patient cohort. Rectal mechanical and cutaneous sensitivities correlated (p<0.001), and both were associated with heart rate variability as well as PAGI-SYM and SF-36 scores (p<0.01).

CONCLUSIONS

In diabetic sensorimotor neuropathy there is substantial evidence of concomitant cutaneous, cardiac and visceral autonomic neuropathies. The neuropathy may reduce quality of life and explain the higher prevalence of gastrointestinal complaints.

[Endoscopic ultrasound-guided fine needle aspiration cytology in the mediastinum]

INTRODUCTION

Endoscopic ultrasound and endoscopic ultrasound-guided fine needle aspiration in the posterior mediastinum is technically a relatively simple and safe procedure, and it can provide important information for the further management of patients.

AIM

To analyze and compare the results of mediastinal endoscopic ultrasound-guided fine needle aspiration with the data available in the literature.

PATIENTS AND METHODS

The authors retrospectively analyzed their prospective database on mediastinal endoscopic ultrasound-guided fine needle aspiration of 49 patients referred to their endoscopy centre between 1 November 2009 and 1 November 2012. For the fine needle aspiration 22 and 25 G needles were used. Two to six needle passes were performed in each patient. All slides were prepared at the endoscopy unit and analyzed at the cytology laboratory.

RESULTS

The authors performed mediastinal endoscopic ultrasound-guided fine needle aspiration for enlarged lymph nodes or suspected mediastinal malignancy in all but 4 patients (2 suspected oesophageal cancers, 1 suspected benign oesophageal stenosis with wall thickening and 1 cardia tumour, all with non-diagnostic endoscopic biopsies). Five patients were excluded from the analysis since fine needle aspiration was not performed in them. Benign lesions were suspected based on the endoscopic ultrasound morphology in 7, and malignant disease in 37 patients. In 3 cases samples obtained by biopsy were not informative for cytological analysis. Cytology confirmed all benign lesions and showed malignancy in 28 cases. Cytology failed to reveal malignancy in 6 patients, although it was suspected based upon endoscopic ultrasound finding. Furthermore, endoscopic ultrasound-guided fine needle aspiration provided the diagnosis in 15 of the 17 patients when bronchoscopy was non-diagnostic. The diagnostic accuracy of the EUS-FNA was the following: sensitivity 82%, specificity 100%, positive predictive value 1.0, negative predictive value 0.54. Only one infectious complication was encountered after fine needle aspiration despite antibiotic prophylaxis.

DISCUSSION

Endoscopic ultrasound-guided fine needle aspiration of mediastinal pathology is an accurate, safe and technically relatively easy procedure, however it requires practice and skills in mediastinal anatomy. It has an excellent positive predictive value, a very good sensitivity, but slightly poor negative predictive value. The results of this study are concordant with the literature data. The authors suggest that at least 4 needle passes in the absence of on-site pathologist should be performed in order to minimize the number of false-negative results.

[The effect of endoscopic sphincterotomy on the motility of the gallbladder and of the sphincter of Oddi in patients with acalculous biliary pain syndrome]

INTRODUCTION

Sphincter of Oddi dysfunction usually occurs after cholecystectomy, but it can sometimes be detected in patients with intact gallbladder too. The diagnostic value of the non-invasive functional tests is not established in this group of patients and the effects of sphincterotomy on transpapillary bile outflow and gallbladder motility are unknown.

AIMS

The aim of this study was to determine the effect of endoscopic sphincterotomy on the gallbladder ejection fraction, transpapillary bile outflow and the clinical symptoms of patients with acalculous biliary pain syndrome.

PATIENTS AND METHODS

36 patients with acalculous biliary pain syndrome underwent quantitative hepatobiliary scintigraphy, and all of them had decreased cholecytokinin-induced gallbladder ejection fraction. The endoscopic manometry of the sphincter of Oddi showed abnormal sphincter function in 26 patients who were enrolled the study. Before and after endoscopic sphincterotomy all patients had ultrasonographic measurement of cholecystokinin-induced gallbladder ejection fraction with and without nitroglycerin pretreatment and scintigraphy was repeated as well. The effects of sphincterotomy on gallbladder ejection fraction and transpapillary biliary outflow were evaluated. In addition, changes in biliary pain score with a previously validated questionnaire were also determined.

RESULTS

All 26 patients had decreased gallbladder ejection fraction before sphincterotomy measured with scintigraphy (19+18%) and ultrasound (16+9.7%), which was improved after nitroglycerin pretreatment (48.2+17%; p<0.005). Detected with both methods, the ejection fraction was in the normal range after sphincterotomy (52+37% and 40.8+16.5%), but nitroglycerin pretreatment failed to produce further improvement (48.67+22.2%, NS). Based on scintigraphic examination sphincterotomy significantly improved transpapillary biliary outflow (common bile duct half time 63±33 min vs. 37±17 min; p<0.05). According to results obtained from questionneries, 22 of the 26 patients gave an account of significant symptom improvement after sphincterotomy.

CONCLUSIONS

Endoscopic sphincterotomy improves cholecystokinin-induced gallbladder ejection fraction, transpapillary biliary outflow as well as biliary symptoms in patients with acalculous biliary pain syndrome and sphincter of Oddi dysfunction. Cholecystokinin-induced gallbladder ejection fraction with nitroglycerin pretreatment, measured with ultrasonography can be useful to select a subgroup of patients who can benefit from sphincterotomy.

Heterogeneity in the systems of pediatric diabetes care across the European Union

BACKGROUND

It is known that the systems of pediatric diabetes care differ across the member states of the European Union (EU). The aim of this project was to characterize some of the main differences among the national systems.

METHODS

Data were collected using two questionnaires. The first one was distributed among leading centers of pediatric diabetes (one per country) with the aim of establishing an overview of the systems, national policies, quality control (QC) and financing of pediatric diabetes care. Responses were received from all 27 EU countries. The second questionnaire was widely disseminated among all 354 International Society for Pediatric and Adolescent Diabetes members with a domicile in an EU country; it included questions related to individual pediatric diabetes centers. A total of 108 datasets were collected and processed from healthcare professionals who were treating more than 29 000 children and adolescents with diabetes. Data on the reimbursement policies were verified by representatives of the pharmaceutical and medical device companies.

RESULTS

The collected data reflect the situation in 2009. There was a notable heterogeneity among the systems for provision of pediatric diabetes care across the EU. Only 20/27 EU countries had a pediatric diabetes register. Nineteen countries had officially recognized centers for pediatric diabetes, but only nine of them had defined criteria for becoming such a center. A system for QC of pediatric diabetes at the national level was reported in 7/26 countries. Reimbursement for treatment varied significantly across the EU, potentially causing inequalities in access to modern technologies.

CONCLUSIONS

The collected data help develop strategies toward improving equity and access to modern pediatric diabetes care across Europe.

[Endoscopic submucosal dissection in our practice -- new possibilities in the endoscopic treatment of neoplastic changes in the alimentary canal]

Endoscopic submucosal dissection is a promising new endoscopic technique for en block resection of early, superficial, flat, and laterally spreading gastrointestinal neoplasms. The primary aims of this prospective study were to summarize the first Hungarian experience with endoscopic submucosal dissection, and to compare the experimental in vivo procedures in pigs with the human application of this technique in two academic centers.

METHODS

The ex vivo Erlangen pig model was used until initial competence was achieved. Thereafter 15 endoscopic submucosal dissection procedures were performed in up to 5 sessions in living pigs under general anesthesia. After submucosal injection with saline Fujinone ball tip, a Flush knife was used with a transparent hood for circumferential incision and submucosal dissection. The following variables were analyzed: specimen size, complete and en bloc resection rate, total duration of the procedure, and complications. Furthermore, between 2009 and 2012, 14 endoscopic submucosal dissections were carried out in humans; 1 duodenal, 3 gastric and 10 colorectal interventions were performed due to large laterally spreading intramucosal neoplasms. The specimen size, en bloc resection rate, total duration of the procedure and complications were next analyzed.

RESULTS

87% complete resection rate, 29.4 ± 19.5 cm2 specimen size and 136.2 ± 26.8 min of procedure duration were achieved in the live pig models. Nontransmural damages of the muscular layer occurred in 3/15 (20%) cases which were successfully closed with hemoclips, except in one pig that died due to fatal esophageal perforation. All bleedings were easily managed with hot biopsy forceps coagulation and hemoclips without hemodynamic instability. In humans, endoscopic submucosal dissection was accomplished with an 11/14 (79%) en block resection rate, with average resected specimen size of 11.56 ± 4.9 cm2 and with 157 ± 55 min of operating time. Two cases of bleeding and 2 cases of perforation occurred (14%), all of which were managed endoscopically. After 1.5 year of average follow up, local recurrence occurred in one case only. In addition, due to the 3 incomplete resections and unsuccessful endoscopic submucosal dissection, surgical intervention was required in 4 cases altogether.

CONCLUSIONS

This study demonstrates the first Hungarian experience with endoscopic submucosal dissection. Training in live pig models could help endoscopists to overcome the learning curve and minimize the risk of complications before starting the procedure in humans. Reduction in the resection time and low risk of complications, especially bleeding, could be achieved by the application of a flush knife.

Early ERCP and biliary sphincterotomy with or without small-caliber pancreatic stent insertion in patients with acute biliary pancreatitis: better overall outcome with adequate pancreatic drainage

OBJECTIVE

To analyze the efficacy of pancreatic duct (PD) stenting following endoscopic sphincterotomy (EST) compared with EST alone in reducing complication rate and improving overall outcome in acute biliary pancreatitis (ABP).

METHODS

Between 1 January 2009 and 1 July 2010, 141 nonalcoholic patients with clinical, laboratory and imaging evidence of ABP were enrolled. Emergency endoscopic retrograde cholangiopancreatography (ERCP) was performed within 72 h from the onset of pain. Seventy patients underwent successful ERCP, EST, and stone extraction (control group); 71 patients (PD stent group) had EST, stone extraction and small-caliber (5 Fr, 3-5 cm) pancreatic stent insertion. All patients were hospitalized for medical therapy and jejunal feeding and were followed up.

RESULTS

The mean age, Glasgow score, symptom to ERCP time, mean amylase and CRP levels at initial presentation were not significantly different in the PD stent group compared to the control group: 60.6 vs. 64.3, 3.21 vs. 3.27, 34.4 vs. 40.2, 2446.9 vs. 2114.3, 121.1 vs. 152.4, respectively. Complications (admission to intensive care unit, pancreatic necrosis with septicemia, large (>6 cm) pseudocyst formation, need for surgical necrosectomy) were less frequent in the PD stent group resulting in a significantly lower overall complication rate (9.86% vs. 31.43%, p < 0.002). Mortality rates (0% vs. 4.28%) were comparable, reasonably low and without any significant differences.

CONCLUSIONS

Temporary small-caliber PD stent placement may offer sufficient drainage to reverse the process of ABP. Combined with EST the process results in a significantly less complication rate and better clinical outcome compared with EST alone during the early course of ABP.

Prediction and prevention of type 1 diabetes mellitus: initial results and recent prospects

Epidemiological studies indicate that the incidence and prevalence of type 1 diabetes mellitus is rising worldwide. The increase in incidence has been most prominent in the youngest age group of childhood. Prediction of type 1a autoimmune diabetes can be established by a positive family history or by genetic, immunological or metabolic markers. Prevention of type 1 diabetes can be implemented at three different levels of pathogenesis: primary prevention in individuals without any sign of beta-cell damage, secondary prevention in individuals with signs of beta-cell destruction and tertiary prevention in patients with newly diagnosed type 1 diabetes. In the recent years our knowledge of the disease pathogenesis has grown quickly and worldwide several new prevention trials have been started. Probably immune intervention of type 1 diabetes will prove to be the most effective. Orv. Hetil., 2011, 152, 1916–1921.

PPAR-gamma2 pro12Ala polymorphism is associated with post-challenge abnormalities of glucose homeostasis in children and adolescents with obesity

AIM

The aim of the study was to investigate the association between PPAR-gamma2 Pro12Ala polymorphism and laboratory characteristics of carbohydrate metabolism in children and adolescents with obesity. In addition, serum levels of tumor necrosis factor (TNF)-alpha, and soluble form of its receptors (sTNFR1 and sTNFR2) were assessed.

METHODS

In a cross-sectional study, 79 obese children and adolescents of Caucasian origin were investigated. PPAR-gamma2 Pro12Ala polymorphism was determined using polymerase chain reaction--restriction fragment length polymorphism technique. Serum levels of TNF-alpha, sTNFR1 and sTNFR2 were measured by enzyme amplified sensitivity immunoassay.

RESULTS

The minor Ala allele frequency was found to be 14.56% in our cohort. No significant differences in age, BMI, waist circumference, blood pressure, serum lipid, uric acid, TNF-alpha, sTNFR1 and sTNFR2 values were found between carriers of the Ala allele (Pro/Ala and Ala/Ala; n=21) vs. homozygous carriers of the Pro allele (Pro/Pro; n=58). However, post-challenge (120 min) plasma glucose and insulin values were significantly lower in Ala allele carriers vs. homozygous Pro allele carriers (6.56 +/- 0.26 vs. 7.36 +/- 0.25 mmol/L and 65.9 +/- 13.8 vs. 111.8 +/- 20.7 microU/mL, respectively; p < 0.05); while no significant differences were found at fasting state.

CONCLUSIONS

The association between PPAR-gamma2 Prol2Ala polymorphism and glucose metabolism is already present in children and adolescents with obesity who might be at the very beginning of the natural course of type 2 diabetes. At this stage, higher insulin sensitivity can be detected in Ala allele carriers compared to homozygous Pro subjects at post-challenge but not in fasting state; however, the TNF-system seems not to be involved in the alteration of glucose homeostasis due to PPAR-gamma2 Pro12Ala polymorphism.

[Risk-stratified screening for diabetes in adolescents: results of the first investigation in Hungary]

The prevalence of type 2 diabetes mellitus in children and adolescents is increasing throughout the world. Early detection of blood glucose abnormalities is essential to improve long term prognosis of type 2 diabetes, as intervention strategies could be the most effective in youngsters.

AIM

To assess the prevalence of blood glucose abnormalities in asymptomatic adolescents having increased risk of diabetes, a screening program of the Hungarian Diabetes Association has been carried out in pediatric primary care setting.

METHODS

660 adolescents aged 12-18 years recruited from general pediatric practices were involved in the study. Risk assessment was performed by a questionnaire compiled according to the ADA recommendation for testing type 2 diabetes in childhood. Fasting plasma glucose and OGTT were performed in adolescents having increased risk for type 2 diabetes (overweight plus two additional clinical risk factors) and results were assessed according to WHO criteria.

RESULTS

285 adolescents of 660 were selected with increased risk for type 2 diabetes established by questionnaire (age: 15.2±1.8 years, BMI: 30.2±4.2 kg/m 2 , 141 males). Among subjects with increased risk, 16 (5.6%) had any type of blood glucose abnormalities: 4 (1.40%) IFG, 5 (1.75%) IFG+IGT, 6 (2.11%) IGT and 1 (0.35%) type 2 diabetes. Assessing the effect of clinical variables, increased BMI proved to be the strongest predictor of the diabetes risk [OR (95% CI): 1.216 (1.174-1.258), p<0.0001].

CONCLUSIONS

Screening procedure among asymptomatic adolescents with high risk of type 2 diabetes in the general pediatric practice is a simple and effective method for early detection of blood glucose abnormalities. Screening for type 2 diabetes in adolescents at risk should be encouraged in Hungary, and should be performed in pediatric primary care setting.

A new distensibility technique to measure sphincter of Oddi function

BACKGROUND

Evaluation of the biliary tract is important in physiological, pathophysiological, and clinical studies. Although the sphincter of Oddi (SO) can be evaluated with manometry, this technique has several limitations. This may explain the difficulties in identifying pathophysiological mechanisms for dysfunction of the SO and in identifying patients who may benefit from certain therapies. To encompass problems with manometry, methods such as the functional lumen imaging probe (FLIP) technique have been developed to study GI sphincters. This study set about miniaturising the FLIP probe and validating it for measurements in the SO. In order to get a better physiological understanding of the SO the aims were to show the sphincter profile in vivo and motility patterns of SO in pilot studies using volunteers that were experiencing biliary type pain but had normal SO manometry.

METHODS

The SO probe was constructed to measure eight cross-sectional areas (CSA) along a length of 25 mm inside a saline-filled bag. To validate the technique for profiling the SO, six perspex cylinders with different CSAs were measured nine times to assess reproducibility and accuracy.

KEY RESULTS

Reproducibility and accuracy for these measurements were good. The probe performed well in bench tests and was therefore tested in four humans. The data indicated that it was possible to make distensions in the human SO and that a geometric sphincter profile could be obtained.

CONCLUSIONS & INFERENCES

The probe will in future studies be tested for diagnostic purposes related to sphincter of Oddi diseases.

Gallstone Ileus, Bouveret's Syndrome and Choledocholithiasis in a Patient with Billroth II Gastrectomy - A Case Report of Combined Endoscopic and Surgical Therapy

Intestinal obstruction due to gallstone is a rare, but quite severe gastrointestinal disorder, which always requires a rapid and correct diagnosis to achieve optimal therapy. Digestive endoscopy is an important method to determine the level of the bowel obstruction and to plan an optimal therapeutic strategy. Our present case demonstrates that in a high-risk patient, a combined endoscopic and surgical therapy is the best choice to solve the obstruction of the colon, of the stomach and of the common bile duct caused by multiple gallstones.

Feasibility and safety of emergency ERCP and small-caliber pancreatic stenting as a bridging procedure in patients with acute biliary pancreatitis but difficult sphincterotomy

BACKGROUND

The aims of the present study were: (1) to assess the feasibility and safety of emergency endoscopic retrograde cholangiopancreatography (ERCP) and pancreatic duct (PD) stenting with small-caliber stents as a bridging procedure in acute biliary pancreatitis (ABP) patients in whom biliary endoscopic sphincterotomy (EST) proved difficult, failed or was contraindicated, and (2) to compare the clinical outcome of those patients having emergency ERCP with and without pancreatic stent.

METHOD

Eighty-seven consecutive patients with ABP were referred for emergency ERCP. In 60 of these ABP patients, ERCP, EST, and stone extraction (if necessary) were performed without PD stenting. In the remaining 27 patients, small-caliber (3-5 F, 4 cm) pancreatic stent insertion was initially applied. All patients were hospitalized for medical therapy and were followed up.

RESULTS

The mean ages, the initial symptom-to-ERCP times, the Glasgow severity scores, and the peak amylase and CRP levels at initial presentation were not significantly different in the ERCP + EST with PD stent group versus the ERCP + EST without PD stent group. More importantly, the complication rate was significantly lower in the ERCP + EST with PD stent group versus the ERCP + EST without PD stent group (7.4% vs. 25%); while the mortality rates (0% vs. 6.7%) were comparable, reasonably low, and demonstrated no statistically significant differences.

CONCLUSIONS

Temporary PD stenting with small-caliber stents is a safe and effective procedure that may afford sufficient PD decompression to reverse the process of ABP and serve as a bridging procedure in severe ABP in patients with failed, complicated, or contraindicated biliary EST.

The interferon-induced helicase IFIH1 Ala946Thr polymorphism is associated with type 1 diabetes in both the high-incidence Finnish and the medium-incidence Hungarian populations

AIMS/HYPOTHESIS

The rs1990760 polymorphism (Ala946Thr) of interferon induced with helicase C domain 1 (IFIH1) has been proposed to associate with type 1 diabetes. In this study, association between IFIH1 Ala946Thr and type 1 diabetes was investigated in two distinct white populations, the Hungarians and Finns.

METHODS

The rs1990760 polymorphism was genotyped in 757/509 Hungarian/Finnish childhood-onset cases, 499/250 Hungarian/Finnish control individuals and in 529/924 Hungarian/Finnish nuclear family trios. Disease association was tested using case-control and family-based approaches. A meta-analysis of data from 9,546 cases and 11,000 controls was also performed.

RESULTS

In the Hungarian dataset, the A allele was significantly more frequent among cases than among controls (OR 1.29, 95% CI 1.10-1.52; p = 0.002). Combined analysis of Hungarian and Finnish datasets revealed a strong disease association (OR 1.235, 95% CI 1.083-1.408; p = 0.002). Furthermore, the A allele was significantly overtransmitted in both family trio datasets (p = 0.017 in Hungarians; p = 0.007 in Finns). The A allele was increased in Hungarian vs Finnish cases (64.9% vs 60.8% in Finns; p = 0.003). The meta-analysis yielded a significant effect for IFIH1 rs1990760 A allele on type 1 diabetes risk (OR 1.176, 95% CI 1.130-1.225; p = 5.3 x 10(-15)) with significant heterogeneity between effect sizes across the studied populations (p = 0.023).

CONCLUSIONS/INTERPRETATION

This study represents the first independent confirmation of the association between type 1 diabetes and the IFIH1 gene in Hungarian and Finnish populations. Summarising the data published so far, a clear association between the Ala946Thr polymorphism and type 1 diabetes was detected, with an apparent difference in the contribution to disease susceptibility in different populations of European ancestry.

Prophylactic pancreas stenting followed by needle-knife fistulotomy in patients with sphincter of Oddi dysfunction and difficult cannulation: new method to prevent post-ERCP pancreatitis

INTRODUCTION

The aim of the present study was to reduce post-endoscopic retrograde cholangiopancreatography (ERCP) complications with a combination of early needle-knife access fistulotomy and prophylactic pancreatic stenting in selected high-risk sphincter of Oddi dysfunction (SOD) patients with difficult cannulation.

METHODS

Prophylactic pancreatic stent insertion was attempted in 22 consecutive patients with definite SOD and difficult cannulation. After 10 min of failed selective common bile duct cannulation, but repeated (>5x) pancreatic duct contrast filling, a prophylactic small calibre (3-5 Fr) pancreatic stent was inserted, followed by fistulotomy with a standard needle-knife, then a standard complete biliary sphincterotomy followed. The success and complication rates were compared retrospectively with a cohort of 35 patients, in which we persisted with the application of standard methods of cannulation without pre-cutting methods.

RESULTS

Prophylactic pancreatic stenting followed by needle-knife fistulotomy was successfully carried out in all 22 consecutive patients, and selective biliary cannulation and complete endoscopic sphincterotomy were achieved in all but two cases. In this group, not a single case of post-ERCP pancreatitis was observed, in contrast with a control group of three mild, 10 moderate and two severe post-ERCP pancreatitis cases. The frequency of post-ERCP pancreatitis was significantly different: 0% versus 43%, as were the post-procedure (24 h mean) amylase levels: 206 U/L versus 1959 U/L, respectively.

CONCLUSIONS

In selected, high-risk, SOD patients, early, prophylactic pancreas stent insertion followed by needle-knife fistulotomy seems a safe and effective procedure with no or only minimal risk of post-ERCP pancreatitis. However, prospective, randomized studies are awaited to lend to support to our approach.

Somatosensory hypersensitivity in the referred pain area in patients with chronic biliary pain and a sphincter of Oddi dysfunction: new aspects of an almost forgotten pathogenetic mechanism

BACKGROUND AND AIMS

Somatosensory hyperalgesia in the referred pain area (RPA) in patients with acute or chronic abdominal pain syndromes may result from the convergence of nerve fibers from visceral and somatic tissues at the spinal and supraspinal levels. Chronic biliary pain in patients with the postcholecystectomy syndrome (i.e., biliary hypersensitivity) may be explained by persistent hyperexcitability of neurons in the central nervous system (CNS). The aim of this study was to evaluate the cutaneous neural sensory perception in the RPA in patients with chronic postcholecystectomy biliary pain and a sphincter of Oddi (SO) dysfunction (SOD).

METHODS

Forty-two patients with persistent biliary pain and suspected SOD, 27 age-matched healthy volunteers, and 18 age-matched asymptomatic cholecystectomized controls were prospectively investigated by quantitative sensory testing (Neurometer CPT). The biliary symptoms and the severity of pain were classified on a visual analog pain severity scale system via a previously validated and standardized questionnaire. The patients helped the doctors locate the RPA in the right upper quadrant. The sensory detection threshold was determined noninvasively (Neurometer CPT) with transcutaneous electrical stimulation at 5, 250, and 2,000 Hz, and different current intensities (range from 0.01 to 9.99 mA) applied in a single (patient) blinded method. These three frequencies selectively excite small unmyelinated (C fibers), small myelinated (A-delta), and large myelinated (A-beta) fibers, which transmit dull pain, sharp pain, and touch, respectively. The contralateral region of the abdomen left upper quadrant served as the control area. The sensory current perception threshold ratio (SCPTR) of the data measured in the contralateral area and the RPA was calculated.

RESULTS

The SCPTRs in the definite SOD patients with biliary pain, healthy volunteers, the asymptomatic cholecystectomized controls, and the symptomatic cholecystectomized patients but without SOD were 2.32 +/- 1.4 versus 1.06 +/- 0.24 versus 0.97 +/- 0.16 versus 0.83 +/- 0.35 at 2,000 Hz; 2.19 +/- 1.0 versus 1.01 +/- 0.26 versus 1.02 +/- 0.25 versus 0.88 +/- 0.35 at 250 Hz; and 2.19 +/- 1.1 versus 1.12 +/- 0.26 versus 0.99 +/- 0.37 versus 0.84 +/- 0.32 at 5 Hz, respectively. Significant hypersensitivity was detected in the RPA at different stimulation frequencies in the SOD patients with biliary pain versus the cholecystectomized controls: at 5 Hz: P = 0.00001; at 250 Hz: P = 0.00001; and at 2,000 Hz: P = 0.0001, respectively.

CONCLUSION

Continuous visceral pain (biliary pain) caused by local inflammatory/sensitizing processes or a CNS malfunction could lead to significant hypersensitivity of the peripheral nociceptive nerve fibers in SOD patients. Postcholecystectomy pain may be explained by persistent hyperexcitability of the nociceptive neurons in the CNS with or without objective motility disorders of the SO.

Occurence of thyroid autoimmunity in children with type 1 diabetes mellitus

Ismert, hogy azok a betegek, akikben egy autoimmun betegség már kialakult, fokozottan veszélyeztetettek más autoimmun betegségek fellépésével szemben. Korábban a szerzők kimutatták, hogy 1-es típusú diabéteszben szenvedő betegekben a coeliakia előfordulása gyakoribb, mint a háttérpopulációban. Az autoimmun pajzsmirigybetegség az 1-es típusú diabétesz leggyakoribb társbetegsége, amely általában az élet második évtizedében, az 1-es típusú diabétesz manifesztációját követően lép fel. Célkitűzés: Mindezek alapján a szerzők megvizsgálták a thyreoidea-autoimmunitás, illetve az autoimmun pajzsmirigybetegségek előfordulási gyakoriságát 1-es típusú diabéteszben szenvedő betegekben. Választ kerestek arra a kérdésre is, hogy változik-e a thyreoidea-autoimmunitás prevalenciája azokban a gyermekekben, akik a diabétesz mellett coeliakiában is szenvednek. Módszerek: 268 1-es típusú diabéteszben, valamint 48 1-es típusú diabéteszben és coeliakában szenvedő betegben az autoimmun pajzsmirigybetegségek irányába szűrővizsgálatot végeztek a thyreoglobulin- és a peroxidáz-ellenes antitestek vizsgálatával. Pozitivitás esetén a betegséget a pajzsmirigyfunkció vizsgálatával, illetve ultrahang elvégzésével igazolták. Eredmények: Vizsgálataik szerint a pajzsmirigyellenes antitestek előfordulási gyakorisága szignifikánsan magasabb volt azokban az 1-es típusú diabéteszes betegekben, akik egyidejűleg coeliakában is szenvedtek (1-es típusú diabétesz: 43 (16%), 1-es típusú diabétesz + coeliakia: 16 (33,3%, p < 0,01). A thyreoiditis talaján kialakult hypothyreosis is gyakrabban fordult elő azokban a diabéteszes betegekben, akik coeliakiásak voltak. Következtetések: A szerzők hangsúlyozzák, hogy a coeliakiában szenvedő 1-es típusú diabéteszes betegekben az autoimmun pajzsmirigybetegség fellépésének nagyobb valószínűsége miatt ennek a populációnak az autoimmun pajzsmirigybetegségek iránti rendszeres szűrése feltétlenül indokolt.

Celiac artery compression syndrome – stepchild of abdominal angina?

A krónikus, étkezéssel összefüggést nem mutató epigastrialis fájdalmak hátterében az esetek néhány százalékában a truncus coeliacus külső kompressziója áll. Esetismertetés: A szerzők egy 58 éves nőbeteg kórtörténetét ismertetik, akinél a hasi szervek ischaemiája, a felhasi fájdalom hátterében a preoperatív kivizsgálás a truncus coeliacuson rövid szakaszú stenosist okozó, a rekeszizom-hiátus aorticusát övező inas-izmos ívet igazolt. Előkészítést követően műtétet végeztünk, a trifurcatio eredésétől számított 8–10 mm-re levő heges, gyűrűszerű leszorítást felhasítottuk, a ganglion coeliacum egy részét eltávolítottuk. A beteg a posztoperatív 6. napon gyógyultan, panaszmentesen otthonába távozott. Megbeszélés: A klasszikus értelemben vett angina abdominalis a hasi szervek relatív ischaemiájának következménye. Ennek oka legtöbbször az érintett ér betegsége. Az artéria külső kompressziója csupán az esetek pár százalékát jelenti. A truncus coeliacus esetében ezt betegünknél a rekeszizom-hiátus aorticusát övező inas megerősödés okozta. A kivizsgálás során az erre utaló első jel az ér felett hallható „surranás” volt, a poststenoticus turbulens áramlás miatt. Az erre alapozott részletes radiológiai vizsgálatok igazolták a tényleges kórokot. Ennek ismeretében a felszabadító műtét teljes tünet- és panaszmentességet eredményezett. Következtetés: Bizonytalan hasi panaszok esetén gondolnunk kell az arteria coeliaca stenosisának lehetőségére is. Esetismertetésünkkel kívánjuk felhívni a figyelmet a hasi auscultatio jelentőségére, amely elengedhetetlen része a gasztroenterológiai vizsgálatoknak. A diagnózis felállításában a Doppler-duplexvizsgálat mellett komoly segítséget jelentettek az érfestési eljárások. A műtét lényegét képező érfelszabadítást célszerű mielőbb elvégezni, még mielőtt a tartós külső kompresszió degeneratív érfalelváltozást okoz.

Polymorphisms of the TNF-alpha gene and risk of celiac disease in T1DM children

BACKGROUND

Type 1 diabetes mellitus (T1DM) and celiac disease (CD) frequently occur together. Previous reports suggested that the (-308)A variant of the tumor necrosis factor-alpha (TNF-alpha) gene is associated either with T1DM or with CD. The aim of our study was to determine whether (-308)A and (-238)A allelic variants of the TNF-alpha gene might have any impact on the risk of CD in T1DM children.

METHODS

Three hundred and one T1DM children were enrolled to the study. The presence of CD was screened with IgA endomysial antibodies (EMA) test. Jejunal biopsy was performed to confirm CD. TNF-alpha-308 and -238 genetic variants were tested using the method of restriction fragment length polymorphism.

RESULTS

The prevalence of CD in the enrolled diabetic children was 6.3% (19 out of 301 children). The frequency of the (-308)A TNF-alpha variant was similar in the CD and the non-CD groups, exceeding the Hungarian healthy reference value. The number of (-238)A allele carriers was higher in the CD (4/19) than in the non-CD group (17/277) (p < 0.05).

CONCLUSIONS

Our study is limited by the small number of CD patients. On the basis of our findings, carriers of TNF (-308)A allele do not seem to have an increased risk for CD in T1DM. The association between TNF-alpha(-238)A allele carrier state and CD requires further investigation.

Effect of heat shock protein peptide DiaPep277 on beta-cell function in paediatric and adult patients with recent-onset diabetes mellitus type 1: two prospective, randomized, double-blind phase II trials

BACKGROUND

Aim of this trial was to test whether heat shock protein peptide DiaPep277 treatment in adult and paediatric patients with recent-onset type 1 diabetes (T1D) is safe and whether it can preserve endogenous insulin production.

METHODS

Two studies were performed in a prospective, multicentre, double-blind, placebo-controlled trial. Fifty adult (study p520, aged 16-44 years) and 49 paediatric patients (study p521, 4-15 years) with recent-onset T1D were treated subcutaneously at four different time points with 0.2 mg or 1.0 mg DiaPep277 versus placebo and followed for 18 months. Adult patients were treated with 0.2 mg, 1.0 mg or 2.5 mg DiaPep277 versus placebo. Stimulated C-peptide served as readout for functional beta-cell-mass.

RESULTS

DiaPep277-treatment was not associated with severe side effects. No differences were found in placebo and DiaPep277 treated groups. In adults, a modest trend towards better maintenance of beta-cell function was observed in the 0.2 mg and 1.0 mg group, while there was significant loss of stimulated C-peptide in the placebo and 2.5 mg group. Paediatric patients with low HLA risk showed stable C-peptide levels until 13 months upon treatment with 1 mg DiaPep277. Despite similar stimulated C-peptide levels at baseline, children exhibited a more pronounced loss of beta-cell function over 18 months than adults (p = 0.0003).

CONCLUSION

Administration of DiaPep277 seems safe and may have beneficial effects on C-peptide levels over time in some patients with T1D, but this finding was not accompanied by reduced HbA1c or insulin requirement. Studies with more patients and longer follow-up are needed to further study the effect of DiaPep277.

[Determining factors of cardiac biomarkers in hemodialysed diabetic and non-diabetic patients]

INTRODUCTION

Cardiovascular diseases are highly prevalent in chronic renal failure patients, especially in diabetic population. Cardiac biomarkers such as pro-brain natriuretic peptide N-terminal piece (NT-proBNP), cardiac troponin T (cTnT) and high sensitive CRP (hs-CRP) are increasingly used for early detection.

AIMS

The authors analysed, which factors influence cardiac biomarker levels in hemodialysed patients and whether these factors depend on the presence of diabetes.

METHODS

In 28 diabetic and 40 non-diabetic patients on chronic hemodialysis was analysed the association between routine laboratory data, bioimpedance parameters, results of echocardiography and ambulatory blood pressure monitoring on cardiac biomarkers. Multivariate linear regression analysis (ANOVA) was applied for statistical evaluation.

RESULTS

The authors found stronger correlation (p = 0.034 vs. p = 0.001) between NT-proBNP and extracellular volume/total water volume hyperhydration ratio (ecv/twv) evaluated in diabetics than in non-diabetics. In case of cTnT, no relation was found with CaxP, iPTH, Kt/V, beta2-microglobulin, and serum uric acid levels. The hs-CRP was correlated with total cholesterol (p = 0.039) and EPO-dose (p = 0.03) in diabetics, while with serum fibrinogen (p = 0.025) in non-diabetics. The HbA1c didn't influence biomarkers in the diabetic group.

CONCLUSIONS

The factors having an impact on cardiac biomarker levels are similar in diabetic and non-diabetic hemodialysed patients. According to results the presence of end-stage renal disease in a cross-sectional survey probably overcomes the impact of diabetes and quality of glycaemic control on cardiac biomarker levels.

Characterization of functional biliary pain and dyspeptic symptoms in patients with sphincter of Oddi dysfunction: Effect of papillotomy

AIM: To characterize functional biliary pain and other gastrointestinal (GI) symptoms in postcholecystectomy syndrome (PCS) patients with and without sphincter of Oddi dysfunction (SOD) proved by endoscopic sphincter of Oddi manometry (ESOM), and to assess the post-endoscopic sphincterotomy (EST) outcome.

METHODS: We prospectively investigated 85 cholecystectomized patients referred for ERCP because of PCS and suspected SOD. On admission, all patients completed our questionnaire. Physical examination, laboratory tests, abdominal ultrasound, quantitative hepatobiliary scintigraphy (QHBS), and ERCP were performed in all patients. Based on clinical and ERCP findings 15 patients had unexpected bile duct stone disease and 15 patients had SOD biliary typeI. ESOM demonstrated an elevated basal pressure in 25 patients with SOD biliary-type III. In the remaining 30 cholecystectomized patients without SOD, the liver function tests, ERCP, QHBS and ESOM were all normal. As a control group, 30 ‘asymptomatic’ cholecystectomized volunteers (attended to our hospital for general cardiovascular screening) completed our questionnaire, which is consisted of 50 separate questions on GI symptoms and abdominal pain characteristics. Severity of the abdominal pain (frequency and intensity) was assessed with a visual analogue scale (VAS). In 40 of 80 patients having definite SOD (i.e. patients with SOD biliary typeIand those with elevated SO basal pressure on ESOM), an EST was performed just after ERCP. In these patients repeated questionnaires were filled at each follow-up visit (at 3 and 6 mo) and a second look QHBS was performed 3 mo after the EST to assess the functional response to EST.

RESULTS: The analysis of characteristics of the abdominal pain demonstrated that patients with common bile duct stone and definite SOD had a significantly higher score of symptomatic agreement with previously determined biliary-like pain features than patient groups of PCS without SOD and controls. In contrary, no significant differences were found when the pain severity scores were compared in different groups of PCS patients. In patients with definite SOD, EST induced a significant acceleration of the transpapillary bile flow; and based on the comparison of VASs obtained from the pre- and post-EST questionnaires, the severity scores of abdominal pain were significantly improved, however, only 15 of 35 (43%) patients became completely pain free. Post-EST severity of abdominal pain by VASs was significantly higher in patients with predominant dyspepsia at initial presentation as compared to those without dyspeptic symptoms.

CONCLUSION: Persistent GI symptoms and general patient dissatisfaction is a rather common finding after EST in patients with SOD, and correlated with the presence of predominant dyspeptic symptoms at the initial presentation, but does not depend on the technical and functional success of EST.

Evaluation of the biliary tract in patients with functional biliary symptoms

The aim of this paper was to describe functional biliary syndromes and methods for evaluation of the biliary tract in these patients. Functional biliary symptoms can be defined as biliary symptoms without demonstrable organic substrate. Two main syndromes exist: Gallbladder dysfunction and sphincter of Oddi dysfunction. The most important investigative tools are cholescintigraphy and endoscopic sphincter of Oddi manometry. In gallbladder dysfunction a scintigraphic gallbladder ejection fraction below 35% can select patients who will benefit from cholecystectomy. Endoscopic sphincter of Oddi manometry is considered the gold standard in sphincter of Oddi dysfunction but recent development in scintigraphic methods is about to change this. Thus, calculation of hilum-to-duodenum transit time and duodenal appearance time on cholescintigraphy have proven useful in these patients. In conclusion, ambient methods can diagnose functional biliary syndromes. However, there are still a number of issues where further knowledge is needed. Probably the next step forward will be in the area of sensory testing and impedance planimetric methods.

Assessment of the reproducibility of quantitative hepatobiliary scintigraphy (QHBS) in patients with sphincter of Oddi dysfunction (SOD)--inappropriate method or intermittent disease?

BACKGROUND/AIMS

Although quantitative hepatobiliary scintigraphy (QHBS) was originally suggested as a promising method in the diagnosis of sphincter of Oddi dysfunction (SOD), it was recently claimed that QHBS displays poor reproducibility and specificity in cholecystectomized patients. The aim of the present study was to assess the reproducibility of QHBS in cholecystectomized patients.

METHODOLOGY

28 cholecystectomized patients with suspected SOD underwent QHBS evaluation on two separate occasions. On the basis of the clinical and endoscopic retrograde cholangiopancreatography (ERCP) data, patients with suspected SOD were categorized by applying the Geenen and Hogan classification: 10 were identified as having SOD of biliary type I (SO stenosis group), and the remaining 18 patients as having SOD of biliary type II or III (SO dyskinesia group). During the same period, 12 asymptomatic cholecystectomized individuals (control group) were recruited to undergo QHBS evaluation on two separate occasions. QHBS was performed with our standard method in all subjects. After an overnight fast, 140MBq 99mTc-EHIDA was injected intravenously. Digital images were recorded continuously on a 128 x 128 matrix, at one frame/min for 90 min. For the final analysis, the liver-choledochus T. difference (LCTD), half-time of excretion of the common bile duct (CBD T1/2), and the duodenum appearance time (DAT) were applied.

RESULTS

In the 12 asymptomatic controls, the QHBS parameters were highly reproducible, all but 6 of the 72 separate parameters obtained from two repeated studies were within our normal limits. In all 10 patients belonging in the SO stenosis group, the QHBS parameters were markedly abnormal and again highly reproducible. All of the 60 separate quantitative parameters obtained in this group from the two repeated studies were high above our normal range. In contrast, in the 18 patients with SO dyskinesia, the QHBS parameters were distinctly variable and poorly reproducible. Of the 108 separate quantitative parameters obtained in this group the two separate studies, 55 were normal and 53 were above our normal range. Of the 18 SO dyskinesia patients, only 9 had at least one quantitative parameter abnormal in both QHBS examinations.

CONCLUSIONS

QHBS is a highly reproducible technique in cholecystectomized controls and in patients with SO stenosis. In contrast, the reproducibility of QHBS is poor in patients with SO dyskinesia, which is probably a consequence of the disease characteristics rather than methodological insufficiency of QHBS.

The HLA 8.1 ancestral haplotype is strongly linked to the C allele of -429T>C promoter polymorphism of receptor of the advanced glycation endproduct (RAGE) gene. Haplotype-independent association of the -429C allele with high hemoglobinA1C levels in diabetic patients

Previously we reported on strong linkage disequilibrium (LD) between the mono-S-C4B-RCCX module (mono-S) and the TNF2 allele (both known constituents of the 8.1 ancestral haplotype (8.1 AH)) in two Caucasian populations. The gene for the receptor of advanced glycation endproducts (RAGE) is encoded between the RCCX module and the HLA class II genes in the central MHC region. In order to assess the relationship between the promoter polymorphisms of the RAGE gene and the 8.1 AH, we performed a family study in eight informative families affected with type 1 diabetes mellitus; haplotypes of a RAGE promoter SNP (-429T>C) with the HLA-DQ2, -DR-3(17) and TNF2 alleles, as well as the mono-S genotype were determined. A similar analysis was performed in 82 unrelated patients with type 1 diabetes mellitus, and in unrelated healthy individuals of three different Caucasian populations (Hungarians, Ohioian females, Icelandics). In the diabetic patients clinical correlations were also investigated. Out of the 32 paternal and maternal chromosome 6 from the eight families, 15 different MHC haplotypes were found. Haplotypes containing at least three of the known constituents of the 8.1 AH (HLA-DQ2, -DR17, mono-S, TNF2) were always linked to the RAGE -429C allele. The RAGE -429C allele exhibited highly significant (p<0.0001) LD coefficients to known constituents of the 8.1 AH both in healthy persons and patients with type 1 diabetes. In the group of patients with diabetes we found significantly (p=0.013) higher maximal hemoglobinA1C concentration in the carriers of the RAGE -429C allele, this trait, however was not linked to the 8.1 AH. Our present findings indicate that the RAGE -429C allele can be considered as a candidate member of the 8.1 AH. The results also reveal a spectrum of recombinant MHC haplotypes in addition to the conserved ancestral haplotypes.

Association between interleukin-6 polymorphism and age-at-onset of type 1 diabetes. Epistatic influences of the tumor necrosis factor-alpha and interleukin-1beta polymorphisms

Multiple immune mediators have been mentioned as playing a role in the pathomechanism of type1 DM. Interleukin (IL)-1beta, and tumor necrosis factor (TNF)-alpha play a central role in the autoimmune destruction of pancreatic beta-cells, whereas IL-6 inhibits TNF-alpha secretion, and may have some protecting effects. In our study, we aimed to investigate the association between these three cytokines' single nucleotide polymorphisms (IL-6 gene G(-174)C, TNF-alpha gene G(-308)A and IL-1beta gene C(3954)T polymorphisms) and age-at-onset of type 1 diabetes mellitus (T1DM) in 165 diabetic children (median age: 17 years). Polymorphisms were determined using the PCR-RFLP method. We found that the age-at-onset of T1DM was significantly different in patients with a different IL-6 genotype (median age-at-onset of T1DM was: 8, 6 and 4.5 years in children with the (-174)GG, GC and CC genotypes, respectively; p < 0.01). Adjusted for TNF-alpha and IL-1beta polymorphisms, patients with a IL-6 (-174)CC genotype have a 3.0-fold (95% CI: 1.2-7.1) increased risk of developing diabetes before the age of 6 years than (-174)G allele carrier patients. However, we found this association to be present only in patients who carried the TNF-alpha (-308)A or IL-1beta (3954)T allele, i.e. in patients with high TNF-alpha and high IL-1beta producer genotypes. We suppose that in the case of high TNF-alpha and IL-1beta producer genotypes, elevated proinflammatory cytokine levels result in a higher production of IL-6 in (-174)G allele carrier patients. This elevated IL-6 level may have a protective effect against the development of T1DM and may delay the destruction of pancreatic beta-cells.

Diagnosis of gallbladder dyskinesia by quantitative hepatobiliary scintigraphy

AIM

The aim of the present study was to develop a new pharmacologic method during hepatobiliary scintigraphy by which patients with functional and organic forms of gallbladder (GB) dysfunction can be differentiated.

METHODS

Quantitative hepatobiliary scintigraphy (QHBS) was performed on 31 patients with impaired GB motility selected by cerulein-augmented ultrasonography. Nineteen patients had acalculous biliary pain (ABP) and suspected GB dyskinesia, 6 patients had celiac disease, and 6 patients had type II diabetes mellitus. Sixty minutes after the isotope administration, 1 ng/bwkg/min cerulein (CCK10) was infused for 10 minutes, and then from the 90th minute, an equivalent dose of CCK10 was infused in the presence of 0.5 mg sublingual glyceryl trinitrate (GTN) in 12 or placebo in 7 consecutive patients. The GB ejection fraction (GBEF) was calculated repeatedly in time periods from 60 to 90 and from 90 to 120 minutes.

RESULTS

In the majority of patients with ABP and suspected GB dyskinesia, CCK10 and GTN coadministration normalized the previously impaired GB-emptying. When the cumulative results of all 12 patients were calculated, we demonstrated significant differences (P=0.003) in the GBEF between the first (CCK10) versus the second (CCK10 plus GTN) stimuli: 19+/-11% versus 40+/-17%, respectively. In contrast, in 12 patients with celiac sprue and diabetes mellitus, no differences in the GBEF were detected when the first (CCK10 alone) versus the second (CCK10 plus GTN) stimuli was compared: 21+/-10% versus 22+/-13%, respectively. Finally, placebo and CCK10 coadministration in 7 consecutive patients with ABP and suspected GB dyskinesia did not influence the GBEF as compared with CCK10 alone: 13+/-9% versus 15+/-10%, respectively.

CONCLUSION

GTN and CCK10 coadministration induces a significant improvement of the GBEF in patients with GB dyskinesia. The application of this new pharmacologic test during QHBS permitted the noninvasive separation of those patients with secondary impaired GB-emptying as a result of GB dyskinesia from those with primary forms of GB hypokinesia.

Analysis of the motor function of the human sphincter of Oddi by endoscopic retrograde cinecholangiography gated by manometry--a report of a case

Although the motor function of the sphincter of Oddi (SO) has been clearly identified by endoscopic SO manometry (ESOM), the physiologic role of the phasic contractions of the SO remains unsettled in humans. The aim of this study was to correlate SO motor activity measured by ESOM with bile flow characteristics determined by simultaneously recorded endoscopic retrograde cinecholangiography. We investigated a 55-year-old female patient by means of ESOM. During the station pull-through recording, the ESOM catheter was withdrawn into the SO zone and retained there for 15 min. The pressures transmitted by the external transducers and the enlarged video picture of the choledochoduodenal junction from the X-ray fluoroscopic monitor (25 digital pictures/sec) were recorded simultaneously on the computer system with a time-correlated basis. During the analysis without taking note of the cinefluoroscopic events, we selected different manometric periods manually, such as the pressure wave of the SO phasic contraction, no SO phasic activity and the first second of the beginning of the next phasic contraction. Cumulative cinecholangiographic pictures were then constructed by the computer for each period, at a frequency of one frame/sec to create representative sum-of-pictures for each manometric period. By means of the application of manometrically gated cinecholangiography, we succeeded in demonstrating an exact time correlation between the SO systolic and diastolic movements on cinecholangiography and the pressure recording detected by ESOM in humans.

[Continuous glucose monitoring system, as a valuable tool in the care of children and adolescents with diabetes mellitus]

INTRODUCTION

Good metabolic control of diabetic patients is mainly based on the results of self measured blood glucose levels. Important excursions of blood glucose may, however, be hidden in the usual case of 4-5 daily determinations. The aim of this paper was to give detailed information about this new diagnostic tool and to report the first Hungarian pediatric experiences with continuous glucose monitoring.

METHOD

Continuous glucose monitoring system (Mini-Med) is able to monitor the changes of tissue glucose levels for up to 72 hours by measuring glucose concentration via a s.c. canula every 5 minutes. In its present form the results of continuous glucose monitoring cannot be observed real time by the patient, it provides useful information retrospectively mainly for the doctor.

RESULTS

The sensor detected unexpectedly high fluctuation of glucose levels in several patients. It was possible to distinguish between nighttime hypoglycaemia (Somogyi-effect) or dawn phenomenon-induced morning hyperglycaemiae by the use of continuous glucose monitoring. Fever may influence peripheral circulation representing a limitation in the use (or evaluation) of continuous tissue glucose monitoring. The authors found good correlation between continuous glucose monitoring and self blood glucose monitoring results. The best correlation was observed in the low blood glucose range.

CONCLUSIONS

The continuous glucose monitoring results provide useful information for the diabetologist in order to modify insulin treatment. Continuous glucose monitoring-based changes in insulin treatment are reported to result in better long term metabolic control. Continuous glucose monitoring in the near future will obviously play a primary role in insulin pump therapy where it will provide glucose result for the pump.

Altered Distribution of the Debrisoquine Oxidative Phenotypes in Children with Type 1 Diabetes mellitus

OBJECTIVE

The recently observed increase in the incidence of type 1 diabetes mellitus (Type 1 DM) suggests a major role of environmental factors in the etiopathogenesis of the disease. The individual variation in cytochrome P(450)IID6 may influence the individual susceptibility to environmentally linked diseases. We aimed to evaluate the prevalence of cytochrome P(450)IID6 phenotypes in Hungarian children with Type 1 DM (n = 69) compared to healthy controls (n = 100).

METHODS

Debrisoquine was administered orally and debrisoquine hydroxylation phenotype was determined as a metabolic ratio of urinary recovered debrisoquine and 4-hydroxydebrisoquine.

RESULTS

Eight of the 100 healthy subjects (8%) and 15 of the 69 diabetic children (22%) (p < 0.05) had cytochrome P(450)IID6 poor metabolizer phenotype (metabolic ratio > or =12.6).

CONCLUSION

Cytochrome P(450)IID6's activity may play a role in the development of Type 1 DM.

Effect of nalbuphine on the motility of the sphincter of Oddi in patients with suspected sphincter of Oddi dysfunction

BACKGROUND

Nalbuphine is an ideal supplementary analgesic drug for midazolam-induced conscious sedation during operative endoscopy because it has no cardiovascular effect and only a moderate depressive effect on respiration. However, no data are available as to whether nalbuphine is suitable as an analgesic drug during endoscopic sphincter of Oddi manometry. The aim of the present study was to investigate the effect of nalbuphine on the sphincter of Oddi motility in patients with a suspected sphincter of Oddi dysfunction.

METHODS

Seventeen patients who were suspected clinically to have SOD after cholecystectomy were prospectively investigated. Five mg of midazolam was administered intravenously before the procedure to induce conscious sedation. After approximately 5 minutes of stationary sphincter of Oddi manometry recording (baseline), either 10 mg of nalbuphine or saline solution (placebo) was administered intravenously in random fashion and pressure was recorded for a further 5 minutes. Maximum sphincter of Oddi basal pressure and average phasic contraction amplitude and frequency were measured before and after the infusion of the drug or saline solution.

RESULTS

Nalbuphine administration effectively enhanced the sedation obtained with midazolam without any adverse effect. When the sphincter of Oddi manometric periods before and after the administration of nalbuphine versus placebo were compared, there was a significantly increased basal sphincter of Oddi pressure only in the nalbuphine group: respectively, 49 (18) and 77 (29) mm Hg (p = 0.003) versus 51 (24) and 49 (23) mm Hg (p = 0.9). The phasic contraction amplitude did not change in response to nalbuphine, but the phasic contraction frequency increased significantly, from 5 (3) to 8 (4) per minute (p = 0.04).

CONCLUSIONS

Nalbuphine has a stimulatory effect on sphincter of Oddi motility in patients with a suspected sphincter of Oddi dysfunction. Nalbuphine should not be used as premedication before endoscopic ERCP if sphincter of Oddi manometry is to be performed.