Journal of Clinical Gastroenterology

Published by Lippincott, Williams & Wilkins
Online ISSN: 0192-0790
Publications
Article
Submucosal injection of a viscoelastic solution prolongs submucosal lift, thus, facilitating endoscopic mucosal resection. Our objective was to assess the safety and clinical effectiveness of 0.4% hydroxypropyl methylcellulose (HPMC) as a submucosal injectant for endoscopic mucosal resection. A prospective, open-label, multicenter, phase 2 study was conducted at 2 academic institutions in Brazil. Eligible participants included patients with early gastrointestinal tumors larger than 10 mm. Outcomes evaluated included complete resection rates, volume of HPMC injected, duration of the submucosal cushion as assessed visually, histology of the resected leisons, and complication rates. Over a 12-month period, 36 eligible patients with superficial neoplastic lesions (stomach 14, colon 11, rectum 5, esophagus 3, duodenum 3) were prospectively enrolled in the study. The mean size of the resected specimen was 20.4 mm (10 to 60 mm). The mean volume of 0.4% HPMC injected was 10.7 mL (range 4 to 35 mL). The mean duration of the submucosal fluid cushion was 27 minutes (range 9 to 70 min). Complete resection was successfully completed in 89%. Five patients (14%) developed immediate bleeding requiring endoclip and APC application. Esophageal perforation occurred in 1 patient requiring surgical intervention. There were no local or systemic adverse events related to HPMC use over the follow-up period (mean 2.2 mo). HPMC solution (0.4%) provides an effective submucosal fluid cushion and is safe for endoscopic resection of early gastrointestinal neoplastic lesions.
 
Article
Background: Despite its high potency against hepatitis B virus (HBV), entecavir (ETV) 0.5 mg daily may not be sufficient to induce complete viral suppression in some patients with very high pretreatment viremia. It is not clear whether ETV 1.0 mg daily would have additive effect in such patients. Goals: Our goal was to examine virologic outcome of ETV 1.0 mg daily in patients with partial response to ETV 0.5 mg daily. Methods: We retrospectively studied 31 consecutive treatment-naive patients who were switched to ETV 1.0 mg daily after partial response [reduction of HBV DNA ≥2 log10 IU/mL but with detectable HBV DNA levels (>100 IU/mL) after 24 weeks of therapy or longer] with ETV 0.5 mg daily from January 2005 to January 2010 at 2 clinics. Results: All patients were Asians and 90% had positive hepatitis B e antigen. Mean HBV DNA was 8.04±0.65 log10 IU/mL before therapy and 3.64±0.91 log10 IU/mL at the time of switch. Overall rate of complete viral suppression were 29% (n=9/31) after 24 weeks of ETV 1.0 mg daily and 22% (n=5/23) after 48 weeks. Complete viral suppression after 24 weeks with ETV 1.0 mg daily was significantly higher in patients with lower HBV DNA (<3 log10 IU/mL) at time of switch: 75% versus 5%, P<0.0001. Conclusions: The majority of patients with partial response to ETV 0.5 mg daily did not achieve complete viral suppression with the higher dose of ETV 1.0 mg daily except those with minimal residual viremia (HBV DNA <3 log10 IU/mL).
 
Article
To determine the efficacy of triple therapy supplemented with a specially designed fermented milk product containing specific probiotic Lactobacillus casei (L. casei) DN-114 001 strain on Helicobacter pylori eradication in children. Lactobacillus species possess in vitro activity against H. pylori. There are no consistent data on the impact of eradication therapy supplemented with probiotics on H. pylori cure rates in childhood in vivo. Multicenter, prospective, randomized, double-blind controlled study. Eighty-six symptomatic H. pylori-positive children were randomized either to receive the control treatment of omeprazole, amoxicillin, and clarithromycin (OAC) for 7 days or the test treatment of omeprazole, amoxicillin, and clarithromycin for 7 days supplemented with fermented milk (Actimel) containing L. casei DN-114 001 (OAC-LC), for 14 days. H. pylori status was assessed at 4 weeks following therapy using two noninvasive tests. Intention-to-treat (ITT) based eradication rates for the OAC-LC group were 84.6% (95% CI, 71.2%-95.5%), and 91.6% (95% CI, 76.9%-98.2%) by per-protocol (PP) analysis. Eradication in the OAC group was 57.5% (95% CI, 42.2%-72.3%) in the ITT set and 61.3% (95% CI, 44.4%-75.0%) in the PP group. Eradication success was higher in the OAC-LC group compared with the OAC group in both ITT (P=0.0045) and PP analysis (P=0.0019). Primary resistance for clarithromycin could be determined in 21.2%. Side effects were infrequent. Drug compliance was good throughout the study. Supplementation with fermented milk, containing live special probiotic L. casei DN-114 001, confers an enhanced therapeutic benefit on H. pylori eradication in children with gastritis on triple therapy.
 
Article
0157:H7 is a known etiologic agent of hemorrhagic colitis. The clinical and histologic picture of colitis is largely similar to that of ischemic colitis, with areas of submucosal hemorrhage and edema, erosions, and ulcerations. We present a case report and review of the literature. A 52-year-old HIV-positive man, in apparently good immunologic condition, developed severe hemorrhagic colitis characterized by the onset of multiple colonic perforations and an unfavorable outcome. The diagnosis of 0157:H7 colitis should therefore be considered in all patients with indeterminate hematic diarrhea. Further studies are warranted to verify whether HIV infection may play a determinant role in the clinical course of 0157:H7 infection.
 
Article
Recent data suggest a role for the intestinal microbiota in the pathogenesis of functional bowel disorders (FBDs). Probiotic studies in FBDs generated inconsistent results suggesting a strain-specific and product-specific effect. To investigate the clinical efficacy of Lactobacillus acidophilus NCFM (L-NCFM) and Bifidobacterium lactis Bi-07 (B-LBi07) in nonconstipation FBDs. A double-blind, placebo-control clinical trial of the probiotic bacterias L-NCFM and B-LBi07 twice a day (2×10(11) CFU/d) versus placebo over 8 weeks. Primary endpoints were global relief of gastrointestinal symptoms and satisfaction with treatment. Secondary endpoints were change in symptoms severity, well-being, and quality of life. Microbiological effect was assessed by quantitative real time polymerase chain reaction on fecal samples. Sixty patients (probiotic, n=31; placebo, n=29), 72% females, 84% whites, mean age 37 years. Abdominal bloating improved in the probiotics compared with the placebo group at 4 weeks (4.10 vs 6.17, P=0.009; change in bloating severity P=0.02) and 8 weeks (4.26 vs 5.84, P=0.06; change in bloating severity P<0.01). Analyses on the irritable bowel syndrome subgroup (n=33) showed similar results. L-NCFM and B-LBi07 twice a day improve symptoms of bloating in patients with FBDs. These data supports the role of intestinal bacteria in the pathophysiology of FBD and the role for probiotic bacteria in the management of these disorders.
 
Article
Patients with small hepatocellular carcinoma (HCC) are usually treated with hepatic resection or percutaneous ethanol injection (PEI). To compare the effects of hepatic resection versus PEI on survival in a matched case-control study. STUDY Patients with single-nodule HCC (<or=5 cm) who were treated with hepatic resection (cases) or PEI (controls) were eligible. Matching criteria were date of diagnosis, Child-Pugh stage, and age at diagnosis. Kaplan-Meier survival curve of the control group was drawn weighing each stratum by the inverse of its size. Treatments were compared by a stratified Cox's model, adjusted by CLIP score. Of 912 patients, 197 were eligible and 82 (17 cases and 65 controls) were matched, creating 17 strata. Nine (53%) cases and 41 (63%) controls died. Cox model showed no survival difference between the two groups; hazard ratio of PEI versus hepatic resection was 1.04 (95% CI = 0.43-2.52). One- and 3-year survival rates in the hepatic resection and PEI groups were 82% versus 91% and 63% versus 65%, respectively. Patients with small HCC treated with hepatic resection or PEI have similar survival rates. In view of the higher cost and morbidity of hepatic resection, a prospective randomized study is warranted.
 
Article
We examined retrospectively 1,003 patients with chronic liver disease who underwent laparoscopy and liver biopsy. The diagnosis of cirrhosis was made in 411 patients and excluded in 570; in the remaining 22 patients, the laparoscopic/histologic diagnosis was inconclusive. When the two techniques were considered separately, a final diagnosis of cirrhosis was possible in 78.4% by laparoscopy and in 78.8% by biopsy of the total of 411 cases, whereas, doing both procedures improved the diagnostic yield to 97.7% by decreasing the percentage of false negatives for each technique. Laparoscopy can also provide important additional information by detecting intrabdominal signs of portal hypertension and so improve the macroscopic diagnosis of cirrhosis. In particular, splenomegaly seen at laparoscopy seems to be an important feature for the diagnosis and evaluation of chronic liver disease.
 
Article
Earlier studies have described a profile of peptic ulcer different in developing and developed countries. In a prospective endoscopic study in India over 5 years and 8 months involving 5,948 patients with upper gastrointestinal symptoms, we detected peptic ulcers in 1,188. There were 920 patients with duodenal ulcer (DU), 185 with gastric ulcer (GU), and 83 with combinations of the two. The male to female ratio was 4.2:1. About half the ulcers were in patients age greater than or equal to 40 years. Of the 223 (18.7%) patients with peptic ulcer complications, gastrointestinal bleeding was the most common (12.7%) and gastric outlet obstruction was less common (6.2%). Endoscopic evidence of duodenal bulb deformity was seen in 74.4% of DU patients. A comparison of these results with data from previous Indian studies suggests a changing trend of peptic ulcer with respect to age and sex distribution, the ratio between DU and GU, and complications of peptic ulcer. The profile of peptic ulcer in north India today is similar to that seen in Western countries four to five decades ago. We discuss possible factors responsible for this change.
 
Article
We carried out a 3-year pilot study of 59 consecutive women with osteoporosis of primary biliary cirrhosis (PBC), allocating them to two groups according to the severity of bone demineralization assessed by means of dual-photon absorptiometry (DPA) of the lumbar spine, Group A (36 patients; bone mineral density [BMD] > 0.800 g/cm2) received no treatment; group B (23 patients; BMD < 0.800 g/cm2) was treated as follows: oral 1,25-dihydroxyvitamin D (0.5 microgram twice a day for 5 days) followed by a 1-month course with oral calcium carbonate (1,500 mg/day) +carbocalcitonin (40 UMRC intramuscularly three times weekly). This treatment was repeated every 3 months. The following parameters were assessed at baseline and every 12 months: DPA, serum and urinary minerals, serum parathyroid hormone (PTH), osteocalcin (BGP), 25-hydroxyvitamin D, and 1,25-dihydroxyvitamin D. During follow-up, 11 initially untreated patients whose BMD dropped below 0.800 g/cm2 were switched to the treatment group (8 after 12 months and 3 after 24 months). No significant changes were observed in either group for PTH, BGP, or vitamin D metabolites. Comparing patients who were always treated, those who were never treated, and those who switched to the treatment group (ever treated) in this 36-month period, the percentage of annual bone loss in the never-treated patients was significantly less (p < 0.002) than in the ever-treated patients, suggesting the presence of two subgroups in PBC patients; one with rapid bone loss and the other with slow bone loss. Moreover, in the ever-treated patients, ADFR (activate, depress, free, repeat) therapy resulted in an improvement in BMD (p < 0.05 compared with the value before therapy). We conclude that ADFR therapy is effective in the treatment of patients with PBC with severe osteodystrophy, despite no change in osteoblastic activity, although controlled, randomized studies are in order to confirm our data.
 
Article
Americans 50 years of age and older are advised to test their stools for occult blood to detect colorectal neoplasms. Many will be taking 1,300 mg of aspirin daily because of cerebrovascular disease or smaller amounts for cardiovascular disease. To determine if 1,300 mg of aspirin causes positive hemoccult II tests, 27 healthy volunteers ate a red meat-free, high-fiber diet. Their stools were negative for occult blood during a 3-day control period and remained negative while they took 1,300 mg aspirin daily for an additional 7 days. This indicates that 1,300 mg aspirin daily for 1 week does not cause positive hemoccult II testing. Those taking this dose of aspirin probably need not interrupt therapy to perform hemoccult II testing.
 
Article
Background: Second-line bismuth-containing quadruple therapy is complex and frequently induces adverse effects. A triple rescue regimen containing levofloxacin is a potential alternative; however, resistance to quinolones is rapidly increasing. Aim: To evaluate the efficacy and tolerability of a second-line triple-regimen-containing levofloxacin in patients whose Helicobacter pylori eradication treatment failed and to assess whether the efficacy of the regimen decreases with time. Methods: Design: Prospective multicenter study. Patients: In whom treatment with a regimen comprising a proton-pump inhibitor, clarithromycin, and amoxicillin had failed. Intervention: Levofloxacin (500 mg bid), amoxicillin (1 g bid), and omeprazole (20 mg bid) for 10 days. Outcome: Eradication was confirmed using the C-urea breath test 4 to 8 weeks after therapy. Compliance/tolerance: Compliance was determined through questioning and recovery of empty medication envelopes. Incidence of adverse effects was evaluated by means of a questionnaire. Results: The study sample comprised 1000 consecutive patients (mean age, 49 ± 15 y, 42% men, 33% peptic ulcer) of whom 97% took all medications correctly. Per-protocol and intention-to-treat eradication rates were 75.1% (95% confidence interval, 72%-78%) and 73.8% (95% confidence interval, 71%-77%). Efficacy (intention-to-treat) was 76% in the year 2006, 68% in 2007, 70% in 2008, 76% in 2009, 74% in 2010, and 81% in 2011. In the multivariate analysis, none of the studied variables (including diagnosis and year of treatment) were associated with success of eradication. Adverse effects were reported in 20% of patients, most commonly nausea (7.9%), metallic taste (3.9%), myalgia (3.1%), and abdominal pain (2.9%). Conclusions: Ten-day levofloxacin-containing therapy is an encouraging second-line strategy, providing a safe and simple alternative to quadruple therapy in patients whose previous standard triple therapy has failed. The efficacy of this regimen remains stable with time.
 
Article
A fictional study of patient preference was conducted in 1,534 women who received both laparoscopy and a pelvic examination plus pelvic ultrasonography. The overwhelming majority of women (87%) preferred laparoscopy, with most patients (78%) indicating they would undergo a repeat examination if requested. Hospital occupancy rose 24% while gynecologists' incomes rose 58%. Radiologists' incomes declined 14%. Seven deaths occurring in conjunction with laparoscopy were determined to be statistically insignificant. Based on these findings, it is suggested that the pelvic examination be replaced by routine laparoscopy.
 
Article
The authors retrospectively studied the efficacy of endoscopic injection sclerotherapy (EIS) with 1.5% Sotradecol (STD) in patients with bleeding cardiac varices (CV). Case histories of 27 patients with large, isolated, bleeding CVs were reviewed. Case records of another 27 patients with isolated esophageal varices (EV), matched for age, sex, and year EIS was performed, were selected from a computer data bank as controls. Using a small volume (2-4 ml) of injection per vessel, the rate of immediate control of bleeding was 66.7% (18 of 27) in the CV group and 70.4% (19 of 27) in the EV group. The early rebleeding rate was higher for patients in the EV group (48.1%, 13 of 27) than for those in the CV group (18.5%, 5 of 27) (p = 0.0209). On the other hand, it was more difficult to control the rebleeding from CV (p = 0.00494). In terms of mortality, there was no statistically significant difference between the CV and EV groups (33.3 versus 29.6%) within 1 week after EIS, but the 1-month post-EIS mortality rate was significantly higher (p = 0.0278) in the CV group (18 of 27, 66.7%) than in the EV group (10 of 27, 37.0%). Among those in the CV group who died of late complications within 1 month after EIS, three died of recurrent hemorrhage, five of infection, and one of viscus perforation. In the EV group, only two patients died of infection. Thus, it was concluded that EIS with small volumes (2-4 ml) of 1.5% STD was equally effective in controlling immediate bleeding from CV and EV. However, it was more difficult to control early rebleeding from CV, and the mortality and complications within 1 month after EIS were significantly higher in patients with CV. These observations are currently under careful study and evaluation.
 
Article
The aim of this study is to investigate whether there were any association between the 102 T/C and -1438 G/A polymorphisms of the 5-HT2A receptor gene and IBS, and abdominal pain, anxiety and depression. Genes involved in serotonin (5-HT) metabolism are good candidates for the pathogenesis of irritable bowel syndrome (IBS). Recently, a silent polymorphism in the 5-HT2A receptor gene was identified that is defined by a T to C transition at position 102. Also, a novel G to A base change at position -1438 of the promoter region has been detected in 5-HT2A receptor gene. Fifty-four patients with IBS diagnosed according to the Rome 1 criteria and 107 healthy individuals were included in the study. PCR was used to amplify a 468-bp (G-->A) and 342-bp (T-->C) fragment of genomic DNA containing the polymorphism. Hospital anxiety and depression scale was used to assess the risk of depression and anxiety. Severity of chronic abdominal pain was determined by visual analogue scale (VAS). It was shown that there was a high incidence of homozygote C allele of the 102T/C polymorphism (%22.2; OR: 7.89, P = 0.04) and homozygote A allele of the -1438 G/A promoter region (%%37; OR: 11.14, P = 0.01) in patients with IBS. The risk of having an anxiety disorder was 83.3% in patients with C/C genotype, which was higher than other allele carrying patients, and overall mean (%52.7). (chi = 8.56, P = 0.014). The patients with T/T genotype had a VAS score of 54.93 +/- 2.59 mm, which was significantly higher than that of the patients with other genotypes (p1 = 0.02, p2 = 0.001). This study suggests that the patients with homozygote C allele of the 102 T/C polymorphisms or homozygote A allele of the -1438 G/A polymorphism of the 5-HT2A receptor gene, have a high risk of IBS. On the other hand, T/T genotype of 102 T/C polymorphism may be associated with more severe pain in patient with IBS.
 
Article
To evaluate long-term follow-up and predictors of relapse of anemia in a cohort of 102 very elderly patients previously explored for iron-deficiency anemia (IDA). One hundred and two patients [61 women and 41 men, mean age 82+/-5.8 y (75 to 98)] explored for IDA were prospectively followed up from inclusion (June 2003 to May 2005) until death or May 2006. Survival rate was estimated by the Kaplan-Meier method and compared by the log-rank test. Predictors of recurrence of anemia were identified by multivariate analysis in the 4 following subgroups: unexplained IDA (subgroup 1, n=27), benign lesion (subgroup 2, n=37), cancer treated curatively (subgroup 3, n=28), cancers treated palliatively (subgroup 4, n=10). Median follow-up was 20 months. At baseline, main clinical and laboratory data were not significantly different in the 4 subgroups, especially as regards severe comorbidities. Thirty-three patients died, 10 (30%) of them in the first month. Ten (100%) belonged to subgroup 4 versus, respectively, n=7 (26%), n=8 (22%), and n=8 (29%) of patients from subgroups 1, 2, and 3 (P<0.001). No death was directly related to recurrence of anemia. Survival rate at 1 year was 10% in subgroup 4, significantly lower than the other 3 subgroups (subgroup 1: 84%; subgroup 2: 86%; subgroup 3: 78%; log-rank test, P<0.0001). Anemia recurred in 18 cases, and required red cell transfusion in 13 cases. Predictive factors of recurrence of anemia [odds ratio (confidence interval 95%), P] were cancers treated palliatively [14.9 (3-72), P<0.01] and angiodysplasias [4.5 (1.1-18.2), 0.035]. In a cohort of very elderly patients explored for IDA, the mortality rate and the long-term survival were not different for patients with IDA related to a cancer treated curatively than those with unexplained IDA and those with IDA related to a benign lesion. Angiodysplasias and cancers treated palliatively were associated with recurrence of anemia. These results suggest interventionist strategies (including endoscopic investigation and appropriate surgery) for elderly patients with IDA.
 
Article
The aim of this study was to analyze clinical presentation, course of disease, and management of patients with hepatocellular carcinoma (HCC) in a German referral center between 1998 and 2009. HCC is a rare tumor in Germany, but its incidence has increased over the last 30 years. New therapies such as chemoembolization with drug-eluting beads, selective internal radiotherapy, and sorafenib were introduced recently; however, the impact on clinical management and overall survival (OS) is unclear. In this retrospective analysis, 1066 patients with HCC, separated into two 6-year periods (n=385; 1998 to 2003 and n=681; 2004 to 2009) were evaluated. The number of patients presenting each year (64 vs. 114 per year), with an age over 80 years or with nonalcoholic steatohepatitis increased significantly between periods. The main risk factors were alcoholic liver disease in 51.7%, chronic hepatitis C virus in 28.2%, and chronic hepatitis B virus in 13.4% of patients with liver cirrhosis and HCC. Patients presented with more advanced tumor stages and with worse liver function in period 2. The majority (61.6%) of patients received local treatment over a spectrum of Barcelona Clinic Liver-Cancer (BCLC) stages, whereas systemic therapy was offered to a minority (8.8%) and limited to BCLC stage C patients only. OS decreased in BCLC stage A and D and improved in BCLC stage B and C and decreased for all patients from 16.5 to 15.3 months between periods. No improvement of OS was observed when comparing time periods, partly because of the more advanced stage of HCC and because of the increasing age in the second time period. Improved and new therapeutic options and the intensification of surveillance programs are likely to increase survival of HCC patients in the future.
 
Article
Primary small-cell carcinoma of the esophagus is an uncommon esophageal malignancy. This report details the clinical and pathologic aspects of 11 cases seen at our institution over 20 years, as well as 123 other cases reported in the literature. Small-cell carcinomas of the esophagus show considerable histologic heterogeneity. Neurosecretory granules can be found in the majority of cases and some show evidence of multidifferentiation. Like primary small-cell cancers of the lung, those in the esophagus are highly aggressive, are usually associated with spread at the time of diagnosis, and have a dismal prognosis regardless of treatment. The possible origin of this interesting variety of esophageal neoplasm is also discussed.
 
Article
Granulomatous hepatitis is a common cause of fever of unknown origin in up to 13% of patients with prolonged fever. Attempts to define an exact etiology of the granulomatous hepatitis frequently does not yield a precise diagnosis, so that the physician must consider empiric treatment. In this paper we retrospectively review 23 patients in whom granulomatous hepatitis was found as part of the initial assessment of fever of unknown origin, and we report on their outcomes after an overall prospective follow-up of 37 months. In 26% a precise diagnosis was established at the time of assessment: Q-fever in three, mycobacterial disease in two, and histoplasmosis in one. In the remaining 74% no etiology was established after 44 months follow-up. Forty-one percent of the idiopathic group resolved spontaneously without therapy, and 18% received short-term prednisone or indomethacin with a favourable outcome. The remaining 41% required long-term prednisone therapy for a mean of 33.1 months, but all have remained afebrile and otherwise healthy after 59.6 months follow-up. We conclude that patients with fever of unknown origin who are diagnosed as having idiopathic granulomatous hepatitis have an excellent prognosis, even the minority who require long-term corticosteroids.
 
Article
Indium-111 leukocyte scanning of the abdomen (IAS) was performed in 10 patients with ulcerative colitis and in 39 patients with Crohn's disease involving the small intestine (in 25 occasions) and/or the colon (17 cases). Radionuclide uptake by the gut was seen in 84% of the patients with active inflammation. We compared the extent of the disease displayed by IAS with the findings obtained by either radiological or endoscopic studies or at surgery. In two-thirds of the patients, the IAS gave an accurate evaluation of the extent of the disease (sensitivity 68%). False-positive IASs were not seen in small bowel disease (specificity 100%), but were observed on 4 occasions on the colon (specificity 86%). The intensity of the radionuclide uptake could not be correlated with the clinical activity of the disease as evaluated by the Crohn's disease activity index. These results suggest that IAS is not superior to the standard procedures used to detect and localize inflammatory bowel disease and that IAS cannot replace these techniques. However, the simplicity of IAS and the complete lack of complications associated with its use render it useful in the evaluation of the extent and distribution of inflammation in some patients, mainly those with severe disease in whom standard diagnostic procedures would be contraindicated.
 
Article
An asymptomatic woman with Crohn's colitis developed an ESR of 92 and was found by 111Indium leucocyte scanning to have two hepatic abscesses. Their early detection led to successful treatment.
 
Article
In a period of 33 months, we performed endoscopic injection with pure alcohol (PA) to try to stop peptic ulcer hemorrhage in 115 patients. The sex ratio (M/F) was 104/11. The average age was 59.5 +/- 1.5 years (mean +/- SEM). Sixty-two patients (53.9%) were in shock before endoscopic injection. Thirty-three (28.7%) had spurting hemorrhage, 31 (27%) oozing hemorrhage, and 51 (44.3%) nonbleeding visible vessels (NBVV). We obtained initial success in 92 patients (80%). Rebleeding episodes occurred in 7 patients (7.6%) within 7 days of endoscopic injection. Five of those who rebled received a second injection with PA and bleeding stopped in three of them. In 88 (76.5%) patients, therapy was ultimately successful. The duration of hospitalization was 5.1 +/- 0.6 days (mean +/- SEM). The total volume of blood transfused was 1450 +/- 192 ml (mean +/- SEM). We conclude that endoscopic injection is an inexpensive, convenient, and effective means for arresting peptic ulcer hemorrhage. It can be used as the first therapeutic approach.
 
Article
Between January and May 1989, 65 patients with symptomatic gallbladder stones were treated with extracorporeal piezoelectric lithotripsy (EPL) and supplementary dissolution therapy with oral bile acids. In 98% of the patients, fragmentation of stones was achieved. On average, each patient received 3.18 treatments. In addition to attacks of colic and asymptomatic changes in laboratory parameters, one hematoma of the gallbladder and one of the liver were observed, together with pancreatitis and cholecystitis in two patients each. During the follow-up period, three patients developed symptomatic bile duct stones. An endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy was performed on four occasions, while one female patient had to undergo urgent cholecystectomy for inflammation of the gallbladder and empyema. Six months after the initial treatment, 36 (55%) patients were free of stones, while the stone-free rate after 12 months was 64.5% (41 of 65). Ninety percent of the patients with a solitary stone less than or equal to 2 cm in diameter became stonefree within a year. Extracorporeal piezoelectric lithotripsy is clearly a feasible procedure for the treatment of certain gallstone patients.
 
Article
We report an adult case of intrahepatic cholangiocarcinoma with remarkable sarcomatous changes. At autopsy a yellowish-white tumor (8 x 6 cm) was found in the left hepatic lobe, and there were several daughter nodules in both hepatic lobes. Histologically, most of the main tumor, and all of the daughter nodules examined, showed sarcomatous changes (spindle- or fusiform-shaped and pleomorphic cells). Histologic examination of a whole slice of the main tumor disclosed a focus of adenosquamous carcinoma (cholangiocarcinoma) within the tumor. Frequent transitions between adenosquamous carcinoma areas and sarcomatous areas suggested that sarcomatous transformation occurred in cholangiocarcinoma and then grew to spread rapidly. Immunohistochemically, squamous carcinoma and, to a lesser degree, adenocarcinoma elements were strongly positive for keratin and epithelial membrane antigen, both being also weakly positive in sarcomatous cells, supporting that possibility. Vimentin was positive only in sarcomatous elements. Cholangiocarcinoma should be included in the list of hepatic tumors showing sarcomatous change.
 
Article
Colorectal cancers rarely present with bone metastases. Regular postoperative monitoring after resection by conventional imaging techniques and carcinoembryonic antigen levels aids physicians in identifying such tumor recurrences. However, some recurrences might elude detection by bone scan, computed tomography, and magnetic resonance imaging, and newer tests such as immunoscintigraphy using radioimmune-tagged monoclonal antibodies may be more diagnostic. Here we report a case, presenting with delayed recurrence at a rare bony site, in which application of immunoscintigraphy helped in the definitive detection of the tumor recurrence.
 
Article
Before the development of efficient medications for peptic ulcer disease many patients were treated surgically by partial gastrectomy. The pathogenetic role of Helicobacter pylori was also not known yet. Some of these patients may therefore still harbor H. pylori in their remnant stomach as a carcinogenic agent for gastric cancer. This could be even more relevant for patients who were operated for tumors in the stomach. The efficacy of the urea breath test (UBT) is not clear in this population. To study the prevalence of H. pylori and to evaluate the sensitivity and specificity of the continuous UBT (BreathID) in postgastrectomized patients in Israel. In this system, the pH of the stomach is lowered by the addition of citric acid that may be beneficial in the smaller and more alkalic stomach. We compared retrospectively the results of our continous UBT with a rapid urease test (RUT) and the histology in all our patients who underwent gastroscopy for any clinical indication, and had a history of partial gastrectomy during the years 2002 to 2010. Only patients in whom H. pylori was tested by all the 3 methods during the same day were included in the study. We identified 76 such patients older than 18 years and performed a statistical analysis of all possibly related clinical data. The 3 methods were compared with each other. H. pylori was positive in 14/76 (18.4%) patients when histology was considered as the gold standard method. The positive predictive value of the continuous UBT and the RUT was 0.64 and 0.35, respectively. The negative predictive value was high by both the methods, 0.92 and 0.95, respectively. Weight loss was correlated with positivity for H. pylori (P=0.032) and a longer gastric stump was marginally related to H. pylori (P=0.071). There was no difference for H. pylori positivity between patients with Billroth I or Billroth II operations. Prevalence of H. pylori was not lower in patients who had partial gastrectomy several years earlier. The prevalence of H. pylori is considerable even several years after partial gastrectomy. The BreathID is reliable to exclude H. pylori after partial gastrectomy. The positive predictive value of the UBT is not very high but better than the RUT. We suggest that all positive patients found by the breath test should be treated. Our results support the view that alternative noninvasive methods, such as the stool antigen test should be further studied and compared with the BreathID in larger populations.
 
Article
Follicular lymphoma (FL) is a common nodal lymphoma. Primary gastrointestinal follicular lymphoma (GIFL) is rare and most commonly occurs in the elder women with indolent clinical course, mainly in the duodenum and terminal ileum. We conducted this study to characterize GIFL in Taiwan. A total of 13 cases were retrospectively collected in 4 hospitals in southern and eastern Taiwan up to 2006. Pathology review and immunohistochemistry were performed and the clinical data were obtained from chart review. There were 5 men and 8 women with a median age of 58 years (range, 31 to 74; mean, 55). The most frequent site was ileum (7/13, 54%) with 4 tumors in the terminal ileum and the most common symptom was abdominal pain (8/13, 62%). Multiple lymphomatous polyposis was present in 6 patients (46%). Five (45%) of 11 tumors with surgical resection showed transmural involvement. Most of the cases revealed a predominantly follicular pattern (7/13, 54%) and low-grade disease (grades 1 and 2; 10/13, 77%). The tumors expressed CD10 (62%), Bcl-2 (77%), Bcl-6 (77%), and MUM1 (38%). Five patients (38%) were at stage IE and 8 (62%) at stage IIE. Treatment included surgery with or without chemotherapy. All patients achieved complete remission and relapse occurred in 3 patients. At a median follow-up time of 51 months (range, 3 to 180; mean, 63), 11 patients (85%) were disease free and no patient died of lymphoma. We characterized the clinicopathologic features of the first series of GIFL in Taiwan. These tumors frequently involved ileum with a favorable prognosis.
 
Article
Autoimmune enteropathy (AIE) is a rare cause of small bowel villous atrophy, characterized by malabsorption, unresponsiveness to dietary restriction, circulating autoantibodies to enterocytes, and an overall predisposition to autoimmunity. Albeit mainly regarded as a disease of early childhood, several adult-onset AIE cases have been identified. This report describes for the first time the life-threatening clinical presentation and the management of overlapping AIE in a compliant-to-diet young celiac girl. A 13-year-old celiac girl was admitted because of vomiting, weight loss, diarrhea, hypoproteinemia, and neurological disturbances such as head tremors, vertical nystagmus, and lower limb hyperesthesia. Before this, she had always been compliant on a strict gluten-free diet and her medical history was unremarkable. The diagnosis of AIE was established on histologic findings and on the presence of antienterocyte antibodies. She was initially treated with high-dose Methylprednisolone and Azathioprine. However, only Infliximab proved itself as a highly effective tool for achieving clinical remission and restoring small bowel villous architecture.
 
Article
Complicated gastroesophageal reflux disease may be seen in a variety of congenital developmental syndromes, but progression of Barrett's metaplasia to adenocarcinoma is rare. We report the first case of esophageal adenocarcinoma in a young adult with Cornelia de Lange syndrome who had long-standing gastroesophageal reflux disease. We review the literature concerning Barrett's metaplasia in children and make recommendations for surveillance.
 
Article
Gastric acid provides protection against enteric bacterial pathogens. We reviewed the records of 93 patients with salmonella infections over a 14-year period. Of 65 adults, five had had prior gastrectomy for ulcer disease and one had achlorhydria without gastric surgery. The bactericidal actions of gastric acid against salmonella and other enteric pathogens are no doubt responsible for some protection against infection. Diminished gastric acid secretion should be considered, therefore, in patients with salmonellosis who do not have other conditions that predispose to infection. (C) Lippincott-Raven Publishers.
 
Article
Esophagogastroduodenoscopy (EGD) can be routinely performed via a nasal route in adults by using small-caliber endoscopes. The aim of this study was to evaluate the adequacy of biopsy specimens obtained with small forceps for histologic diagnosis. From January to April 2007, we prospectively compared all biopsy specimens obtained, during conventional EGD (8.8-mm-diameter endoscope), with (CS-EGD) or without sedation (C-EGD), and transnasal or transoral-EGD (4.9-mm-diameter endoscope) without sedation (T-EGD). All biopsy specimens were blindly evaluated by a pathologist. For each specimen, were recorded: site, biopsy size and thickness, type of lesion (focal or diffuse), and in case of focal abnormalities described by the endoscopist, presence of the histologic lesions in the targeted biopsies. One thousand and thirty-five biopsy specimens were obtained from 300 procedures (109 T-EGD, 48 C-EGD, and 143 CS-EGD): 983 biopsy specimens were untargeted (esophagus and cardia in 21%, stomach in 85% and duodenum in 84%) and 352 biopsy specimens were targeted to focal lesions (esophagus and cardia in 79%, stomach in 15%, and duodenum in 16%). The mean size of specimens was 1.8, 2, 2.2 mm diameter, in T-EGD, C-EGD, and CS-EGD groups, respectively (P<0.001). The whole thickness of mucosa was present in 68%, 84%, 71% of the cases among T-EGD, C-EGD, and CS-EGD groups, respectively (P=0.9). There was no significant difference in the rate of definitive histologic diagnosis from targeted or nontargeted biopsies according to the endoscopic procedure. Biopsy specimens obtained during EGD with small forceps are as effective for diagnosis as those obtained with standard forceps.
 
Article
Vitamin C intake, and serum and leukocyte ascorbate levels were assessed serially over 6 months in 137 outpatients with Crohn's disease. Vitamin C intake was low in 18% of males and 37% of females. Serum ascorbate levels were suboptimal in 11% of males and 18% of females. Leukocyte ascorbate levels were low in 26% of males and 49% of females. Serum ascorbate levels were more frequently below the reference range in patients who smoked, but neither the serum nor the leukocyte ascorbate levels were affected by Crohn's disease activity, the use of an oral contraceptive agent, or by taking prednisone or sulfasalazine. Monthly diet counseling sessions significantly increased vitamin C intake, led to more patients consuming a normal ascorbate intake, and to a normalization of serum ascorbate values. We did not establish the importance of these ascorbate abnormalities on the clinical course of Crohn's disease. We conclude that low serum or leukocyte ascorbate levels are relatively common in patients with active or inactive Crohn's disease; these abnormalities are due in part to the reduced intake of dietary ascorbate; and the ascorbate status in patients with Crohn's disease may be normalized by improving the dietary intake of vitamin C.
 
Article
Ingested foreign bodies and food bolus impaction are frequently seen in endoscopic practice. Successful foreign body and food bolus removal may depend on the method used, the choice of device, and the experience level of the endoscopist, although few papers report experience and outcome of tertiary centers. To investigate the effectiveness of our protocol designed for removal of ingested foreign bodies and food boluses. We retrospectively reviewed all patients with a diagnosis of foreign body ingestion and food bolus impaction from 1994 to 2005 identified by computer search. Patients were excluded if medical record was incomplete. The analysis included 171 patients. Foreign bodies and impacted food boluses were found in 77 and 62 patients, respectively. In 32 cases (23%), the foreign bodies passed spontaneously through the gastrointestinal tract. The overall success rate for endoscopic management was obtained in 137 patients (98.6%). Surgical removal of a foreign body was required in only 2 cases (1.4%). According to the type and location of the foreign object and food bolus we used Dormia baskets, retrieval forceps, polypectomy snares, and all sizes of Roth net. No complications relating to the endoscopic procedure were observed; 50 patients (35.2%) had an underlying esophageal disease. Endoscopic removal of upper gastrointestinal tract foreign bodies and food bolus impaction is efficacious and safe. Especially the Roth net is the best device for safe retrieval of food boluses and button disc batteries.
 
Article
Although the [13C]-urea breath test has been reported to provide high specificity and sensitivity, its reliability in determination of cure, including when and how the assessment of cure is made, is not fully established. Here we evaluate the reliability of judgment of cure after 1 month of therapy using the [13C]-urea breath test, including the appropriate time to assess its cure. Our subjects were 199 H. pylori-infected patients (144 men and 55 women; 50.5+/-0.76 years) who underwent cure therapy, took the breath test at 1 month, and underwent both the breath test and invasive tests using endoscopy at 6 months after completion of therapy. Accuracy of the breath test in judgment of cure at 1 month was investigated by comparing the results at 1 month with those at 6 months when cut-off value of the breath test was set at 5 per thousand. Chronologic alterations of the delta13C value were also analyzed in cured patients who underwent the breath test at 1, 3, and 6 months. In 167 (94.9%) of 176 patients whose breath test values were less than 5 per thousand, cure was reconfirmed at 6 months. In 14 (60.9%) of 23 patients whose values were greater than 5 per thousand, cure was demonstrated at 6 months. The mean delta13C values of 33 cured patients who took the breath test at 1 month and repeated the breath test at 3 and 6 months for any reasons were 4.14+/-0.74 per thousand, 2.02+/-0.23 per thousand, and 1.72+/-0.19 per thousand, respectively, and the value at 3 months was significantly smaller than that at 1 month. The reliability of assessment of cure by only the breath test at 1 month was sufficiently high (94.9%) once the patients were judged to be cured. However, because the breath test at 1 month yielded a high false-positive rate and the breath test values at 3 and 6 months were similar, evaluation of cure of H. pylori infection by the [13C]-urea breath test should preferably be done at 3 months after treatment to minimize false-positive results, or the concept of a borderline group should be established for patients with positive but relatively high delta13C values (5-10 per thousand) who repeated the breath test 3 months after treatment.
 
Article
The C-caffeine breath test (CBT) is a noninvasive tool for the evaluation of the cytochrome P450 system, implicated in the development of nonalcoholic steatohepatitis. To apply the CBT to assess the extent of hepatic fibrosis in patients with nonalcoholic fatty liver disease (NAFLD). Twenty-six consecutive patients (mean age 56.1+/-6.85 y, 69.2% women) with NAFLD underwent the CBT, in addition to the clinical and laboratory evaluations and liver biopsy. Ten healthy individuals matched for age served as controls. Mean delta over baseline values differed significantly between patients and controls (1.51+/-0.9 vs. 2.37+/-0.8 Delta per thousand/mg, respectively) (P=0.01) and were significantly higher in patients with fibrosis stage <2 (Brunt's system) (2.0+/-0.77 vs. 1.3+/-0.9 for stage > or =2, P=0.05). Mean delta over baseline values correlated highly with fibrosis stage (P=0.01), albumin (P=0.007), international normalized ratio (P=0.04), bilirubin (P=0.0008), and platelet count (P=0.0001). On multivariate stepwise logistic regression analysis, CBT was the best predictor of severe fibrosis (stage > or =2) (odds ratio 0.274, 95% confidence interval 0.086-0.872, P=0.028), with an area under the curve of 0.788. The CBT is safe and easy to perform. It can reliably predict severe hepatic fibrosis in patients with NAFLD. Further large-scale studies are still needed.
 
Article
The family is the core unit for Helicobacter pylori (Hp) infection. In most instances, Hp colonization occurs in early childhood, and correlates with socioeconomic parameters. Helicobacter pylori infection is highly prevalent in many countries, and may cause chronic gastritis and peptic ulcer in adults and in children. Gastritis induced by Hp may be associated with recurrent abdominal pain in children, and eradication of the bacterium may improve the clinical symptoms. AIM The primary aim of this study is to characterize the group of pediatric patients according to the referral patterns and results of 13C-urea breath test (13C -UBT) in our laboratory. The secondary aim is to investigate the result of different treatment combinations for Hp eradication. The 13C-UBT was performed with 75 mg urea labeled with 13C in 200 mL orange juice. Breath samples were collected at 0 and 30 minutes, and the results expressed as the change in the 13C/12C ratio at T30' minus T0' The cutoff for Hp eradication was 3.5. The physicians who ordered the test completed a questionnaire covering demographic data (age, gender, and origin), indication for the test was use of a proton pump inhibitor (PPI), and type of combination eradication therapy. The study sample consisted of 1655 children, aged 1 to 18 years, 992 (59.9%) boys and 663 (40.1%) girls, from all parts of the country. The 13C-UBT was positive in 763 (46.1%). The prevalence of positive results was directly correlated with age. History of peptic disease was the main indication for the test, in 1346 (81.4%) cases. Details on eradication therapy were available for 435 children of whom 42.5% had a positive 13C-UBT, indicating a successful eradication rate of 57.5%. Compared with Israeli and American-European origin, children of Asian-African origin had a higher rate of referrals for reason of validation of successful Hp eradication, greater long-term PPI use, and a higher rate of 13C-UBT positivity. No significant difference was demonstrated between the triple therapy regimens used. 13C-UBT may be performed in children of all age groups. The main indication is a history of peptic ulcer disease. The prevalence of Hp infection increased with age and the only factor associated with increased Hp infection was Asian-African origin. The most frequent eradication therapy used in children is a combination of omeprazole, amoxicillin, and clarithromycin.
 
Article
H. pylori infection and peptic ulcerations and their complications such as bleeding are causally related, but the available methods used in bleeding to confirm active H. pylori lack accuracy. AIM To evaluate the usefulness of 13C-urea breath test (UBT) in diagnosing of H. pylori infection in bleeding patients. Eighty-one patients with upper gastrointestinal bleeding and 258 matched controls without bleeding were enrolled to the study. UBT was performed using low-dose capsulated 13C-urea and IgG antibodies to H. pylori were determined by ELISA. UBT performed in bleeding patients was positive in 77.7%. In this group anti Hp IgG was positive in 79% of cases and among them gastroscopy showed 40.7% of bleeding duodenal ulcer, 38% bleeding gastric ulcer, and 86% hemorrhagic gastritis. UBT was positive in 90.9%, 77.4%, and in 52.97% cases, respectively, and it was not statistically different from that in non-bleeding controls, duodenal and gastric ulcers and gastritis. All patients with blood or "coffee grounds" in the stomach had both UBT and serology positive. The UBT is simple and non-invasive method, which can be successively applied also in patients with upper gastrointestinal bleeding to detect active H. pylori infection prior to emergency endoscopy.
 
Article
The stable isotope [13C]-labeled urea breath test (13C-UBT) is very useful for detecting Helicobacter pylori. Conventionally, a mass spectrometer is used to measure the presence of 13CO2 in breath. However, this technique is complex and expensive. Therefore, we carried out the 13C-UBT using an easy-to-operate infrared spectrometer, and we studied its usefulness. The 95 subjects included 35 patients with gastric ulcers, 32 with duodenal ulcers, 13 with gastroduodenal ulcers, some patients with nonulcer gastroduodenal disease, and normal controls. The 13C-UBT was negative in normal controls and positive in 86 of 91 (95%) patients with illness. Peaks appeared 15 to 30 min after [13C]urea administration. The 33 patients who were 13C-UBT-positive were then given lansoprazole 30 mg/day and the 13C-UBT was repeated after 8 to 16 weeks. Lansoprazole was found to be effective in patients who exhibited peak 13CO2 values that were at least two-thirds less than the pretreatment values. This effect was seen in 16 patients (48%), 13 of whom (81%) had gastric ulcers. Thirteen of the 17 patients (76%) who exhibited no effect had duodenal ulcers, and there were clear treatment response differences between the two types of ulcers.
 
Top-cited authors
Azadeh Emam
  • St. Michael's Hospital
Julia M W Wong
  • Boston Children's Hospital
Russell J de Souza
  • McMaster University
Kris Kowdley
  • Liver Institute Northwest
Capecomorin S Pitchumoni
  • Saint Petersburg State University