Serum antibodies to Helicobacter pylori and the CagA antigen do not explain differences in the prevalence of precancerous gastric lesions in two Chinese populations with contrasting gastric cancer rates

Incidence and mortality rates for gastric cancer in rural People's Republic of China differ greatly over short distances. In Shandong Province, we studied asymptomatic adult subjects from Bei Duan village (n = 196) in Linqu County (a high-risk area for gastric cancer) and from Shi Huang village (n = 192) in Cangshan County (a low-risk area for gastric cancer). The prevalence of advanced precancerous gastric lesions (APGL) was assessed by microscopic examination of endoscopic stomach biopsies. ELISAs were used to detect serum IgG to Helicobacter pylori whole-cell antigen and to the CagA protein. A logistic regression model was used to quantify the role of the two H. pylori seromarkers in explaining the differences in prevalence of APGL between the two villages after adjusting for age and sex. The prevalence of APGL was much greater in Bei Duan than in Shi Huang. Although H. pylori seroprevalence by the whole-cell ELISA was similar in the two populations, seroprevalence of CagA was significantly greater in Bei Duan. Although age, sex, and both H. pylori seromarkers were associated with APGL in the logistic regression model, the effect of village of residence remained strong after adjustment for all four covariates. Only a relatively small proportion of the difference in prevalence of APGL between these two rural Chinese populations can be explained by differences in H. pylori or CagA seroprevalence.

[Epidemiology and pathogenesis of Helicobacter pylori infection]

Since Marshall and Warren reported the first isolation of Helicobacter pylori basic and clinical research on pathogenesis and epidemiology of Helicobacter pylori infection have been tremendous. Childhood is clearly established as the period of major risk for Helicobacter pylori acquisition. The transmission pathways may be several including the oral-oral, the gastro-oral or the fecal-oral transmission route. The colonization of Helicobacter pylori occurs exclusively in the gastric mucosa or in areas of gastric metaplasia especially in the duodenum. Helicobacter pylori possesses several factors to adhere to the epithelial cells and to cause mucosal damage. The acquisition of Helicobacter pylori always induces a chronic gastritis. The development to clinical manifestations (peptic ulcer or gastric cancer) are further dependent on specific bacterial strain virulence factors as well as on host and environment factors. The mechanisms involved in the inflammatory process have been elucidated in great detail and will further be focused and related to specific associated disease development.

Intestinal metaplasia of the gastric cardia: a study from Turkey

BACKGROUND/AIMS

We aimed to investigate the prevalence of intestinal metaplasia in the cardia of a patient group with high incidence of Helicobacter pylori infection presenting for elective upper endoscopy. We also re-evaluated the relation between intestinal metaplasia in the cardia and gastroesophageal reflux disease, smoking, alcohol history, H. pylori infection, Barrett's esophagus and intestinal metaplasia elsewhere in the stomach.

METHODOLOGY

Sixty patients presenting for elective upper endoscopy were included in this study. Prior to undergoing endoscopy each patient was questioned with regard to the clinical indication and symptoms including heartburn, regurgitation, and dysphagia. In addition, a smoking and alcohol history were recorded. Endoscopic biopsies: 1) one from the midantrum on the lesser curvature, 2) one from the incisura angularis, 3) one from the mid-corpus on the lesser curvature, 4) one from the columnar side of the squamocolumnar junction, 5) one from the squamous side of the squamocolumnar junction, 6) one from 2 cm distal to the esophagogastric junction, 7) one from across the squamocolumnar junction. Slides were stained using a combination of hematoxylin-eosin with Alcian blue at pH 2.5 for intestinal metaplasia. Each specimen was examined for the presence of H. pylori.

RESULTS

The prevalence of H. pylori infection was 63%. Prevalence of the H. pylori infection was significantly lower in the patients with intestinal metaplasia of the cardia than in the patients without intestinal metaplasia of the cardia (P = 0.025). There was a positive correlation between the age of the patients and having intestinal metaplasia of the cardia (r = 0.286, P = 0.008). There was no relationship between intestinal metaplasia of the cardia and pyrozis, regurgitation, dysphagia, history of alcohol and smoking esophagitis determined by endoscopy or histopathology, sex, intestinal metaplasia elsewhere in the stomach (P > 0.05).

CONCLUSIONS

The incidence of the intestinal metaplasia of the gastric cardia in Turkey is less than that of western countries. Intestinal metaplasia of the gastric cardia negatively correlates with H. pylori infection. And there was no relationship between gastric cardia intestinal metaplasia and reflux disease. Further investigations are needed for determining the premalign lesion and etiologic factors for cancer of the gastric cardia.

[Helicobacter pylori and chronic gastroduodenal pathology in specialists of the Air Forces sunken installations]

283 contract military men serving in the AF units were investigated. 105 of them served in AF sunken installations. During the prophylactic medical examination all servicemen underwent the complex investigation during which together with the study of professional and life conditions using the questionnaire, the complains and history duration the esophagogastroduodenoscopy (EGDS) and detection of Helicobacter pylori in gastric mucosa were performed. The number of factors significantly aggravating the course of chronic gastroduodenal pathology in the staff working in AF sunken installations was revealed. The most significant was the gastric Helicobacter pylori dissemination that probably is conditioned by professional activities of this contingent.

Prevalence and clinical characterization of gastric Helicobacter species infection of dogs and cats in Korea

This study was carried out to evaluate the prevalence and clinical characterizations of gastric Helicobacter spp. infection of dogs and cats in Korea. The prevalence of Helicobacter spp. infection of dogs and cats determined by urease test was 78.4% and 64%, respectively, although Helicobacter genus-specific PCR assay showed that it was 82.3% and 84%. Urease mapping results based on urease test showed that total positive rate of tested tissues from clinically abnormal dogs was significantly higher than that from clinically normal dogs (p=0.0018; Odds ratio = 6.118; 95% Confidence Interval = 1.96-19.103). These findings were consistent with the results of Helicobacter genus-specific PCR assay which showed that positive rate of the fundus (100%) and the antrum (100%) of clinically abnormal dogs was significantly higher than that of same gastric regions of clinically normal dogs (77.5 and 67.5% respectively). In comparison of gastric regions between clinically normal dogs and abnormal dogs, positive rate of urease test for the fundus (100%) and body (90.9%) in clinically abnormal dogs was significantly higher than that of abnormal dogs (72.5% and 57.5% respectively; p<0.05). The results of urease mapping in dogs and cats also indicated that Helicobacter colonization in the fundus was more dense compared with the density in the body and antrum. In Helicobacter species-specific PCR assay for dogs, 32 of 42 fundic tissues (76.2%) were positive for H. heilmannii and two (4.8%) were positive for H. felis. In cats, 18 of 21 fundic tissues (85.7%) were positive for H. heilmannii and 2 (9.5%) were positive for H. felis. Gastritis scores of fundic tissues from clinically abnormal infected dogs were similar to that from noninfected dogs and evidence of upregulation of IL-1beta, IL-8, and TNF-alpha mRNA was not detected in gastric fundic tissues from clinically abnormal infected dogs. This study suggested that Helicobacter spp. infection in domestic dogs including private owned pet dogs and cats is highly prevalent usually with no clinical sign but high density of colonization can be related to gastrointestinal signs

A case-control study on risk factors of helicobacter pylori infection in out-patients with stomach diseases

OBJECTIVE

To investigate the risk factors of Helicobacter Pylori (Hp) infection.

METHODS

All cases and controls came from 561 cases of out-patients with stomach diseases seeking gastroscopy in the Zhejiang Province First Hospital between April and July in 2000. The tissue samples of patients were stained for Hp by the improved Warthin-Starry technique and by methylene blue stain for routine histopathology. We classified patients as cases or controls based on the detection of Hp or not. Before gastroscopy, a questionnaire on lifestyle and health condition of was administered to patients by the interviewers.

RESULTS

The overall prevalence of Hp infection was 50.21% and the risk factors of Hp infection were significantly different between males and females. As for males, the duration of daily heavy physical activities, numbers of siblings in the household, family history of oliver disease, preference of spicy food and smoking were the risk factors for Hp infection. However, preference of beans and bean products, drinking well water, drinking tea, eating regularly and good education appears to decrease the prevalence of infection. As for females, consumption of caffeine contained beverages seemed to increase risk for infection. By analyzing with unconditional Logistic Regression Model in male and female groups combined, it brought to light that intake of egg and peppery food were the risk factors of infection, and intake of beans and drinking tea were the protective factors.

CONCLUSION

Consumption of beans and drinking tea must be advocated and the consumption of spicy food should be discouraged.

Prevalence of serum antibodies to Helicobacter pylori VacA and CagA and gastric diseases in Chile

The objective of this study was to evaluate the prevalence of antibodies to Helicobacter pylori CagA and VacA proteins and correlate this prevalence with gastric diseases in colonised Chileans. The study was performed in 418 adults colonised with H. pylori: 316 with gastroduodenal pathology (152 duodenal ulcer, 14 gastric cancer and 150 gastritis patients) and 102 asymptomatic subjects. Serum IgG antibodies to H. pylori were determined by enzyme immunoassay (EIA). Antibodies to VacA and CagA proteins were detected by Western blotting. In a subgroup of the patients, the vacuolating activity was determined by HeLa cell assay and the CagA product was confirmed by PCR assay. IgG antibodies to both VacA and CagA proteins of H. pylori were found in 270 (85%) of 316 colonised gastric patients and in 72 (71%) of 102 asymptomatic subjects. Colonisation with virulent strains was significantly higher among duodenal ulcer and gastric cancer patients than in gastritis patients or asymptomatic subjects. Infections with VacA+/ CagA+ H. pylori strains is common in Chile but, in contrast to some Asian countries, this phenotype was more prevalent in isolates from patients with more severe gastric pathologies.

Prepartum monensin for the reduction of energy associated disease in postpartum dairy cows

A total of 1317 Holstein cows from 45 farms in the Canadian provinces of Quebec, Prince Edward Island (PEI) and Ontario were enrolled in a randomized trial during 1998 and 1999 to further confirm the efficacy of a monensin controlled release capsule in preventing periparturient disease in lactating dairy cows. Cows were randomized on the farms to receive either a monensin controlled release capsule (CRC) 2 to 4 wk before expected calving or to serve as negative controls. Health data were collected for 90 d postcalving and were analyzed with logistic regression accounting for the intraherd correlation with generalized estimating equations. Monensin CRC significantly reduced the incidence of both clinical ketosis and abomasal displacement post-calving. There was a numerical but nonsignificant decrease in the incidence of retained placenta in cows receiving a monensin CRC. A pooled analysis of two separate but similar studies (conducted in 1995 and 1998) demonstrated a strengthened association between monensin CRC administration precalving and reduced periparturient disease. A 40% reduction in both abomasal displacement and clinical ketosis was observed with precalving administration of a monensin CRC. In addition, the larger dataset highlighted a trend for a 25% reduction in the incidence of retained placenta in monensin-treated cows. Improved energy metabolism as a result of monensin treatment is likely the mechanism for the reduction in incidence of all three of these diseases. Thus the term "energy associated disease" was created to assess the combined impact of the precalving monensin treatment on the incidence of retained placenta, displaced abomasum, and clinical ketosis. The monensin controlled release capsule reduced the incidence of energy associated disease by 30%.

Short report: socioeconomic and seasonal variations of Helicobacter pylori infection in patients in Venezuela

Infection by Helicobacter pylori is recognized as a risk factor for gastric cancer and peptic ulcer disease. Venezuela has regions with different gastric cancer risks; the Andean region has the highest gastric cancer mortality in the country. We performed a cross-sectional study on 357 patients who underwent endoscopy attending 2 private (n = 76) and one public hospital in Caracas, Venezuela (n = 215), and one public hospital in the Andes (n = 66) to determine H. pylori infection (by a rapid biopsy urease test and histology). The proportion of infected patients in Caracas was significantly higher in public hospitals (72%) than in private hospitals (46%; P = 0.00001), and there was no significant variation the Andes and Caracas (P = 0.7001). When analyzing the data from the public hospital in Caracas, we found that the frequency of infected patients was significantly higher during the rain (96%) than during the dry months (70%, P = 0.00000001). Differences in prevalence of infection in symptomatic patients was not related to the risk of gastric cancer but to socioeconomic differences. Rain-dependent factors that may be exacerbating the clinical activity of nonulcer dyspepsia in people infected with H. pylori deserve further study.

[Influences on the occurrence of abomasal displacements in German Holstein cows]

The objectives of this study were to analyse risk factors for the prevalence of abomasal displacement in German Holstein cows. In the period from 02/01/1999 to 01/31/2000 five veterinary surgeons in Northern Lower Saxony registered all cases of abomasal displacement in German Holstein cows being under the official milk recording scheme. In total, the investigation included 160 farms and 9315 cows. An abomasal displacement was registered in 151 German Holstein cows, corresponding to a frequency of 1.6%. More than 75% of the abomasal displacements appeared during the first 30 days after calving. The left abomasal displacement (74.8%) was recorded more often than the right abomasal displacement (25.2%). Milk recording and pedigree data were supplied by the VIT (Vereinigte Informationssystem Tierhaltung), Verden, and merged with the own recordings. The influences of the calving month, the lactation number, the age at calving, the inbreeding coefficient, calving performance, duration of pregnancy, breed of calf sire, calf sire and the breeding values for the milk performance did not explain a significant part of the variation of the frequency of the abomasal displacement. Significant effects of the sire, birth of twins or even more calves and the herd were obtained for the leftsided abomasal displacement. For the rightsided abomasal displacement and for all abomasal displacements the herd effect was not significant. Heritability estimates using bivariate linear REML models were h2 = 0.043 +/- 0.012 for the leftsided abomasal displacement, and h2 = 0.007 +/- 0.004 for the rightsided abomasal displacement, respectively. Using the threshold model the heritabilities yielded estimates of h2 = 0.51 for the left abomasal displacement, and for the right abomasal displacement of h2 = 0.19, respectively.

Gastro-intestinal nematode infections in four Alpine chamois herds: influence of host density on helminth egg output

A three years survey on gastro-intestinal nematode egg output was carried out in four Alpine chamois herds (Rupicapra rupicapra rupicapra) from Belluno province (Italy). Data were analysed in order to detect the influence of cattle presence and chamois density on egg output, and to evaluate the stability of host-parasite relationship. As expected, variations related to the season were present, with the major peak of egg output observed in the summer. Results highlighted an unexpected inverse influence of host density on egg counts. The results are in relation to host-parasite relationship stability. Parasites seem to be able to self-regulate in the absence of parasite-induced host mortality. No effect due to cattle presence was detected.

A review of diabetic gastropathy

Diabetes mellitus affects various organs, including the gastrointestinal tract. The stomach is commonly affected, and symptoms related to the upper GI tract are frequently reported. Management of diabetic gastropathy involves dietary modifications, pharmacological agents, and occasionally, alternative feeding methods.

Current management of Helicobacter pylori infection

Helicobacter pylori is commonly found throughout the world. It is associated with a wide range of gastroduodenal diseases. Knowledge regarding the characteristic organism, behaviour, and related clinical conditions is extensive. Indeed, the bacteria is not the only factor which can cause the diseases, the host as well as environmental factors are also important. Largely, H. pylori is disappearing worldwide due to eradication of this organism allowing frequency of an H. pylori negative ulcer to relatively increase and may be more difficult to treat. The PPI triple therapy remains the first line of treatment with quadruple therapy as the second rescue line. The rising of bacterial resistant strains is a new problem which requires new drugs to improve the efficacy of the current regimens.

Crohn's disease of the foregut

Historically, Crohn's disease of the esophagus, stomach, and duodenum has been reported only rarely. With more frequent use of upper endoscopy, however, upper gastrointestinal involvement has been found to be more common than previously suspected. The surgeon with an interest in Crohn's disease needs to be familiar with all areas that are potentially affected in this perplexing and sometimes devastating disease. This article examines the literature on foregut Crohn's and discusses the incidence, clinical manifestations, diagnosis, medical management, surgical indications, and operative techniques.

Characteristics of Helicobacter pylori infection in Jamaican adults with gastrointestinal symptoms

Helicobacter pylori infection is common in Jamaica. Describing its epidemiology in a population-based study depends largely on serology, but serologic assays have not been validated in this population. To address this issue, we examined the presence of H. pylori infection in 30 sequential adult patients with gastroduodenal symptoms by three biopsy-based methods (rapid urease test, histology, and culture) as well as by one research and two commercial enzyme-linked immunosorbent assays (ELISAs). A patient was considered H. pylori positive if the organism was detected by at least one biopsy-based method. Eighteen (60%) of the 30 patients were H. pylori positive by these criteria, whereas 21 (70%) were seropositive for H. pylori immunoglobulin G by our research ELISA. The presence of H. pylori infection in patients with gastric cancer and those with chronic gastritis was missed by biopsy-based methods but was detected by serologic assays. This observation indicates that serologic assays may be better suited for the detection of this infection in a population in which H. pylori-associated pathology is prevalent. The performance of our research ELISA in detecting biopsy-based H. pylori-positive cases was excellent, with a sensitivity and specificity of 100% and 75%, respectively. Molecular genotyping of the isolates revealed that the predominant H. pylori genotypes in this cohort of Jamaicans were cagA(+) vacA slb-m1, and iceA2. The validated serologic assay enables us to interpret epidemiologic data from population-based studies in Jamaica by comparison to those from other populations.

Antibiotic resistance in Helicobacter pylori

OBJECTIVE

To describe antibiotic resistance patterns in Helicobacter pylori.

DESIGN

Culture and antibiotic sensitivity testing of antral and gastric body biopsy samples from patients having gastroscopy.

PARTICIPANTS

Consecutive consenting patients aged 18 years or more presenting for gastroscopy from 1 July 1998 to 30 June 1999.

SETTING

An open-access gastroscopy service at an urban university tertiary hospital.

MAIN OUTCOME MEASURES

Number of H. pylori isolates showing resistance to antibiotics; correlates of such resistance with demographic and clinical information.

RESULTS

Of 1580 patients undergoing endoscopy, 434 agreed to participate in the study. 108 (24.9%) had positive cultures for H. pylori, and 88 of these isolates (81%) were available for further testing. Resistance to metronidazole and clarithromycin was detected in 36% and 11%, respectively. No resistance was found to tetracycline or amoxycillin. Metronidazole resistance was commoner in younger patients (P = 0.0004) and macrolide resistance was commoner in those born outside Australia or New Zealand (P = 0.03).

CONCLUSIONS

We found substantial resistance to metronidazole, and emerging clarithromycin resistance, but complete susceptibility to amoxycillin, tetracycline, gentamicin and cefaclor. These factors may influence the effectiveness of presently recommended eradication regimens.

Long-term follow-up of intestinal metaplasia of the gastric cardia

OBJECTIVE

Recent studies have found a relatively high prevalence of gastric cardia intestinal metaplasia in individuals presenting for elective upper endoscopy. It has been hypothesized that this lesion may be a precursor of gastric cardia cancer. Our objective was to identify the incidence of dysplasia in patients with gastric cardia intestinal metaplasia.

METHODS

Twenty-eight patients who had previously been identified with cardia intestinal metaplasia had follow-up examinations performed. None of the patients had dysplasia at the time of diagnosis. All had an examination at 1 yr, and 20 patients had an examination at 3 yr after diagnosis. During follow-up examinations all patients underwent vital staining with methylene blue to help identify areas of intestinal metaplasia in the cardia. Two to four biopsies were taken from blue-stained mucosa. Histological specimens were stained using a combination of hematoxylin and eosin with Alcian blue at pH 2.5.

RESULTS

There were 27 men and one woman with a mean age of 69.8 yr (range, 48-83 yr). The mean length of follow-up was 2.5 yr (range, 12-46 months). Only one patient was diagnosed with dysplasia (low-grade) during the study, for an incidence of 1.4% per yr.

CONCLUSIONS

The prevalence (0%) and incidence (1.4%/yr) of dysplasia in cardia intestinal metaplasia are low. Although further studies are needed, screening and surveillance for gastric cardia intestinal metaplasia is unlikely to be clinically useful for the prevention of gastric cardia cancer.

Cooperia pectinata and C. punctata, parasites of the abomasum of cattle in northern Cameroon (Central Africa)

Cooperia pectinata Ransom, 1907 and C. punctata von Linstow, 1907 are common trichostrongyles of zebu cattle in Africa. Their intestinal localization within the digestive tract is considered by many authors to be exclusive. Nevertheless, some limited surveys in Malagasy, Mauritania, The Gambia and Cameroon reported the presence of both Cooperia species in the abomasum. The present survey was carried out in a slaughterhouse of northern Cameroon on 17 zebu cattle and confirms the infection of the small intestine and the abomasum by the two species within the total number of cattle examined. Abomasal infections especially with Cooperia punctata were heavier than those in the intestine. Due to the movements of herdbreeders in Central Africa, and to the preliminary results obtained in Mauritania, The Gambia, Burkina Faso and Malagasy, abomasal localization of C. pectinata and C. punctata may be encountered in very large areas of Africa, and that cooperiosis may contribute together with Haemonchus species to the digestive disorders involving the abomasum.

Prospective evaluation of the prevalence of gastric Helicobacter pylori infection in patients with GERD, Barrett's esophagus, Barrett's dysplasia, and Barrett's adenocarcinoma

OBJECTIVE

This study was undertaken to prospectively determine the prevalence of gastric H. pylori infection in Barrett's esophagus and Barrett's complicated by dysplasia or adenocarcinoma.

METHODS

The prevalence of H. pylori was determined in Barrett's esophagus patients compared to a control population of patients with gastroesophageal reflux disease (GERD) only. All patients had a minimum of 10 gastric surveillance biopsies obtained. H. pylori colonization was determined upon the basis of hematoxylin and eosin and use of a modified Giemsa and or Steiner's silver stain of all gastric biopsy specimens.

RESULTS

Two hundred and eighty-nine Barrett's patients and 217 GERD control patients were included in the study. H. pylori was found in 95/289 (32.9%) of the Barrett's patients, compared with 96/217 (44.2%) of the GERD controls (NS). Forty-seven of the Barrett's patients had low-grade dysplasia/indefinite dysplasia, 14 high-grade dysplasia, and 20 Barrett's adenocarcinoma. When Barrett's was subgrouped according to absence of dysplasia, and presence of low-grade dysplasia, high-grade dysplasia, or adenocarcinoma, H. pylori prevalence was found to be significantly less for patients with Barrett's high-grade dysplasia (14.3%) and adenocarcinoma (15.0%) versus patients with GERD alone (44.2%), Barrett's alone (35.1%), or Barrett's with low-grade dysplasia (36.2%) (p = 0.016). This difference could not be explained by differences between Barrett's esophagus patients infected with H. pylori and those who were not with respect to gender, smoking history, alcohol consumption, use of proton pump inhibitor, or length of Barrett's mucosa.

CONCLUSIONS

Barrett's high-grade dysplasia and adenocarcinoma are significantly more prevalent in patients who are not infected with H. pylori. H. pylori appears to have a protective effect against the development of Barrett's adenocarcinoma.

Histological findings after routine biopsy at the gastro-oesophageal junction

OBJECTIVE

Endoscopy with biopsy is an important diagnostic procedure in patients with gastro-oesophageal reflux disease. However, it is still unclear whether histological findings such as intestinal metaplasia, squamous epithelial hyperplasia, and carditis should have an impact on patient management, and whether routine biopsies at the gastro-oesophageal junction should be taken.

DESIGN

Patients undergoing routine gastroscopy for various indications were biopsied twice just below, directly at, and right above the gastro-oesophageal junction.

METHODS

Clinical symptoms, endoscopic oesophagitis, and histopathologies such as carditis, reflux disease, and intestinal metaplasia were determined and graded.

RESULTS

Epithelial hyperplasia suggestive of reflux disease (63%), chronic carditis (94%), active carditis (40%), foveolar hyperplasia (75%), and intestinal metaplasia (14%) were frequently observed. For patients with a normal appearing Z-line, there was a weak correlation of intestinal metaplasia at the cardia with intestinal metaplasia in the stomach (Spearman's R = 0.2, P = 0.008), but no correlation with either chronic or active carditis, or with epithelial hyperplasia in the oesophagus. There was no correlation between H. pylori status or symptoms of reflux disease with epithelial hyperplasia. The severity of chronic and active carditis was closely correlated with H. pylori status (R = 0.37, P < 0.00001). The median time for gastroscopy in 30 control patients was 4.6 min, while endoscopy with additional biopsies at the gastro-oesophageal junction took a median of 8 min (U-test, P < 0.00001).

CONCLUSIONS

Intestinal metaplasia at the gastro-oesophageal junction was encountered too frequently to warrant regular follow-up in a surveillance programme. Correlation of epithelial hyperplasia with symptoms of reflux disease is poor. We propose that routine biopsy at the gastro-oesophageal junction is not warranted until an impact on patient management can be demonstrated.

[Children exposed to "earth rays" are not more frequently ill than other children]

From time to time newspapers bring reports on "earth rays" and their alleged damaging effects on health. There is, however, no objective evidence which suggests the existence of earth rays. In spite of this, dowsers claim that earth rays are a main cause of disease, also in children. In this study we wanted to evaluate, using a double-blind design, the alleged effects of earth rays on young children. A total of 44 children in four nursery schools in the Bergen area were recruited. Two dowsers and one interviewer visited the homes of all the children. The dowsers evaluated the presence of earth rays over the child's bed while the parents were interviewed in an independent procedure about the child's medical history over the past 12 months. Whether or not earth rays where found over the child's bed, there where no differences in the reported health of the child with regard to upper and lower respiratory tract infections, stomach aches, allergies or sleeping habits. Parents' report on restlessness and hyperactivity were also the same. The study failed to find any health effects, adverse or not, of earth rays.

Seroepidemiology of Helicobacter pylori infection among preschool children in Taiwan

Helicobacter pylori is associated with chronic antral gastritis that is related to duodenal ulcer, gastric ulcer, and probably gastric adenocarcinoma. Infection with H. pylori during childhood is considered an important risk factor for gastric carcinoma in adult life. To examine the epidemiologic characteristics of H. pylori infection among preschool children in central Taiwan, a community-based survey was carried out in 54 kindergartens in 10 urban townships, 10 metropolitan precincts, and 2 aboriginal townships randomly selected through stratified sampling. Serum specimens of 2,551 healthy preschool children (3-6 years old) randomly sampled from study kindergartens were screened for antibodies to H. pylori by latex agglutination and ELISA methods. Multivariate-adjusted odds ratios (ORs) with their 95% confidence intervals (CIs) were estimated by multiple logistic regression analysis. A total of 207 subjects were antibody-positive, giving a prevalence of 8.1%. The overall seropositive rates were 4.5% in 3-year-old group, 4.4% in 4-year-old group, 9.4% in 5-year-old group, and 11.7% in 6-year-old group. The older the age, the higher the seroprevalence (OR = 3.2, 95% CI = 1.5-6.8 for 3-year-old children versus the 6-year-old children). Seroprevalence was not different between boys and girls. The aboriginal townships had a seroprevalence greater than the urban townships and metropolitan precincts (OR = 2.6, 95% CI = 1.9-3.7). The larger the number of siblings, the higher the seroprevalence (OR = 2.4, 95% CI = 1.0-5.8 for those with no sibling versus those with > or = 3 siblings). In the multiple logistic regression analysis, the seroprevalence of H. pylori remained significantly increased with age, aboriginal township, and large sibship size after multivariate adjustment. A poor water supply system, sewage disposal, and other environmental hygiene in the aboriginal townships might have played some role in infection with H. pylori. The early childhood transmission among siblings might also be an important determinant of H. pylori seropositivity in Taiwan.

High frequency of gastrointestinal parasites in refugees and asylum seekers upon arrival in Sweden

The results of routine screening for intestinal parasites in 1377 refugees and asylum seekers within 2 weeks of arrival in Sweden showed that protozoa, mainly Giardia intestinalis, were found in 235/1377 (17%) and helminths, mainly hookworms, in 264/1377 (19%). Intestinal parasites were more frequently recovered in refugees coming from South East Asia, Africa and Latin America (infection rates 48%, 43% and 42%, respectively) than in those from Eastern Europe (22%) and the Middle East (32%). Refugees who reported gastrointestinal symptoms were less often infected than those without symptoms (p < 0.001). Of the European refugees, 127 came from Bosnia. A high rate of hookworms was found in this group (15%), suggesting that hookworms may also be transmitted in temperate areas under special conditions. We thus identified relatively high rates of pathogens in all groups of refugees. Screening may therefore be recommended, though more for the benefit of refugees than for the prevention of further spread of the infections.

Risk factors for abomasal displacement in dairy cows

OBJECTIVE

To determine whether various periparturient events or 305-day milk production during the previous lactation period were associated with abomasal displacement in dairy cows.

DESIGN

Retrospective, case-control study.

ANIMALS

75 pairs of case and control cows from 3 university-owned and 3 commercial dairy herds.

PROCEDURE

Cows with abomasal displacement were matched with control cows on the basis of herd of origin, breed, age, and calving date. Frequency of specific periparturient events during the period from 2 weeks prior to parturition to diagnosis of abomasal displacement, as well as milk production during the preceding lactation period, were compared between case and control cows.

RESULTS

Multivariate analyses indicated that case cows were significantly more likely to have had retained placenta, ketosis, a stillborn calf, metritis, twins, or parturient paresis than were control cows. Dystocia, mastitis, and milk production during the previous lactation period were not associated with abomasal displacement.

CLINICAL IMPLICATIONS

Results indicated that a variety of periparturient events were associated with development of abomasal displacement among dairy cows.

Gastric emptying in diabetes mellitus: relationship to blood-glucose control

The application of novel investigative techniques has established that disordered gastric motility is a frequent complication of diabetes mellitus. Thus, gastric emptying of solid or nutrient liquid meals is abnormal in 30% to 50% of randomly selected outpatients with long-standing type 1 or type 2 diabetes. Delayed gastric emptying occurs more frequently than rapid emptying. There is increasing evidence that disordered gastric motility has a major impact on the management of patients with diabetes mellitus by leading to gastrointestinal symptoms and poor glycemic control. Although both gastroparesis and upper gastrointestinal symptoms have been attributed to irreversible autonomic damage, it is now clear that acute changes in the blood-glucose concentration have a major effect on both gastrointestinal motor function and the perception of sensations arising in the gut. For example, there is an inverse relationship between the rate of gastric emptying and the blood-glucose concentration, so that gastric emptying is slower during hyperglycemia and accelerated during hypoglycemia. This article reviews some issues in the etiology, diagnosis, and management of problems associated with gastric emptying in elderly persons with diabetes mellitus.

Gastric emptying in diabetes mellitus: relationship to blood-glucose control

The application of novel investigative techniques has established that disordered gastric motility is a frequent complication of diabetes mellitus. Thus, gastric emptying of solid or nutrient liquid meals is abnormal in 30% to 50% of randomly selected outpatients with long-standing type 1 or type 2 diabetes. Delayed gastric emptying occurs more frequently than rapid emptying. There is increasing evidence that disordered gastric motility has a major impact on the management of patients with diabetes mellitus by leading to gastrointestinal symptoms and poor glycemic control. Although both gastroparesis and upper gastrointestinal symptoms have been attributed to irreversible autonomic damage, it is now clear that acute changes in the blood-glucose concentration have a major effect on both gastrointestinal motor function and the perception of sensations arising in the gut. For example, there is an inverse relationship between the rate of gastric emptying and the blood-glucose concentration, so that gastric emptying is slower during hyperglycemia and accelerated during hypoglycemia. This article reviews some issues in the etiology, diagnosis, and management of problems associated with gastric emptying in elderly persons with diabetes mellitus.

Isolated gastric tuberculosis of the cardia

BACKGROUND

Isolated gastric tuberculosis is extremely rare, especially in the subcardiac region, where the low pH, high motility and absence of lymphoid tissue result in an unfavourable environment for the development of tuberculous lesions.

METHODS AND RESULTS

Here we present a case of isolated gastric tuberculosis in the gastric cardia with no evidence of pulmonary involvement. Our patient was a young man with vague gastrointestinal symptoms and no previous history of tuberculosis. His condition was first detected on upper endoscopy as a raised subcardiac ulcer similar in appearance to a submucosal tumour. An endoscopic forceps biopsy showed the presence of caseating granulomata and acid-fast bacilli. The lesion resolved completely with 12 months of oral anti-tuberculosis therapy.

CONCLUSIONS

This case illustrates the need for a high index of suspicion in order to diagnose this rare condition, as it can present in patients with no particular risk factors or symptoms. Once diagnosed, a complete cure can often be achieved with a course of oral anti-tuberculosis medication, with surgery being reserved for severely symptomatic or refractory lesions.

Fifteen years of upper gastrointestinal endoscopy in Zaria (1978 - 1993)

Seven hundred and ninety patients had upper gastrointestinal endoscope in a fifteen-year review in the Ahmadu Bello University Hospital, Zaria. Dyspepsia was the commonest indication for the procedure. The male female ratio was 1.5:1 The mean age of the patients was 37.8 years and most patients presented in the 4th and 5th decade of life. Epigastric tenderness was the commonest physical finding and chronic liver disease was seen in only 4.3%. Gastritis and doudenitis were the commonest endoscopic findings. The duodenal and gastric ulcer ratio was 10:1. Gastric and oesophgeal malignancies were seen in the 6th and 7th decade of life. Non-ulcer dyspepsia was seen in 39% of the patients.

Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction

BACKGROUND

Gastro-gastric fistulas and marginal ulcers are frequent and serious complications of gastric compartmentalization procedures for obesity.

METHODS

The authors analyzed 810 patients after 911 operations for gastro-gastric fistulas and marginal ulcers over an 8-year period. All patients underwent a form of gastric bypass, in which a pouch is constructed along the lesser curvature of the stomach. The outlet of the pouch was restricted with a prosthetic band. In the first 189 patients (Group I), the pouch and stomach were stapled in continuity or partially divided. In the next 222 patients (Group II), segments were stapled and separated by transection. In the remaining 492 cases (Group III), in addition to transection of the stomach, a limb of jejunum was interposed between the pouch and excluded stomach. Stapled anastomoses were done in Group I and II patients and a portion of Group III patients. The remaining patients underwent hand-sewn anastomosis.

RESULTS

Gastro-gastric fistulas occurred in 49% of the patients in Group I, 2.6% of those in Group II, and 0% of those in Group III. In stapled anastomosis, the incidence of marginal ulceration in Groups I, II, and III were 8.5%, 5.4%, and 5.1%, respectively. In a subset of Group III patients, in whom a two-layer, hand-sewn anastomosis was done, the incidence was 1.6% when the outer layer was not absorbable and 0% when both layers were absorbable.

CONCLUSIONS

Gastro-gastric fistulas and marginal ulcerations are likely the result of breakdown of the mucosa resulting from migrating staples and other foreign material. Lack of integrity of the gastric lining facilitates the action of the gastric digestive process. Transection of gastric segments with interposition of jejunum prevents gastro-gastric fistula formation. An intact serosa appears to block the digestion of bowel wall by gastric enzymes. Our early data suggest that the use of absorbable sutures at the gastrojejunostomy significantly decreases the incidence of marginal ulceration.

Postpartum body condition score and results from the first test day milk as predictors of disease, fertility, yield, and culling in commercial dairy herds

The study used field data from a regular herd health service to investigate the relationships between body condition scores or first test day milk data and disease incidence, milk yield, fertility, and culling. Path model analysis with adjustment for time at risk was applied to delineate the time sequence of events. Milk fever occurred more often in fat cows, and endometritis occurred between calving and 20 d of lactation more often in thin cows. Fat cows were less likely to conceive at first service than were cows in normal condition. Fat body condition postpartum, higher first test day milk yield, and a fat to protein ratio of > 1.5 increased body condition loss. Fat or thin condition or condition loss was not related to other lactation diseases, fertility parameters, milk yield, or culling. First test day milk yield was 1.3 kg higher after milk fever and was 7.1 kg lower after displaced abomasum. Higher first test day milk yield directly increased the risk of ovarian cyst and lameness, increased 100-d milk yield, and reduced the risk of culling and indirectly decreased reproductive performance. Cows with a fat to protein ratio of > 1.5 had higher risks for ketosis, displaced abomasum, ovarian cyst, lameness, and mastitis. Those cows produced more milk but showed poor reproductive performance. Given this type of herd health data, we concluded that the first test day milk yield and the fat to protein ratio were more reliable indicators of disease, fertility, and milk yield than was body condition score or loss of body condition score.

Helicobacter pylori in gastric biopsies of Taiwanese patients with gastroduodenal diseases

This study was designed to study the in vivo prevalence and the heterogeneity of H. pylori in patients with gastroduodenal diseases in central Taiwan. H. pylori infection was detected in 74.1% (575/776) of the symptomatic population studied. The prevalence of H. pylori infection increased from 11.1% in those between the ages of one to 20, to 82.9% in those between the ages of 41 and 50, and to 84% in those between the ages of 51 and 60. There was no significant difference in the prevalence of H. pylori infection between men and women. Among different blood types, the prevalence and relative risk of H. pylori infection was significantly higher in blood group O patients (90.3%) than in blood group A (41%), blood group B (27.4%), or blood group AB (62%) patients. Metronidazole resistance was found in 6.7% of the primary isolates. The prevalence of metronidazole-resistant H. pylori strains was higher in women (7.69%) than in men (6.25%), but this difference was not significant. A total of 88% of H. pylori strains were cagA-positive. CagA gene-positive strains were present in 90.1% of duodenal ulcers, 90% of duodenal ulcers combined with gastric ulcer, 85.8% of gastric ulcers, and 69.2% of gastritis patients, and was significantly higher in peptic ulcer disease groups than in the gastritis group. In conclusion, there was a low incidence (6.7%) of metronidazole-resistant H. pylori strains and a high prevalence (88%) of H. pylori cagA-positive strains in central Taiwan. This study also demonstrated a significant in vivo correlation between active H. pylori infection and blood group O-positive patients, and showed a significant association between cagA gene-positive H. pylori strains and the development of peptic ulcers.

Recommendations for recording and calculating the incidence of selected clinical diseases of dairy cattle

The report upon which the current discussion is based was prepared in response to the increasing interest of the dairy industry in the recording of clinical disease data. The major objective was to introduce guidelines and standards for the recording and presentation of the diseases of dairy cattle. Eight clinically identifiable diseases of economic importance to the dairy industry were considered: milk fever, retained placenta, metritis, ketosis, left displaced abomasum, cystic ovarian disease, lameness, and clinical mastitis. Standardized definitions for these diseases were established through consultation with industry partners. Two approaches to summarization and reporting were proposed. For retrospective analysis, which is used when historical data are summarized for genetic evaluation for example, lactational incidence risk (cumulative incidence) has been recommended. For current analysis, which is used for herd health monitoring, a true incidence rate has been recommended. Milk fever and retained placenta were exceptions to the latter because of their short periods of risk. For these two diseases, lactational incidence risks are reported.

Gasterophilus intestinalis infections in horses in Belgium

Over a period of one year, from December 1995 to November 1996, larvae of Gasterophilus intestinalis were found in 193 horse stomachs (58%) of 330 that were examined in two Belgian slaughter houses. When August is excluded, 62% of the stomachs had bot larvae. No other Gasterophilus species were identified. The monthly prevalence ranged from 9% in August to 75% in November and December. The mean intensity of bot larvae varied from 8 in August to 29 in March, and the majority of the horses (67%) harboured less than 50 larvae. Prevalences and intensities were not affected by age, but mares were more frequently infected than stallions and geldings (P < 0.014). The mean size of the lesions increased from 1 cm2 to 17 cm2. The majority of the larvae were localised near the margo plicatus.

An evaluation of protein/fat ratio in first DHI test milk for prediction of subsequent displaced abomasum in dairy cows

First DHI test milk that was sampled prior to displaced abomasum (DA) diagnosis was used to evaluate milk protein/fat ratio (PFR) for prediction of subsequent DA in dairy cows. Odds ratio, sensitivity, specificity, and likelihood ratio were determined. Twenty-seven DA cases were matched to 3 controls per case by herd and calving date. Milk was tested at a median of 19 d after calving, which was 8 d prior to the median time of DA diagnosis. Adjusted for parity and days in milk, a protein/fat ratio < or = 0.72 was 8.2 times more likely to come from a cow subsequently diagnosed with DA than a protein/fat ratio > 0.72. Using the cut off value of 0.72, the sensitivity of PFR for DA was 80% and the specificity was 68%. A receiver operating characteristics curve indicated that the minimum sum of false negative and false positive results was at a PFR cut off value of 0.72. The likelihood ratio indicated that protein/fat ratios < or = 0.62 are 3.8 times more likely to come from cows that are diagnosed subsequently with DA than from cows without DA. The protein/fat ratio in 1st DHI test milk may predict subsequent DA in dairy cows.

[Frequency of Helicobacter pylori infection in symptomatic patients in Senegal]

This prospective study was carried out in Dakar, Senegal, to assess the prevalence of Helicobacter pylori infection in symptomatic patients undergoing endoscopy and to evaluate the factors of risk for infection by this type of bacteria in the population. From October to December 1995, 134 patients were included in this study and replied to a standardized questionnaire designed to determine socioeconomic level and living conditions. Diagnosis of Helicobacter pylori infection was based on the combined results of the urea breath test (Clo-test) and histological findings. Helicobacter pylori infection was detected in 82.8% of patients with no significant difference according to sex, age, ethnic group, or living environment (urban or rural). The incidence of infection was also the same in all socioeconomic groups. It was already high in the age group between 11 and 20 years (90.9%). Helicobacter pylori was identified in 76.2% of patients with normal endoscopic findings and in 100% presenting ulcers, erosions, or gastritis. This study shows that the incidence of Helicobacter pylori infection is extremely high regardless of socioeconomic level and that infection begins at a young age. These findings are consistent with the poor hygiene of most people in Senegal.

[Incidence and causes of upper gastrointestinal hemorrhage]

The incidence rate of the upper gastrointestinal haemorrhage in Nowy Sacz region in years 1991-1995 was 43.5/100 thousand/year among men and 20.1/100 thousand/year among women. The most common causes of bleeding among male were: duodenal ulcer, gastric ulcer and haemorrhagic gastritis. Among female gastric ulcer was more frequent than duodenal ulcer. In the whole group of haemorrhage, the average age of men was lower than the age of women. In similar, in the bleeding duodenal ulcer, gastric ulcer, haemorrhagic gastritis and gastric cancer groups--male were significantly younger.

Gastrointestinal perforation after pediatric orthotopic liver transplantation

PURPOSE

The aim of this review was to determine the incidence of gastrointestinal perforation after pediatric liver transplantation and to identify risk factors and clinical indicators that may lead to an earlier diagnosis.

METHODS

A retrospective chart review of all children who presented with gastrointestinal perforation after liver transplantation at our institution between January 1, 1987 and August 1, 1996 was performed.

RESULTS

One hundred fifty-seven orthotopic liver transplants were performed in 128 children. Fifty-eight reexplorations, excluding those for retransplantation, were performed in 38 children. Ten perforations occurred in six children (incidence, 6.4%). Two children required multiple reexplorations because of several episodes of perforation. The sites of perforation were duodenum (n=1), jejunum (n=8), and ileum (n=1). A single-layer closure was used to repair five perforations, two-layer closures in four, and resection with primary anastomosis in another. The type of repair did not affect the occurrence of subsequent perforations. All the children were less than 18 months old. Four children had undergone prior laparotomy. All children had choledochoenteric anastomoses, but only one had a perforation associated with it. One child sustained bowel injury during the dissection for the liver transplant, but none of the perforations occurred at this site. Bowel function had returned before perforation in five children. Five children were receiving systemic antibiotics at the time of their perforation, and none had been dosed with pulse steroids for rejection. All of the children had significant changes in their temperature. Acute leukopenia developed in one child. A leukocytosis developed in the rest of the children. Abdominal radiographs demonstrated pneumoperitoneum in only one child. All children had positive culture findings from their abdominal drains. Cytomegalovirus developed in one child. Although the diagnosis of gastrointestinal perforation after pediatric liver transplant remains difficult, positive drain culture findings and significant alterations in temperature and leukocyte counts suggest its presence. Pneumoperitoneum is rarely present.

CONCLUSION

A high index of suspicion and timely laparotomy, especially in children less than 2 years of age, may be the only way to rapidly diagnose and treat this potentially devastating complication of liver transplant.

The role of gastric mucosal dysplasia in the development of gastric carcinoma

It is widely acknowledged that most stomach carcinomas developed from dysplastic lesions of gastric mucosa. They can be found in known precancerous conditions as chronic gastritis, gastric adenoma, giant rugal hypertrophy, chronic peptic ulcer, gastric stump after partial resection and pernicious anemia. Several grading systems of gastric dysplasia have been suggested. Nagayo's or the ISGGC classification was applied to 367 biopsy specimens of 258 patients between 1979-1995. The frequency of moderate and severe dysplasia was 0,84% regarding all gastric endoscopies in the same period of time. Follow-up studies were performed in 56 cases in a period of 1 7 ys. In this group cancer developed during 14 patients. The authors' recommendation is to follow up the patients gastric dysplasia for least 10 ys after with diagnosis.

Portal hypertensive gastropathy: reproducibility of a classification, prevalence of elementary lesions, sensitivity and specificity in the diagnosis of cirrhosis of the liver. A NIEC multicentre study. New Italian Endoscopic Club

OBJECTIVE

To classify elementary endoscopic lesions of portal hypertensive gastropathy, assess their reproducibility, prevalences, sensitivity and specificity in the diagnosis of cirrhosis of the liver.

METHODS

1) A classification of portal hypertensive gastropathy elementary lesions was defined. 2) Thirty-two endoscopists evaluated videotapes of endoscopic examinations of patients with liver cirrhosis to assess beyond-chance agreement (kappa). 3) Fifteen centres enrolled consecutive patients with or without cirrhosis of the liver and recorded portal hypertensive gastropathy pattern according to its location.

RESULTS

1) Four elementary lesions (Mosaic-Like Pattern, Red Point Lesions, Cherry Red Spots, Black-Brown Spots) were identified, and graded. 2) A fair to good beyond-chance agreement was obtained for all 4 lesions. 3) portal hypertensive gastropathy prevalence was higher in patients with cirrhosis of the liver (0.63, sensitivity) than in controls (0.17). Mosaic-like pattern was the most prevalent sign (0.54). Specificity of portal hypertensive gastropathy was 0.83. Portal hypertensive gastropathy was tentatively classified as mild or severe when mosaic-like pattern alone or red marks of any kind were present, respectively; this classification led to a further improvement in reproducibility.

CONCLUSIONS

Our results suggest that a sufficient degree of agreement can be achieved in recording portal hypertensive gastropathy. Therefore, the New Italian Endoscopic Club classification should be used to evaluate the natural history of this condition.

Impact of abomasal nematodes on roe deer and chamois body condition in an alpine environment

Abomasal helminths were examined from 101 roe deer and 43 chamois, shot or found-dead, in the period July-November 1993-95, in the Parco Naturale Paneveggio Pale di San Martino (Italian Eastern Alps). Twelve helminth species were observed in both roe deer and chamois. For both host species, discriminant analysis, using the abundance of each parasite species in the hosts, failed to distinguish between subjects from each of the three study years. For 44 roe deer and 27 chamois data on body weight, body length, foot length, withers height, thoracic circumference and kidney fat index were also available. Principal Component Analysis was performed on the biometrical data in order to group related variables into a few compound variables. In both host species it was possible to identify two principal components, with an explained variance > 80%: the first component, led by body length, was an expression of skeletal development and the second, led by kidney fat index, of nutritional status. Parasite abundance and richness appeared to be negatively correlated with the scores of both skeletal and nutritional Components in the two host species, although only the correlation between parasite abundance and the scores of the nutritional component in roe deer was statistically significant (Spearman r = -0.411; p < 0.05). These results support the susceptibility of roe deer to abomasal helminths, which could be important considering the spatial and nutritional interspecific competition between domestic and wild ruminants often recorded in alpine environments.

A survey of the gastro-intestinal nematodes of roe deer (Capreolus capreolus) in a mountain habitat

Two hundred and twenty one roe deer from a xeric inner-alpine valley in Italy were investigated along four yearly cycles for the presence of gastro-intestinal nematodes. Road kills were the main source of this material. Spiculopteragia spiculoptera and Ostertagia leptospicularis, with their "minor" morphs S. mathevossiani and O. kolchida, were the dominant abomasal species, whereas Nematodirus europaeus was the only dominant species in the small intestine; therefore, species composition was typical of this ruminant host. Nematodes whose prime hosts are domestic and wild Bovids (Rupicapra rupicapra) were found occasionally. Abundances were low (407 nematodes in the abomasum, 209 in the small intestine, 6 in the large intestine) in spite of a high population density. Significant differences in worm counts were observed between seasons (abomasal worm counts peaked in late spring and summer whereas N. europaeus was more abundant in winter), years and between sex and age classes (higher abomasal counts in bucks vs does and in adult individuals vs fawns). Associations between worm counts and the condition of roe deer (five parameters taken into account) could not be demonstrated unambiguously. Based on data, the use of abomasal counts as a herd health index in the study area is not recommended.

Acute upper gastrointestinal haemorrhage in west of Scotland: case ascertainment study

OBJECTIVES

To determine the incidence and case fatality of acute upper gastrointestinal haemorrhage in the west of Scotland and to identify associated factors.

DESIGN

Case ascertainment study.

SETTING

All hospitals treating adults with acute upper gastrointestinal haemorrhage in the west of Scotland.

SUBJECTS

1882 patients aged 15 years and over treated in hospitals for acute upper gastrointestinal haemorrhage during a six month period.

MAIN OUTCOME MEASURES

Incidence of acute upper gastrointestinal haemorrhage per 100,000 population per year, and case fatality.

RESULTS

The annual incidence was 172 per 100,000 people aged 15 and over. The annual population mortality was 14.0 per 100,000. Both were higher among elderly people, men, and patients resident in areas of greater social deprivation. Overall case fatality was 8.2%. This was higher among those who bled as inpatients after admission for other reasons (42%) and those admitted as tertiary referrals (16%). Factors associated with increased case fatality were age, uraemia, pre-existing malignancy, hepatic failure, hypotension, cardiac failure, and frank haematemesis or a history of syncope at presentation. Social deprivation, sex, and anaemia were not associated with increased case fatality after adjustment for other factors.

CONCLUSIONS

The incidence of acute upper gastrointestinal haemorrhage was 67% greater than the highest previously reported incidence in the United Kingdom, which may be partially attributable to the greater social deprivation in the west of Scotland and may be related to the increased prevalence of Helicobacter pylori. Fatality after acute upper gastrointestinal haemorrhage was associated with age, comorbidity, hypotension, and raised blood urea concentrations on admission. Although deprivation was associated with increased incidence, it was not related to the risk of fatality.

Portal-hypertensive gastropathy develops less in patients with cirrhosis and fundal varices

BACKGROUND/AIMS

The aim of this prospective study was to examine the association of portal-hypertensive gastropathy and fundal varices in patients with cirrhosis.

METHODS

We carried out an endoscopic observation in 476 patients with cirrhosis (study 1), including 62 patients undergoing endoscopic obliteration of esophageal varices (study 2). In study 1, patients were classified into five subgroups: no esophagofundal varices (n=119), small esophagofundal varices (n=127), dominant esophageal varices (n=177), dominant fundal varices (n=27), and large esophagofundal varices (n=26). The severity of liver dysfunction was assessed by Pugh-Child classification: class A (n=222), class B (n=200), and class C (n=54). In study 2, two groups, poorly developed fundal varices (n=50) and well developed fundal (n=12), were distinguished and the follow-up endoscopic examinations were performed on the basis of 3-month intervals for 2 years. In each study, the severity of portal-hypertensive gastropathy was scored: 0 (absent), 1 (mild), 2 (severe), and 3 (bleeding).

RESULTS

Study 1: One-way ANOVA showed that both variceal pattern and Pugh-Child class significantly influenced portal-hypertensive gastropathy score. However, two-way ANOVA indicated that variceal pattern was the only significant variable. Portal-hypertensive gastropathy score was significantly higher in patients with dominant esophageal varices than in either patients with no esophagofundal varices or patients with small esophagofundal varices. In contrast, portal-hypertensive gastropathy score in patients with dominant fundal varices was similar to that in patients with no esophagofundal varices and was significantly lower compared with that in patients with dominant esophageal varices. Furthermore, portal-hypertensive gastropathy score was significantly lower in patients with large esophagofundal varices than in patients with dominant esophageal varices. Study 2: After the obliteration of esophageal varices, portal-hypertensive gastropathy score in patients with poorly developed fundal varices became significantly higher at 3-, 6-, 9-months while it was not modified in patients with well developed fundal varices during the follow-up period. Furthermore, the integrated incremental change in portal-hypertensive gastropathy score during the first 1-year follow-up period was significantly lower in patients with well developed fundal varices than in patients with poorly developed fundal varices.

CONCLUSIONS

These results indicate that both spontaneous and obliteration-induced portal-hypertensive gastropathy lesions develop less in patients with cirrhosis and fundal varices.