Gastrointestinal motility disorders in patients with inactive Crohn's disease

BACKGROUND

Although some symptoms of Crohn's disease may be related to gastrointestinal motility disorders, studies on gastrointestinal motility in inactive Crohn's disease are lacking.

METHODS

Fasting and postprandial motor activity (1 h) was recorded in the gastric antrum and upper small intestine of 35 patients with inactive Crohn's disease and 18 controls, using conventional manometry.

RESULTS

Motor disorders were observed in 26 of 35 patients. The number of phase-II contractions was reduced (1.3 +/- 0.7/min versus 1.8 +/- 0.6/min in controls; P < 0.02) (mean +/- standard deviation), whereas the incidence of propagated single (2.2 +/- 3.2/h versus 0.5 +/- 0.6/h; P < 0.03) and clustered contractions (3.8 +/- 7/h versus 1.1 +/- 1.4, P < 0.04) was markedly increased. Motor abnormalities were more frequent and severe in patients with Crohn's ileitis than in controls, and in patients with gastrointestinal symptoms than in asymptomatic patients.

CONCLUSION

Most patients with inactive, uncomplicated Crohn's disease show marked gastrointestinal motor disorders, characterized either by reduced incidence of small-bowel contractions and increased incidence of single or clustered propagated contractions.

Helicobacter pylori infection and growth delay in older children

It is thought that Helicobacter pylori infection may influence growth rate in children. The aim of this study was to evaluate the prevalence of H pylori infection in healthy Italian children, and to look for differences in height between infected and non-infected subjects. Two hundred and sixteen children, aged 3 to 14 years, were tested for H pylori infection by 13C-urea breath test. Centile values for height were calculated. Composite indices for socioeconomic class and household crowding were also determined. Forty nine of 216 children (22.7%) were H pylori positive. The prevalence of infection increased with age. Eight of 49 H pylori positive children (16.3%) were below the 25th centile for height, compared with 13 of 167 H pylori negative children (7.8%). This difference became significant in children aged 8.5 to 14 years; in this group (n = 127), eight of 31 infected children (25.8%) were below the 25th centile for height, compared with eight of 96 non-infected children (8.3%). A significant correlation was found between socioeconomic conditions, household crowding, and H pylori status. By using stepwise logistic regression, only the centile value for height was significantly related to H pylori status in older children. Thus H pylori infection was associated with growth delay in older children, poor socioeconomic conditions, and household overcrowding. This finding is consistent with the hypothesis that H pylori infection is one of the environmental factors capable of affecting growth.

Appendectomy is an independent protective factor for ulcerative colitis: results of a multicentre case control study. The Italian Group for the Study of the Colon and Rectum (GISC)

BACKGROUND

Different exogenous factors are believed to play a role in the pathogenesis of ulcerative colitis. Smoking habits and other risk factors have received much attention. It has recently been reported that appendectomy decreases the risk of ulcerative colitis.

AIM

Aim of the study was to further examine the role of appendectomy in ulcerative colitis.

METHODS

A large multicentre case control study was performed. Cases were all patients with a recent new diagnosis of ulcerative colitis (from 1990 to 1994) at participating centres. One or two controls attending the orthopaedic and surgical units were considered and matched to cases for age (+/- 5 years), sex and year of diagnosis. A total of 536 cases and 755 controls were enrolled. Mean age of cases was 37.9 years (range 2-92). Assessment of exposure was done by examining the clinical records and by interview, if necessary. Smoking habits, alcohol consumption, use of oral contraceptives, type of occupation and area of residence were also recorded. Odds ratio and 95% confidence intervals were calculated by conditional logistic regression analysis.

RESULTS

Forty-one out of the 536 cases (7.6%) and 150 out of the 755 controls (19.9%) had been submitted to appendectomy. A total of 110 out of 536 cases (20.5%) and 135 out of 753 (17.9%) controls had had tonsillectomy. Seven out of 41 cases and 15 out of 755 controls underwent appendectomy for recurrent pain. In all ulcerative colitis patients, appendectomy had been performed before the onset of disease. When data were adjusted for the confounding variables, ulcerative colitis patients were less likely to have had appendectomy compared with controls (odds ratio = 0.3, confidence interval = 0.19-0.48). There was no significant association of ulcerative colitis with tonsillectomy (odds ratio = 1.09, confidence interval = 0.76-1.58). The well recognized inverse association of ulcerative colitis with cigarette smoking was also shown in this study.

CONCLUSIONS

The present data emerging from a large multicentre study, confirm that appendectomy has a protective role for the development of ulcerative colitis.

Cisapride and erythromycin prokinetic effects in gastroparesis due to type 1 (insulin-dependent) diabetes mellitus

BACKGROUND

Erythromycin, a macrolide antibiotic, has been shown to have gastric prokinetic effects and has been proposed as an alternative therapeutic option for diabetic gastroparesis. However, its efficacy has not yet been compared with that of other prokinetic drugs.

AIMS

The purpose of the present study was to compare the effects of erythromycin (250 mg 60 min before meals) and cisapride (10 mg 30 min before meals) on gastric emptying of healthy subjects and insulin-dependent diabetics.

PATIENTS AND METHODS

Six type 1 diabetic patients with a previous scintigraphic demonstration of gastroparesis and five healthy subjects were recruited for the study. Gastric emptying was scintigraphically studied by labelling the solid component of a standard test meal. Three scintigraphic studies, spaced at least 3 days apart, were carried out on each subject, basally and after erythromycin or cisapride.

RESULTS

Cisapride significantly accelerated gastric emptying in both the healthy subjects and the diabetic patients without any significant effect on the lag-time, whereas erythromycin in addition to a significant improvement of the overall gastric emptying also showed a pronounced effect on the lag-time in both groups (controls 25 +/- 5 vs. 37 +/- 8 min, P < or = 0.04; diabetics 65 +/- 11 vs. 112 +/- 16 min, P < 0.03).

CONCLUSIONS

Erythromycin may represent an effective therapeutic alternative to more established forms of treatment in patients with diabetic gastroparesis, especially when other drugs have failed.

[Electrogastrography. Evolution and clinical applications]

Electrogastrography (EGG) is a non invasive technique of recording gastric myoelectrical activity by cutaneous electrodes. Although first reported about 70 years ago, the development of this methodology has been very slow, mainly because of several shortcomings in data acquisition, interpretation of EGG data and poor correlation with the antral contractile activity. Recently, EGG has received increasing interest and technical improvements. The better quality of the signal obtained and the applications with automated signal processing, have improved the interpretation of the EGG. For this reasons, the number of EGG applications, both experimental and clinical, has rapidly increased. However, the lack of invasivity of this methodology has suggested some clinical applications which probably exceeded the specific possibility of the EGG. We aimed in this study at analysing several parameters, whose clinical relevance is not clearly understood, obtained by the automatic analysis, to identify patients with gastric electrical abnormalities between 10 patients with abnormal gastric emptying and 10 healthy controls. The best separation between these two groups was obtained by combining both mean dominant frequency and power.

Controlled trial of botulinum toxin injection versus placebo and pneumatic dilation in achalasia

BACKGROUND & AIMS

Intrasphincteric injection of botulinum toxin has been suggested as an alternative treatment modality in esophageal achalasia. A controlled trial comparing botulinum toxin, placebo, and pneumatic dilation is reported.

METHODS

Sixteen patients received random intrasphincteric injections of either botulinum toxin or saline. The efficacy of treatment was assessed by symptom score, esophageal manometry, and scintigraphy. In case of failure, pneumatic dilation was performed.

RESULTS

One month after injection, symptoms had improved in all patients treated with botulinum toxin (symptom score, 0.9 +/- 0.6 vs. 5.5 +/- 1.4; P < 0.02). In the placebo group, symptoms were unchanged in all patients, who were all dilated. Lower esophageal sphincter pressure decreased by 49% after treatment with botulinum toxin (P < 0.03) and by 72% after dilation (P < 0.01). Similarly, esophageal retention decreased by 47% after treatment with botulinum toxin (P < 0.02) and by 59% after dilation (P < 0.02). No significant difference in symptom score and esophageal function test results was found between patients treated with botulinum toxin injections and those undergoing dilation. However, 7 of the 8 patients in the botulinum toxin group required a second injection because of recurrent dysphagia.

CONCLUSIONS

Treatment of achalasia with botulinum toxin was as effective as pneumatic dilation in relieving symptoms and improving esophageal function. The effect of the first injection was temporary, but the effect of the second injection lasted longer.

Microscopic colitis progressed to collagenous colitis: a morphometric study

Microscopic (also called lymphocytic) colitis and collagenous colitis are two newly recognised clinicopathologic entities of unknown aetiology presenting with chronic watery diarrhoea. In both conditions, the colon appears normal by barium enema and colonoscopy, however, colonic biopsies reveal infiltration of plasma cells and neutrophils within the lamina propria and increased intraepithelial lymphocytes within the surface epithelium. Lack of a thickened collagen band beneath the surface epithelium histologically differentiates microscopic from collagenous colitis. The exact relationship between the two disorders is as yet unknown. The two entities may be variants of the same spectrum of disease or distinct conditions with and without collagen table thickening. The present case report shows progression of microscopic colitis to collagenous colitis in sequential colonic biopsies taken from a patient during a 7-year endoscopic follow-up suggesting that progression of microscopic to collagenous colitis is a possibility and the two diseases are likely to represent variants of the same condition.

Gastric emptying of solids in patients with nonobstructive Crohn's disease is sometimes delayed

To date, only a few studies of gastric emptying in Crohn's disease have been published in the literature. This might be clinically important because slow-release drug formulations are increasingly available for treatment. Studies in children with gastric involvement suggest that gastric emptying may be delayed in this condition. We studied the scintigraphic gastric emptying of 21 adult patients with nonobstructive Crohn's disease and without gastric or duodenal involvement by the disease, compared with that of 20 healthy volunteers. Overall, no significant differences were found, but subgroup analysis showed that symptomatic patients [half-time (t1/2) 133 +/- 75.9] and those with colonic involvement (t1/2 127.2 +/- 64) had a significantly (p < 0.01) delayed gastric emptying over controls (t1/2 85.5 +/- 15.4). Such a difference was also observed between symptomatic and asymptomatic patients (p < 0.05). We conclude that gastric emptying is slowed in symptomatic patients with nonobstructive Crohn's disease and in those with colonic involvement. This may have therapeutic implications.

[Osteoarticular manifestations during liver and gastrointestinal diseases]

The most important osteoarticular complications occurring during gastrointestinal and liver diseases are reviewed. Although etiopathogenesis of these disorders is not yet fully understood, their knowledge is required to gastroenterologists for two main reasons: to establish a correct diagnosis and to start an appropriate therapy.

The aminopyrine breath test

The metabolic basis and clinical application of the aminopyrine breath test (ABT) as a measure of liver function is reviewed in this article. Several papers have been published in the 20 years that have elapsed since the test was validated in man by Hepner and Vesell. Nevertheless, even if the aminopyrine breath test has been shown to be a non-invasive, reliable and semiquantitative liver function test with diagnostic and prognostic accuracy, it is not yet extensively used in clinical practice, probably because it is not widely known to clinicians. The aminopyrine breath test, like other newer tests (phenacetin, caffeine and erythromycin breath tests), allows the effects of drugs on hepatic cytochrome P-450 to be explored both in normal subjects and in liver patients. This interesting field of application is sure to expand the appeal of the aminopyrine breath test in the future.

Segmental motor abnormalities of the distal oesophagus

Patients with chest pain and/or dysphagia may present non-specific motor abnormalities that do not fit into classical categories of primary motor disorders. Two such patients are described, both with segmental aperistalsis of the distal oesophagus and with fairly normal proximal motility and LES function. Delayed radionuclide oesophageal transit was noted in both cases. Medical treatment was only partially effective and one patient required pneumatic dilatation. The aperistaltic segments have remained unchanged over 3-4 year follow-ups. These patients account for less than 1% of all those diagnosed with oesophageal motor abnormalities in our hospital in the last ten years.

Antroduodenojejunal manometry in the diagnosis of chronic idiopathic intestinal pseudoobstruction in children

We analyzed the antroduodenojejunal (ADJ) manometric patterns in a group of 19 consecutive children (mean age, 53 months; range, 5 months to 14 years) referred for suspected chronic idiopathic intestinal pseudoobstruction. Diagnosis was based on typical symptoms, absence of extraintestinal diseases, and structural lesions of the gut at endoscopy and radiology. Surgical full-thickness intestinal biopsies were evaluated in nine patients. Manometry of the stomach and small bowel was performed in the fasting and fed state with a multilumen perfused probe. All patients showed severe abnormalities of ADJ motor activity that were not seen in the eight controls (mean age, 38.2 months; range, 1-9 years). In 12 patients, manometric patterns suggesting neuropathic disease were detected with fasting and/or fed sustained and incoordinated duodenojejunal phasic waves, aberrant propagation and/or configuration of phase III of the inter-digestive motility complex, inability of a meal to convert a fasting into a fed pattern, and prolonged groups of fasting and fed nonpropagated phasic waves. In seven of these patients, histology revealed marked changes of the intrinsic neurons. In four cases, manometry disclosed features suggestive of a myogenic disease, including severe fasting and fed infrequent low-amplitude contractions, sometimes with some degree of propagation; in two of these cases, histology showed morphological abnormalities of smooth muscle cells of the gut wall. In three patients, manometry revealed signs suggestive of mechanical obstruction of the gut, such as repetitive post-feeding clusters and simultaneous repeated broad-based waves; in these patients, more detailed x-ray studies showed organic obstructive causes (ileal lymphoma, Hirschsprung's disease, and intestinal malrotation).(ABSTRACT TRUNCATED AT 250 WORDS)

Bursts of non-deglutitive simultaneous contractions may be a normal oesophageal motility pattern

The frequency and characteristics of non-deglutitive motor activity of the human oesophagus and its relation to motility patterns in the antrum and upper small intestine were studied in 25 fasted healthy subjects. Motility of the oesophagus, antrum, and upper small intestine was recorded by means of a manometric perfused catheter system. The most striking non-deglutitive motility pattern consisted of repetitive bursts of non-sequential pressure peaks occurring in the smooth muscle portion of the oesophagus. The mean number of pressure peaks per burst was 2.7 (SD 2) waves with a mean amplitude of 19.5 (SD 9.9) mm Hg and a duration of 3.09 (SD 0.22) seconds. The highest amplitude was 80 mm Hg and the longest burst consisted of 13 repetitive waves. The bursts were recorded up to a distance of 15-20 cm above the lower oesophageal sphincter. Ninety five per cent of the bursts occurred during a 15 minute period before the onset of phase 3 of the migrating motor complex in the antral or upper small intestinal area, or during the lower oesophageal sphincter component of the migrating motor complex. In conclusion, spontaneous bursts of non-sequential pressure peaks occurred in the smooth muscle part of the human oesophagus in relation to phase 3 of the migrating motor complex. They represent the oesophageal body component of phase 3 of the migrating motor complex and are not a sign of oesophageal motor abnormalities.

Effect of erythromycin on gastric motility in controls and in diabetic gastroparesis

The effect of three doses of erythromycin on interdigestive gastrointestinal motility and on plasma motilin levels was studied in healthy volunteers and patients with diabetic gastroparesis. Abnormalities of interdigestive motility were observed in 40% of the patients. In healthy volunteers, 40 mg erythromycin elicited a premature phase 3 that started in the stomach. In contrast to the spontaneous gastric phase 3, this erythromycin-induced phase 3 was not accompanied by a motilin peak. In patients with diabetic gastroparesis, 40 mg erythromycin induced a premature phase 3 in three patients, no response in one patient, and a burst of antral contractions in another patient. Doses of 200 and 350 mg erythromycin elicited a burst of antral phase-3-like contractions in both volunteers and patients, which was not accompanied by a motilin peak. This phase-3-like activity did not migrate to the small intestine and was not followed by a phase 1, but by a prolonged period of antral contractile activity. The number and amplitude of antral contractions after 200 or 350 mg erythromycin were significantly higher than after 40 mg. The motor patterns induced by different doses of erythromycin offer potential therapeutic applications.

Erythromycin accelerates gastric emptying by inducing antral contractions and improved gastroduodenal coordination

Erythromycin has been shown to act as a motilin agonist by binding to motilin receptors on gastrointestinal smooth muscle and to improve the severely impaired gastric emptying in patients with diabetic gastroparesis. To elucidate the motor pattern that accounts for this accelerated emptying, the effect of 200 mg erythromycin vs. placebo on postprandial motility of the stomach and the upper small intestine was examined in 13 normal subjects. Erythromycin significantly increased the amplitude of the antral contractions during the 2-hour postprandial study period (maximal difference in mean amplitude of distal antral contractions between erythromycin and placebo recorded from 80 to 90 minutes after meal: 123 +/- 17 vs. 44 +/- 12 mm Hg; P less than 0.005). The total number of antral contractions was not affected, but the contractions could be recorded manometrically higher up in the stomach after erythromycin than after placebo (9-12 vs. 3-6 cm above the pylorus). Antroduodenal coordination was significantly improved during the first postprandial hour, and the first normal phase 3 of the migrating motor complex, indicating the reappearance of fasting motility, occurred earlier after erythromycin than after placebo (128.3 +/- 14.3 vs. 173.4 +/- 16.1 minutes; P less than 0.05). These changes in postprandial motility induced by erythromycin may well account for its accelerating effect on gastric emptying.

Is the irritable bowel really irritable?

We studied 5 healthy volunteers and 9 patients with irritable bowel syndrome (IBS) during infusion of the colon with saline solution, bile acids, fatty acids and balloon distension. Our results show that the pain threshold was significantly (p less than 0.001) higher in controls than in IBS patients. Bile acids and fatty acids brought on the habitual pain in 5/7 and 7/8 patients respectively, while they did not have any effect in the control group. On the basis of our data we can conclude that the IBS patients are more sensitive to colonic distension and perfusions, thus suggesting a non-specific irritability of the colon which could be a characteristic of these patients.

Gallbladder function and gastric liquid emptying in achalasia

Because of evidence that the abnormalities in achalasia are not restricted to the distal esophagus, we investigated gallbladder function by cholescintigraphy in the steady state and in response to CCK and the scintigraphic gastric emptying of a liquid caloric meal in 10 individuals with achalasia and 10 normal controls. No abnormalities were found during the filling phase of the gallbladder but seven of the 10 patients showed a 50% reduction in the ejection fraction (39.4% +/- 30.4 vs 80.3 +/- 8.3 of controls, mean +/- SD, P = 0.007) and a slower than normal ejection phase (9.1%/min +/- 6.6 vs 18.1 +/- 4.5, P = 0.02. In eight of the 10 patients, gastric liquid emptying was accelerated with a T1/2 of 41.5 min +/- 15.4 vs 74.7 min +/- 11.5 in the controls (P = 0.007). It is concluded that in some achalasia patients extraesophageal functional abnormalities of the gastrointestinal tract may be found. Whether these findings are promoted by degenerative charges of extraesophageal nerve fibers as well as their clinical significance require further investigations.

[Esophageal manometry. Normalcy and pathology]

Esophageal manometry is an established method of investigation in patients with suspected motor abnormalities. However, some degree of standardization of technique and method of analysis are still needed among different Laboratories. It is actually the gold standard for assessing the esophageal motor function but a correlation with other esophageal tests (i.e. radiology, endoscopy, pH-metry, scintigraphy) is usually required to reach a clinical diagnosis. Because of the large interindividual variability of manometric findings it is suggested that each laboratory could obtain its "own normal population". Recent evidences support that values outside the normal range may not always be associated with a functional abnormality. New physiopathological insights and widely accepted scheme of classification of manometric data are needed to improve its diagnostic usefulness.

Are the lower oesophageal sphincter relaxations in achalasia always incomplete? A manometric and scintigraphic study

In two patients with achalasia we found intermittent, complete lower oesophageal sphincter (LES) relaxations at manometric evaluation. These patients had no weight loss, minimal oesophageal dilation, lower LES pressure and faster radionuclide oesophageal emptying when compared with other achalasia patients. Concurrent performing of radionuclide oesophageal emptying and manometry showed that the complete relaxations (CRs) were too short and functionally unsuccessful. Our findings suggest that these patients may be at an earlier disease stage and that intermittent CRs of LES may occasionally occur in achalasia.

[Primary esophageal motility disorders: medical treatment]

Primary esophageal motility disorders consist of a complex group of motor disturbances, affecting the characteristics of esophageal contractions, occurrence of peristalsis and lower esophageal sphincter function. The medical treatment is still challenging because of the absence, except for Achalasia, of generally agreed criteria for diagnosis and the still unresolved relationship between esophageal symptoms and some motor abnormalities. In Achalasia, the medical therapy does not constitute a main role and should be reserved to selected conditions. Current medical therapies for Diffuse Esophageal Spasm and Esophageal Chest Pain are often considered less than satisfactory, however, a better physiopathological knowledge of these conditions might produce a more appropriate therapeutic management of the patients with continual and disabling symptoms.

ABO blood groups and cancer of the pancreas

Few investigations discussing an association between ABO blood groups and pancreatic cancer exist. We have selected a series of 224 patients with histologically-confirmed pancreatic cancer, and their ABO blood groups distribution was compared with two control groups: 7086 patients with various diseases (Group 1) and 7320 voluntary blood donors (Group 2). There was an increased number of pancreatic cancer among the patients with blood group B (relative risk 1.5 vs Group 1 p = 0.021; 1.7 vs Group 2 p = 0.0025) and a decreased number in patients with blood group O, when compared with the two control groups.

[ERCP in the diagnosis of bilio-pancreatic pathology. Comparison with echography and CT]

The authors have evaluated both sensitivity and specificity of ERCP in comparison with other imaging methods, such as US and CT, on the basis of a study of 63 patients with suspected pancreatobiliary pathologies. Our results show ERCP of chronic pancreatitis to have 83% sensitivity and 66% specificity. As for biliary pathologies, sensitivity was 94% and specificity 88%. In pancreatic pathologies, CT sensitivity was 99% and its specificity was 70%. The combined use of ERCP and CT determines a considerable rise in the percentages, and allows the evaluation of both the excretory tree and the parenchyma. As for biliary pathologies, the role of ERCP is fundamental, since its combination with the other methods (CT: sensitivity 72%, specificity 3.5%; US: sensitivity 70%, specificity 3.5%) has not determined but a slight increase in sensitivity, and no significant increase in specificity.

Somatostatin response to a mixed meal in normals and in type I diabetics

Somatostatin has been proposed as a regulatory peptide of nutrient entry and fuel homeostasis because of its ability to inhibit the release of substances involved in food digestion and metabolism. The aim of the study was to evaluate the somatostatin response to a test meal in type I diabetics at the clinical onset of the disease and after two months of intensive insulin therapy. Normal subjects and diabetics in good metabolic control showed a characteristic biphasic somatostatin rise after a test meal; this response was lacking in diabetics at the onset of the disease. The response of somatostatin to a mixed meal in normals confirms its involvement in nutrient digestion and metabolism. The lacking somatostatin response in newly diagnosed type I diabetics might be related to deficient GIP response to the test meal or to other factors such as the insulinopenia or metabolic derangement characteristic of the clinical onset of the disease.

Relapsing polychondritis with severe aortic insufficiency

Relapsing polychondritis (RP) is a rare disease characterized by auricular, nasal and respiratory tract chondritis, ocular inflammation, inflammatory polyarthritis and cardiovascular abnormalities. Here we describe a patient with a five-year history of mild nasal and auricular chondritis, which suddenly developed into a severe aortic insufficiency with rest dyspnea. The pathogenesis and the management of this rare connective tissue disease are discussed.

Chronic active hepatitis and Behçet's syndrome

In a patient with Behcet's syndrome the finding of five times the normal level of serum transaminase accompanied by weakness may be correlated to the syndrome itself. We performed needle biopsy of the liver in our patient which showed piecemeal necrosis and portal lympho-monocytic infiltration extending into the lobule. It is interesting that HLA B5 and B27 antigens were present. Simultaneous occurrence of chronic active hepatitis and Behcet's syndrome may imply the same autoimmune pathogenesis, as we suggest in this work.

Association of ankylosing spondylitis with hairy cell leukemia: a previously once reported case

We report a case of ankylosing spondylitis associated with hairy cell leukemia. This is the second observed case (I3) of ankylosing spondylitis with a B-type lymphoproliferative disorder which allows us to make some observations about the pathogenesis of these rare diseases.

[Acute adult respiratory distress in a gram-negative infection. Clinical contribution]

The adult respiratory distress syndrome in major complication of hospitalized patients. The therapeutic role of intravenous albumin, diuretics, corticosteroids and oxygen administration is yet doubtful. The Authors, after a description of pathogenetic, histological and clinical aspects of the syndrome, report a case occurred at their observation; it is showed the important role of intravascular coagulopathy and reversible ECG alterations, and the therapeutic valve of positive end-expiratory pressures (PEEP).