Impact of Helicobacter pylori on multiple sclerosis-related clinically isolated syndrome

OBJECTIVES

There are no data regarding the relationship between Helicobacter pylori infection (Hp-I) and clinically isolated syndrome (CIS) suggestive of multiple sclerosis. The purpose of this pilot study was to investigate the association between active Hp-I, confirmed by histology, and CIS and to evaluate the impact of Hp eradication on the CIS clinical course.

MATERIAL AND METHODS

We conducted a study on 48 patients with CIS and 20 matched controls. At baseline, apart from histology, serum anti-Hp-specific IgG titer, inflammatory mediators, and HLA-A, HLA-B, HLA-DR genetic polymorphisms were estimated. Hp-positive patients received standard triple eradication regimen, and all patients were followed up for 2 years.

RESULTS

The prevalence of Hp-I was significantly higher in patients with CIS (43/48, 89.6%) than in control (10/20, 50%) (P < 0.001, OR: 8.6, 95% CI: 2.4-30.8). When compared with controls, patients with CIS also showed significantly higher serum anti-Hp IgG titer and HLA-A26, HLA-A30, and HLA-B57 frequencies. Hp-positive patients also showed higher serum concentrations of inflammatory cytokines and homocysteine. At 2-year clinical endpoint, in the subgroup of CIS patients with successful Hp eradication, the number of patients who presented with a second episode was significantly lower accompanied by significant improvement in mean Expanded Disability Status Scale score.

CONCLUSIONS

Hp-I seems more frequent in a Greek CIS cohort and its eradication might delay CIS progression, suggesting a possible link between Hp-I and CIS.

Polyautoimmunity in a Greek cohort of multiple sclerosis

OBJECTIVES

The aim of this study was to assess the existence of polyautoimmunity in a Greek cohort of multiple sclerosis (MS), particularly multiple autoimmune syndrome (MAS), i.e., the presence of three or more distinct autoimmune disorders (ADs) in the same individual.

METHODS

Cross-sectional control study.

RESULTS

The overall prevalence of polyautoimmunity in 2140 MS patients (female to male ratio: 2.1:1) was 8.3% (vs 6.07% in 1580 matched control participants, P = 0.008) mainly due to differences in autoimmune thyroid disorders (AITD) and vitiligo. The prevalence of MAS was 1.0%. The most frequent diseases encountered in MS were organ-specific ADs. There was no statistical difference in the total rates of ADs between female and male MS patients. There were higher rates of AITD in women (P = 0.004) and higher rates of iritis (P = 0.039) and ankylosing spondylitis (P = 0.003) in men. MS was diagnosed in the same year with AD in 7.4% of patients with additional ADs, earlier than AD in 42.0% and later than AD in 50.6%.

CONCLUSION

Polyautoimmunity and particularly MAS occur more frequently in MS patients than in control participants indicating that MS may be part of a generalized susceptibility to autoimmunity. Therefore, polyautoimmunity may be implicated in the etiopathogenesis of MS-related ADs, with a potential impact on relative therapeutic strategies.

Prevalence of Barrett's esophagus in Northern Greece: A Prospective Study (Barrett's esophagus)

BACKGROUND

Barrett's esophagus(BE) is a premalignant condition associated with chronic gastro-esophageal reflux disease (GERD). As only a small proportion of BE progresses to malignancy, it is important to study BE prevalence to prevent adenocarcinoma.

MATERIALS AND METHODS

Between January 2007 and December 2010, all consecutive individuals who underwent routine upper endoscopy were prospectively recruited. Patients referred for GERD were excluded from the study. Clinical and endoscopic data were collected.

RESULTS

A total of 1,990 patients (mean age 47.48±13.4 years; 52.8% males) were included. Of them, 496 (24.9%) reported GERD. Erosive esophagitis (EE) was found in 221 participants (11.1%, 193 patients with LA grade A and 28 patients with LA grade B). Overall 31 of 1494 participants not reporting reflux symptoms (2.07%) suffered from silent GERD. BE was diagnosed in 75 participants (3.77%), four (5.3%) with long-segment BE and 71 (94.7%) with short-segment BE. Low-grade dysplasia was noticed in 1 patient with long-segment BE. Hiatal hernia (HH) was found in 196 patients (9.8%), and mean HH length was 3.22 ± 0.2 cm. BE was correlated to EE, GERD and the presence of HH (p= 0.0167, <0.001 and 0.017, respectively) whereas it was not associated with age, alcohol consumption and smoking (p= 0.057, 0.099 and 0.06, respectively). BE was not correlated with Helicobacter pylori infection (p=0.542).

CONCLUSION

The prevalence of BE was 3.77% in a Greek population undergoing upper endoscopy not referred for GERD. Long-segment BE was very uncommon (0.2%) whereas 2.07% of patients not reporting symptoms suffered from silent GERD.

Trimebutine as a potential antimicrobial agent: a preliminary in vitro approach

AIM

The aim of this preliminary study was to investigate the in vitro effect of "non-antibiotic" trimebutine against reference strains Staphylococcus aureus ATCC 29213, ATCC 25923, Escherichia coli ATCC 25922, ATCC 35218, Pseudomonas aeruginosa ATCC 27853 and Enterococcus faecalis ATCC 29212; microbiota that are potentially involved in the pathophysiology of post-infectious functional gastrointestinal disorders.

METHODS

Trimebutine activity was assessed by the broth microdilution method according to Clinical and Laboratory Standards Institute recommendations against reference strains S. aureus ATCC 29213 and ATCC 25923, E. coli ATCC 25922 and ATCC 35218, P. aeruginosa ATCC 27853 and E. faecalis ATCC 29212. Bactericidal activity of the compound was determined by spreading a 10 μL aliquot on Mueller-Hinton agar from each dilution showing non-visible growth. All tests were carried out in triplicate.

RESULTS

Trimebutine was active against all strains tested presenting with MIC ranging from 1024 to 4000 mg/L. MIC and MBC were similar for E. coli ATCC 25922 and P. aeruginosa ATCC 27853 whereas for Gram-positive isolates and E. coli ATCC 35218 the MBC was higher.

CONCLUSIONS

We demonstrated the in vitro bacteriostatic/bactericidal activity of trimebutine against bacteria frequently colonizing the gastrointestinal tract and potentially involved in human gastrointestinal infections that might trigger post-infectious functional gastrointestinal disorders.

The emerging role of endocrine disruptors in pathogenesis of insulin resistance: a concept implicating nonalcoholic fatty liver disease

Endocrine disruptors or endocrine-disrupting chemicals (EDCs) represent a highly heterogeneous group of molecules found in the environment or in consumer products. Toxicology and epidemiology studies have suggested the involvement of diverse EDCs in an increasing number of metabolic disorders, including insulin resistance (IR) and IR-related co morbidities, such as obesity, type 2 diabetes mellitus (T2DM) and polycystic ovary syndrome. Nonalcoholic fatty liver disease (NAFLD), another IR related condition, is emerging as a significant public health concern, affecting 30-45% of the general population in the Western world. To evaluate whether EDCs may also play a role in the pathogenesis of NAFLD, we reviewed the literature on well-studied EDCs, such as dioxins, bisphenol A, phthalates and other persistent organic pollutants, in relation to pathways that might contribute to the pathogenesis of fatty liver / NAFDL. Certain EDCs may be responsible for inducing alterations similar to those encountered in NAFLD either directly through a hepatotoxic effect and/or indirectly by triggering hepatic and systematic IR. Considering these effects, which act in concert with the effects of the epidemics of obesity and T2DM, EDCs may play a significant role in the pathogenesis of fatty liver, thereby increasing the prevalence of NAFLD worldwide. Translational studies and clinical trials investigating the association between EDCs and NAFLD are required to confirm and extent these studies.

Combination of diclofenac plus somatostatin in the prevention of post-ERCP pancreatitis: a randomized, double-blind, placebo-controlled trial

BACKGROUND AND STUDY AIMS

Pancreatitis is the most common complication of therapeutic endoscopic retrograde cholangiopancreatography (ERCP), and many pharmacoprophylactic approaches have been suggested, though not without controversy. The aim was to investigate the impact of combined therapy with diclofenac plus somatostatin on reducing the frequency and severity of post-ERCP pancreatitis (PEP).

PATIENTS AND METHODS

A prospective, double-blind, placebo-controlled trial was conducted in two tertiary referral centers, with 540 eligible patients randomized to receive either combined therapy with diclofenac 100 mg rectally 30 to 60 minutes before ERCP plus somatostatin 0.25 mg/h for 6 hours (group A), or a placebo suppository identical in appearance to the diclofenac along with saline solution (group B). Patients were clinically evaluated and serum amylase levels were determined before ERCP and at 6 and 24 hours post-procedure. Standardized criteria were used to diagnose and grade the severity of PEP. Adverse events were recorded prospectively.

RESULTS

There were no statistical differences between the groups regarding demographic data, ERCP findings, and procedure risk factors for PEP. The overall incidence of acute pancreatitis was 7.2 %. The PEP rate was significantly lower in the patients who received the combination therapy than in controls (4.7 % vs. 10.4 %, P = 0.015). Previous history of acute pancreatitis (P = 0.001), pancreatic opacification of first-class branches and beyond (P = 0.008), and absence of pharmacoprophylaxis (P = 0.023) were identified as independent risk factors for PEP in multivariate analysis.

CONCLUSION

Although combined prophylactic therapy with diclofenac plus somatostatin was promising in reducing frequency of PEP, further comparative large-scale studies are needed to confirm our findings before definitive conclusions can be drawn.

Outpatient therapeutic endoscopic retrograde cholangiopancreatography is safe in patients aged 80 years and older

BACKGROUND AND STUDY AIM

The aim of this observational prospective study was to evaluate the safety of outpatient therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in a very elderly cohort.

PATIENTS AND METHODS

A total of 600 patients were included in the study between June 2006 and June 2009. All underwent first therapeutic ERCP and were scheduled to be discharged on the same day following a postprocedure observation period of 6 hours. Of the 600 patients, 123 patients (group A) were re-admitted due to postprocedure complications that presented during the observation period, and 477 patients (group B) were discharged on the same day. Concomitant diseases, details of ERCP procedures, complications, and outcomes were all evaluated. The accuracy of the 6-hour postprocedure observation period, clinical criteria in predicting those patients aged 80 years and older in whom all therapeutic ERCP can be performed on an outpatient basis, and costs saved were all assessed.

RESULTS

There was a statistical difference in incidence of concomitant diseases between groups A and B (group A 84.5 % vs. group B 74.6 %; P = 0.020). However, there was no difference between the groups with regard to indication for ERCP and type of intervention. There was no difference in postprocedure complication rate between very elderly patients and younger patients (< 80 years), except for prolonged sedation or hypotension, which occurred more frequently in older (≥ 80 years) than in younger (< 80 years) patients (7.6 % vs. 3.2 %; P = 0.037). In group B, complications necessitating re-admission after the 6-hour observation period occurred in 10 patients (2.09 %) (patients ≥ 80 years 0.8 % and patients < 80 years 2.5 %). The costs saved by performing the procedure on an outpatient basis was calculated as 150 € per patient.

CONCLUSION

Outpatient therapeutic ERCP with postprocedure observation of 6 hours is a safe and cost-effective procedure in a significant proportion of very elderly patients.

Diagnostic yield and clinical management after capsule endoscopy in daily clinical practice: A single-center experience

BACKGROUND

Capsule endoscopy is an effective method of examining the small bowel in patients with obscure gastrointestinal bleeding, suspected inflammatory mucosal diseases and neoplasms. We herein evaluate the diagnostic yield of capsule endoscopy and its effect on clinical management in daily clinical practice.

PATIENTS AND METHODS

One hundred and one capsule endoscopies performed at the Department of Endoscopy and Motility Unit of G. Gennimatas General Hospital of Thessaloniki from May 2007 to February 2009 were retrospectively reviewed. Clinical management following capsule endoscopy findings was evaluated. The most frequent indication was obscure gastrointestinal bleeding (n=56, overt=20).

RESULTS

The overall diagnostic yield was 47.5%. The diagnostic yield was 88.9% in patients with overt bleeding who underwent early capsule endoscopy (within 5 days), versus 36.4% in patients who underwent late capsule endoscopy (p=0.028). Moreover, it reached 81.8% in patients with abdominal pain, with/without diarrhea and abnormal biological markers, versus 8.3% in patients with normal biological markers (p<0.0001). Capsule endoscopy was diagnostic in all patients with symptomatic celiac disease. Adenomas were found in 9 of 14 familial adenomatous polyposis patients. Capsule retention (>72 hours) occurred in two patients. Forty-three of 48 (89.6%) patients with positive capsule endoscopy findings that received intervention or medical treatment had positive clinical outcomes.

CONCLUSIONS

Capsule endoscopy has an important diagnostic role and contribution in the clinical management during routine clinical practice; however, it remains to be determined which patients are more likely to benefit from this expensive examination.

Prospective randomized study comparing double layer and Tannenbaum stents in distal malignant biliary stenosis

BACKGROUND AND STUDY AIMS

This prospective randomized study compared the patency and effective drainage rate of two stents with different materials but similar design, in the palliation of inoperable malignant biliary obstruction.

PATIENTS AND METHODS

A total of 49 patients (26 women, mean age 72.55 +/- 10.75 years, range: 48-91 years) with obstructive jaundice due to inoperable malignant stricture of the distal common bile duct without previous drainage procedure, were randomly assigned to receive 10F Double Layer (DLS) (n = 24) or 10F Tannenbaum (TAN) (n = 25) biliary plastic stent. The diagnosis included pancreatic cancer (n = 33), cholangiocarcinoma (n = 8), ampullary cancer (n = 7) and metastatic lymphadenopathy (n = 1). The duration of stent patency, the effective drainage, and the adverse events were analyzed.

RESULTS

Stent placement was successful in all patients with minor complications. The overall median patency rates between the two groups did not differ (107.5 days for DLS group vs. 101 days for TAN group ; p = 0.066). Effective drainage rate at the end of second week was 95.8% for DLS group and 96% for TAN group, (p = 1.00). Proximal stent migration occurred in one patient with TAN stent.

CONCLUSIONS

The present study demonstrated that both DLS and TAN stents are comparable in terms of placement, overall stent patency, and complications.

Endoscopic closure of a large iatrogenic rectal perforation using endoloop/clips technique

Retroflexion to evaluate the rectal vault provides significant additional information compared with standard forward view of the rectum. The procedure is easily performed with rare complications and is well tolerated by patients. We describe the first case of a large oval rectal perforation after retroflexion of the colonoscope in a healthy rectum during a follow-up colonoscopy, immediately closed with the endoloop/clips technique. The patient had an uneventful course and was discharged after 5 days. At his 2-month follow-up visit he remained asymptomatic and endoscopy revealed complete healing of the perforation.

Should inspection of the laryngopharyngeal area be part of routine upper gastrointestinal endoscopy? A prospective study

BACKGROUND

Examination of the laryngopharyngeal area is not always performed during routine upper gastrointestinal (UGI) endoscopy although initial studies reported pathological findings in 0.9-3.5% of cases. The aim of this study was to prospectively evaluate the accuracy of screening the laryngopharyngeal area during routine UGI endoscopy, before insertion of endoscope into the oesophagus, to avoid a misinterpretation of trauma-related hyperaemia or erythema as signs of laryngitis.

METHODS

The study included 1297 patients undergoing elective UGI endoscopy, asymptomatic in the laryngopharyngeal area, who underwent a carefully structured examination of the laryngopharyngeal area, videotaped for later blinded review. If pathological findings were suspected, patients were referred to otorhinolaryngologists for additional evaluation. In all cases the DVDs were reviewed by two ear, nose, and throat (ENT) specialists blinded to the endoscopic findings.

RESULTS

In 1130 (87.12%) patients the examination was performed successfully before insertion of the endoscope into the oesophagus. Gastro-oesophageal reflux disease (GORD) symptoms were present in 254 (22.5%) patients, and erosive oesophagitis was documented in 89 (7.9%) patients. In 44 (3.89%) patients the pathology was suspected by the endoscopist and confirmed by the otorhinolaryngologists. Moreover, 8 (0.71%) patients were found to have laryngeal pathology in the DVDs reviewed by the ENT specialists, further confirmed by laryngoscopy. Sensitivity, specificity, positive, and negative predictive values were 84.61%, 100%, 100%, and 99.26%, respectively, for detecting laryngeal abnormalities by the endoscopist. The most important findings were leukoplakia (n=4), posterior laryngitis (n=16), Reinke's oedema (n=2), and hyperkeratosis of arytenoid folds (n=2). A strict correlation emerged between GORD and posterior laryngitis (75%) and between GORD and Reinke's oedema (100%), documented by pHmetry. A significant association was also observed between heavy smoking and leukoplakia (75%), and hypertrophy of pharyngeal tonsils (100%), respectively. All other findings were lesions without clinical significance.

CONCLUSIONS

Screening examination of the laryngopharyngeal area should be part of each UGI endoscopy revealing important laryngeal pathology.

Capsule endoscopy findings in congenital afibrinogenemia-associated angiopathy

Congenital afibrinogenemia is a rare genetic disorder characterized by the complete absence of functional fibrinogen. We report a 22-year-old female who developed nephrogenic arterial hypertension and intestinal ischemia due to congenital afibrinogenemia-associated angiopathy of large abdominal arteries. We describe, for the first time, the capsule findings and discuss the pathophysiology of this unusual condition.

A comparative study of standard ERCP catheter and hydrophilic guide wire in the selective cannulation of the common bile duct

BACKGROUND AND STUDY AIMS

Deep cannulation of the common bile duct (CBD) is paramount for the success of endoscopic biliary intervention. The aim of the present study was to compare standard ERCP catheter and hydrophilic guide wire (HGW) in the selective cannulation of the CBD.

PATIENTS AND METHODS

A total of 332 patients were randomly assigned to cannulation with a standard catheter (n = 165) or a HGW (n = 167). If cannulation had not succeeded after 10 minutes with the technique assigned at randomization, a further attempt was made for an additional 10 minutes using the alternative technique. The following were assessed: primary and overall selective cannulation, time to cholangiography, number of pancreatic opacifications and guide-wire pancreatic duct insertions, and complication rates.

RESULTS

The primary success rate of selective CBD cannulation was higher in the HGW (81.4 %) than in the standard catheter group (53.9 %; P < 0.001). The overall cannulation rate after crossover was comparable between the two groups (standard catheter 84 % vs. HGW 83.8 %; P = 0.19). Time required for primary selective CBD cannulation was 3.53 +/- 0.32 minutes in the standard catheter vs. 4.48 +/- 0.32 minutes in the HGW group ( P = 0.04), and the number of insertions of the guide wire into the pancreatic duct was 3.29 +/- 0.47 in the standard catheter vs. 2.7 +/- 0.21 in the HGW group ( P = 0.22). Pancreatic opacifications occurred 3.19 +/- 0.20 times in the standard catheter vs. 1.50 +/- 0.22 times in the HGW group ( P < 0.001). Precut techniques were used in 56 patients (16.9 %) (n = 31 in the standard catheter vs. n = 25 in the HGW group; P = 0.07). The frequency of postinterventional pancreatitis and hemorrhage did not differ between the two groups. A young woman developed post-ERCP hemolytic crisis due to glucose-6-phosphate dehydrogenase deficiency. There was no procedure-related mortality.

CONCLUSIONS

The use of HGW, as primary technique or as a secondary technique after failure of cannulation with a standard catheter, achieves a high rate of selective CBD cannulation.

Association between Helicobacter pylori infection and mild cognitive impairment

The association of Helicobacter pylori infection and Alzheimer's disease (AD) has recently been addressed, but no relative data exist regarding mild cognitive impairment (MCI), a prodromal phase of AD. The aim of this prospective study was to evaluate H. pylori infection, by histology in a Greek MCI cohort. Sixty-three consecutive patients with amnestic MCI and 35 normal controls underwent upper gastrointestinal endoscopy, histologic and serological examinations. The prevalence of H. pylori infection was 88.9% (56/63) in MCI patients and 48.6% (17/35) in anaemic controls, as confirmed by biopsy (P < 0.001, odds ratio: 8.47, 95% CI: 3.03-23.67). Mean serum anti-H. pylori IgG concentration and plasma total homocysteine (Hcy) titre were higher in MCI patients than controls (74.86 +/- 57.22 vs. 17.37 +/- 9.30 U/ml; and 16.03 +/- 4.28 vs. 13.5 +/- 1.20 micromol/l; P < 0.001 and P = 0.015, respectively). When compared with the anaemic participants, MCI patients exhibited more often multifocal (body and antral) gastritis (92.1% vs. 68.6%; P = 0.03); in H. pylori positive MCI patients cognitive state correlated with serum anti-H. pylori IgG concentration. In conclusion, H. pylori prevalence was significantly higher in MCI patients than controls. This infection might contribute, at least in part, to the pathophysiology of MCI, possibly through induction of chronic atrophic gastritis and elevated Hcy consequences.

A novel technique of injection treatment for endoscopic sphincterotomy-induced hemorrhage

BACKGROUND

We prospectively investigated the efficacy and safety of double injection of dextrose 50 % plus epinephrine (D (50)+E) solution in endoscopic hemostasis of postendoscopic sphincterotomy (ES) hemorrhage.

PATIENTS AND METHODS

The study included 1331 consecutive patients who underwent 1331 ES procedures between March 2002 and June 2006. Bleeding patterns (trickle, oozing, pulsatile, none) were recorded. Patients with oozing or trickle bleeding who did not respond to spray irrigation of D (50)+E solution and all the patients with pulsatile bleeding, received double injection of D (50)+E solution at 2 - 3 cm proximal and into the bleeding point with a sclerotherapy needle. Risk factors for post-ES hemorrhage were also assessed.

RESULTS

ES-induced hemorrhage occurred in 63 patients (4.73 %). Visible bleeding patterns immediately following ES were: 44 trickle (69.84 %), 13 oozing (20.63 %) and six pulsatile (9.52 %). Hemostasis was achieved by spray irrigation of solution in 41 of 44 patients (93.18 %) with trickle, and in three of 13 patients (23.07 %) with ooze bleeding. Double injection was required in all patients with pulsatile bleeding, in 10 patients (76.92 %) with oozing, and in three patients (6.82 %) with trickle bleeding. Overall, successful hemostasis was achieved with double injection in 18 of 19 patients (94.74 %). The "zipper" cut was revealed to be a sole significant risk factor to the occurrence of bleeding ( P < 0.001). Five non-bleeding patients (0.37 %) presented with delayed hemorrhage. The difference in the incidence of other complications between the groups treated or not treated by endoscopic hemostasis was not statistically significant.

CONCLUSION

Double injection of the readily available and inexpensive D (50)+E solution is a safe and effective treatment and is recommended for post-ES hemorrhage.

Single use of fentanyl in colonoscopy is safe and effective and significantly shortens recovery time

BACKGROUND

Colonoscopy remains an uncomfortable examination and many patients prefer to be sedated. The aim of this study was to evaluate the efficacy and safety of intravenous administration of fentanyl in titrated doses compared with intravenous administration of the well-known midazolam in titrated doses.

METHODS

One hundred twenty-six patients scheduled for ambulatory colonoscopy were randomly assigned to receive either 25 mcg fentanyl (Fentanyl group, n = 66, 35 females, mean age = 61.5 years) and titrated up to 50 mcg or 2 mg midazolam (Midazolam group, n = 60, 33 females, mean age = 63.2 years) and titrated up to 5 mg. Patients graded discomfort on a scale from 0 to 4 and pain on a scale from 0 to 10. Success of the procedure, time to cecum, complications, and recovery time for each patient were independently recorded.

RESULTS

Mean discomfort scores were 0.4 in the Fentanyl group and 1.0 in the Midazolam group (p = 0.002). Similarly, mean scores for pain and anus to cecum time were lower in the Fentanyl group than in the Midazolam group [2.59 vs. 4.43 (p = 0.002) and 8.7 vs. 12.9 min (p = 0.012), respectively]. No adverse events were reported in the Fentanyl group, while in the Midazolam group a decrease in oxygen saturation was noted in 23/60 (35%) patients. Mean recovery time was 5.6 min in the Fentanyl group and 16 min in the Midazolam group (p = 0.014). Mean dosage was 36 mcg for fentanyl and 4.6 mg for midazolam.

CONCLUSION

Administration of fentanyl in low incremental doses is sufficient to achieve a satisfactory level of comfort during colonoscopy.

Gastric predominant hereditary hemorrhagic telangiectasia

Hereditary hemorrhagic telangiectasia (HHT) or Rendu-Osler-Weber disease is an autosomal-dominant disorder that frequently presents with epistaxis and gastrointestinal bleeding which may be a diagnostic and therapeutic challenge. We describe a 48-year-old monk with familiar history of HHT, who presented with frequent epistaxes and symptoms of ferropenic anemia. Upper gastrointestinal endoscopy revealed innumerable telangiectasias in the stomach. The patient underwent three sessions with argon plasma coagulation treatment but the results were poor. We also review the literature on the pathophysiology of the disease and discuss the suggested treatment.

Tannenbaum and metal stents in the palliative treatment of malignant distal bile duct obstruction: a comparative study of patency and cost effectiveness

BACKGROUND

Stent clogging is the major limitation of palliative treatment for malignant biliary obstruction. Metal stents have much better patency than plastic stents, but are more expensive. Preliminary data suggest that the recently designed plastic (Tannenbaum) stent has better duration of patency than the polyethylene stent. This study aimed to compare the efficacy and cost effectiveness between the Tannenbaum stent without side holes and the uncovered metal stent for patients with malignant distal common bile duct obstruction.

METHODS

In this study, 47 patients (median age, 73 years, range, 56-86 years) with inoperable malignant distal common bile duct strictures were prospectively randomized to receive either a Tannenbaum stent (n = 24) or an uncovered self-expandable metal stent (n = 23). The patients were clinically evaluated, and biochemical tests were analyzed if necessary until their death or surgery for gastric outlet obstruction. Cumulative first stent patency and patient survival were compared between the two groups. Cost-effectiveness analysis also was performed for the two study groups.

RESULTS

The two groups were comparable in terms of age, gender, and diagnosis. The median first stent patency was longer in the metal group than in the Tannenbaum stent group (255 vs 123.5 days; p = 0.002). There was no significant difference in survival between the two groups. The total cost associated with the Tannenbaum stents was lower than for the metal stents (17,700 vs 30,100 euros; p = 0.001), especially for patients with liver metastases (3,000 vs 6,900 euros; p < 0.001).

CONCLUSIONS

Metal stent placement is an effective treatment for inoperable malignant distal common bile duct obstruction, but Tannenbaum stent placement is a cost-saving strategy, as compared with metal stent placement, especially for patients with liver metastases and expected short survival time.

Endoloop-assisted polypectomy for large pedunculated colorectal polyps

BACKGROUND

The use of an endoloop may minimize the risk for bleeding after endoscopic polypectomy of large colorectal polyps. This study aimed to assess the safety and efficacy of colonoscopic ligation of the stalk of large pedunculated polyps by means of an endoloop technique, and to focus particular attention on the instances in which the use of this device was unsuccessful.

METHODS

This study retrospectively evaluated attempted endoloop endoscopic polypectomy in 33 patients (19 men and 14 women; mean age, 62.5 years) with large pedunculated polyps.

RESULTS

Application of the endoloop was impossible in four patients, and the snare became entangled with the loop in one patient. The remaining 28 patients underwent endoloop-assisted polypectomy. Bleeding occurred in four patients, either because the loop slipped of the stalk after polypectomy (2 patients) or because a thin stalk (< or = 4 mm) was transected by the loop before polypectomy (2 patients).

CONCLUSION

Colonoscopic polypectomy with an endoloop may be safer than conventional polypectomy. The reasons for technical failure of this technique include a narrow left colon lumen, a thin stalk (< or = 4 mm), and close cutting in relation to the site of encirclement by the loop.

Relationship between insulin-like growth factor-1 and human testicular cancer

4586

Background: Insulin-like growth factor (IGF) has an established role in various types of cancer inducing cellular proliferation, possessing anti-apoptotic properties, and stimulating angiogenesis. We have recently published the concept that IGF-1 system might also be implicated in the pathogenesis of testicular germ cell tumors. The present study aims to elucidate our initial concept by measuring IGF-1, IGF-binding protein (IGFBP)-3, and their molar ratio in patients with testicular cancer. Methods: We measured serum IGF-1 and IGFBP-3 using solid phase Elisa in 48 patients (mean age 31,6±8,07 years) with testicular cancer who underwent chemotherapy, and in 10 healthy male, age-matched (mean age 31.2 ± 2.54), controls. Three serum samples were obtained from patients with testicular cancer: prior to chemotherapy (baseline), before cycle 3, and 9–14 months after completion of chemotherapy. One serum sample was obtained from controls. Results: Baseline mean serum IGF-1, IGFBP-3, and molar ratio IGF-1:IGFBP-3 were 254.3 ± 242 ng/ml, 3541 ± 1740 ng/ml, and 0.293 ± 0.268 in patients, and 145.8 ± 110 ng/ml, 5440 ± 3504 ng/ml, and 0.108 ± 0.168 in controls (p = 0.048, p = 0.016, and p = 0.047, respectively). Mean IGF-1, IGFBP-3, and IGF-1:IGFBP-3 before cycle 3 were 242.4 ± 177.6 ng/ml, 3606 ± 2491 ng/ml, and 0.28 ± 0.234 (p = NS in all 3 parameters). Not all 48 patients have as yet completed chemotherapy; however, preliminary results from 10 patients show a trend for normalization in mean values of the third sample (IGF-1: 157.5 ± 129.4 ng/ml, IGFBP-3: 4500 ± 2351 ng/ml, and IGF-1:IGFBP-3: 0.141 ± 0.128), comparable to those of healthy controls. A trend for higher baseline IGF-1 values was noticed in patients with poor prognosis (n = 6, IGF-1: 367.5 ± 228.7 ng/ml) compared to those with good prognosis (n = 28, IGF-1: 211.1 ± 207.8 ng/ml). Conclusions: These results confirm our initial concept that IGF-1 system may play a significant role in testicular cancer. The trend showing that chemotherapy decreases IGF-1, IGFBP-3, and their ratio to normal, may provide evidence that these parameters can be useful surrogate markers for diagnosis and surveillance of testicular tumor growth.

No significant financial relationships to disclose.

Relationship between Helicobacter pylori infection and Alzheimer disease

The authors investigated the association between Helicobacter pylori infection (Hp-I) and Alzheimer disease (AD) by using histology for diagnosis of Hp-I. Fifty patients with AD and 30 iron deficiency anemic control participants without AD were included. The histologic prevalence of Hp-I was 88% in patients with AD and 46.7% in controls (p < 0.001).

Relationship between Helicobacter pylori infection and Alzheimer disease

The authors investigated the association between Helicobacter pylori infection (Hp-I) and Alzheimer disease (AD) by using histology for diagnosis of Hp-I. Fifty patients with AD and 30 iron deficiency anemic control participants without AD were included. The histologic prevalence of Hp-I was 88% in patients with AD and 46.7% in controls (p < 0.001).

Rheumatic-like syndrome as a symptom of underlying gastric cancer

Several observations imply that atypical rheumatic manifestations may be associated with occult neoplasia. A 71-year-old woman was admitted to the hospital three times in 2 years. Initially, she was admitted for investigation of an iron-deficient anemia associated with upper intestinal tract symptoms. Endoscopy revealed hiatus hernia, esophagitis, and duodenal ulcer with a Helicobacter pylori infection, but there were no signs of malignancy, and the patient received appropriate drug treatment. Two years later, she presented with arthralgias concerning the upper and lower limbs in an asymmetrical distribution, low fever, and persistence of the anemia, despite the treatment she had received and the fact that her gastrointestinal symptoms had long ceased. Immunological assays showed no specific rheumatic disorder, and the patient was discharged after showing significant improvement with the use of COX-2 selective NSAIDs. Finally, 4 months later, she was readmitted with worsening of the arthralgias, arthritis in the right radiocarpal joint, and severe anemia. Hematemesis that occurred during her hospital stay led to an emergency endoscopy and the diagnosis of gastric adenocarcinoma. Only a few cases have been reported so far concerning rheumatic manifestations as signs of an occult gastric cancer. Thus, there must be some degree of suspicion when dealing with patients with anemia and rheumatic symptoms that cannot be classified into a particular rheumatologic entity, because they might conceal a gastrointestinal malignancy not yet evident.