Flat adenomas in a colonic bladder augmentation patch: cystoscopic removal using an endoscopic mucosal resection technique

Bladder augmentation using colonic patches is being increasingly performed and a substantial risk of neoplasia in such patches has been reported. We present the case of a 62-year-old man who developed a large flat adenoma in the colonic mucosa of an augmented bladder. The adenoma was indigo-carmine dye sprayed and completely resected via a cystoscope using an endoscopic mucosal resection technique. We discuss how methods used at colonoscopy to detect and remove early neoplastic lesions may readily be employed during colonic patch surveillance at cystoscopy.

Alteration in human defensin-5 expression following gastric bypass surgery

BACKGROUND

Roux-en-Y gastric bypass surgery provides a novel human model to investigate small bowel mucosal innate immunity, in which there is loss of gastric acid-mediated protection against orally-acquired microorganisms.

AIM

To study changes in jejunal mucosal immunoreactivity of human defensin (HD)-5, an antimicrobial peptide normally produced by Paneth cells.

METHODS

Mucosal samples were obtained from 18 female patients (24-54 years), from the same segment of jejunum during and after gastric bypass surgery. Samples were used for bacterial culture and immunohistochemistry using anti-HD-5 antibody. The number of immunoreactive cells per crypt and villus were determined and expressed as mean (SD).

RESULTS

No bacteria were cultured from any of the perioperative jejunal samples but colonies of bacteria normally present in the pharynx were identified during culture of all postoperative jejunal biopsy specimens (1->100 colonies). Paneth cell numbers per crypt were unchanged after gastric bypass (4.16 (0.71) vs 4.24 (0.78)). However, following surgery, there was an increase in HD-5-positive intermediate cells per crypt (0.25 (0.41) vs 1.12 (0.66), p<0.01), HD-5 staining enterocytes per crypt (0.03 (0.09) vs 1.38 (1.10), p<0.01), HD-5 staining material in the crypt lumen (crypt lumens: 5.0% (10.9%) vs 68.1% (27.9%), p<0.01) and HD-5 immunoreactivity coating the luminal surface of villus enterocytes (villi sampled: 15.0% (31.0%) vs 67.5% (42.0%), p<0.01).

CONCLUSIONS

Bacteria normally resident in the pharynx were present in the proximal jejunal mucosa following Roux-en-Y gastric bypass surgery. After gastric bypass, there was increased secretion of HD-5 and an increase in HD-5 expressing intermediate cells and enterocytes in the crypt. The increase in HD-5 expression in the jejunal mucosa following gastric bypass surgery is likely to be secondary to exposure to orally-acquired microorganisms.

Spectrum of liver histology in presumed decompensated alcoholic liver disease

BACKGROUND

In presumed decompensated alcoholic liver disease (ALD; liver decompensation, heavy alcohol intake, and negative results of noninvasive screening for other causes), liver biopsy is often performed to assess severity of liver injury and to rule out other liver diseases.

AIM

The aim of the study is to describe the spectrum of liver histology in such patients.

METHODS

We reviewed all patients with presumed decompensated ALD seen between 1998 and 2004, in whom liver tissue was available for histology (N = 110).

RESULTS

A total of 104 of the 110 patients had at least one of the histological features suggestive of ALD: fat, Mallory's hyalin, neutrophilic infiltrate, and hepatocyte ballooning. These features were more prevalent in tissue obtained within a month after presentation with decompensation than in that obtained before decompensation or more than 1 month after. These features were also associated with more severe liver dysfunction. Histology revealed a major additional diagnosis (Budd-Chiari syndrome) in only one case. In 41 patients biopsied within a month of first presentation with decompensation, Child score and Maddrey discriminant function (DF), but none of the histological features, were predictive of survival by Cox multivariate analysis. Of the 26 of these 41 patients with a Maddrey DF >32, 22 (85%) had alcoholic hepatitis.

CONCLUSIONS

In patients with presumed decompensated ALD, other liver diseases are uncommon. Routine liver biopsy is of limited added value but biopsy should be considered in those in whom the noninvasive workup, or failure to recover despite abstinence, raises the possibility of other liver diseases.

Small bowel bacterial overgrowth. An underrecognized cause of malnutrition in older adults

Small bowel bacterial overgrowth (SBBO) is an important and under-recognized clinical syndrome in the elderly. It is the most common cause of malabsorption among older adults. Presentation of SBBO syndrome is often occult, which makes it imperative to maintain a high index of suspicion for this disorder. When symptomatic bacterial overgrowth is appropriately identified and treated there can be positive dramatic results. This article discusses the importance of considering a diagnosis of bacterial overgrowth in those predisposed to its development and the mechanisms by which nutrient malabsorption occurs. Signs and symptoms of bacterial overgrowth, differential diagnosis, investigation, and current treatment options are discussed.

Conservation of whole body nitric oxide metabolism in human alcoholic liver disease: implications for nitric oxide production

OBJECTIVE

Patients with advanced liver diseases tend to develop a hyperdynamic circulation which complicates cirrhosis. Impairment of nitric oxide (NO) metabolism has been implicated in the pathogenesis of portal hypertension. The aim of this study was to determine nitric oxide synthase (NOS)-dependent whole body NO production in patients with decompensated liver cirrhosis and portal hypertension.

MATERIAL AND METHODS

Ten patients with decompensated alcoholic liver disease and portal hypertension (Child-Pugh Classifications B and C with no signs of infection) and 10 age- and gender-matched control subjects received an intravenous infusion of L-[15N]2-arginine (50 micromol/min for 30 min). Urine and serum nitrite and nitrate concentrations were determined using ion chromatography-mass spectrometry.

RESULTS

NOS-dependent whole body NO synthesis was estimated by the conversion of [15N]guanidino nitrogen of arginine to urine 15N-nitrite and 15N-nitrate. The amount of 15N-nitrite and 15N-nitrate in the urine of patients and control subjects was significantly correlated with the amount of urine nitrite and nitrate over 36 h (r=0.91 and 0.77, respectively, p<0.0001). However, neither a median of 12 h 15N-nitrite and 15N-nitrate nor nitrite and nitrate excretion in the urine was different between patients and control subjects, 46.4 (9.4-152.2) versus 98.7 (29.9-146.5) nmol/mmol creatinine and 20.6 (2.1-69.0) versus 40.0 (27.0-70.1) micromol/mmol creatinine, respectively. No differences were found in serum nitrite and nitrate concentrations and glomerular filtration rates between patients and control subjects, 111.4 (73.2-158.8) versus 109.3 (83.5-176.4) micromol/l.

CONCLUSION

Our results contraindicate a greater basal NOS-dependent whole body NO production in patients with decompensated liver disease and portal hypertension.

Small Bowel Bacterial Overgrowth in Symptomatic Older People: Can It Be Diagnosed Earlier?

BACKGROUND/OBJECTIVES

In older people, small bowel bacterial overgrowth syndrome may be a common, but under-diagnosed, cause of diarrhoea and nutrient malabsorption. We aim to determine which clinical features and baseline laboratory investigations indicate a high likelihood of small bowel bacterial overgrowth as defined by a positive glucose breath test.

METHODS

A retrospective analysis of records for all patients referred for glucose breath test over a 6-year period to a teaching hospital.

RESULTS

Out of 197 referrals, 168 patient records were located and analysed (62 male, 106 female; median age 65). Patient characteristics predictive of a positive glucose breath test were: increasing age (p < 0.01), low serum vitamin B12 (p = 0.02), low serum albumin (p = 0.03), previous partial gastrectomy (p < 0.01), previous right hemi-colectomy (p < 0.01), presence of small bowel diverticulae (p = 0.01) and concurrent use of a proton pump inhibitor (p < 0.01). 52.5% (n = 21/40) of patients studied who were over 75 years old versus 21.8% (n = 28/128) of those under 75 years old had a positive glucose breath test (p < 0.01). The median time to diagnosis, from first hospital visit to positive glucose breath test, was 39 weeks.

CONCLUSIONS

There is often a significant delay in diagnosis of small bowel bacterial overgrowth. We suggest that this diagnosis should be considered earlier in the investigative algorithm in older patients with indicative symptoms and a predisposing factor (including previous partial gastrectomy, previous right hemi-colectomy, small bowel diverticulae or use of a proton pump inhibitor) or concurring laboratory indices (low vitamin B12 or albumin).

Self-expanding metal stents in the palliation of malignant dysphagia: outcome analysis in 100 consecutive patients

SUMMARY. Patients with inoperable esophageal malignancy often undergo palliative self-expanding metal stent insertion. This analysis of cases shows that although such stents provide good palliation of dysphagia, complications frequently occur. Complications reported were pain after insertion, bleeding, food bolus impaction, stent migration and increased gastroesophageal reflux. Furthermore, in patients with esophageal adenocarcinoma, survival was less if the distal end of the stent entered the stomach, rather than lying entirely within the esophagus. Reduced survival, in this group with gastroesophageal junction tumors, may be a result of increased gastroesophageal reflux leading to pulmonary aspiration. Stents incorporating an antireflux valve have been shown to reduce symptomatic gastroesophageal reflux. It may be that such valves offer a survival advantage where stent insertion ablates the function of the lower esophageal sphincter. Further studies are needed to assess the role of antireflux stents on survival in patients with gastroesophageal junction tumors.

Comparing the urinary pancreolauryl ratio and faecal elastase-1 as indicators of pancreatic insufficiency in clinical practice

BACKGROUND

The urine pancreolauryl ratio (uPLR) and, more recently, the faecal pancreatic elastase-1, are widely used for the noninvasive diagnosis of exocrine pancreatic insufficiency. Both tests have previously been validated against 'gold standard' tests of pancreatic function, but their use in a clinical setting has never been directly compared.

METHODS

We performed a comparative study of the pancreolauryl ratio (PLR) and the faecal elastase-1 (FE-1) test in patients with a clinical suspicion for pancreatic insufficiency. The results were compared with the clinical response to pancreatic enzyme supplementation using pre-defined criteria.

RESULTS

Forty-five patients were enrolled in the study and 33 were given a trial of pancreatic enzyme supplementation. Twenty-four out of these 33 showed a positive clinical response to enzyme supplements. Of the 24 responders, 19 had positive FE-1 (<200 microg/g faeces), but only 12 had a positive uPLR (<20). There was a significant correlation between the FE-1 result and clinical response to enzyme supplements (p = 0.01), but not between the PLR and clinical response (p = 0.15).

CONCLUSIONS

FE-1 is a simpler test for the patient to perform and more accurately predicts the response to pancreatic enzyme supplementation in patients with chronic, unexplained diarrhoea with a clinical suspicion of pancreatic insufficiency than the PLR. This makes the FE-1 of greater use in clinical practice than the PLR.