Association of occupational exposures and work characteristics with the occurrence of gastrointestinal disorders

BACKGROUND

Work is a daily activity with various conditions, exposures, and habits that may affect health either positively or negatively. Aim of this study was to investigate the relationship between occupational factors and conditions, and the occurrence of gastrointestinal disorders.

METHODS

We enrolled in this study a sample of 891 consecutive individuals, who were examined by standard colonoscopy and gastroscopy and interviewed regarding their working conditions and exposures. Consecutively, data were statistically analyzed to explore possible associations.

RESULTS

Peptic ulcer diagnosis was associated with reports of muscle pain/headache [odds ratio (OR): 3.656, 95 % confidence interval (95% CI): 1.898-7.043], with working in shifts (OR: 2.463, 95% CI: 1.058-5.731), and with the presence of occupational stress (OR: 2.283, 95% CI: 1.162-4.486). Gastritis was associated with muscle pain/headache (OR: 2.258, 95% CI: 1.096-4.652), shift work (OR: 3.535, 95% CI: 1.345-9.29), occupational stress (OR: 2.182, 95% CI: 1.072-4.444), and sedentary work (OR 0.275 lower risk 95% CI: 0.113-0.671). Ulcerative colitis was associated with muscle pain/headache (OR: 6.211, 95% CI: 2.162-17.840) and occupational stress (OR: 6.418, 95% CI: 2.243-18.361), while Crohn's disease diagnosis with muscle pain/headache (OR: 3.554, 95% CI: 1.628-7.759), frequent ordering food at work (OR: 4.928, 95% CI: 2.3-10.559), occupational stress (OR: 3.023, 95% CI: 1.413-6.469), work with intense physical activity (OR: 0.665 lower risk, 95% CI: 0.252-0.758). Colon cancer diagnosis was associated with frequent ordering food at work (OR: 2.739, 95% CI: 1.268-5.916) and occupational stress (OR: 3.175, 95% CI: 1.384-7.286), while stomach cancer diagnosis with ordering food at work (OR: 2.794, 95% CI: 1.154-6.763) and exposure to dust (OR: 5.650, 95% CI: 1.551-20.582). Finally, presence of polyps was associated with ordering food at work (OR: 2.154, 95% CI: 1.135-4.091), and constipation with ordering food at work (OR: 2.869, 95% CI: 1.451-5.672), occupational stress (OR: 2.112, 95% CI: 1.097-4.066), and occupational noise (OR: 0.248, 95% CI: 0.084-0.737).

CONCLUSION

The incidence of the gastrointestinal diseases is affected by occupational exposures and related lifestyle habits. HIPPOKRATIA 2017, 21(2): 74-79.

Severe eosinophilic infiltration in colonic biopsies predicts patients with ulcerative colitis not responding to medical therapy

AIM

Eosinophils are potent proinflammatory cells that are involved in the pathogenesis of ulcerative colitis (UC). We evaluated the infiltration of eosinophils into the lamina propria in patients with active and inactive ulcerative colitis (UC) and investigated its clinical significance, among other variables, in predicting the outcome of medical treatment in active disease.

METHOD

We studied colorectal biopsy specimens from 18 UC patients with disease in long-standing remission, from 22 patients with active disease who responded to therapy (12 with complete response and 10 with partial response) and from 10 patients who were nonresponders. Demographic information was obtained at baseline, and clinical, endoscopic and laboratory data were obtained at baseline and 12 weeks post-treatment. We evaluated five histological features: mucosal ulceration; mucosal erosions; crypt abscesses; cryptitis; and eosinophilic infiltration of the lamina propria. The severity of these lesions was graded as: none or minimal; mild; moderate; or severe. Statistical analyses were performed between responders and nonresponders for differences in demographic, clinical, laboratory, endoscopic and histological parameters.

RESULTS

Laboratory, endoscopic and histological parameters were significantly improved after treatment only in the complete responders group. Analyses of baseline data revealed no significant differences in parameters between complete or partial responders and nonresponders, except for a less severe eosinophilic infiltration of lamina propria in complete responders (P < 0.05). Multiple logistic regression analysis showed that severe eosinophilic infiltration in colonic biopsies was the most significant predictor of poor response to medical therapy.

CONCLUSION

Assessing the severity of eosinophilic infiltration in the lamina propria of colonic biopsies in patients with ulcerative colitis could be a valuable predictive tool of response to medical therapy.

Chromogranin A as a biomarker of disease activity and biologic therapy in inflammatory bowel disease: a prospective observational study

OBJECTIVE

To access the correlation of Chromogranin A (CgA) with inflammatory bowel disease (IBD) activity and responsiveness to medical therapy.

MATERIAL AND METHODS

A prospective observational study was conducted in 56 patients with moderate ulcerative colitis (UC) or Crohn's disease (CD) (UC, n = 29, CD, n = 27), 17 patients with irritable bowel syndrome and predominant diarrhea (IBS-D) and 40 healthy volunteers. IBD patients were treated by biologics (infliximab or adalimumab) or conventional agents (aminosalicylates, thiopurines or methotrexate and steroids) and were classified according to their treatment in two groups. Serum CgA was measured at baseline and 4-week posttreatment period.

RESULTS

Serum CgA was significantly higher in IBD patients than in those with IBS-D or healthy volunteers (p < 0.01). Furthermore, serum CgA was markedly increased in CD patients than in UC patients (p < 0.01). CgA value was significantly reduced in 'biologic' group (24 IBD patients, UC, n = 15, CD, n = 9) at 4-week posttreatment period (p < 0.01), while 18/24 (72%) patients were already in remission during that time. In contrast, CgA value was significantly increased in the 'conventional' treatment group (32 IBD patients, UC, n = 14, CD, n = 18) between the two visits (p < 0.01), although 22/32 (69%) patients were in remission during the 4-week posttreatment period.

CONCLUSION

CgA appears to be a reliable marker of disease activity in IBD patients and especially in those who received biologic therapy. IBS-D patients presented normal CgA values.

Patients with established gastro-esophageal reflux disease might benefit from Helicobacter pylori eradication

BACKGROUND

The aim of this study was to investigate the effect of Helicobacter pylori (H. pylori) eradication in selected H. pylori-positive patients with a primary diagnosis of gastro-esophageal reflux disease (GERD) by using the 3-h postprandial esophageal pH monitoring.

METHODS

We recruited patients with erosive esophagitis at endoscopy and H. pylori infection at histology, successfully cured following eradication therapy; the selected H. pylori-positive patients had weekly reflux symptoms for at least six months and endoscopically established Grade A or B esophagitis. Twenty-nine eligible patients were initially subjected to esophageal manometry and ambulatory 3-h postprandial esophageal pH monitoring. All patients received H. pylori triple eradication therapy accompanied by successful H. pylori eradication. After successful eradication of H. pylori (confirmed by ¹³C urea breath test), a second manometry and 3-h postprandial esophageal pH monitoring were introduced to assess the results of eradication therapy, after a 3-month post-treatment period.

RESULTS

All 29 selected H. pylori-positive patients became negative due to successful H. pylori eradication, evaluated by ¹³C urea breath test after a 4-week post-treatment period. Post-eradication, 62.1% patients showed similar manometric pattern at baseline; 17.2% showed improvement; 17.2% normalization; and 3.4% deterioration of the manometric patterns. The DeMeester symptom scoring in the 3-h postprandial ambulatory esophageal pH monitoring was improved after eradication of H. pylori (median 47.47 vs. 22.00, Wilcoxon's singed rank; P=0.016). On comparing the pH monitoring studies for each patient at baseline and post-eradication period, 82.8% patients showed improvement and 17.2% deterioration of the DeMeester score.

CONCLUSION

By using 3-h postprandial esophageal pH monitoring, this study showed, for the first time, that H. pylori eradication may positively influence GERD symptoms. Large-scale controlled relative studies are warranted to confirm these findings.

Development of primary malignant melanoma during treatment with a TNF-α antagonist for severe Crohn's disease: a case report and review of the hypothetical association between TNF-α blockers and cancer

It is recognized that immunosuppression may lead to reduced immune surveillance and tumor formation. Because of the immunosuppressive properties of tumor necrosis factor (TNF)-alpha (TNF-α) antagonists, it is plausible that these biologics may increase the risk of the occurrence of malignancies or the reactivation of latent malignancies. TNF-α antagonists have gained momentum in the field of dermatology for treating rheumatoid arthritis and psoriasis, and they have revolutionized the treatment of other inflammatory autoimmune diseases such as refractory Crohn's disease. However, there is accumulating evidence that TNF-α inhibitors slightly increase the risk of cancer, including malignant melanoma (MM). The authors herein report the case of a 54-year-old female patient who developed a primary MM during treatment with adalimumab for severe Crohn's disease resistant to successive medical therapies. The patient had been receiving this TNF-α blocker therapy for 3 years before the occurrence of MM. After wide surgical excision of the lesion and staging (based on Breslow thickness and Clark level), evaluation with a whole-body computed tomography scan was negative for metastatic disease. The long duration of the adalimumab therapy and the patient's lack of a predisposition to skin cancer suggest an association between anti-TNF-α drugs and melanocytic proliferation. The authors also review the literature on the potential association between anti-TNF regimens and the occurrence of malignancies such as melanocytic proliferations. There is a substantial hypothetical link between anti-TNF-α regimens such as adalimumab and the potential for cancers such as melanoma. However, the risk of malignancy with biological therapy remains to be established, and most of the relevant studies have lacked the statistical power and randomization required for large clinical trials. Further long-term controlled clinical trials and registries are required to investigate this potentially serious association.

Inflammatory bowel disease: Greek patients' perspective on quality of life, information on the disease, work productivity and family support

BACKGROUND

The aim of this study was to identify inflammatory bowel disease (IBD) patients' perspectives regarding everyday life issues.

METHODS

From October 2010 till April 2011, 1,181 IBD patients completed an anonymous questionnaire through the internet (827 cases) or at the outpatient clinic of the participating centers (354 cases), aiming to identify: a) the impact of disease on social life, emotional status and work productivity; b) the source of disease information; and c) the level of support from family members and friends.

RESULTS

Fifty-five percent of the patients reported that IBD interferes with their social life, while 65% felt stressed, 60% depressed and 19% tired because of it. Disease information (physician/ internet) was reported only by 31%, while 26% admitted not discussing their therapy with their gastroenterologist. Forty percent felt that the health service they receive is not satisfactory, with 76% desiring more gastroenterologists, 67% more outpatient clinics, 49% more dieticians and 42% more psychologists specialized in IBD. IBD interfered with working capacity in 40% of the participants, while 57% needed time off of work (ranging from 1-20 days per year). One of three patients (32%) has not informed his work environment about the disease; however, 88% had the support of their family and friends for coping with it.

CONCLUSIONS

Greek IBD patients claim that health-related social life, emotional status and work productivity are severely affected by their disease, whereas they complain about lack of information regarding the therapy. These unmet demands call for immediate action by healthcare providers and society.

Non-Hodgkin lymphoma and GIST: molecular pathways and clinical expressions

We report the case of a 64-year-old woman with a gastrointestinal stromal tumor and a diffuse large cell lymphoma. For this case, we conducted a literature review in an attempt to correlate these two neoplasms on a molecular basis. Diffuse large cell lymphoma is a subtype of non-Hodgkin lymphomas. The etiologic factor of these lymphomas is considered to be the mutations or allelic losses of the TP53 tumor suppressor gene and the overexpression of the bcl-2 oncogene. Gastrointestinal stromal tumors are mesenchymal tumors, which are typically defined by the expression of c-KIT (CD117) and CD34 genes in the tumor cells. Although there are references to dispersants in the literature about patients with both non-Hodgkin lymphoma and gastrointestinal stromal tumors, there is no common molecular pathway between these two diseases. In conclusion, there is no indication that these two neoplasms are relevant on a molecular basis.

Primary umbilical endometrioma: a rare case of spontaneous abdominal wall endometriosis

Umbilical endometrioma is a rare condition, with an estimated incidence of 0.5%–1% in all patients with endometrial ectopia. Spontaneous abdominal wall endometriosis is an even rarer and more unusual condition with unclear pathogenetic mechanisms. A 44-year-old parous woman presented with an umbilical skin lesion, and no history of bleeding from the umbilical mass or swelling in the umbilical area. The initial clinical diagnosis was granuloma, and excision was planned. Pathology examination revealed endometrial glands with mucinous-type metaplasia surrounded by a disintegrating mantle of endometrial stroma. Clinical examination and magnetic resonance imaging did not reveal pelvic endometriosis lesions, and given that the umbilical endometrioma was totally excised, no further treatment with hormonal therapy was proposed for the patient. Three years after excision, she was free of disease and no recurrence has been observed. Complete excision and histology is highly recommended for obtaining a definitive diagnosis and optimal treatment in spontaneous abdominal wall endometriosis.

Tuberculosis in the peritoneum: not too rare after all

Peritoneal tuberculosis is rare with increased incidence rates in recent years. The absence of characteristic clinical features of the disease often makes its diagnosis difficult and elusive. We present the case of 61-year-old female with peritoneal tuberculosis. The patient suffered from abdominal pain for a period of 5 months prior to admission. The diagnosis was established on the basis of findings from an abdominal computed tomography scan, a chest radiograph and histopathological analysis of the laparoscopic resection of the two masses. The patient was discharged from hospital receiving a fourfold antituberculous treatment with isoniazid, rifampicin, pyrazinamide and ethambutol. A high index of suspicion and a combination of radiologic, endoscopic, microbiologic and histopathological examination achieves diagnostic accuracy and prevents clinical mismanagement.

Benign post-radiation rectal stricture treated with endoscopic balloon dilation and intralesional triamcinolone injection

Post-radiation stricture is a rare complication after pelvis irradiation, but must be in the mind of the clinician evaluating a lower gastrointestinal obstruction. Endoscopy has gained an important role in chronic radiation proctitis with several therapeutic options for management of intestinal strictures. The treatment of rectal strictures has been limited to surgery with high morbidity and mortality. Therefore, a less invasive therapeutic approach for benign rectal strictures, endoscopic balloon dilation with or without intralesional steroid injection, has become a common treatment modality. We present a case of benign post-radiation rectal stricture treated successfully with balloon dilation and adjuvant intralesional triamcinolone injection. A 70-year-old woman presented to the emergency room complaining for 2 weeks of diarrhea and meteorism, 11 years after radiation of the pelvis due to adenocarcinoma of the uterus. Colonoscopy revealed a stricture at the rectum and multiple endoscopic biopsies were obtained from the stricture. The stricture was treated with endoscopic balloon dilation and intralesional triamcinolone injection. The procedure appears to have a high success rate and a very low complication rate. Histologic examination of the biopsies revealed non-specific inflammatory changes of the rectal mucosa and no specific changes of the mucosa due to radiation. All biopsies were negative for malignancy. The patient is stricture-free 12 months post-treatment.

Abdominal wall endometrioma mimicking an incarcerated hernia: a case report

The case of a tender, isolated abdominal wall tumor within a Pfannenstiel incision due to a seeding deposit of endometrial tissue secondary to a previous obstetric operation (caesarean section) in a 39-year-old female without previously reported pelvic endometriosis is presented. The lesion clinically mimicked the appearance of an incarcerated incisional hernia at the outer corner of the healed Pfannenstiel incision. The preoperative differential diagnosis also included that of a locally forming post-operative tender granuloma and the remote possibility of an incisional endometrioma (although no link to menstruation could be made). Local malignancy was not taken as a serious possibility. Definitive diagnosis of the excised lesion was made at histology. The pre-operative diagnostic dilemma is presented, along with a short review of the literature.

Quality training in laparoscopic colorectal surgery: does it improve clinical outcome?

Laparoscopic colorectal surgery (LCRS) is a safe, effective and cost-efficient option for the treatment of various benign and malignant conditions. However, its implementation to surgical practice is still limited. That is mainly due to its association with a steep learning curve. We performed a review of the literature to determine whether quality training in LCRS can reduce that learning curve and lead to better clinical outcomes. We concluded that a structured training program with pre-clinical phase focused on basic skill acquisition and a clinical phase focused on mentoring from experts can shorten the learning curve and improve clinical outcomes.

Adalimumab - an effective and promising treatment for patients with fistulizing Crohn's disease: a case series

Introduction

Crohn's disease is a chronic inflammatory bowel disease of unknown etiology which may affect any part of the bowel. Fistulas are a common and often serious complication of Crohn's disease. The treatment for fistulizing Crohn's disease can be medical, surgical or a combination of the two. Recently, adalimumab, a fully human anti-tumor necrosis factor monoclonal antibody, has been suggested as a safe and effective treatment for the induction and maintenance of remission in adult patients with moderate to severe Crohn's disease, who are refractory to conventional therapy or intolerant to infliximab. However, large studies focusing on evaluating the efficacy of adalimumab in fistulizing Crohn's disease have not yet been published.

Case presentation

We report the cases of three patients, of European Caucasian ethnicity and Greek nationality, with active luminal and fistulizing Crohn's disease. All of the cases were treated successfully with adalimumab. Patient 1 (a 44-year-old man) and patient 2 (an 18-year-old woman) developed early post-surgical enterocutaneous fistulas, while patient 3 (a 20-year-old woman) had peri-anal fistulizing Crohn's disease. Adalimumab treatment (160 mg subcutaneously at week zero, 80 mg at week two, and 40 mg every other week) was used for three different indications: (1) after the failure of other conservative medical treatments for Crohn's disease (patient 1); (2) as a monotherapy in treating a naive patient (patient 2); (3) after an intolerance to infliximab (patient 3). A remission of the active luminal and fistulizing disease was achieved soon after the initiation of adalimumab and sustained thereafter with maintenance doses. No further surgical intervention was required and no adverse effects were observed in any of the cases.

Conclusions

Fistulizing Crohn's disease remains a challenge in clinical practice. Adalimumab seems to be an effective, well-tolerated and safe treatment option for the induction and maintenance of remission in patients with moderate to severe peri-anal fistulizing Crohn's disease. Furthermore, adalimumab seems to be a promising treatment option for patients with moderate to severe fistulizing Crohn's disease with enterocutaneous fistulas. However, this clinical observation needs to be investigated in further clinical trials.

Concurrent liposomal cisplatin (Lipoplatin), 5-fluorouracil and radiotherapy for the treatment of locally advanced gastric cancer: a phase I/II study

PURPOSE

Liposomal drugs have a better tolerance profile and are highly accumulated in the tumor environment, properties that promise an optimal radiosensitization. We investigated the feasibility of the combination of 5-fluorouracil/lecovorin-based radio-chemotherapy with the administration of high weekly dose of a liposomal platinum formulation (Lipoplatin).

METHODS AND MATERIALS

Lipoplatin was given at a dose of 120 mg/m(2)/week, 5-fluorouracil at 400mg/m(2)/week (Day 1), whereas radiotherapy was given through 3.5-Gy fractions on Days 2, 3, and 4. Two groups of 6 patients received four and five consecutive cycles, respectively.

RESULTS

Minimal nephrotoxicity (18.2% Grade 1) and neutropenia (9% Grade 3) was noted. Fatigue Grade 2 appeared in 25% of cases. Abdominal discomfort was reported by 18% of patients. No liver, kidney, gastric, or intestinal severe acute or late sequellae were documented, although the median follow-up of 9 months is certainly too low to allow safe conclusions. A net improvement in the performance status (from a median of 1 to 0) was recorded 2 months after the end of therapy. The response rates assessed with computed tomography, endoscopy, and biopsies confirmed 33% (2 of 6) tumor disappearance in patients treated with four cycles, which reached 80% (4 of 5) in patients receiving five cycles.

CONCLUSIONS

Lipoplatin radio-chemotherapy is feasible, with minor hematological and nonhematological toxicity. The high complete response rates obtained support the testing of Lipoplatin in the adjuvant postoperative or preoperative radio-chemotherapy setting for the treatment of gastric cancer.

Bevacizumab, capecitabine, amifostine, and preoperative hypofractionated accelerated radiotherapy (HypoArc) for rectal cancer: a Phase II study

PURPOSE

Bevacizumab has established therapeutic activity in patients with metastatic colorectal cancer, and anti-vascular endothelial growth factor therapy enhances the activity of radiotherapy in experimental models. We assessed the feasibility and efficacy of preoperative radiochemotherapy combined with bevacizumab in patients with rectal cancer.

METHODS AND MATERIALS

Nineteen patients with radiologic T3 and/or N+ rectal carcinoma were treated with preoperative conformal hypofractionated accelerated radiotherapy (3.4 Gy in 10 consecutive fractions) supported with amifostine (500-1,000 mg daily), capecitabine (600 mg/m(2) twice daily, 5 days per week), and bevacizumab (5 mg/kg every 2 weeks for 2 cycles). Surgery followed 6 weeks after the end of radiotherapy. A cohort of 14 sequential patients treated with the same regimen without bevacizumab was available for comparison.

RESULTS

Grade 2 or 3 diarrhea was noted in 7 of 19 patients (36.8%), which was statistically worse than patients receiving the same regimen without bevacizumab (p = 0.01). A higher incidence of Grade 2 or 3 proctalgia was also noted (21.1%) (p = 0.03). Bladder and skin toxicity was negligible. All toxicities regressed completely within 2 weeks after the end of therapy. Pathologic complete and partial response was noted in 7 of 19 cases (36.8%) and 8 of 19 cases (42.1%). Within a median follow-up of 21 months, none of the patients has had late complications develop and only 1 of 18 evaluable cases (5.5%) has had locoregional relapse.

CONCLUSIONS

Bevacizumab can be safely combined with hypofractionated radiotherapy and capecitabine as a preoperative radiochemotherapy regimen for patients with rectal cancer. The high pathologic complete response rates urges the testing of bevacizumab in randomized studies.

Phase I/II trial of bevacizumab and radiotherapy for locally advanced inoperable colorectal cancer: vasculature-independent radiosensitizing effect of bevacizumab

PURPOSE

Anti-vascular endothelial growth factor therapy enhances the activity of radiotherapy in experimental models, and bevacizumab has therapeutic activity in patients with metastatic colorectal cancer.

EXPERIMENTAL DESIGN

Twenty-two patients with locally advanced inoperable colorectal carcinomas (LA/I-CRC) were treated with conformal hypofractionated (3.4 Gy/fraction x 15) split-course accelerated radiotherapy (biological equivalent dose, 67.2 Gy) supported with amifostine, capecitabine (600 mg/m2 daily, 5 days/week), and bevacizumab (5 mg/kg every 2 weeks, five cycles). Biopsies from nine patients, performed before and 1 week after bevacizumab administration, were analyzed for changes in mRNA expression with Illumina gene arrays.

RESULTS

No serious grade 3 chemotherapy-related side effects were recorded. There was low acute toxicity, with moist perineal desquamation noted in 2 of 22 patients, diarrhea grade 2 to 3 in 5 of 22 patients, and severe proctalgia in 2 of 22 patients. One patient died from Fournier's gangrene before treatment completion. Within a median follow-up of 18 months, two patients with preradiotheraphy direct involvement of adjacent organs expressed recto-vaginal/perineal fistula. Out of 19 evaluable cases, 13 (68.5%) showed complete response and 4 showed (21.1%) partial response. Fourteen patients are alive with no evidence of loco-regional relapse. In the gene array analysis, 30 known genes associated with transcription factors, DNA repair, and proliferation were downregulated by bevacizumab. DUSP1 gene was the most consistently downregulated transcript.

CONCLUSIONS

The combination of radiotherapy with bevacizumab is feasible and results in a high rate of durable complete responses in patients with LA/I-CRC. Radiosensitization may occur through a direct effect on tumor cells followed by a wide scale suppression of transcription factors and genes involved in DNA repair and proliferation.

Evaluation of guide wire cannulation technique in elderly patients with choledocholithiasis

AIMS

Post-ERCP pancreatitis is the most frequent complication of ERCP. We aimed to evaluate guide-wire cannulation as compared to conventional contrast-assisted cannulation with regard to the rate of post-ERCP pancreatitis (PEP) in elderly patients with choledocholithiasis.

METHODS

Patients aged 80 years or over with known choledocholithiasis, who were referred to ERCP in one single district hospital from January 2005 to March 2008 were reviewed retrospectively.

RESULTS

During this period, 246 ERCPs were performed in 217 patients. In 82 procedures (37.0%) deep cannulation of the biliary tree was achieved by means of a contrast-assisted procedure, whereas in the remaining 135 attempts a guide wire was used. Among the 64 patients older than 80 years, cannulation was accomplished in 25 by contrast visualization of the biliary tree and in 39 by means of the guide-wire. In the overall population of 217 patients, PEP occurred in 11 patients (5%), 10 and 1 case, respectively, for each of the two procedures (p = 0.00042). In the elderly patients, PEP occurred in 5 out of 25 patients after contrast filling of the bile duct, and in 1 out of 39 patients after the guide-wire utilization (p = 0.021). Cannulation was successful in 201 of 217 patients (92.6%), and in 57 of the 64 elderly patients (89%) (36 with guide wire, p = 0.42). Bleeding occurred in 5 patients (2.3%) and perforation in one (0.46%).

CONCLUSION

The guide-wire seems to reduce the incidence of pancreatitis in the elderly compared to conventional contrast but does not improve the success rate for cannulation.

Massive intestinal ischemia, a rare complication of oral contraceptive-induced mesenteric venous thrombosis: a case report and review of literature

Intestinal necrosis and perforation is a clinical and pathological presentation of the infrequently seen mesenteric venous thrombosis in women using oral contraceptives.We report a case of a previously healthy 31-year-old female patient, who presented with a 3-day history of abdominal pain.Although chest and abdomen radiographs showed small bowel obstruction, conservative treatment failed and the patient developed peritonism. Contrast-enhanced Tomography of the abdomen revealed free air associated with dilated and thickened small bowel. A laparotomy was performed and segmental resection of both small and large bowel was required. The pathological examination showed intestinal ischemia and mesenteric venous thrombosis. There were no further predisposing factors and mesenteric venous thrombosis was ascribed to oral contraceptives.

Endoscopic resection of large pedunculated colonic polyps and risk of postpolypectomy bleeding with adrenaline injection versus endoloop and hemoclip: a prospective, randomized study

BACKGROUND

Postpolypectomy bleeding is a major complication, especially in large pedunculated colonic polyps. Several endoscopic techniques have been evolved for prevention of bleeding episodes. The aim of this study is to evaluate postpolypectomy bleeding rates in large (>2 cm) pedunculated colonic polyps using either adrenaline injection alone or loop and clip application as prophylactic methods.

MATERIALS AND METHODS

Patients with one pedunculated colonic polyps (>2 cm) were included in a double-blind study and studied prospectively. Exclusion criteria were coexistence of other large polyps, antiplatelet, nonsteroidal anti-inflammatory drugs or aspirin. In group A (n = 32), adrenaline (1:10,000) was injected in the base of the stalk followed by conventional polypectomy using mixed coagulation and cutting current. In group B (n = 32), a detachable snare was placed at the base of the stalk followed by conventional polypectomy and clip application in the residual stalk above the snare. We evaluate the efficacy of combined endoscopic methods in early and late postpolypectomy bleeding rate in large pedunculated colonic polyps, severity of bleeding, days of hospitalization, and required transfusions.

RESULTS

Overall, bleeding complications occurred in 5/64 patients (7.81%). In group A (adrenaline injection alone), four patients (12.5%) had a bleeding episode: two (6.25%) occurred during the first 24 h and two (6.25%) between days 7 and 14 from the procedure. In group B only one patient (3.12%) had a late bleeding episode (p = 0.02). Severity of late bleeding in group B patients (one moderate bleeding) versus group A patients (one moderate and one severe bleeding) and need for transfusions (1 versus 5 blood units) were lower (p = 0.02). Hospitalization days did not differ between the two groups, but colonoscopy time was significantly higher in group B versus group A (p = 0.04).

CONCLUSION

Combined endoscopic techniques seem to be more effective in preventing postpolypectomy bleeding in large pedunculated colonic polyps.

Endoscopic resection of large pedunculated colonic polyps and risk of postpolypectomy bleeding with adrenaline injection versus endoloop and hemoclip: a prospective, randomized study

BACKGROUND

Postpolypectomy bleeding is a major complication, especially in large pedunculated colonic polyps. Several endoscopic techniques have been evolved for prevention of bleeding episodes. The aim of this study is to evaluate postpolypectomy bleeding rates in large (>2 cm) pedunculated colonic polyps using either adrenaline injection alone or loop and clip application as prophylactic methods.

MATERIALS AND METHODS

Patients with one pedunculated colonic polyps (>2 cm) were included in a double-blind study and studied prospectively. Exclusion criteria were coexistence of other large polyps, antiplatelet, nonsteroidal anti-inflammatory drugs or aspirin. In group A (n = 32), adrenaline (1:10,000) was injected in the base of the stalk followed by conventional polypectomy using mixed coagulation and cutting current. In group B (n = 32), a detachable snare was placed at the base of the stalk followed by conventional polypectomy and clip application in the residual stalk above the snare. We evaluate the efficacy of combined endoscopic methods in early and late postpolypectomy bleeding rate in large pedunculated colonic polyps, severity of bleeding, days of hospitalization, and required transfusions.

RESULTS

Overall, bleeding complications occurred in 5/64 patients (7.81%). In group A (adrenaline injection alone), four patients (12.5%) had a bleeding episode: two (6.25%) occurred during the first 24 h and two (6.25%) between days 7 and 14 from the procedure. In group B only one patient (3.12%) had a late bleeding episode (p = 0.02). Severity of late bleeding in group B patients (one moderate bleeding) versus group A patients (one moderate and one severe bleeding) and need for transfusions (1 versus 5 blood units) were lower (p = 0.02). Hospitalization days did not differ between the two groups, but colonoscopy time was significantly higher in group B versus group A (p = 0.04).

CONCLUSION

Combined endoscopic techniques seem to be more effective in preventing postpolypectomy bleeding in large pedunculated colonic polyps.

Enterobius Vermicularis infection of the appendix as a cause of acute appendicitis in a Greek adolescent: a case report

Gastrointestinal infection due to Enterobius vermicularis occurs worldwide and is considered to be the most common helminth infection. The simple presence of E. vermicularis in the appendix usually produces symptoms of acute appendicitis. The association of this parasitic infestation with acute appendicitis varies from 0.2%-41.8% worldwide. We present a case of a 15 year old female with enterobiasis of appendix presented with clinical features of acute appendicitis. The appendix was surgically removed and the specimen was pathologically diagnosed to contain of E. vermicularis in non-inflamed and histologically normal appendix. Even if this condition is not uncommon in the Greek population, to the best of our knowledge this is the first report presented in the English literature.

Colorectal carcinoma: correlation between age, gender and subsite distribution

BACKGROUND

Several studies have shown a migration in the occurrence of colorectal cancer (CRC) toward a proximal colonic location. The aim of this study was to examine the interrelationship between the anatomical distribution of CRC and gender, age at presentation, and incidence rates for the disease in the inhabitants of Thrace, Northern Greece.

METHODS

A retrospective study was conducted on CRC cases diagnosed in a northern part of Greece (Evros region, 150.000 inhabitants), in the First Department of Surgery of the University General Hospital of Thrace, between 1982 and 1997. Two time periods were compared (1982-1989 and 1990-1997), at which age at diagnosis (28-88 years), gender, the incidence and subsite location of CRC were identified in the patients. Tumors were classified into right-sided cancers (from the cecum to and including the splenic flexure), left-sided cancers (located in the descending and the sigmoid colon), and rectal cancers (rectal lesions). The chi-square test and Fischer's exact test were used to compare the data.

RESULTS

During the entire study period (1982-1997), 143 cases of CRC were identified in our department. This cohort comprised 71 males and 72 females, with mean ages of 66 years and 64.7 years, respectively. The population remained almost stable during this time period. The incidence of CRC was significantly higher in the latter part of the study (1990-1997 compared to 1982-1989) for both genders (p < 0.001), with this increase being higher among the female patients with CRC (by 17.32%, p = 0.474). The analysis also revealed that the disease occurred at a significantly higher frequency at a later age (p = 0.002), especially in patients with RC (p = 0.001). A proximal migration of CRC was observed in the latter part of the study (p = 0.495), with the frequency of right-sided cancers increasing significantly among the females (by 119%, p = 0.025).

CONCLUSIONS

The incidence of CRC has increased in our region. In addition, a proximal migration of tumors over time was identified, especially in older and female individuals, which was linked to a decrease in the incidence of left colon cancer. These findings have important implications for the choice of CRC screening strategies.

Hypofractionated accelerated radiotherapy, cytoprotection and capecitabine in the treatment of rectal cancer: a feasibility study

BACKGROUND

This is a report on the feasibility and efficacy of hypofractionated accelerated radiotherapy combined with amifostine cytoprotection (hypoARC) and capecitabine in the treatment of rectal adenocarcinoma.

PATIENTS AND METHODS

Twenty-seven patients (pts) received pre- (14 pts) or postoperative (13 pts) conformal radiotherapy with 10 consecutive fractions of 3.4 Gy in 12 days, supported with subcutaneously administered high-dose amifostine (up to 1000 mg) and capecitabine (daily dose of 600 mg/m2 twice a day, 5 days per week for 4 weeks). Ten additional patients with inoperable tumors received a higher dose (15 fractions of 3.4 Gy) as a radical intervention and 5 received a lower dose for palliation.

RESULTS

Chemotherapy-related toxicity was minimal and radiation grade 2 diarrhoea and proctitis was noted in 3/42 and 4/42 cases, respectively. No peri- or postoperative complications were noted in patients receiving pre-operative radiochemotherapy. Significant tumor regression was confirmed in post- RT CT-imaging and major histological responses were noted in 85% of cases treated before surgery. Late toxicity (median follow-up 26 months) was negligible. The 2-year local relapse-free survival was 85-90% in patients treated with pre- or postoperative radiotherapy and 35% in patients with inoperable tumors.

CONCLUSION

Capecitabine-based hypoARC is feasible with only minimal early and late toxicity and encouraging efficacy.

Evidence for the ''paradox'' association between hypertensive lower esophageal sphincter and gastroesophageal reflux disease

There are several studies suggesting the paradoxical simultaneous presence of hypertensive lower oesophageal sphincter and gastroesophageal reflux disease. We present a case of a 22-year-old male patient who was examined in our outpatient clinic with oesophageal food bolus impaction during a meal, severe chest pain and drooling. Manometry revealed a hypertensive lower esophageal sphincter pressure (resting pressure 35 mmHg) and pHmetry revealed a DeMeester score > 14.72 (43.27). Six months after therapy with lansoprazole, manometry revealed a normal lower oesophageal sphincter (resting pressure 14 mmHg) and the DeMeester score was < 14.72 (5.89). The patient is now asymptomatic. This report is the only published case which exhibits the normalization of lower oesophageal pressure 6 months after gastroesophageal reflux disease management with lansoprazole, thus proving and establishing the above ''paradox''.

Complicated Crohn's-like colitis, associated with Hermansky-Pudlak syndrome, treated with Infliximab: a case report and brief review of the literature

Introduction

Hermansky-Pudlak syndrome (HPS) is a rare autosomal recessive inherited disorder consisting of a triad of albinism, increased bleeding tendency secondary to platelet dysfunction, and systemic complications associated with ceroid depositions within the reticuloendothelial system. HPS has been associated with gastrointestinal (GI) complications related to chronic granulomatous colitis with pathologic features suggestive of Crohn's disease. This colitis can be severe and has been reported to be poorly responsive to medical therapies including antibiotics, corticosteroids, sulfasalazine, mesalamine and azathioprine.

Case presentation

We report a patient with HPS which was complicated by inflammatory bowel disease with clinical and pathologic features of Crohn's disease, refractory to antibiotics, corticosteroids and azathioprine. A trial of infliximab was attempted and repeated infusions produced a complete response.

Conclusion

The occurrence of ileitis and perianal lesions and also the histopathological findings in our case suggest that HPS and Crohn's disease may truly be associated. Given this similarity and the failure of the standard medical therapy of corticosteroids and azathioprine, our patient received infliximab with marked clinical improvement.

Early antivascular effects of bevacizumab anti-VEGF monoclonal antibody on colorectal carcinomas assessed with functional CT imaging

BACKGROUND

The complex effect on anti-VEGF (vascular endothelial growth factor) monoclonal antibodies on the tumor vasculature urges studies to identify the optimal time frames for the administration of such agents with chemotherapy and radiotherapy.

PATIENTS AND METHODS

Using CT scan functional imaging, we examined the perfusion changes of contrast medium induced 7 days following administration of bevacizumab (5 mg/kg iv) in 12 patients with colorectal cancer.

RESULTS

CT imaging 7 days after the administration of bevacizumab confirmed tumor shrinkage in 3 of 12 cases. The mean Haunsfield units after the injection of contrast medium were significantly lower 7 days following the administration of bevacizumab (P = 0.002). The "perfusion score" significantly decreased after the administration of bevacizumab (P = 0.01). In 5 of 12 cases the perfusion score was by 45% to 75% decreased, in 3 of 12 minor drop of the perfusion score was noted, in 1 of 12 a slight increase was noted, and in 3 of 12 remained unchanged.

CONCLUSION

It is concluded that the antivascular effects of bevacizumab are evident within 7 days from administration in 40% of colorectal carcinomas. The mechanisms by which this early antivascular effect may favor the antitumor efficacy of radiotherapy and chemotherapy require further investigation.

Inflammatory fibroid polyp or Vanek's tumour

We report a case of a 65-year-old woman who presented with recurrent episodes of severe, postprandial abdominal pain followed by projectile vomiting. Gastroscopy revealed a large polyp in the prepyloric region. During peristalsis, the polyp was repeatedly 'passing' through the pylorus into the duodenal bulb, hence obstructing the lumen. The polyp was eventually removed in a piecemeal fashion. Histopathologic examination revealed an inflammatory fibroid polyp (known also as Vanek's tumour). A brief review on inflammatory fibroid polyps follows.

Cholestatic hepatitis with severe systemic reactions induced by trimethoprim-sulfamethoxazole

Trimethoprim-Sulfomethoxazole (TMP-SMX) related hepatotoxicity and associated severe systemic reaction are not frequent and documented only in case reports. We report a case of a 30-year-old man, who underwent a 15-day therapy with TMP-SMX for urinary tract infection and two weeks later developed acute cholestatic hepatitis, fever and a skin rash followed by severe systemic reaction. He was admitted in Intensive Care unit and with supportive therapy and prednisolone administration, he showed subsequent improvement over a period of few days. He had fully recovered months later. All tests for other causes of liver disease were negative and his liver biopsy showed evidence of drug-induced hepatic injury.

Acute paraplegia after the initiation of anti-tumour necrosis factor-alpha therapy for Crohn's disease

Therapies aimed at inhibiting tumour necrosis factor are currently successfully administered to an increasing number of patients with autoimmune diseases. Infliximab has been approved to induce and maintain remission in Crohn's disease and fistulizing Crohn's disease. We report a case of acute-onset flaccid paraplegia after the initiation of anti-tumour necrosis factor therapy (infliximab) for Crohn's disease. Neuroimaging findings revealed an extensive longitudinal myelopathy. Two months later, no abnormal signal intensity was observed in the spinal cord and after 4 months, the patient presented improvement of motor function. A possible correlation between anti-tumour necrosis factor therapy and acute myelitis is discussed. This case highlights that patients developing new neurological symptoms while on anti-tumour necrosis factor medication should be monitored closely.

Enterolith small-bowel obstruction caused by jejunal diverticulosis: Report of a case

We report the successful surgical treatment of intestinal obstruction caused by enteroliths formed in jejunal diverticula. A 78-year-old man with bowel obstruction of unknown etiology was initially managed conservatively, but suffered recurrence of the obstruction. Thus, we performed a laparotomy, which revealed multiple diverticula in the jejunum, with one enterolith inside a diverticulum and one enterolith in the terminal ileum. There was no abnormal communication between the gallbladder and the intestinal tract, excluding the possibility of a gallstone ileus. The stone in the terminal ileum could not be broken manually, so we performed an enterotomy to remove the stones. Intestinal obstruction caused by enteroliths in small-bowel diverticula is a rare event, which is difficult to diagnose and manage. To our knowledge, only 35 such cases have ever been reported.

Lateral subcutaneous internal sphincterotomy in the treatment of chronic anal fissure: our experience

BACKGROUND

Chronic anal fissure is the most common cause of anal pain associated with internal anal sphincter hypertonia. Reduction of hypertonia favours fissure healing. Temporary reduction in sphincter tone can be achieved by conservative treatment. Surgical sphincterotomy achieves permanent reduction of sphincter hypertonia and is very successful at healing anal fissures, but requires an operation with associated small morbidity.

METHODS

A study was undertaken on 246 patients (120 men, 126 women, mean age 48.3 years), undergoing subcutaneous lateral internal sphincterotomy for a chronic fissure-in-ano from January 1, 1981 to December 31, 2004. Therapeutical outcome, postoperative course and early and long-term results were recorded.

RESULTS

During the study period, the 246 patients underwent total subcutaneous lateral internal sphincterotomy, 62 of them under general anesthesia (1981-1991), and the remainder under local anesthesia. Two-hundred-forty-two patients returned for their postoperative visits at 2, 6, 24 and 48 weeks, while four patients were lost to follow-up. At 3 months postoperatively, 97.5% of fissures had healed; 224 fissures were healed by 6 weeks, 10 by 7 weeks and 2 by 3 months. Pain was significantly reduced in all patients at Day 1 postoperative. Minor complications included hematoma (0.8%) and pain (0.4%). New minor incontinence was seen in 7.02% of patients at 48-week follow up. Patients' satisfaction was 91.7%.

CONCLUSIONS

Total subcutaneous internal sphincterotomy is a safe and effective treatment for chronic anal fissures, that only rarely impairs continence to flatus.

Infliximab for treatment of pyoderma gangrenosum associated with clinically inactive Crohn's disease. A case report

We report the case of a 57-year old female patient with refractory to treatment pyoderma gangrenosum associated with clinically inactive Crohn's disease. Pyoderma gangrenosum was successfully treated with Infliximab, a chimeric monoclonal antibody that inhibits tumour necrosis factor alpha (TNF-alpha). Our case report suggests that Infliximab, a therapeutic agent for refractory and fistulizing Crohn's disease, may also be safe and effective in the treatment of Crohn's disease associated pyoderma gangrenosum, even though the inflammatory bowel disease is clinically inactive and repeated infusions may be required for successful treatment.