Comparison between small bowel manometric patterns and full-thickness biopsy histopathology in severe intestinal dysmotility

BACKGROUND

Intestinal manometry is the current standard for direct evaluation of small bowel dysmotility. Patients with abnormal motility can either be diagnosed of pseudo-obstruction when there are radiological findings mimicking mechanical intestinal obstruction or of enteric dysmotility when these findings are absent. The aim of the present study was to prospectively compare small bowel manometric abnormalities with histopathological findings in intestinal full-thickness biopsies in patients with severe dysmotility disorders.

METHODS

We investigated 38 patients with intestinal manometry and a subsequent full-thickness intestinal biopsy. Manometric recordings were read by 4 investigators and a diagnostic consensus was obtained in 35 patients. Histopathological analysis, including specific immunohistochemical techniques of small bowel biopsies was performed and compared to manometric readings.

KEY RESULTS

Patients with abnormal intestinal manometry had abnormal histopathological findings in 73% of cases. However, manometric patterns did not match with the specific neuromuscular abnormalities. Among patients with a neuropathic manometry pattern and abnormal histopathology, only 23% had an enteric neuropathy, whereas 62% had neuromuscular inflammation, and 15% an enteric myopathy. On the other hand, patients with a myopathic manometry pattern all had abnormal histopathology, however, none of them with signs of enteric myopathy.

CONCLUSION & INFERENCES

Small bowel dysmotility detected by intestinal manometry is often associated with abnormal neuromuscular findings in full-thickness biopsies. However, there is no correlation between the specific manometric patterns and the histopathological findings.

Colonic content: effect of diet, meals, and defecation

BACKGROUND

The metabolic activity of colonic microbiota is influenced by diet; however, the relationship between metabolism and colonic content is not known. Our aim was to determine the effect of meals, defecation, and diet on colonic content.

METHODS

In 10 healthy subjects, two abdominal MRI scans were acquired during fasting, 1 week apart, and after 3 days on low- and high-residue diets, respectively. With each diet, daily fecal output and the number of daytime anal gas evacuations were measured. On the first study day, a second scan was acquired 4 hours after a test meal (n=6) or after 4 hours with nil ingestion (n=4). On the second study day, a scan was also acquired after a spontaneous bowel movement.

RESULTS

On the low-residue diet, daily fecal volume averaged 145 ± 15 mL; subjects passed 10.6 ± 1.6 daytime anal gas evacuations and, by the third day, non-gaseous colonic content was 479 ± 36 mL. The high-residue diet increased the three parameters to 16.5 ± 2.9 anal gas evacuations, 223 ± 19 mL fecal output, and 616 ± 55 mL non-gaseous colonic content (P<.05 vs low-residue diet for all). On the low-residue diet, non-gaseous content in the right colon had increased by 41 ± 11 mL, 4 hours after the test meal, whereas no significant change was observed after 4-hour fast (-15 ± 8 mL; P=.006 vs fed). Defecation significantly reduced the non-gaseous content in distal colonic segments.

CONCLUSION & INFERENCES

Colonic content exhibits physiologic variations with an approximate 1/3 daily turnover produced by meals and defecation, superimposed over diet-related day-to-day variations.

Digestive, cognitive and hedonic responses to a meal

BACKGROUND

Gut dysfunctions may be associated to digestive symptoms. We hypothesized that the gut can also originate pleasant sensations, and wished to demonstrate the hedonic component of the digestive response to a meal.

METHODS

Healthy subjects (n = 42) were evaluated during basal fasting conditions and during experimentally induced fullness sensation (either by gastric distension or duodenal nutrient infusion). In each set of studies, a 240 mL test meal (12 kcal broth) and water, as inert control meal, were administered on separate days in a randomized, cross-over design. Gastric accommodation, the cognitive response and the hedonic dimension (both by 10 score scales) were measured 9 min before and 60 min after the meal.

KEY RESULTS

In basal conditions, the test meal induced a significantly greater gastric relaxation than the control meal (166 ± 28 mL isotonic volume increase 67 ± 14 mL; p = 0.002). Both meals induced epigastric fullness (3.8 ± 0.7 score and 3.2 ± 0.8 score, respectively; p = 0.740), but contrary to the inert meal, with the active meal this conscious sensation had a pleasant dimension (digestive comfort increase by 1.3 ± 0.6 score with active meal vs -1.1 ± 0.6 decrease with inert meal; p = 0.015). Experimentally induced fullness was associated to a decrease in digestive well-being or abdominal discomfort, which improved only after the active meal but not the inert meal.

CONCLUSIONS & INFERENCES

When appropriate conditions are met, the response to a meal includes a hedonic dimension involving pleasant sensation of digestive well-being.

Nitrergic and purinergic mechanisms evoke inhibitory neuromuscular transmission in the human small intestine

BACKGROUND

Inhibitory neuromuscular transmission in the human colon is due to nitrergic and purinergic (P2Y1 -mediated) inputs. The aim of this study was to determine the mechanisms of neuromuscular transmission in different regions of the human small intestine.

METHODS

Ileal (n = 6) and jejunal (n = 6) samples underwent histological examination and were studied using sharp microelectrodes in smooth muscle cells and conventional muscle bath techniques. Electrical field stimulation (EFS) was used to stimulate inhibitory neurons.

KEY RESULTS

No histological abnormalities were found. Resting membrane potential was -39.7 ± 1.5 and -45.5 ± 2.1 mV in the jejunum and ileum, respectively. Slow waves and spontaneous contractions were recorded at a frequency of about 8-9 and 6-7 cpm in the jejunum and ileum, respectively. In non-adrenergic, non-cholinergic conditions, EFS caused an inhibitory junction potential and mechanical relaxation. Both responses were blocked by tissue incubation with the nitric oxide synthase inhibitor (Nω-nitro-l-arginine 1 mM) and the P2Y1 receptor blocker 2'-deoxy-N(6) -methyladenosine 3',5'-bisphosphate tetrasodium salt (MRS2179; 10 μM). Both exogenous addition of sodium nitroprusside (1 μM) and the preferential P2Y1 receptor agonist ADPβS (1 μM) hyperpolarized and relaxed smooth muscle cells. MRS2179 (10 μM) blocked ADPβS-induced responses.

CONCLUSIONS & INFERENCES

Similar to colon, inhibitory neurotransmission in the human small intestine is mainly mediated by purinergic (via P2Y1 receptors) and nitrergic inhibitory neurotransmission. Similar mechanisms of inhibitory neurotransmission are present in different regions of the human intestine.

Acute experimental stress evokes a differential gender-determined increase in human intestinal macromolecular permeability

BACKGROUND

Intestinal epithelial dysfunction is a common pathophysiologic feature in irritable bowel syndrome (IBS) patients and might be the link to its clinical manifestations. We previously showed that chronic psychosocial stress induces jejunal epithelial barrier dysfunction; however, whether this epithelial response is gender-specific and might thus explain the enhanced female susceptibility to IBS remains unknown.

METHODS

Intestinal responses to acute stress were compared in age-matched groups of healthy women and men (n = 10 each) experiencing low background stress. A 20-cm jejunal segment, was perfused with an isosmotic solution, and intestinal effluents were collected under basal conditions, for 15 min during cold pain stress and for a 45-min recovery period. Epithelial function (net water flux and albumin output), changes in stress hormones, and cardiovascular and psychologic responses to cold stress were measured.

KEY RESULTS

Heart rate and blood pressure significantly increased during cold pain stress with no differences between men and women. Adrenocorticotropic hormone and cortisol levels during cold pain stress were significantly higher in men. Basal net water flux and epithelial permeability were similar in men and women. Cold pain stress increased water flux in both groups (72 ± 23 and 107 ± 18 μL min(-1) cm(-1) , respectively; F(5, 90) = 5.5; P = 0.003 for Time) and, interestingly, this was associated with a marked increase of albumin permeability in women but not in men (0.8 ± 0.2 vs.-0.7 ± 0.2 mg/15 min; P < 0.0001).

CONCLUSIONS & INFERENCES

Intestinal macromolecular permeability in response to acute experimental stress is increased in healthy women, a mechanism that may contribute to female oversusceptibility to IBS.

Functional gut disorders or disordered gut function? Small bowel dysmotility evidenced by an original technique

BACKGROUND

This study aimed to determine the proportion of cases with abnormal intestinal motility among patients with functional bowel disorders. To this end, we applied an original method, previously developed in our laboratory, for analysis of endoluminal images obtained by capsule endoscopy. This novel technology is based on computer vision and machine learning techniques.

METHODS

The endoscopic capsule (Pillcam SB1; Given Imaging, Yokneam, Israel) was administered to 80 patients with functional bowel disorders and 70 healthy subjects. Endoluminal image analysis was performed with a computer vision program developed for the evaluation of contractile events (luminal occlusions and radial wrinkles), non-contractile patterns (open tunnel and smooth wall patterns), type of content (secretions, chyme) and motion of wall and contents. Normality range and discrimination of abnormal cases were established by a machine learning technique. Specifically, an iterative classifier (one-class support vector machine) was applied in a random population of 50 healthy subjects as a training set and the remaining subjects (20 healthy subjects and 80 patients) as a test set.

KEY RESULTS

The classifier identified as abnormal 29% of patients with functional diseases of the bowel (23 of 80), and as normal 97% of healthy subjects (68 of 70) (P < 0.05 by chi-squared test). Patients identified as abnormal clustered in two groups, which exhibited either a hyper- or a hypodynamic motility pattern. The motor behavior was unrelated to clinical features.

CONCLUSIONS & INFERENCES

With appropriate methodology, abnormal intestinal motility can be demonstrated in a significant proportion of patients with functional bowel disorders, implying a pathologic disturbance of gut physiology.

International validation of a health-related quality of life questionnaire in patients with erosive gastro-oesophageal reflux disease

BACKGROUND

Although erosive gastro-oesophageal reflux disease (GERD) is a highly prevalent condition, there is no specific, valid, reliable and sensitive questionnaire that allows evaluating treatment-induced changes in health-related quality of life (HRQoL).

AIM

To design a self-administered questionnaire, the GERD Analyzer (GERDyzer), for use in clinical studies.

METHODS

The GERDyzer comprises 10 dimensions each illustrated by pictogram-like drawings, simplifying communication with the patients. Self-assessment is performed by 100 mm Visual Analogue Scales. For validation, a 5-week clinical trial involving 395 patients (per-protocol) with oesophagitis was conducted. Patients were treated with pantoprazole (40 mg o.d.) for 28 days. Psychometric analyses included internal consistency, test-retest reliability, responsiveness and construct validity.

RESULTS

Factor analysis showed consistency of the dimensions and no reduction was necessary. Validation of GERDyzer indicated high internal consistency (Cronbach's alpha = 0.95) and test-retest reliability (intraclass correlation coefficient =0.91). Responsiveness of the total score expressed by nonparametric effect size was 1.38. Comparison of scores with other questionnaires resulted in logical correlation levels depending on the respected concepts measured. Conclusions GERDyzer proved to be highly valid, reproducible and responsive. It allows reliably assessing treatment-induced changes in HRQoL in erosive GERD.

[Spanish translation, adaptation, and validation of the 32-item questionnaire on quality of life for inflammatory bowel disease(IBDQ-32)]

INTRODUCTION

The measurement of health-related quality of life (HRQoL) has an established relevance in the assessment, management, and follow-up of inflammatory bowel disease. The most commonly used measuring instrument is the 32-item version of Inflammatory Bowel Disease Questionnaire (IBDQ-32), which has never been adapted to Spanish.

OBJECTIVE

To translate IBDQ-32 into Spanish, and to establish its validity, reliability, and sensitivity both in ulcerative colitis and Crohn s disease.

METHOD

A prospective study in two phases -translation into Spanish and subsequent validation of IBDQ-32. Translation was based on the validated Spanish version of IBDQ-36, and IBDQ-32 items not included in IBDQ-36 were translated from scratch. Once the IBDQ32 translation was completed a comprehension-specific questionnaire was administered. To establish IBDQ-32 psychometric properties a group of patients completed both the validated Spanish version of IBDQ-36 and IBDQ-32.

RESULTS

Eighty-four patients (53 with Crohn s disease and 31 with ulcerative colitis) were included. Median overall scores in both questionnaires for all 84 patients did not differ (6.1 vs. 6.2, p = ns), and Spearman s correlation was highly significant (r = 0.97, p < 0.001). The ability to discriminate between patients in flare-up or remission was also equivalent for both questionnaires (6.4 vs. 6.4 with r = 0.96 in remission and 3.8 vs. 3.9 with r = 0.95 active, p < 0.001 for remission vs. activity). These results were obtained in both the analyses for CD and UC independently (6.4 vs. 6.4 and 6.7 vs. 6.6, respectively; p = ns).

CONCLUSION

The Spanish version of IBDQ-32 is valid and discriminating for patients with Crohn s disease or ulcerative colitis.

[Inflammatory bowel disease in celiac patients]

INTRODUCTION

A potential association between celic disease and inflammatory bowel disease hs been suggested, which may explain the fact that both disorders occasionally present in one patient or in his/her first-degree relatives more frequently than expected.

OBJECTIVE

To establish the prevalence of Crohn s disease and ulcerative colitis in celiac patients and their relatives.

METHOD

A cross-sectional, prospective epidemiological study in a group of celiac patients, their first-degree relatives, and a control group with similar epidemiological characteristics including the relatives of patients presenting at the ER for acute conditions. A semistructured interview was used to identify the presence of Crohn s disease and ulcerative colitis in celiac patients and their relatives.

RESULTS

In all, 86 celiac patients and 432 relatives were included, who were compared to 809 control subjects (129 patients with acute conditions and 680 first-degree relatives). Three cases of Crohn s disease were identified among celiac patients, and 4 cases among their relatives. Only 1 case of Crohn s disease was detected in the control group (p < 0.01). No cases of ulcerative colitis were detected in any of the study groups.

CONCLUSION

Patients with celiac disease and their relatives have a greater predisposition to Crohn s disease versus the control population.

Factors that impact health-related quality of life in adults with celiac disease: A multicenter study

AIM: To evaluate the factors involved in the impairment of health-related quality of life (HRQOL) in patients with celiac disease.

METHODS: A multicenter, cross-sectional prospective study was performed in patients with celiac disease who completed two HRQOL questionnaires: the gastrointestinal quality of life index (GIQLI) and the EuroQol-5D (EQ).

RESULTS: Three hundred and forty patients (163 controlled with a gluten-free diet, and 177 newly diagnosed with a normal diet) were included. The GIQLI score was significantly better in patients on a gluten-free diet (GFD) than in non-treated patients on their usual diet, both in terms of the overall score (3.3 vs 2.7, respectively; P < 0.001), as well as on the individual questionnaire dimensions. Both the preference value of the EQ as the visual analogue scale were significantly better in treated than in non-treated patients (0.93 vs 0.72, P < 0.001 and 80 vs 70, P < 0.001, respectively). Variables significantly associated with a worse HRQOL score were female gender, failure to adhere to a GFD, and symptomatic status.

CONCLUSION: In untreated celiac disease, the most important factors that influence patient perception of health are the presence of symptoms and a normal diet. HRQOL improves to levels similar to those described in the general population in celiac disease patients well controlled with a GFD.

Pancreas transcription factor 1alpha expression is regulated in pancreatitis

BACKGROUND

Expression of acinar cell-specific genes requires the pancreas transcription factor 1alpha (Ptf1alpha). p48 is the only component of Ptf1alpha that is involved in both acinar gene regulation and pancreatic ontogenesis.

MATERIALS AND METHODS

To determine whether Ptf1alpha/p48 expression is regulated during pancreatitis, acute pancreatitis was induced in rats by repeated caerulein injections; early chronic pancreatitis by the combined administration of caerulein and cyclosporin A; and focal pancreas fibrosis by trinitrobenzene sulfonic acid infusion into the pancreatic duct. AR42J cells were used to examine caerulein effects on acinar cells. Ptf1alpha/p48 expression was examined using immunohistochemistry, Western blotting, and qRT-PCR methods.

RESULTS

In acute pancreatitis, Ptf1alpha/p48 decreased markedly within 6 h as determined by Western blotting and immunohistochemistry. After 24 h, Ptf1alpha/p48 increased continuously and normalized at day six. In contrast, pancreas amylase reached a nadir at 48 h, when Ptf1alpha/p48 had largely recovered. In the early chronic pancreatitis model Ptf1alpha/p48 levels did not completely recover even at day 14, and this was associated with a failure to restore normal histology and amylase content. qRT-PCR showed that p48 mRNA were reduced after pancreatitis induction and were followed by a decrease in elastase mRNA. In the focal pancreas fibrosis model, Ptf1alpha/p48 expression was undetectable in areas with substantial acinar cell loss and tubular complexes. Caerulein did not affect Ptf1alpha/p48 expression in AR42J cells.

CONCLUSIONS

Ptf1alpha/p48 protein and mRNA levels are regulated in acute and chronic experimental pancreatitis. Inability to re-express Ptf1alpha/p48 after injury may preclude acinar cell differentiation and appropriate pancreatic regeneration.

Long-term efficacy of octreotide in the prevention of recurrent bleeding from gastrointestinal angiodysplasia

OBJECTIVES

Preliminary studies suggested that octreotide may be therapeutic in bleeding angiodysplasia. Our aim was to investigate the efficacy of long-term octreotide therapy in the prevention of rebleeding from gastrointestinal angiodysplasia.

METHODS

A cohort of 32 patients diagnosed with bleeding from angiodysplasia was treated with octreotide 50 mu 12 h subcutaneously for a 1-2 yr period. This cohort was compared with an external control group (38 patients who had received placebo [1 tablet/day] in a concurrent randomized clinical trial for the same period.

RESULTS

Two patients of the octreotide group were lost to follow-up. Treatment failure occurred in seven of 30 (23%) patients in the octreotide group and in 17 of 35 (48%) in the placebo group (three dropouts before first visit) (P= 0.043). The actuarial probability of remaining free of rebleeding at 1 and 2 yr of follow-up was 77% and 68%, respectively, for the octreotide group and 55% and 36%, respectively, for the placebo group (log rank P= 0.030). Multivariate proportional hazards-regression analysis showed that octreotide therapy and previous bleeding episodes were positive and negative predictors of efficacy, respectively. No significant differences between the groups were observed according to number of bleeding episodes (0.4 +/- 0.7 vs 0.9 +/- 1.5, P= 0.070) and transfusion requirements (1.1 +/- 2.6 vs 0.7 +/- 1.5 units); however, iron requirements were lower in the octreotide than in the placebo group (22 +/- 62 vs 166 +/- 267 units; P < 0.001). Likewise, major adverse events (1 vs 1) and mortality (0 vs 1) were similar between groups.

CONCLUSIONS

This study suggests that octreotide treatment may be beneficial in preventing rebleeding from gastrointestinal angiodysplasia.

Current epidemiology and accessibility to diet compliance in adult celiac disease

BACKGROUND

The widespread of serologic diagnosis for celiac disease has brought about an epidemiologic shift. Little up-to-date information is available on relevant epidemiologic issues regarding diagnosis, information, and therapy.

OBJECTIVE

To examine forms of presentation, diagnostic difficulties, follow-up, information sources, and treatment-related issues regarding celiac disease.

METHOD

A cross-sectional observational study using a self-completed questionnaire.

RESULTS

Seventy-three adult patients were included; 15.0% of cases were diagnosed over 60 years of age. Most were non-smokers (91.8%). The rate of first-degree relatives with celiac sprue was 10.9%. The disease had a classic presentation in only 54.7% of cases. A functional gastrointestinal disorder was initially suspected in 42.4% of patients. Diet adherence is adequate, with unintentional lack of compliance in 15.5% of patients. Diet results in absent or improved symptoms in virtually all patients, but most of them consider compliance a challenge. Forty percent had difficulty finding gluten-free food, and 50.8% had problems in labelling recognition.

CONCLUSIONS

Celiac disease presents at any age, has a great variety of manifestations, and responds very well to gluten-free diet. It is crucial that patients be highly motivated and informed, and that they know for certain which foods and manufactured products are to be to used. Therefore, adequate control will result from coordination and cooperation regarding all resources involved, including medical care, and information provided by associations and other sources such as the Web.

Review article: from gastrin to gastro-oesophageal reflux disease--a century of acid suppression

To commemorate Edkins' discovery of gastrin in 1905, we review a century of progress in the physiology and pathobiology of gastrin and acid secretion especially as it pertains to clinical aspects of gastro-oesophageal reflux disease. Although initially ignored, Edkins' observations eventually led to the enthusiastic investigation of gastrin and acid regulation in peptic ulcer disease, culminating in important therapeutic advances in the management of acid peptic disease. Following the improved understanding of gastric secretory physiology, and the development of acid suppressants with increasing efficacy, the use of surgical intervention for peptic ulcer disease was almost eliminated. Surgery became obsolete with the discovery of Helicobacter pylori. Three other advances are also influencing modern practice: the gastrotoxicity of aspirin and non-steroidal anti-inflammatory drugs is now increasingly appreciated, the role of endoscopy in the diagnosis and therapy of upper gastrointestinal bleeding, and the use of intravenous acid-suppressive agents. The major issue for the future resides within the epidemic of gastro-oesophageal reflux disease. How to diagnose, categorize and treat this condition and how to identify and prevent neoplasia, are the challenges of the new century.

Perceived health status in celiac disease

INTRODUCTION

Chronic conditions modify perceived health in affected individuals. For this reason celiac disease, being a chronic condition, may impair health-related quality of life (HRQOL).

OBJECTIVE

To analyze the impact of celiac disease in affected individuals.

METHOD

Observational, cross-sectional, prospective study in patients with celiac disease by administering two HRQOL questionnaires: EuroQol-5D and GastroIntestinal Quality of Life (GIQLI).

RESULTS

54 stable patients on a gluten-free diet for a median 60 months, and 9 newly diagnosed individuals still on their usual diet were included. Overall GIQLI score was significantly higher, meaning a better HRQOL, in treated celiac patients versus pre-treated celiac patients (3.1 [2.7-3.5] vs. 2.4 [2.1-2.6], p < 0.01). Similarly, EuroQol s health status preference value was also significantly better in treated patients (0.87[0.8-1.0] vs. 0.7 [0.5-0.8], p < 0.01). EuroQol s visual analogic scale had also better scores, representing a better perceived health, among treated patients (80.0 [70.0-90.0] vs. 65.0 [40.0-71.0], p < 0.05). In comparison to EuroQol-5D scores among the healthy Spanish population, values obtained for celiac patients under treatment are similar to those seen in the general population.

CONCLUSIONS

celiac disease impairs perceived health in affected individuals, which improves and reaches results similar to those in the general population when on a gluten-free diet.

Increased plasma fibrinolytic activity in bleeding gastrointestinal angiodysplasia

OBJECTIVE

Gastrointestinal angiodysplasia is a major cause of recurrent bleeding. Haemostatic abnormalities have been implicated in the haemorrhage from these common vascular lesions but their precise contribution remains to be established. Our aim was to investigate whether bleeding angiodysplasia is associated with any specific coagulation disorder.

METHODS

Clinical features and blood samples were prospectively obtained from 21 patients with bleeding gastrointestinal angiodysplasia 3 months after the last episode of haemorrhage. Plasma levels of von Willebrand factor, D-dimer, plasminogen activator inhibitor type 1 (PAI-1), tissue-plasminogen activator activity, tissue factor pathway inhibitor and activated factor VII (FVIIa-rTF) were measured. A group of 14 patients with bleeding duodenal ulcer were similarly studied as controls.

RESULTS

Mean plasma von Willebrand factor levels were higher in angiodysplasia patients (208+/-12%) than in controls (143+/-11%) (P<0.05). D-dimer levels (661+/-80 ng/ml) and tissue-plasminogen activator activity levels (2.04+/-0.14 IU/ml) were also higher than in controls: 395+/-99 ng/ml and 1.6+/-0.1 IU/ml, respectively (P<0.05), whereas levels of PAI-1, FVIIa-rTF and tissue factor pathway inhibitor were similar in both groups. However, PAI-1 levels (31.5+/-11 ng/ml) were lower in high-bleeding-rate angiodysplasia (more than two bleeding episodes/year) than in low-bleeding-rate angiodysplasia (< or = 2 bleeding episodes/year) (PAI-1 47+/-14 ng/ml) (P<0.05). In a multivariate regression analysis, the plasma level of PAI-1 was a predictor of haemorrhage from angiodysplasia (P<0.05).

CONCLUSIONS

Increased plasma fibrinolytic activity may contribute to bleeding from angiodysplasia. Low plasma PAI-1 levels constitute a risk factor for bleeding tendency in patients with angiodysplasia.

Hydrogen breath test with low-dose rice flour for assessment of exocrine pancreatic insufficiency

OBJECTIVES

The hydrogen (H2) breath test is widely used in the assessment of carbohydrate malabsorption. Severe exocrine pancreatic insufficiency markedly diminishes pancreatic amylase production and results in malabsorption of complex carbohydrates. Thus, the H2 breath test with low-dose rice flour starch was tested to determine its value in detecting exocrine pancreatic insufficiency by comparison with a direct measurement of pancreatic function.

METHODS

Ten patients with clinically suspected pancreatic insufficiency confirmed with a duodenal perfusion technique and measurement of trypsin and lipase output after cerulein stimulation were included. An H2-rice flour breath test was performed by orally administering 30 g of rice flour. End-alveolar breath samples were obtained before rice load and at 30-minute intervals thereafter for the next 5 hours.

RESULTS

The results are expressed as median (percentile 25-75). Patients included 8 men and 2 women with moderate to severe exocrine pancreatic insufficiency due to chronic pancreatitis, pancreatectomy, or cystic fibrosis. Stimulated duodenal output of lipase and trypsin was abnormally low in all patients (median release, 1.7; range, 0.5-4.5 and 0.8, range, 0.1-11.3 KU/h, respectively). Basal H2 excretion was 9 ppm (range, 7-17) and delta increase over basal H2 excretion was 4 ppm (range, 1-6). Correlation between H2-rice breath test and basal or stimulated duodenal output of lipase and trypsin was not significant.

CONCLUSION

In exocrine pancreatic insufficiency, an oral load of 30 g rice flour slightly raises H2 excretion in breath. This increase is not useful for detecting pancreatic insufficiency due to poor sensitivity and because it is influenced by extrapancreatic factors such as small bowel bacterial overgrowth.

Usefulness of jejunal biopsy in the study of intestinal malabsorption in the elderly

BACKGROUND

small bowel structure and function are not different between elderly people and young people. Thus, in principle it is advisable to perform diagnostic investigation of elderly patients as well as younger patients when they present with symptoms suggestive of intestinal malabsorption. A key test for the etiologic diagnosis of intestinal malabsorption, jejunal biopsy, has not been specifically examined to assess its usefulness and risk of complications in this advanced age patients.

AIM

to establish the usefulness of jejunal biopsy with the Watson's capsule in the elderly patients with suspected intestinal malabsorption.

PATIENTS

patients older than 65 years referred to our Unit for performance of a jejunal biopsy from 1996 to 2001 for suspicion of intestinal malabsorption.

RESULTS

forty-seven patients were included. Appropriate biopsy sample was obtained in 45 cases, although in 3 patients a second try was required. Histologic findings: partial villous atrophy in 10 cases (22.2%), complete villous atrophy in 5 cases (11.1%), intraepithelial lymphocytosis in 5 cases (11.1%), and single cases of intestinal lymphangiectasia, amyloidosis, unspecific jejunitis, and Whipple's disease. Histology was normal in 19 cases (42%). Definitive diagnosis was celiac disease in 14 patients, bacterial overgrowth in 3, jejunitis in 3, Whipple's disease in 1, lymphangiectasia in 1, atrophic gastritis in 3, amyloidosis in 1, and ischemic colitis in 1. Jejunal biopsy achieved an etiologic diagnosis in 20 patients. There were no cases of perforations or bleeding.

CONCLUSION

jejunal biopsy is a useful and safe test for the etiologic diagnosis of intestinal malabsorption in elderly patients.

Fecal excretion of human deoxyribonucleic acid as an index of inflammatory activity in ulcerative colitis

BACKGROUND & AIMS

Several indices evaluate disease activity in ulcerative colitis, but most have drawbacks to their application (invasiveness, complexity, or lack of specificity), and discrepancies between them are frequent. Assuming that desquamation of epithelial and inflammatory cells increases in damaged colonic mucosa, we hypothesized that fecal excretion of human DNA is an index of mucosal inflammation and damage. The aim of our study was to determine whether excretion of human DNA is useful in the evaluation of disease activity in ulcerative colitis.

METHODS

Thirty-one controls and 36 ulcerative colitis patients were included. Ulcerative colitis patients and controls underwent colonoscopic examination after preparation by gut lavage with polyethylene-glycol electrolyte solution. In patients, disease activity was established using the clinical index of Rachmilewitz and an endoscopic score. Feces and gut lavage fluid were obtained and DNA levels were measured by quantitative polymerase chain reaction of the human beta-globin gene.

RESULTS

Fecal DNA excretion correlated with the clinical index (r = 0.59, P < 0.05) and the endoscopic score (r = 0.76, P < 0.01). Gut lavage fluid DNA levels also correlated with clinical and endoscopic activity scores (r = 0.41 and 0.51, respectively, P < 0.05). Fecal DNA excretion was significantly higher in patients with endoscopically or clinically active disease than in controls or patients in remission. Fecal DNA excretion discriminates between endoscopically active disease and remission (sensitivity 0.67, specificity 1.00, P < 0.01).

CONCLUSIONS

Excretion of human DNA in feces, as an expression of cellular desquamation, is a novel noninvasive technique to objectively assess disease activity in ulcerative colitis.

The opinion of patients with inflammatory bowel disease on healthcare received

BACKGROUND

an item to consider in analyzing a healthcare model for a population group suffering from chronic disease is necessary health-care resources, their use, and their rating by end-users. Regarding inflammatory bowel disease (IBD), healthcare resources used by patients are numerous and varied, and yet they have been never assessed.

DESIGN

an anonymous self-rated questionnaire has been developed with 24 basic questions on overall disease, who is monitoring the patient, how are visits scheduled, need for urgent care, patient view on how control may be improved, etc. This questionnaire was sent to 393 patients who were asked to fill it out and then return it by mail.

RESULTS

two hundred and thirty-seven patients returned a filled-out questionnaire. Most patients were followed up in a hospital, and only 8.8% were being monitored by a general practitioner or area specialist. Ninety-two percent of patients reported visits were routinely scheduled irrespective of clinical status, and 79.6% of patients reported having occasionally presented to an emergency department, because of not knowing what to do or due to having no other resources available in 25.2% of times. This entails that 38% of visits to an emergency unit may be prevented with a better understanding of disease or by means of a phone call. Thirty percent of patients reported that current healthcare is inadequate in terms of contents, form, or waiting time. In all, 97.8% of patients feel that information and knowledge on their disease would help in its control, and 69.6% consider that adequate information would allow them to initiate a proper treatment before visiting their doctor. Family care is another poorly looked-after aspect that 74.6% of subjects believe would be of help in controlling their disease.

CONCLUSIONS

overall, the opinion of patients with IBD on healthcare received is good; however, a number of deficiencies were detected, as is the case with insufficient information, care of family members, and healthcare resources accessibility/agility.

Ileal brake failure in streptozotocin-induced diabetic rat

BACKGROUND

Diabetes mellitus frequently alters gastrointestinal function, but the pathophysiology of the diabetic gut has not been fully elucidated. Our aim was to characterize the enterogastric modulation of gastric emptying in an experimental model of diabetic rat and to determine the putative consequences of impaired regulation on glycaemic control.

METHODS

Studies were performed in streptozotozin-induced diabetic and control groups of male Sprague-Dawley rats. In rats fitted with chronic ileal cannulae, gastric emptying of a peptide meal was measured during ileal infusion of either lipids (ileal brake) or saline. The influence of the ileal brake mechanism on blood glucose levels after oral administration of a glucose solution was also evaluated.

RESULTS

Diabetic rats exhibited a precipitous gastric emptying (80% +/- 3% versus 57% +/- 3% in controls; P < 0.05). Ileal lipids delayed gastric emptying in control (38 +/- 4%; P < 0.05 versus ileal saline) but not in diabetic animals (77 +/- 5%; N.S. versus ileal saline). As the ileal brake contributes to the management of postprandial blood glucose levels (114 +/- 4.9 mg/dL after ileal lipids versus 134 +/- 7.8 mg/dL after ileal saline in control rats; P < 0.05), the failure of this mechanism in diabetic rats worsens glycaemic control after feeding (455 +/- 20.4 mg/dL after ileal lipids versus 399 +/- 8.7 mg/dL after ileal saline; P < 0.05).

CONCLUSION

Experimental diabetes impairs the ileal brake mechanism and disturbs gastric emptying. These abnormalities may contribute to difficult glycaemic control.

Assessment of the influence of disease activity on the quality of life of patients with inflammatory bowel disease using a short questionnaire

OBJECTIVES

Inflammatory bowel disease impairs health-related quality of life. Therefore, it is very important to develop adequate instruments to measure the disease impact, but these instruments need to be practical as well as accurate. Our aim was to determine whether a short questionnaire obtained from the reduction of the 36-item version of the inflammatory bowel disease questionnaire (IBDQ-36) accurately reflects the impact of clinical and endoscopic activity on health-related quality of life.

METHODS

To this purpose the original IBDQ-36 and a reduced version, composed of only 9 items (IBDQ-9), were administered to 68 patients with inflammatory bowel disease. Disease activity was established by standard clinical activity indices (Rachmilewitz for ulcerative colitis (UC) and Harvey-Bradshaw for Crohn's disease (CD)) and by information gathered at colonoscopy.

RESULTS

In UC patients the Spearman's correlation coefficients between IBDQ-9 and clinical and colonoscopic indices were statistically significant (-0.67 and -0.70, respectively, p < 0.01) and similar to those obtained with IBDQ-36 (-0.61 and -0.67). In CD patients IBDQ-9 also correlated well with the clinical index (-0.59, p < 0.05) but less with the colonoscopic index (-0.30, p= 0.1). In CD patients, the correlation of the IBDQ-36 with clinical and colonoscopic indices gave similar results to the IBDQ-9 (-0.58 and -0.21, respectively). The IBDQ-9 power to discriminate between clinical relapse and remission was statistically significant (p < 0.01) both for UC (55 (48-57) vs 69 (63-75) and CD (58 (51-63) vs 69 (64-83)) patients. Similar results were obtained for conoloscopic indices of endoscopic relapse and remission (56 (52-65) vs 70 (66-77) in UC and 58 (52-63) vs 68 (62-73) in CD).

CONCLUSIONS

Quality of life impairment produced by relapses of inflammatory bowel disease can be reliably assessed with a short questionnaire, with considerable savings in time and expense.

Review article: supra-oesophageal manifestations of gastro-oesophageal reflux disease

Supra-oesophageal manifestations of gastro-oesophageal reflux disease (GERD) are common and often under-appreciated, in part due to the absence of classic symptoms of heartburn and regurgitation. Patients with supra-oesophageal manifestations of GERD may report symptoms involving the pulmonary, otolaryngologic or pharyngeal systems. Endoscopy is often negative and therefore of limited diagnostic value in these patients, and while laryngoscopy and 24 h dual-channel intra-oesophageal pH-metry may have greater yields they are costly, invasive and time-consuming. Therefore, a trial of proton pump inhibitor therapy is now widely considered a first-line diagnostic test in those with suspected GERD-induced supra-oesophageal symptoms. The dose as well as duration of the proton pump inhibitor trial is dependent upon a patient's presenting symptoms. For example, GERD-related non-cardiac chest pain may be relieved with a short-term (e.g. 1 week) treatment with standard doses of a proton pump inhibitor. The use of high-dose twice daily proton pump inhibitor therapy for an extended period (e.g. 2-3 months) may be required before any discernible improvement in pulmonary symptoms or pharyngo-laryngitis is noted. Patients who do not experience symptom improvement following a proton pump inhibitor trial may require further diagnostic evaluations including 24 h oesophageal pH studies, while on acid anti-secretory therapy, to establish the absence of persistent acid reflux. The role of anti-reflux surgical or endoscopic interventions in those with supra-oesophageal manifestations of GERD remains to be established.

Outcome of patients with ischemic colitis: review of fifty-three cases

PURPOSE

Ischemic colitis is a disease of elderly patients and includes a wide clinical spectrum ranging from mild to severe forms. Some patients may develop complications. Management of this disorder depends on disease severity. Our aim was to review the clinical characteristics of patients diagnosed of ischemic colitis and analyze predictive factors of poor prognosis.

METHODS

This study is a retrospective analysis of 53 cases of ischemic colitis (33 men, 20 women), 35 with moderate and 18 with severe forms, respectively. Clinical characteristics, diagnostic procedures, segment of colon involved and long-term evolution after discharge were analyzed.

RESULTS

Hypertension (51 percent) was the main risk factor associated with ischemic colitis. Clinical presentation did not differ between groups, except for peritonitis which was present only in the severe group. Colonoscopy and histologic studies were the most used diagnostic procedures (90 percent). Peripheral vasculopathy (P < 0.01) and right colonic involvement (P < 0.001) were risk factors for severe outcome. Five patients died during admission. Among these, the right colon was affected in four (80 percent). No patient in either group developed chronic ischemic colitis during follow-up.

CONCLUSION

Ischemic colitis usually runs a benign course after acute colonic insult. Peripheral vasculopathy and right colonic involvement are associated with severe forms of ischemic colitis.

Clinical trial guidelines for pharmacological treatment of irritable bowel syndrome

Appropriate guidelines for clinical trials in irritable bowel syndrome are needed because of the inadequacy of previously performed trials, the use of new and more adequate patient definition, new emerging pathophysiological models and the unique requirements related to the assessment of treatment outcome that, in the absence of a biological marker, can rely only on the evaluation of clinical manifestations. This consensus report highlights the following points. (a) A 4-week period is considered to be adequate to assess drug efficacy for the control of symptoms. (b) For the cyclic and non-life-threatening nature of the disease, a long-term study of 4-6 months or more of active treatment to establish efficacy is considered to be inappropriate in the large majority of patients. (c) In the initial assessment phase of drug efficacy, the withdrawal effect of treatment can be ascertained during a follow-up period prolonged for a sufficient time (4-8 weeks) after stopping treatment. Subsequent trials with proper withdrawal phase design and duration can then ascertain the drug post-treatment benefit. (d) Considering the intermittent clinical manifestations of irritable bowel syndrome, designing trials with on-demand or repeated cycles of treatment could be envisaged. However, the lack of a definition of what constitutes an exacerbation is a major obstacle to the design of such trials. In the absence of an established gold standard, appropriately justified novel trial designs are welcome. (e) Patients eligible for inclusion should comply with the Rome II diagnostic criteria for irritable bowel syndrome. (f) The main efficacy outcome of the treatment should be based on one primary end-point. (g) The primary efficacy end-point could combine, in a global assessment, the key symptoms (abdominal pain, abdominal discomfort, bowel alterations) of irritable bowel syndrome or rate any single symptom for drugs considered to target specific symptoms. (h) A 50% improvement in the primary efficacy end-point seems to be a reasonable definition of a responder.

Applicability of short hydrogen breath test for screening of lactose malabsorption

The gold standard for diagnosing lactose malabsorption is the H2 hydrogen breath test (HBT). Different methods of HBT have been proposed. However, in clinical practice the HBT is often shortened to 1-2 hr without proper validation. Our objective was to establish whether the usefulness of the HBT is influenced by shortening of the test and/or by substrate variations. In 62 patients with clinically suspected lactose intolerance and a positive lactose HBT we calculated the sensitivity of the HBT depending on the duration of the HBT. To determine whether substrate variations influence the sensitivity of the HBT, in another group of 32 patients with clinically suspected lactose intolerance and a positive milk HBT, the sensitivity of the HBT was also calculated depending on the duration of the test after milk ingestion. In other unselected 97 individuals, the result of the HBT with 360 ml of whole milk supplemented with lactose was compared with a symptomatic score for lactose intolerance to evaluate the specificity of the shortened milk HBT. Breath H2 excretion was significantly higher after lactose than after milk load (P < 0.01), and the increase in H2 appeared earlier with lactose than with milk (60 vs 90, min respectively). HBT duration influenced the sensitivity of the test that decreased from 95% for the 3-hr HBT to 37% for the 1-hr HBT with lactose and from 80% for 3-hr HBT to 21% for 1-hr HBT with milk. The specificity was similar for the 3-hr milk HBT and the 5-hr test (67 vs 62%). In conclusion, for screening of lactose malabsorption, the HBT can be shortened to 3 hr without loss of sensitivity and specificity, when a high dose of lactose load is used.

Increased mucosal tumour necrosis factor alpha production in Crohn's disease can be downregulated ex vivo by probiotic bacteria

BACKGROUND AND AIMS

Tumour necrosis factor alpha (TNF-alpha) plays a key role in the pathogenesis of intestinal inflammation in Crohn's disease. The effect of bacteria on TNF-alpha release by intestinal mucosa was investigated.

METHODS

Ileal specimens were obtained at surgery from 10 patients with Crohn's disease (ileal stricture) and five disease controls undergoing right hemicolectomy (caecal cancer). Mucosal explants from each specimen were cultured for 24 hours with either non-pathogenic Escherichia coli, Lactobacillus casei DN-114001, L bulgaricus LB10, or L crispatus (each study contained blank wells with no bacteria). Tissue and bacterial viability was confirmed by lactate dehydrogenase (LDH) release and culture. Concentrations of TNF-alpha were measured in supernatants and the phenotype of the intestinal lymphocytes was analysed by flow cytometry.

RESULTS

Coculture of mucosa with bacteria did not modify LDH release. Release of TNF-alpha by inflamed Crohn's disease mucosa was significantly reduced by coculture with L casei or L bulgaricus; changes induced by L crispatus or E coli were not significant. The effect of L casei and L bulgaricus was not prevented by protease inhibitors. Coculture with L casei and L bulgaricus reduced the number of CD4 cells as well as TNF-alpha expression among intraepithelial lymphocytes from Crohn's disease mucosa. None of the bacteria induced changes in non-inflamed mucosa.

CONCLUSIONS

Probiotics interact with immunocompetent cells using the mucosal interface and modulate locally the production of proinflammatory cytokines.

Digestive system involvement in cystic fibrosis

Cystic fibrosis is a hereditary disease well known to paediatricians. Over recent years, its prevalence among the adult population has dramatically increased; thus becoming a disease increasingly seen in adult practice. Cystic fibrosis is a multi-organ disease, with a wide spectrum of clinical manifestations involving many organs. The aim of this article is to review the digestive system manifestations of this disease: the involvement of the gastrointestinal tract, liver, biliary system and pancreas, with a special emphasis on the adult population.

Assessing the quality of life of household members of patients with inflammatory bowel disease: development and validation of a specific questionnaire

OBJECTIVE

Household members of patients with inflammatory bowel disease (IBD) are impacted in their daily lives by close interaction with chronic illness. However, the effect of IBD on the quality of life of household members has not been evaluated because appropriate instruments to measure it are lacking. The aim of this study was to develop and validate a specific instrument to measure the quality of life of household members of patients with IBD.

METHODS

Household members were interviewed to generate an initial pool of items. A group of investigators excluded redundant and incomprehensible items, and the resulting preliminary questionnaire was completed by 81 subjects. Further item reduction was performed using the psychometric method. The psychometric properties of the final questionnaire were determined in a group of 106 subjects.

RESULTS

Of the initial 67 items, 19 were excluded by investigators. The remaining 48 items were answered by 81 household members, and 32 items were excluded by factor analysis. Two others were excluded because of poor comprehension. The definitive questionnaire consisted of 14 items.

CONCLUSIONS

We have developed and validated a questionnaire to measure the quality of life of household members of IBD patients. It will greatly enhance the possibilities of quantifying the effects of IBD on home life and should become a useful tool in health care planning.

Achalasia treatment in the elderly: is botulinum toxin injection the best option?

BACKGROUND

Achalasia treatment in elderly patients is a matter of controversy. Botulinum toxin injection has been proposed as the best option in this group of patients as it is a safe procedure. However, concern persists regarding its short-term effect.

AIMS

To analyse the clinical and economic effectiveness of botulinum toxin injection in the treatment of achalasia patients who are elderly.

METHODS

Seventeen consecutive achalasia patients older than 65 years were treated with 80 units of botulinum toxin. Clinical follow-up at 1, 6 and 12 months was performed. Control manometry when symptoms recurred was carried out. Results were compared with those of an historical control group of 16 achalasia patients also older than 65 years and who had been treated with endoscopic dilation. The costs of both procedures were compared.

RESULTS

Twenty-nine botulinum toxin injections were performed in the 17 patients of the botulinum toxin group (follow-up, 12-36 months). In the dilation group only two patients had to be retreated (follow-up, 12-108 months). No major complications were observed in either group. The average duration of symptom alleviation was 48 +/- 33 months for endoscopic dilation and 13.8 +/- 9.5 months for botulinum toxin injection. Maintaining a patient free of symptoms cost E348.31 per year for botulinum toxin injection, whilst if endoscopic dilation was chosen the cost was only E117.47 per year.

CONCLUSIONS

The effect of botulinum toxin injections wanes with time in elderly patients, necessitating repeated injections to keep the patients symptom-free. Due to the required repeated injections this procedure is more expensive than endoscopic dilation.

Therapeutic effect of phenantroline in two rat models of inflammatory bowel disease

BACKGROUND

Phenantroline is a zinc-chelator that inhibits biological activities of matrix metalloproteinases (MMPs). Over-expression of MMPs can accelerate tissue destruction and disrupt subsequent tissue repair. The effects of phenantroline in two rat models of inflammatory bowel disease (IBD) are evaluated: transmural colitis induced by trinitrobenzensulphonic acid (TNBS) and distal colitis caused by dextran sulphate sodium (DSS).

METHODS

Transmural colitis was induced by TNBS in two groups of 15 rats each, and distal colitis was induced by DSS in two other groups of 15 rats each. Phenantroline was administered by oral gavage at 20 mg kg(-1) day(-1) to the test groups, whereas matched control groups received oral vehicle. On the last day of dosing, rats were subjected to intracolonic dialysis under anaesthesia for assessment of luminal eicosanoid release (PGE2, TXB2 and LTB4) and euthanized. Colons were removed and lesions were blindly scored according to macroscopic and histological scales. Myeloperoxidase (MPO) activity was measured in homogenates of colonic tissue.

RESULTS

In the TNBS model, phenantroline treatment significantly reduced colonic strictures; in the DSS model, phenantroline significantly decreased scores of epithelial injury. In both models, the levels of PGE2, TXB2 and LTB4 and tissue MPO were not significantly altered.

CONCLUSIONS

Although phenantroline did not modify the activity of inflammatory mediators, this compound substantially reduced intestinal injury associated with tissue remodelling.

A multicenter, randomized, clinical trial of hormonal therapy in the prevention of rebleeding from gastrointestinal angiodysplasia

BACKGROUND & AIMS

The efficacy of hormonal therapy for recurrent bleeding from gastrointestinal angiodysplasia remains uncertain. We investigated the efficacy of long-term estrogen-progestagen therapy in the prevention of rebleeding from gastrointestinal angiodysplasia.

METHODS

Seventy-two noncirrhotic patients bleeding from gastrointestinal angiodysplasia confirmed by endoscopy or angiography were randomized to receive in double-blind conditions treatment with ethinylestradiol (0.01 mg) plus norethisterone (2 mg) (1 tablet/d), or placebo (1 tablet/d) for a minimum period of 1 year (range: 1-2 years).

RESULTS

Four patients could not be assessed because they did not attend the first follow-up visit. Failure of treatment occurred in 13 of 33 (39%) patients in the treatment group and in 16 of 35 (46%) patients in the placebo group (P = NS). No significant differences between groups were found according to number of bleeding episodes (0.7 +/- 1.0 vs. 0.9 +/- 1.5) and transfusional requirements (0.9 +/- 1.9 vs. 0.7 +/- 1.5 units). Treatment received was not an independent predictor for rebleeding prevention in the multivariate regression analysis. Severe adverse events (2 vs. 1) and mortality (0 vs. 1 patient, respectively) were similar between the treatment and placebo groups.

CONCLUSIONS

Continuous estrogen-progestagen treatment is not useful in the prevention of rebleeding from gastrointestinal angiodysplasia.

Hydrogen breath test with D-xylose for celiac disease screening is as useful in the elderly as in other age groups

Up to one fifth of celiac disease patients are diagnosed after the age of 60. The hydrogen breath test with D-xylose as substrate (xylose-BT) has proved useful for the diagnosis of adult celiac disease. Our aim was to determine the potential influence of age-related intestinal mucosal changes on the reliability of this test. We reviewed the results of the xylose-BT in 50 patients with clinical celiac disease in whom the diagnosis was confirmed by histology. A control group of 53 patients with various diarrheal disorders and without jejunal mucosal atrophy at biopsy was similarly studied. Both celiac patients and controls were divided into adults (age < or = 60 years) and elderly (age >60 years). Seven of the 50 celiacs and 8 of the 53 controls were in the elderly category (P = NS). In the celiac disease group, no differences were observed between the elderly and adult patient subgroups for basal H2 excretion (22.4 +/- 42 vs 9.7 +/- 11 ppm), delta increase (56 +/- 43 vs 53 +/- 36 ppm), or area under the curve (7,452 +/- 5,546 vs 6,739 +/- 5,951 ppm x min). The false negative rate was similar for celiac adult (7/43) and elderly (2/7, P = ns) patients. Sensitivity of the xylose-BT was 0.83 in adults and 0.71 in the elderly, and specificity 0.51 in adults and 0.50 in the elderly. In conclusion, the results of the xylose-BT in celiac patients are not influenced by age. The xylose-BT is as valuable a tool for the screening of celiac disease in the elderly as it is in younger patients.

Mechanisms of intestinal gas retention in humans: impaired propulsion versus obstructed evacuation

To explore the clinical role of intestinal gas dynamics, we investigated two potential mechanisms of gas retention, defective propulsion and obstructed evacuation. In healthy subjects, a gas mixture was continuously infused into the jejunum (4 ml/min) 1) during a 2-h control period of spontaneous gas evacuation and 2) during a 2-h test period either with impaired gut propulsion caused by intravenous glucagon (n = 6) or with obstructed (self-restrained) anal evacuation (n = 10) while anal gas evacuation, symptom perception (0-6 scale), and abdominal girth were measured. Impaired gut propulsion and obstructed evacuation produced similar gas retention (558 +/- 68 ml and 407 +/- 85 ml, respectively, vs. 96 +/- 58 ml control; P < 0.05 for both) and abdominal distension (8 +/- 3 mm and 6 +/- 3 mm, respectively, vs. 1 +/- 1 mm control; P < 0.05 for both). However, obstructed evacuation increased symptom perception (2.3 +/- 0.6 score change; P < 0.05), whereas gas retention in the glucagon-induced hypotonic gut was virtually unperceived (-0.4 +/- 0.7 score change; not significant). In conclusion, the perception of intestinal gas accumulation depends on the mechanism of retention.

Pancreatitis and haemobilia due to arterioportal fistula after percutaneous liver biopsy resolved by selective arterial embolization

Haemobilia and arterioportal fistula are uncommon complications secondary to percutaneous liver biopsy. We report the case of a patient who developed haemobilia and subsequently acute pancreatitis as a result of a liver biopsy. Selective hepatic angiogram showed an arterioportal fistula. Transcatheter arterial embolization successfully occluded the fistula. The patient remained asymptomatic 4 months later. We review the published literature concerning acute pancreatitis associated with haemobilia and draw conclusions for management of similar cases in the future.

Review article: the continuing dilemma of dyspepsia

This article reviews the issue of dyspepsia from various perspectives. Firstly, the current relevance of dyspepsia as a major health problem on account of its high prevalence and substantial morbidity. Secondly, the various definitions of dyspepsia and the epidemiological and pathophysiological evidence that support them, as well as subclassifications. Thirdly, the issue of dyspepsia as a clinical challenge, in the absence of well established and uniform management guidelines. Thus, the title "The continuing dilemma of dyspepsia" describes realistically the current status of this important condition.

Guidelines for adults on self-medication for the treatment of acute diarrhoea

Acute uncomplicated diarrhoea is commonly treated by self-medication. Guidelines for treatment exist, but are inconsistent, sometimes contradictory, and often owe more to dogma than evidence. An ad hoc multidisciplinary group has reviewed the literature to determine best practice. In general it is recognized that treatment of acute episodes relieves discomfort and social dysfunction. There is no evidence that it prolongs the illness. Self-medication in otherwise healthy adults is safe. Oral loperamide is the treatment of choice. Older anti-diarrhoeal drugs are also effective in the relief of symptoms but carry the risk of unwanted adverse effects. Oral rehydration solutions do not relieve diarrhoea, and confer no added benefit for adults who can maintain their fluid intake. Probiotic agents are, at present, limited in efficacy and availability. Antimicrobial drugs, available without prescription in some countries, are not generally appropriate for self-medication, except for travellers on the basis of medical advice prior to departure. Medical intervention is recommended for the management of acute diarrhoea in the frail, the elderly (> 75 years), persons with concurrent chronic disease, and children. Medical intervention is also required when there is no abatement of the symptoms after 48 h, or when there is evidence of deterioration such as dehydration, abdominal distension, or the onset of dysentery (pyrexia > 38.5 degrees C and/or bloody stools).

Prospective evaluation of esophageal motor dysfunction in Down's syndrome

OBJECTIVE

The aim of this study was to determine the prevalence and way of presentation of esophageal motor dysfunction in a nonselected population of subjects with Down's syndrome.

METHODS

The study was conducted in 58 Down's syndrome patients and 38 healthy controls. A global symptom score and individual scores for dysphagia for liquids and solids, heartburn, vomiting/regurgitation, and chest pain were obtained. Esophageal function was evaluated initially by scintigraphy using liquid and semisolid bolus. Time-activity curves based on the mean condensed images were used to calculate residual activity at 100 s after swallowing. According to both scintigraphy and clinical evaluation results, participants underwent a radiological and manometric study.

RESULTS

The most frequent symptoms in Down's syndrome patients were: dysphagia for liquids (n = 9), dysphagia for solids (n = 10), vomiting/regurgitation (n = 8), and chest pain (n = 2). Liquid and semisolid retention of the tracer was significantly higher in Down's syndrome patients than in controls (p < 0.05). In 15 participants with Down's syndrome, tracer retention was higher than the 95 percentile of controls' retention. No correlation was found between the global or individual symptom score and esophageal retention quantified by scintigraphy. Hypothyroidism was unrelated to esophageal symptoms or retention. Five of the 15 esophagograms performed were abnormal, showing barium retention and/or esophageal dilation. Manometry showed achalasia in two subjects, total body aperistalsis in one, and nonspecific esophageal motor disorder in two.

CONCLUSION

Esophageal motor disorders, particularly achalasia, are frequent in individuals with Down's syndrome. Awareness of esophageal dysmotility in this population is important, even though symptoms are not evident, to avoid potential complications.

Influence of inflammatory bowel disease on different dimensions of quality of life

OBJECTIVE

To establish the impairment of different dimensions of quality of life in inflammatory bowel disease (IBD).

DESIGN

Prospective observational study.

PARTICIPANTS

289 patients [160 with ulcerative colitis (UC) and 129 with Crohn's disease (CD)].

MEASURES

Health-related quality of life was assessed by means of the Inflammatory Bowel Disease Questionnaire (IBDQ) and the Psychological General Well Being Index (PGWBI).

RESULTS

In active IBD, all dimensions of the quality of life scored significantly lower than in inactive IBD, indicating a poor quality of life. Social impairment was the least impaired dimension of the IBDQ in active UC and CD, compared with digestive and systemic symptoms. In inactive IBD, the systemic symptoms domain received the lowest score (P < 0.01). In a subgroup of 22 patients studied before and after remission, emotional function was the most impaired dimension after achieving remission. The Psychological General Well Being Index was significantly impaired in active UC [78.5 (range 64-89)] and CD [76.5 (range 69-97)] relative inactive IBD [104 (range 93-111)] vs 106 (95-113), respectively; P < 0.05].

CONCLUSIONS

Quality of life is impaired in IBD. During relapse, clinicians should pay attention to digestive symptoms and psychological distress. In remission, they should be sensitive to systemic symptoms.

Modification of small bowel mechanosensitivity by intestinal fat

BACKGROUND

Lipids may exacerbate symptoms induced by gut stimuli.

AIM

To determine the mechanism whereby fat exerts this effect.

SUBJECTS

Twenty four healthy subjects were studied during fasting.

METHODS

We measured perception (0-6 scale) in response to jejunal balloon distension and transmucosal electrical nerve stimulation; phasic stimuli (one minute) were randomly applied at five minute intervals during intestinal infusion (2 ml/min) of saline and then Intralipid 2 kcal/min (high fat; n=8 subjects), Intralipid 0.5 kcal/min (low fat; n=8), or saline (n=8).

RESULTS

Intestinal lipids increased the perception of jejunal distension regardless of concentration (by 53% with high fat, 49% with low fat, and 17% with saline; p<0.05 for both fat loads). This effect could not be attributed to changes in intestinal compliance as intraballoon pressures remained unchanged during lipid infusion (2% change; NS). Sensitisation induced by lipids seemed to be specifically related to intestinal mechanoreceptors because electrical stimulation, which non-specifically activates gut afferents, was perceived equally during saline and lipid administration (10%, 11%, and 15% change during high fat, low fat, and saline, respectively; NS).

CONCLUSION

Physiological amounts of lipids heighten intestinal sensitivity by modulating intestinal mechanoreceptor response.

Gastrointestinal, liver, and pancreatic involvement in adult patients with cystic fibrosis

BACKGROUND

The clinical prevalence of cystic fibrosis (CF) in adults continues to rise, with a consequent impact on adult gastroenterology practice.

AIM

To characterize the gastrointestinal manifestations of CF in adult patients.

PATIENTS AND METHODS

The clinical records of 89 adult CF patients treated at our institution from 1992 to 1999 were reviewed. Patients were distributed into two groups: group A (39 patients), which consisted of patients who were diagnosed with CF at when they were younger than 14 years old and who survived into adulthood; and group B (50 patients), who were diagnosed with CF at the age of 14 years or older. Data on CF genetic mutations, nutritional state, evidence of pulmonary, gastrointestinal, liver, or pancreatic involvement were collected for each patient.

RESULTS

The most prevalent genetic mutation in our series was deltaF508, present in 50 patients (56.2%), 29 of whom belonged to group A and 21 who belonged to group B. In group A, the deltaF508 mutation was associated with exocrine pancreatic insufficiency (PI) in 26 of 29 patients (89.6%), whereas in group B it was associated with PI in only four patients (19%). Overall, PI was present in 33 of 39 patients (84.6%) in group A and in eight of 50 patients (16%) in group B. Four patients in group B had experienced previous episodes of acute pancreatitis; two of them had associated PI. Of the 89 patients, 12 (10 in group A) were malnourished. Malnutrition was invariably associated with PI. Hepatic and biliary tree abnormalities were particularly prevalent in patients in group A and was usually associated with PI. Intestinal manifestations were uncommon.

CONCLUSIONS

Diagnosis of CF before the age of 14 years is associated with greater gastrointestinal compromise than diagnosis at an older age, particularly with regard to PI. CF carriers of the deltaF508 mutation have an increased risk of developing gastrointestinal manifestations.

Dietary inulin improves distal colitis induced by dextran sodium sulfate in the rat

OBJECTIVES

Inulin stimulates intracolonic generation of butyrate and growth of lactic acid bacteria. This study investigated whether inulin protects against colitis.

METHODS

Rats with dextran sodium sulfate colitis received inulin either orally (1% in drinking water, or 400 mg/day) or by enema. Matched groups received vehicle. In addition, fecal water obtained from inulin-fed rats was administered by enema to rats with colitis and compared with fecal water from control rats. Finally, rats with colitis received daily enemas of either butyrate (at 40 or 80 mmol/L) or vehicle. Inflammation was assessed by eicosanoid asssay in rectal dialysates and MPO activity in colonic tissue. Mucosal lesions were blindly scored by microscopic examination. Luminal pH was measured from cecum to rectum by a surface microelectrode.

RESULTS

Oral inulin prevented inflammation, as evidenced by lower lesion scores (p < 0.05), decreased release of mediators (p < 0.05), and lower tissue MPO (p < 0.05) as compared with controls. Inulin induced acidic environment (pH <7.0) from cecum to left colon and increased counts of lactobacilli. Fecal water from inulin-fed rats also reduced scores (p < 0.05) and inflammation (p < 0.05). However, inulin or butyrate enemas had no effect.

CONCLUSIONS

Oral inulin reduces the severity of dextran sodium sulfate colitis. The effect seems to be mediated by modification of the intracolonic milieu.

Epidermal growth factor increases surface hydrophobicity and resistance to acid in the rat duodenum

Epidermal growth factor (EGF) is produced in Brunner's glands and plays a role in healing and repair of duodenal ulcers. We examined the participation of zwitterionic phospholipids of mucus in the effects of EGF. Under anesthesia, groups of rats received an intraduodenal bolus of either saline or EGF. Some rats received subcutaneous indomethacin followed by EGF or EGF followed by a detergent (5% Brij 35, a nonionic detergent that solubilizes luminal phospholipids). Thirty minutes after treatment, mucosal surface hydrophobicity and phospholipid concentration in the mucus layer were measured. Matched groups of rats were challenged with 0.5 M HCl, instilled intraduodenally 30 min after treatment, and mucosal damage was assessed 1 h after acid challenge. Exogenous EGF significantly increased surface hydrophobicity and phosphatidylcholine concentration in the mucus layer. EGF treatment also reduced mucosal damage induced by acid. However, indomethacin pretreatment or detergent administration after EGF abolished both protection against acid and changes in the mucus layer. These data suggest that EGF increases duodenal resistance to luminal acid via stimulation of mucosal zwitterionic phospholipids.

Modulation of colonic barrier function by the composition of the commensal flora in the rat

BACKGROUND AND AIMS

Altered intestinal permeability is a key pathogenetic factor of idiopathic bowel inflammation. We investigated in the rat if changes in the composition of the bowel flora can alter colonic permeability.

METHODS

A colonic segment was surgically excluded from faecal transit and brought out as a loop to the abdominal wall through two colostomies. The loop was used for colonisation with specific bacterial strains after eradication of the native flora with antibiotics. Lumen to blood clearance of dextran (molecular weight 70 000) and mannitol (molecular weight 182) was measured in rats recolonised with a single bacterial strain from rat colonic origin, and in control rats whose colonic loop was kept free of bacteria by antibiotics. Actual colonisation was confirmed by culture of segment effluents.

RESULTS

Colonisation with Escherichia coli, Klebsiella pneumoniae, and Streptococcus viridans significantly increased lumen to blood clearance of mannitol. Colonisation with Lactobacillus brevis had the opposite effect and reduced permeability to mannitol. Bacteroides fragilis did not induce significant changes. Permeability to dextran was not altered by any of the strains tested.

CONCLUSIONS

Certain commensal bacteria can modify colonic wall permeability to luminal substances.