Effectiveness of a novel endoscopy training concept

BACKGROUND AND STUDY AIMS

Training standards in gastrointestinal endoscopy are poorly defined even though different simulators are increasingly used for skills training. In 2001 a new training concept called "GATE--gastroenterological education-training endoscopy" was established, which provides a combination of background theory, video demonstrations, and simulator training. We aimed to evaluate the acceptance and training effect of this training model.

METHODS

In total, 98 physicians participating in four training courses were included. Data were collected on baseline characteristics, acceptance (5-point Likert scale), and pre- and post-course knowledge through a structured questionnaire (A-type and Pick-N multiple choice questions). A total of 13 trainees were randomly selected for additional simulator assessment of training effects on manual skills (5-point Likert scale).

RESULTS

A total of 78 trainees (80%) provided complete data sets. The evaluation showed a positive acceptance of the training program (value 1 and 2, Likert scale); for example, 88% of participants suggested the inclusion of the GATE course as an obligatory part of endoscopic education. There was a significant improvement in theoretical knowledge in the post-test set compared with the pre-test set (mean 3.27 ±1.30 vs. 1.69 ±1.01 points; P<0.001). The training effect on practical skill showed a significant reduction in time needed for a procedure (445 ±189 s vs. 274 ±129 s; P<0.01). The mean assessment rating for practical skills improved from 3.05 ±0.65 at baseline to 2.52 ±0.59 on Likert scale ( P=0.085).

CONCLUSIONS

The integrated GATE training improved theoretical knowledge and manual skill. The GATE courses have been accredited by the German Society of Gastroenterology, underlining the demand for implementing preclinical training courses in endoscopic training.

Intrarenal resistance index for the assessment of early renal function impairment in patients with liver cirrhosis

BACKGROUND

Renovascular vasoconstriction in patients with hepatorenal syndrome can be quantified by the renal arterial resistance index (RI). We investigated the value of RI measurement in detection of renal function impairment in patients with different stages of chronic liver disease.

METHODS

Subjects were divided into 4 groups containing 21 patients with liver cirrhosis and ascites, 25 patients with liver cirrhosis without ascites, 35 patients with fatty liver disease and 78 control subjects. All patients underwent abdominal ultrasound examination with renal RI measurement and correlation with laboratory results for renal function.

RESULTS

RI was significantly higher in ascitic patients compared to non-ascitic patients (0.74 vs. 0.67, p<0.01) and in non-ascitic patients with liver cirrhosis than in control subjects (0.67 vs. 0.62, p<0.01). 48% (19/40) of patients with liver cirrhosis and normal serum creatinine concentration showed elevated RI levels. There were no significant differences in RI levels between patients with fatty liver disease and controls (0.63 vs. 0.62).

CONCLUSIONS

Intrarenal RI measurement is a predictor of renal vasoconstriction and serves to detect early renal function impairment in cirrhotic patients. The diagnosis of elevated RI may be taken into account in the clinical management of these patients.

Age dependency of intrarenal resistance index (RI) in healthy adults and patients with fatty liver disease

BACKGROUND

Our aim was to investigate the influence of age and gender on intrarenal resistance index (RI) measurements in 78 healthy subjects (46 males, 32 females; group 1) and 35 subjects (group 2) with fatty liver disease (28 males and 7 females).

SUBJECTS AND METHODS

First, each subject underwent a conventional abdominal ultrasound examination. Then, intrarenal RI values were determined from three distinct interlobar and cortical arteries respectively on both kidneys. The correlation of intrarenal RI with age and gender as a variable was statistically evaluated by linear regression.

RESULTS

In group 1, the variables gender, kidney region and comparison of right versus left kidney had no significant effect on intrarenal RI (p>0.05). The variable age, on the other hand, showed a significant positive correlation on all four defined measuring points (p<0.01) with linear correlation coefficients of r = 0.26 (left kidney, central) to r = 0.37 (right kidney, cortical). Therefore normal RI values at ages 25, 45, 65 years could be defined as 0.59, 0.61 and 0.63, respectively. Age dependency can thus be expressed as a function with the formula y = 0.565 + 0.001.x. Patients with fatty liver disease showed age dependency on renal RI (p<0.01) as well.

CONCLUSION

In accordance with other studies, the influence of age on intrarenal RI measurement is significant in healthy subjects. Intrarenal RI values from subjects with a fatty liver disease showed age dependency as well. Therefore it is necessary to consider the age of the examined person to interpret RI values correctly.

Peptide YY release in anorectic patients after liquid meal

Fasting and postprandial levels of human peptide YY (PYY) were recently found to be lower in obesity. To investigate whether PYY levels are correspondingly high in patients with anorexia nervosa, PYY concentrations were analyzed under basal conditions and in response to a liquid meal. We investigated PYY plasma levels in 16 female anorectic (BMI 15.2+/-0.3 kg/m2) and seven lean subjects (BMI 21.3+/-0.6 kg/m2) before and after ingestion of a liquid meal (250 kcal; 15% protein, 55% carbohydrates, and 30% fat). PYY levels were analyzed using PYY ELISA (DSL, USA). Values are given as mean+/-SEM. Basal PYY levels in anorectic patients (89.0+/-14.4 pg/mL) were not significantly different from lean subjects (64.1+/-12.1 pg/mL). Postprandial PYY levels in healthy volunteers increased significantly after 20 and 60 min (80.4+/-12.7 and 96.0+/-19.9 pg/mL, respectively). In anorectic women PYY was increased at 20 min (137.9+/-19.5 pg/mL) and at 60 min (151.3+/-19.2 pg/mL). No difference was found between both groups. We conclude that basal and postprandial PYY levels in normal weight women are not different from anorectic patients. We could not confirm the recently published blunted postprandial PYY response in anorexia, a finding that merits further study.

Carob pulp preparation rich in insoluble dietary fibre and polyphenols increases plasma glucose and serum insulin responses in combination with a glucose load in humans

Dietary fibre consumption is associated with improved glucose homeostasis. In contrast, dietary polyphenols have been suggested to exert both beneficial and detrimental effects on glucose and insulin metabolism. Recently, we reported that a polyphenol-rich insoluble dietary fibre preparation from carob pulp (carob fibre) resulted in lower postprandial acylated ghrelin levels after a liquid meal challenge test compared with a control meal without supplementation. The effects may, however, differ when a different food matrix is used. Thus, we investigated the effects of carob fibre on glucose, insulin and ghrelin responses in healthy humans in combination with a glucose load. In a randomized single-blind cross-over study involving twenty healthy subjects (aged 22-62 years), plasma glucose, total and acylated ghrelin, and serum insulin were repeatedly assessed before and after the ingestion of 200 ml water with 50 g glucose and 0, 5, 10 or 20 g carob fibre over a period of 180 min. The intake of 5 and 10 g carob fibre increased the plasma glucose by 47 % and 64 % (P < 0.001), and serum insulin by 19.9 and 24.8 % (P < 0.001), compared with the control. Plasma acylated ghrelin concentrations did not change significantly after the consumption of carob-enriched glucose solution. Total ghrelin decreased only after 10 g carob fibre (P < 0.001) compared with control. In conclusion, we showed that polyphenol-rich carob fibre, administered within a water-glucose solution, increases postprandial glucose and insulin responses, suggesting a deterioration in glycaemic control.

Blue-Rubber-bleb-Naevus-Syndrom und therapeutische Doppel-Ballon-Enteroskopie

This is the first report about the endoscopic removal of hemangiomas in the gastrointestinal tract using the double-balloon enteroscopic technique. We report on a 16-year-old female patient with a 10-year history of chronic anemia due to recurrent gastrointestinal bleeding. Besides permanent iron substitution, up to 3 blood transfusions per week are necessary. At birth a blue rubber-bleb nevus syndrome was diagnosed, with blue angiomatous lesions preferring her skin and digestive tract. In the 8 years before admittance numerous conventional endoscopic procedures and one intraoperative endoscopy with laser coagulation of many cavernous hemangiomas were performed. In our department the successful treatment of 150 hemangiomas with argon plasma coagulation or polypectomy in combination with double-balloon enteroscopy and conventional endoscopy was achieved without complications.

Regulation of ghrelin is related to estimated insulin sensitivity in obese children

OBJECTIVE

To investigate whether ghrelin concentrations and their changes during weight loss in obese children are associated with parameters of glucose and insulin metabolism.

DESIGN

Total plasma ghrelin, insulin and glucose were measured during oral glucose tolerance testing before and after diet-induced weight loss over 6 weeks.

SETTING

In-patient rehabilitation program in a pediatric hospital.

PARTICIPANTS

Twenty-three obese children (age 10-16 years) and 11 normal weight controls (age 10-15 years).

OUTCOME MEASURES

Changes in ghrelin concentrations during weight loss and correlation analysis of changes in ghrelin and changes in parameters of glucose and insulin metabolism. After data collection, subgroup analysis of obese patients with high, medium and low estimated insulin sensitivity whole-body insulin sensitivity index (WBISI) was performed.

RESULTS

Weight loss increased the area under the curve (AUC) of ghrelin by 26% (P<0.001). The increase in ghrelin AUC correlated significantly with improved estimated insulin sensitivity (WBISI) (r=0.69, P<0.001). The independent predicting effect of WBISI was confirmed in multivariate analysis. In children with low WBISI, ghrelin reached the level of control values after weight loss. In children with high WBISI, ghrelin increased markedly above control levels.

CONCLUSIONS

Changes in ghrelin are independently associated with changes in glucose and insulin metabolism. The increase in plasma ghrelin above control levels was limited to obese children with high WBISI.

[Alternative sonographic determination of liver size by intercostal scans]

BACKGROUND

The evaluation of hepatic size is a daily question in abdominal ultrasound, especially to determine the presence of hepatomegaly. In the literature, different methods of measurement are described, mostly as a subcostal measured organ diameter in one direction. This method has its limits in patients with obesity, accumulation of abdominal gas or in uncooperative patients (lack of coordinative respiration) so that alternative measurements are necessary.

METHODS

In 241 patients hepatic size was first measured in two conventional sections: midclavicular line (MCL) and anterior axillary line (AAL). Additionally, we measured the organs in midaxillary line craniocaudal (MAL) by determination of the cranio-caudal diameter. In 58 patients additional computed tomography was performed due to special diagnostical reasons so that liver size in MCL could be revealed and compared with ultrasonographical values.

RESULTS

The mean value in MCL was 10.7 +/- 2.1 cm measured by ultrasound, 11.4 +/- 3.7 cm measured by computed tomography, 14.0 +/- 1.9 cm in AAL and 14.9 +/- 2.0 cm in MAL. In 5% of the cases the liver could not be measured in the conventional subcostal sections due to obesity or masking by gas, but this was possible in MAL.

CONCLUSIONS

We revealed a good correlation of liver size in MCL between ultrasound and computed tomography, as well as in the measurement of AAL and MAL diameters. However, even in cases with difficult subcostal approach intercostal diameters allow for an accurate determination of hepatic size.

The Munich Polypectomy Study (MUPS): prospective analysis of complications and risk factors in 4000 colonic snare polypectomies

BACKGROUND AND STUDY AIMS

Screening colonoscopy with polypectomy has been shown to reduce the morbidity and mortality associated with colorectal cancer. However, there is a lack of large and systematic prospective studies of the complications of polypectomy.

PATIENTS AND METHODS

Data on all snare polypectomies performed in 13 institutions (six hospitals and seven gastroenterology offices) were recorded prospectively during a 20-month period, including data on a 30-day follow-up period. The primary end points of the study were polypectomy complications, which were classed as "major" or "minor". Risk factors for complications were analyzed for both patient characteristics and polyp parameters.

RESULTS

A total of 3976 snare polypectomies in 2257 patients (mean age 64.5 years) were included in the study. The mean polyp size was 1.1 cm, and 72% were sessile. Complications occurred in 9.7% of patients (6.1% of polyps); 75% of these complications were minor; and the mortality rate was zero. Multivariate regression analysis revealed polyp size as the main risk factor, both for complications overall (odds ratio 6.56, 95%CI 4.45-9.67) and for major complications (odds ratio 31.01, 95%CI 7.53-128.1). Right-sided polyp location was a significant risk factor for major complications (odds ratio 2.40, 95%CI 1.34-4.28). Setting a cut-off value of 3% as an acceptable rate for major complications, polyps larger than 1 cm in the right colon or 2 cm in the left colon, and multiple polyps carried an increased risk.

CONCLUSIONS

Colonoscopic polypectomy is associated with a 10% rate of complications, but three-quarters of these are of minor clinical significance. More than 90% of the complications can be managed conservatively if adequate endoscopic expertise is available. Guidelines for intensified follow-up after polypectomy should be based on the size, location, and number of a patient's polyps.

Postprandial ghrelin release in anorectic patients before and after weight gain

The appetite-modulating hormone ghrelin transmits changes in food intake to the central nervous system. In patients with anorexia nervosa, weight gain reduces elevated fasting ghrelin levels to normal, however, less is known about the effects on postprandial ghrelin levels. In 20 female anorectic in-patients (25.6 +/- 1.0 years; body mass index (BMI) 15.1 +/- 0.3 kg/m2) a standardized test with 250 ml fluid meal (250 kcal: 9.4 g protein, 34.4 g carbohydrates, and 8.3 g fat) was performed at three different times (at admission, after partial weight gain of at least 2 kg, and at discharge) and compared to healthy controls (n = 6; BMI 21.1 +/- 0.7 kg/m2). Plasma ghrelin levels were measured preprandially as well as 20 and 60 min postprandially by a commercially available radioimmunoassay (Phoenix Pharmaceuticals, USA). At admission plasma ghrelin levels significantly decreased postprandially (from 871.9 +/- 124 to 620.3 +/- 80 pg/ml 60 min after meal; P < 0.005). After partial weight gain (2.8 +/- 0.1 kg; BMI 16.1 +/- 0.3 kg/m2) postprandial ghrelin concentrations decreased from 597.0 +/- 79 to 414.7 +/- 39 pg/ml (P < 0.0001), at discharge (weight gain: 7.6 +/- 0.5 kg; BMI 17.9 +/- 0.4 kg/m2) from 570.4 +/- 78 to 395.4 +/- 44 pg/ml (P < 0.0001). Mean postprandial ghrelin decrease was not significantly different between the three tests (29, 25, and 26%, respectively) or to controls (20%). In anorectic patients mean postprandial ghrelin decrease did not change during weight gain. These findings indicate that in anorexia nervosa the suppression of ghrelin release by acute changes of energy balance (feeding) is not disturbed and that it is independent from chronic changes in energy balance (weight gain).

A prospective study of serum ghrelin levels in patients treated with clozapine

We investigated serum ghrelin levels (SGL) in 12 patients with schizophrenia over a 10-week period after initiation of clozapine treatment. In contrast to increments of body mass indices (BMI, kg/m2) and serum leptin levels (SLL), no significant change in SGL was detected. Inverse correlations between delta SGL and delta SLL did not reach statistical significance. Linear mixed model analysis could not detect effects of age, sex, BMI, SLL and serum clozapine levels on SGL. Our results do not support a causal involvement of ghrelin in clozapine-related weight gain.

The Munich Barrett follow up study: suspicion of Barrett's oesophagus based on either endoscopy or histology only--what is the clinical significance?

BACKGROUND

The incidence of distal oesophageal adenocarcinoma is rising, with chronic reflux and Barrett's oesophagus being considered risk factors. Reliable detection of Barrett's oesophagus during upper endoscopy is therefore mandatory but requires both endoscopy and histology for confirmation. Appropriate management of patients with endoscopic suspicion but negative on histology, or vice versa, or of patients with no endoscopic suspicion but with a biopsy diagnosis of intestinal metaplasia at the gastro-oesophageal junction, has not yet been studied prospectively.

PATIENTS AND METHODS

In a prospective multicentre study, 929 patients (51% male, mean age 50 years) referred for upper gastrointestinal endoscopy were included; 59% had reflux symptoms. The endoscopic aspect of the Z line and any suspicion of Barrett's oesophagus were noted, and biopsies were taken in all patients from the Z line (n = 4), gastric cardia (n = 2), and body and antrum (n = 2 each). Biopsies positive for specialised intestinal metaplasia (SIM) were reviewed by a reference pathologist for a final Barrett's oesophagus diagnosis. All patients with endoscopic and/or histological suspicion of Barrett's oesophagus were invited for a follow up endoscopy; the remaining cases (no endoscopic or histological suspicion of Barrett's oesophagus) were followed clinically.

RESULTS

Of 235 patients positive for Barrett's oesophagus on endoscopy and/or histology, 63% agreed to undergo repeat endoscopy (mean follow up period 30.5 months). 46% of patients with an endoscopic Barrett's oesophagus diagnosis but no histological confirmation (group A) showed the same distribution, a further 42% did not have Barrett's oesophagus, and 11% had confirmed Barrett's oesophagus on both endoscopy and biopsy on follow up. In the group with a histological Barrett's oesophagus diagnosis but negative on initial endoscopy (group B), follow up showed the same in 26% whereas 46% had no Barrett's oesophagus, and confirmed Barrett's oesophagus (endoscopy plus histology) was diagnosed in 17%. Of the study population, 16 patients had Barrett's oesophagus on initial endoscopy confirmed by histology which remained constant in 70% at follow up (group C). Of the remaining patients without an initial Barrett's oesophagus diagnosis on either endoscopy or histology (group D) and only clinical follow up (mean follow up period 38 months), one confirmed Barrett's oesophagus case was found among 100 patients re-endoscoped outside of the study protocol. However, no single case of dysplasia or cancer of the distal oesophagus was detected in any patient during the study period.

CONCLUSIONS

Even in a specialised gastroenterology setting, reproducibility of presumptive endoscopic or histological diagnoses of Barrett's oesophagus at follow up were poor. Only 10-20% of cases with either endoscopic or histological suspicion of Barrett's oesophagus had established Barrett's oesophagus after 2.5 years of follow up. The risk of dysplasia in this population was very low and hence meticulous follow up may not be required.

Endogenous and exogenous glucocorticoids decrease plasma ghrelin in humans

OBJECTIVE

The orexigenic and adipogenic peptide hormone ghrelin is predominantly produced and secreted by the stomach and seems to transduce changes in food intake to specific neuronal circuits in the brain. The activity of ghrelin also includes stimulatory effects on the corticotropic system. However, little is known about the influence of glucocorticoids on ghrelin levels. We therefore studied human plasma ghrelin levels in the presence and absence of elevated glucocorticoid levels of either endogenous or exogenous origin.

METHODS

Plasma ghrelin levels were measured in five patients with chronic hypercortisolism (aged 29-58, median 46 years) due to Cushing's syndrome before and after successful surgery for the adenoma, and in eight healthy controls (aged 24-39, median 27.5 years) before and after 30 mg prednisolone (for 5 days) once a day in the morning (median body mass index (BMI) 22.7 kg/m(2)). Plasma ghrelin levels were measured with a commercially available radioimmunoassay.

RESULTS

In patients with Cushing's syndrome, plasma ghrelin levels were low (median 363.2 pg/ml, range 161.9-525.7 pg/ml) and significantly increased by 26.6% (P=0.04) after successful surgery, while BMI decreased (median 26.2-24.0 kg/m(2), P=0.04). A strong negative correlation (r=-0.9, P=0.04) between changes in BMI and plasma ghrelin was observed. In healthy controls, plasma ghrelin levels (median 288.7 pg/ml, range 119.6-827.8 pg/ml) were significantly suppressed by 18.3% (P=0.04) after prednisolone treatment.

CONCLUSIONS

We have shown for the first time that plasma ghrelin levels are decreased under endogenously or exogenously induced hypercortisolism, making ghrelin an unlikely candidate for causing the changes in energy balance or body composition characteristic of Cushing's disease. However, the reduced ghrelin secretion could reflect a compensation mechanism in reaction to the metabolic consequences of chronic hypercortisolism.

Ultrasound in emergency patients: better detection of free intraabdominal fluids by the use of tissue harmonic imaging

BACKGROUND

Ultrasound examination is one of the main investigative procedures in emergency patients who are hospitalized due to abdominal pain. Detectable free fluid collections are important hints to the definite, sometimes life-threatening diagnosis, but their detection in cases of only small amounts is difficult to perform by conventional sonography.

PATIENTS AND METHODS

We report about 25 cases of patients who suffered from acute abdominal pain and who were presented as emergency patients to our department of ultrasound. First, the examination was performed by conventional sonography (3.4 MHz). Only with the additional tissue harmonic imaging (THI, 2.3 MHz, pulse inversion) thin borders of free fluids around the liver or other abdominal organs (gallbladder, spleen, pancreas, bowel) could be detected leading to other important diagnostic or therapeutic steps. In this way, the diagnosis of pancreatitis, cholezystitis, peritonitis, peritoneal carcinosis, ascites (liver cirrhosis, serositis, postoperative status after laparotomy), bleeding or paralytic ileus could be elucidated.

CONCLUSION

THI sonography improves the detection of small amounts of free abdominal fluid collections. Therefore, this technique is helpful in the diagnostic procedure of emergency patients.

Lower esophageal sphincter pressure in patients with gastroesophageal reflux diseases and posture and time patterns

Gastroesophageal reflux disease is caused predominantly by lower esophageal sphincter insufficiency. Reports suggest that it is possible to distinguish between two main mechanisms causing reflux: low basal sphincter pressure leading to free reflux, mostly occurring at night in the supine position, and increased transient lower esophageal sphincter relaxations with normal or increased resting pressure leading to reflux during the day in an upright position. Lower esophageal sphincter pressure (LESP)-- s determined by stationary pull-through manometry--was compared to profiles of acidic reflux measured by 24-h pH monitoring in 207 patients with proven gastroesophageal reflux disease. Differences in LESP were not significant among patients with reflux predominantly during the day in an upright position and those with reflux predominantly at night in a supine position (16.1 +/- 7.4 mmHg versus 15.1 +/- 7.8 mmHg; t-test: P = 0.355). For both patterns of LESP, there was a slight negative correlation with the amount of acidic reflux (determined as a percentage of time with pH < 4). Pearson correlation coefficients were -0.196 for upright refluxers and -0.137 for bipositional/supine refluxers (P = 0.006 and P = 0.049, respectively). As there are no differences in LESP with regard to posture or time patterns of acidic reflux it seems unlikely that upright reflux is associated with increased LESP, whereas supine reflux manifests due to a hypotensive LESP. Alternatively, it may be concluded that stationary pull-through manometry is inadequate for determining the cause of gastroesophageal reflux disease and is therefore of limited use in its routine diagnosis.

Inter- and intra-observer variability of magnification chromoendoscopy for detecting specialized intestinal metaplasia at the gastroesophageal junction

BACKGROUND AND STUDY AIMS

Magnification endoscopy after contrast enhancement with acetic acid or staining with methylene blue has been reported to be highly accurate in predicting specialized intestinal metaplasia (SIM) in Barrett's esophagus. So far, however, no data have been published on the interobserver and intra-observer variability of these new methods.

PATIENTS AND METHODS

Fifty-one patients with reflux symptoms were prospectively evaluated. Endoscopy was carried out with a magnification endoscope, and video sequences were recorded in standard and zoom modes (at the 12-o'clock, 3-o'clock, 6-o'clock, and 9-o'clock positions) before and after instillation of 1.5 % acetic acid (n = 26) or staining with 0.5 % methylene blue (n = 25). Biopsies were obtained from the same locations for histopathological examination. The 102 video sequences were shown to four experienced endoscopists in a mixed and blinded fashion. The evaluation criteria used followed the published criteria; classification was carried out according to the pit-pattern structure, methylene blue positivity, and the presence of villous structures. Finally, a general statement on suspected SIM in relation to Barrett's esophagus was requested.

RESULTS

With regard to the criteria selected for evaluation, there was a high level of interobserver variability among the four examiners (all kappa < 0.4). SIM was histologically detectable in 60.8 % of the patients. The accuracy of all of the examiners for predicting SIM by magnification endoscopy was around 50 %, with no differences observed before and after instillation of acetic acid or methylene blue staining.

CONCLUSIONS

The suggested criteria for identifying SIM using magnification endoscopy are associated with a high level of interobserver variability. When evaluated in a blinded manner, staining techniques do not significantly improve the yield for detecting SIM at the esophagogastric junction.

Improved ultrasound examination of pancreas grafts in type 1 (insulin-dependent) diabetic patients using tissue harmonic imaging

BACKGROUND

Combined kidney/pancreas transplantation is an established therapy for type 1 diabetic patients with end-stage renal disease. Ultrasound examinations are valuable noninvasive methods for postoperative monitoring of transplant recipients. Kidney grafts are easily to detect, whereas pancreas grafts are surrounded or covered by small bowel loops, which makes the examination much more difficult.

PATIENTS AND METHODS

Thirty-three simultaneous pancreas and kidney recipients (SPK) were examined by conventional sonography at 3.4 MHz and THI sonography (pulse inversion, 2.3 MHz) by an investigator experienced in abdominal ultrasound. The images were graded by two "blinded readers" using a scale (1-best image quality, 2-second best, 3-worst) with regard to tissue penetration and detail characterization of the pancreas grafts. The graders were unaware of the sonographic technique, respectively. Statistical evaluation was performed by the Mann-Whitney U test.

RESULTS

In 25 cases (78%) pancreas grafts were detected by conventional sonography. The detection rate was higher using THI sonography, namely 29 cases (91%). Grading for tissue penetration revealed a mean value of 2.05 +/- 0.5 for conventional and 1.94 +/- 0.5 for THI sonography (P =.27). Detail characterization of the pancreas grafts was determined to show a mean value of 2.50 +/- 0.5 for conventional sonography and a significantly better mean value of 1.78 +/- 0.6 for THI sonography (P <.0001).

CONCLUSION

THI sonography improves the detection and the judgment of tissue characteristics of pancreas grafts. Penetration of ultrasound waves is not relevantly decreased by this new technique.

Nutritional status and quality of life in patients with percutaneous endoscopic gastrostomy (PEG) in practice: prospective one-year follow-up

Sixty patients (age 73 +/- 14 years; 22 women, 38 men) with dysphagia (67% neurological diseases, 33% tumors) were followed up for 1 year after placement of a percutaneous endoscopic gastrostomy (PEG). Before PEG placement and at six appointments thereafter, the patients' nutritional status was measured using bioelectric impedance analysis (BIA) and hematological nutritional parameters. A validated questionnaire was used to assess quality of life (the Gastrointestinal Quality of Life Index, GIQLI). The overall mortality rate was 65%, and mortality during the hospitalization period was 22%. Depending on the duration of the dysphagia, marked nutritional deficits were observed at the start of the study (deficiencies in albumin in 49% of the patients, calcium in 15%, magnesium in 18%, retinol in 78%, alpha-tocopherol in 16%, folic acid in 16%, vitamin B12 in 8%, vitamin D in 40%, and zinc in 46%). With the exception of vitamin E, all parameters returned to normal during the follow-up period. At the start of the study, BIA indicated nutritional deficiency in 90% of the patients, with no overall improvement being observed during the follow-up period. The GIQLI scores, on average, reached a figure of 61% of an unrestricted quality of life. In conclusion, long-term nutrition via the PEG tube maintained the patients' quality of life. For BIA most patients were malnourished during the follow-up period, but nevertheless PEG feeding was enough to compensate for gross nutritional deficiencies. Not infrequently, the indication for PEG placement is established too late.

Post-prandial decrease of human plasma ghrelin in the absence of insulin

Ghrelin is the most powerful orexigenic hormone in mammalian physiology. Ghrelin plasma concentrations increase prior to meal onset, but decrease post-prandially. We and others reported previously that insulin reduces circulating ghrelin levels and might therefore be a driving force for post-prandial suppression of ghrelin. To test the influence of insulin on post-prandial ghrelin regulation, a patient with Type I diabetes with complete insulin deficiency received a low glycemic index meal and subsequently an additional high glycemic index meal in the absence of insulin substitution. Subsequently, a sc injection of 0.08 IU Lispro insulin per kg body weight was given. Results were compared to those of a healthy control subject matched for sex, age and body mass index, which was undergoing the same test series (without Lispro bolus) in the presence of endogenous post-prandial insulin secretion. A substantial decrease of plasma ghrelin levels was observed in the insulin-deficient patient following low glycemic index carbohydrate load (27% plasma ghrelin decrease). The subsequent exposure to a high glycemic index meal resulted in a slight additional reduction of ghrelin levels (32% from baseline), while Lispro bolus did not induce further changes in circulating ghrelin (27% of baseline at termination). This post-prandial response was comparable to that of the healthy control subject (33% reduction after the first meal, 40% after the second meal). These data tentatively suggest that post-prandial secretion of ghrelin is not exclusively regulated by plasma insulin or plasma glucose but may depend on other metabolic factors yet to be identified.

Score card endoscopy: a multicenter study to evaluate learning curves in 1-week courses using the Erlangen Endo-Trainer

BACKGROUND AND STUDY AIMS

The present study was carried out in the context of current discussions concerning ways in which simulation systems can be integrated sensibly and effectively into clinical educational structures, in order to shorten the training period for assistants and reduce potential risks for the patient. In our study, a number of centers used a standardized training approach, in 1 week courses, to investigate the learning curve improvement that can be achieved with a group of beginners in upper gastroduodenal endoscopy.

MATERIALS AND METHODS

The multicenter study used the Erlangen Endo-Trainer, with specially prepared biological specimens from pigs. Using this, the individual steps of diagnostic upper gastrointestinal endoscopy with biopsy can be carried out following a score-card system. After a theoretical introduction and a demonstration of the examination by an experienced endoscopist, an initial evaluation score for each participant was obtained on day 1. On the following days, the program consisted of 2 hours' training by a tutor, followed by a test run for each participant. On days 1, 2, 3, 4, and 5 the test run was directly followed by a self-assessment. In addition, on days 1, 3, and 5 the test run for each beginner was recorded on video, with each video assigned an encrypted code number. All the end of the study week, control assessments of these videos were carried out by an experienced endoscopist.

RESULTS

Both the self-assessments and the control assessments showed significant improvements in the endoscopic parameters tested during the course (days 1-5; all parameters P < 0.001, Wilcoxon-test). However, it was found that the trainees tended to give themselves better marks than the marks given by experienced endoscopists.

CONCLUSION

During 1 week of training, using the model and following the score card, a significant improvement in the learning curve was achieved in the beginners' group for the individual steps involved in diagnostic upper gastrointestinal endoscopy. When this approach is used with trainees who are also provided with the necessary theoretical background, this type of preparation may lead to a better, lower-risk start to supervised practical endoscopic examinations in patients.

[Hepatitis of unknown origin with protracted liver failure in a 48-year-old patient with significantly increased pANCA titer]

In spite of intense diagnostic testing, no cause for the chronically aggressive hepatitis of a 48-year old male patient was found. Evidence for an autoimmune process, however, could be derived from a high titer of pANCA. Only according to the revised criteria of the working group on autoimmune hepatitis, but not to the first version, it was possible to classify this as an autoimmune hepatitis. Despite of high-dose steroid treatment and accelerated preparation for liver transplantation the patient died of the complications of rapid liver failure. Thus, in case of unclear rapid progressive hepatitis, the revised criteria of autoimmune hepatitis should be reviewed early and with high priority and consequent high-dose steroid therapy and preparation for liver transplantation should be initiated. The prognostic impact of a high titer of pANCA in patients with autoimmune hepatitis remains to be established.

Adherence and mental side effects during hepatitis C treatment with interferon alfa and ribavirin in psychiatric risk groups

Psychiatric disorders or drug addiction are often regarded as contraindications against the use of interferon alfa (IFN-alpha) in patients with chronic hepatitis C. Our aim was to obtain prospective data on adherence to as well as efficacy and mental side effects of treatment with IFN-alpha in different psychiatric risk groups compared with controls. In a prospective trial, 81 patients with chronic hepatitis C (positive hepatitis C virus[HCV] RNA and elevated alanine aminotransferase[ALT] level) and psychiatric disorders (n = 16), methadone substitution (n = 21), former drug addiction (n = 21), or controls without a psychiatric history or drug addiction (n = 23) were treated with a combination of IFN-alpha-2a 3 MU 3 times weekly and ribavirin (1,000-1,200 mg/d). Sustained virologic response (overall, 37%) did not differ significantly between subgroups. No significant differences between groups were detected with respect to IFN-alpha-related development of depressions during treatment. However, in the psychiatric group, significantly more patients received antidepressants before and during treatment with IFN-alpha (P <.001). Most of those who dropped out of the study were patients with former drug addiction (43%; P =.04) compared with 14% in the methadone group, 13% in the control group, and 18% in the psychiatric group. No patient in the psychiatric group had to discontinue treatment because of psychiatric deterioration. In conclusion, our data do not confirm the supposed increased risk for IFN-alpha-induced mental side effects and dropouts in psychiatric patients if interdisciplinary care and antidepressant treatment are available. Preexisting psychiatric disorders or present methadone substitution should no longer be regarded as contraindications to treatment of chronic hepatitis C with IFN-alpha and ribavirin in an interdisciplinary setting.

Screening for p53 and K-ras mutations in whole-gut lavage in chronic inflammatory bowel disease

OBJECTIVES

Molecular screening for frequently mutated genes may increase the likelihood of identifying cancer risk groups, such as patients with longstanding inflammatory bowel disease. This study investigated the prevalence and time course of p53 and K-ras mutations in colonic lavage fluid of patients with inflammatory bowel disease.

METHODS

Colonic lavage fluid from 190 patients with ulcerative colitis (73), Crohn's disease (58) or controls (49 non-tumour, 10 colorectal cancer) was studied by oligomer-specific hybridization for K-ras mutations and single-strand conformation polymorphism (SSCP) for p53 mutations. Follow-up investigations were carried out after 1-3 years.

RESULTS

Mutations were most frequent in carcinomas (5/10, 50%) and rare in non-tumour controls (1/49, 2.0%). They were found in Crohn's colitis in 15.4%, in extensive ulcerative colitis in 18.6%, in left-sided ulcerative colitis in 13.3%, and in distal ulcerative colitis in 6.7% (P > 0.05). There was a positive association with disease duration (> or =11 years, P < 0.05). Follow-up investigations detected the same mutation in four patients and revealed new mutations in three patients.

CONCLUSIONS

In our large series of patients with inflammatory bowel disease, K-ras and p53 mutations could be detected with reasonable frequency and confirmed at follow-up in at least some patients. Our data encourage the use of molecular screening for the detection of malignant precursor lesions in at-risk patients.

A score card for upper GI endoscopy: Evaluation of interobserver variability in examiners with various levels of experience

BACKGROUND

In most European countries, training in GI endoscopy has largely been based on hands-on acquisition of experience in patients rather than on a structured training programme. With the development of training models systematic hands-on training in a variety of diagnostic and therapeutic endoscopy techniques was achieved. Little, however, is known about methods of objectively assessing trainees' performance. We therefore developed an assessment 'score card' for upper GI endoscopy and tested it in endoscopists with various levels of experience. The aim of the study was therefore to assess interobserver variations in the evaluation of trainees.

METHODS

On the basis of textbook and expert opinions a consensus group of eight experienced endoscopists developed a score card for diagnostic upper GI endoscopy with biopsy. The score card includes an assessment of the single steps of the procedure as well as of the times needed to complete each step. This score card was then evaluated in a further conference including ten experts who blindly assessed videotapes of 15 endoscopists performing upper GI endoscopy in a training bio-simulation model (the 'Erlangen Endo-Trainer'). On the basis of their previous experience (i. e. the number of endoscopies performed) these 15 endoscopists were classified into four groups: very experienced, experienced, having some experience and inexperienced. Interobserver variability (IOV) was tested for the various score card parameters (Kendall's rank-correlation coefficient 0.0-0.5 poor, 0.5-1.0 good agreement). In addition, the correlation between the score card assessment and the examiners' experience levels was analysed.

RESULTS

Despite poor IOV results for all the parameters tested (Kendall coefficient < 0.3), the assessment parameters correlated well when the examiners' different experience levels were taken into account (correlation coefficient 0.59-0.89, p < 0.05). The score card parameters were suitable for differentiating between the four groups of examiners with different levels of endoscopic experience.

CONCLUSIONS

As expected with scores involving subjective assessment of performance, the variability between reviewers was substantial. Nevertheless, the assessment score was capable of distinguishing reliably between different experience levels in terms of a good individual observer consistency. The score card can therefore be used to document both training status and progress during endoscopy training courses using bio-simulation models, and this might be able to provide improved quality assurance in GI endoscopy training.

[Compliance with terminology standards in reflux, ulcers, and gastritis: A study of 881 consecutive upper gastrointestinal endoscopy reports]

BACKGROUND

The German version of the Minimal Standard Terminology document for endoscopy was discussed in 1997 and 1998, and finally published at the end of 1999 as one of the German Gastroenterology Society guidelines. The diagnoses and descriptive terms included in this standard terminology are based on the consensus views of a large number of German endoscopists (20 endoscopists based in Munich and 20 elsewhere in Germany). The aim of the present study was to investigate how much spontaneous compliance there is with the descriptive terms included in the standard terminology - both among the members of the consensus discussions, and among colleagues not involved in this project.

METHODS

A total of 881 endoscopy reports with the diagnoses of reflux, ulcer, and gastritis were collected from 11 centers (2 hospitals and 9 private offices, with a total of 26 examiners) over a one-month period. Nine of the 26 examiners were actively involved in the terminology consensus discussion. The rate of occurrence of the descriptive terms contained in the standard terminology was assessed for the diagnoses listed above.

RESULTS

Compliance with the descriptive terms was high (> 90 %) only for basic parameters such as the Savary classification of reflux and the area in which gastroduodenal ulcers were located. Other important parameters, such as the extent (length) of Barrett's esophagus, ulcer size, and circumferential location, were reported in only three-quarters of cases or less. The descriptions of gastritis were inconsistent. There was no difference in the degree of compliance either between endoscopists using free dictation and those using computerized text blocks, or between members of the terminology group and those not involved in preparing the terminology.

CONCLUSIONS

Adherence to standard terminology and its descriptive parameters is poor even among specialized gastroenterologists who have been involved in terminology consensus discussions. Compliance needs to be improved by providing suitable software programs with automatic reporting functions.

[Duodenosigmoidal fistula in a patient with Crohn's disease]

The development of enteral fistulas - internal and external - is common in Crohn's disease with a frequency of about 45 % in large series of patients. Most internal fistulas arise in the small bowel, but internal large bowel fistulas occur in about one fourth of all patients with fistulas in Crohn's disease. Colonic gastroduodenal fistulas do occur, but are very rare. Of the 35 cases of colonic-duodenal fistulas that we found in the literature, most have been described to involve either a previous ileocolostomy site or the ascending or transverse colon. There are only three cases displaying sigmoidoduodenal fistulas. To these we add a fourth case with this report. A 42-year-old woman presented with upper abdominal pain, loss of appetite and regurgitations with a foul smell as well as abdominal gas complaints. A duodenosigmoidal fistula was diagnosed by local application of contrast and the fistula tract was excised in typical fashion by resection of the colonic fistula and primary closure of the duodenum. The patient experienced a good recovery with relief of symptoms.

K-ras and p53 mutations in colonic lavage fluid of patients with colorectal neoplasias

BACKGROUND

The adenoma-carcinoma sequence has its molecular basis in several gene mutations of which K-ras and p53 are of paramount importance. The aims of this study were to evaluate whether these genetic alterations can be detected in colonic lavage fluid from patients with colorectal adenomas and carcinomas.

METHODS

In 45 patients with adenomas, 20 patients with colorectal carcinomas and 38 patients with non-neoplastic and noninflammatory diseases of the colon p53 and K-ras mutations were evaluated in colonic lavage fluid employing single-strand confirmation polymorphism analysis and dot-blot hybridization, respectively.

RESULTS

Mutations of the K-ras and the p53 gene were found in 15.6% (p = 0.065) of patients with adenomas, in 25.0 % (p = 0.016) of patients with carcinomas and in 2.6% in the control group.

CONCLUSION

Genetic alterations in the colonic lavage fluid could be an additional diagnostic tool for the surveillance of patients with colorectal neoplasias.

Gastric outlet obstruction and pulmonary infiltrate in a patient with Crohn's disease: successful treatment by Billroth-II-resection

We present a 28-year-old women with a 3 yr history of duodenal ulcers. Following four treatment attempts to eradicate helicobacter pylori she was admitted because of gastric outlet obstruction and a weight loss of 20 kg within the last two years. Endoscopy and x-ray showed a circular inflammatory stenosis of the proximal duodenum extending over 8 cm. Additionally, chest x-ray showed a circumscript infiltrate in the third segment of the right lung. Mycobacterial infection could be excluded. Ileocolonoscopy and small intestinal follow-through beyond the duodenum were unremarkable, and Zollinger-Ellison-syndrome was ruled out. Bronchopulmonary histology showed intramucosal epithelioid-cell granulomas and bronchiolitis obliterans. Because the patient did not improve under conservative therapy a Billroth-II-resection was carried out. Histologically the resected specimen showed Crohn-like lesions. Postoperatively, severe peripheral arthritis was treated by steroids over 6 weeks. At follow-up the patient regained 20 kg and was free of symptoms without any medication. The pulmonary infiltrate had subsided almost completely. In summary, this extremely rare coincidence of isolated stenosing duodenal Crohn's disease and pulmonary involvement was successfully treated by Billroth-II-resection. This course of disease is compatible with the hypothesis that Crohn's disease may be maintained by antigens derived from ingested food.

Are guidelines followed in Helicobacter pylori diagnosis and therapy? An inquiry among gastroenterologists, referring physicians and patients in Munich

BACKGROUND AND STUDY AIMS

Attempts to standardize Helicobacter pylori (Hp) diagnosis and therapy have led to the publication of guidelines by various national gastroenterological societies in Europe and the USA. However, little information is available either regarding the compliance of gastroenterologists and referring physicians with these guidelines, or regarding the patients' perspective.

PATIENTS AND METHODS

A retrospective analysis was conducted of all outpatient upper gastrointestinal endoscopy reports for a one-month period in eleven different centers (two university hospitals and nine private practice gastroenterology offices) with a total of 24 gastroenterologists. Endoscopy reports from patients wit the indications of reflux, diarrhea, and tumors were excluded. Diagnoses and treatment recommendations given by gastroenterologists were recorded. Questionnaires concerning Hp diagnosis, treatment indications and performance, and follow-up were sent to referring physicians and patients.

RESULTS

A total of 772 endoscopy reports were included in the study; analyzable questionnaires were returned by 287 referring physicians (47%) and by 265 patients (59%). Gastroenterologists recommended Hp eradication in all ulcers and in 29% of gastritis/nonulcer dyspepsia (NUD) cases. Referring physicians thought that 94% of ulcers should be treated by Hp eradication, which was also considered to be an absolute and relative indication in NUD by 15% and 53% of the referring physicians, respectively. Among the patients who replied, 52% had received Hp eradication regimens; ulcers were found in 22% of the total patient group. Check-up examinations after Hp therapy were considered necessary by 75% of the referring physicians, but only 22% of the responding patients actually underwent some form of check-up (upper gastrointestinal endoscopy in 91%).

CONCLUSIONS

Gastroenterologists and (to a somewhat lesser extent) referring physician appear to be following the current guidelines for Hp treatment. As expected, two thirds of referring physicians consider NUD to be absolute or relative indication for Hp eradication. Check-up examinations are apparently being performed less frequently than recommended.

Rosacea fulminans in a patient with Crohn's disease: a case report and review of the literature

Rosacea fulminans is a rare disorder of unknown cause that mainly affects postadolescent women, with abrupt onset and disfiguring course if left untreated. The simultaneous occurrence of rosacea fulminans and inflammatory bowel disease is rare and has been reported predominantly in the setting of ulcerative colitis. We describe here a case of rosacea fulminans in a patient with Crohn's disease and discuss a possible association between the two conditions.

Accuracy of 13C-urea breath test in clinical use for diagnosis of Helicobacter pylori infection

The 13C-urea breath test (UBT) is a noninvasive test for diagnosis of Helicobacter pylori infection of gastric mucosa. The aim of this prospective study was to assess the accuracy of a simple UBT in clinical routine use.

METHODS

The study population comprised of 100 patients (49 f, 51 m) requiring diagnostic upper GI endoscopy. One biopsy specimen was taken from the gastric antrum, body and fundus, respectively, for standard histological examination and one additional specimen from each location was transformed into transport medium for cultivation of H. pylori. After vaccination of the culture plates the biopsies were tested for urease activity (UAT). After recovery from endoscopy the patients had to pass an one liter endexspiratory breath sample before and 15 min after drinking 200 ml orange juice, pH 3.6, containing 75 mg of 13C-urea. 13CO2 was measured in the breath samples using isotope-selective nondispersive infrared spectrometry.

RESULTS

Defining gold standard groups with all biopsy tests (from antrum and corpus) positive or negative the 13CO2 delta over baseline (DOB) cut-off level of UBT was set at 6.5/1000 in order to best discriminate positive from negative patients (ROC analysis). UBT was positive in 37% of all subjects. Taken UAT and histological examination together (positive when both tests were positive) UBT displayed a sensitivity of 92%, a specificity of 94%, a positive predictive value of 89%, and a negative predictive value of 94%. When including the results of culture sensitivity and negative predictive value reached almost 100%. The mean of the 13CO2-DOB values from H. pylori-positive duodenal or gastric ulcer patients did not differ from controls (H. pylori-positive patients without lesions). The 13CO2-DOB values of the ulcer group were correlated significantly with the active inflammatory component of gastritis in antrum, corpus, and fundus.

CONCLUSION

UBT with this setup detects H. pylori infection in clinical routine use with high accuracy. The increase of exhaled 13CO2 does not predict ulcer disease but reflects the degree of active inflammation of gastric mucosa.

Prospective, randomised, double blind trial of prophylaxis with single dose of co-amoxiclav before percutaneous endoscopic gastrostomy

OBJECTIVE

To determine the efficacy of antibacterial prophylaxis in preventing infectious complications after percutaneous endoscopic gastrostomy.

DESIGN

Prospective, randomised, placebo controlled, double blind, multicentre study.

SETTING

Departments of internal medicine at six German hospitals.

SUBJECTS

Of 106 randomised adult patients with dysphagia, 97 received study medication, and 84 completed the study. The median age of the patients was 65 years. Most had dysphagia due to malignant disease (65%), and many (76%) had serious comorbidity.

INTERVENTIONS

A single intravenous 2.2 g dose of co-amoxiclav or identical appearing saline was given 30 min before percutaneous endoscopic gastrostomy performed by the thread pull method.

MAIN OUTCOME MEASURES

Occurrence of peristomal wound infections and other infections within one week after percutaneous endoscopic gastrostomy.

RESULTS

The incidence of peristomal and other infections within one week after percutaneous endoscopic gastrostomy was significantly reduced in the antibiotic group (8/41 (20%) v 28/43 (65%), P<0.001). Similar results were obtained in an intention to treat analysis. Several peristomal wound infections were of minor clinical significance. After wound infections that required no or only local treatment were excluded from the analysis, antibiotic prophylaxis remained highly effective in reducing clinically important wound infections (1/41 (2%) v 11/43 (26%), P<0.01) and non-wound infections (2 (5%) v 9 (21%), P<0.05).

CONCLUSIONS

Antibiotic prophylaxis with a single dose of co-amoxiclav significantly reduces the risk of infectious complications after percutaneous endoscopic gastrostomy and should be recommended.

Molecular screening of patients with long standing extensive ulcerative colitis: detection of p53 and Ki-ras mutations by single strand conformation polymorphism analysis and differential hybridisation in colonic lavage fluid

BACKGROUND

In patients with long standing ulcerative colitis at risk of developing malignancy, mutations of the p53 and Ki-ras gene were investigated in lavage solution obtained at surveillance colonoscopy.

METHODS

DNA was isolated from 31 consecutive patients with total or subtotal ulcerative colitis and a disease duration of between seven and 26 years. Twenty seven control patients showed no macroscopic or microscopic inflammation on colonoscopy. Exons 5-8 of the p53 gene and exon 1 of the Ki-ras gene were amplified by polymerase chain reaction. Mutations of the p53 gene were detected by single strand conformation polymorphism analysis. Point mutations of the Ki-ras gene were hybridised on dot blots with oligonucleotides marked with digoxigenin.

RESULTS

In all cases of ulcerative colitis and in all of the 27 control patients, wild type p53 and wild type Ki-ras could be detected. In four patients with ulcerative colitis, a mutation in exon 5 to 7 of the p53 gene was found, and two patients had a mutation of the Ki-ras gene (Gly to Asp-12, Gly to Val-12). None of these patients had dysplasia in serial biopsy specimens, and all but one had had the disease for more than 10 years. One control patient had a mutation.

CONCLUSIONS

Mutations were more frequent in patients with long standing ulcerative colitis (19%) than in control patients (3%, p = 0.07). The technique may be useful for screening for early malignancy in ulcerative colitis.

Antinuclear autoantibodies in patients with inflammatory bowel disease. High prevalence in first-degree relatives

Crohn's disease and ulcerative colitis show a familial aggregation. The role of antinuclear autoantibodies, which occur in both diseases, remains to be defined. In 76 patients with Crohn's disease, 61 patients with ulcerative colitis, 105 first-degree relatives of patients with Crohn's disease, 101 first-degree relatives of patients with ulcerative colitis, and 40 healthy unrelated controls antinuclear autoantibodies were detected by indirect immunofluorescence. Existence of autoantibodies was correlated with clinical features. Eighteen percent of patients with Crohn's disease (14/76), 43% of patients with ulcerative colitis (26/61), 13% of relatives of patients with Crohn's disease (14/105), 24% of relatives of ulcerative colitis patients (24/101), and 2% of the healthy controls (1/40) were positive for antinuclear autoantibodies. The difference between controls and patients and the first-degree relatives of patients with ulcerative colitis, respectively, was statistically significant (P < or = 0.0144). In ulcerative colitis, the existence of antinuclear autoantibodies was negatively correlated with immunosuppressive therapy or extraintestinal manifestations (P = 0.0004 and 0.0273, respectively). Antinuclear autoantibodies may represent a factor disposing to the development of ulcerative colitis.

Goblet cell autoantibodies in patients with inflammatory bowel disease and their first-degree relatives

BACKGROUND & AIMS

Crohn's disease and ulcerative colitis show a familial aggregation. In both diseases, anti-goblet cell autoantibodies (GABs) have been described. The aim of this study was to define the role of GABs in the pathogenesis of inflammatory bowel disease.

METHODS

The study population comprised 61 patients with ulcerative colitis, 76 patients with Crohn's disease, 101 first-degree relatives of patients with ulcerative colitis, and 105 first-degree relatives of patients with Crohn's disease. Thirty-five patients with infectious enterocolitis and 56 healthy unrelated subjects served as controls. Autoantibodies were detected by indirect immunofluorescence.

RESULTS

Thirty-nine percent of patients with ulcerative colitis (24 of 61) and 30% of patients with Crohn's disease (23 of 76) were positive for GABs. GABs were detected in 21% (21 of 101) of first-degree relatives of patients with ulcerative colitis and in 19% (20 of 105) of first-degree relatives of patients with Crohn's disease. In patients with infectious enterocolitis and in healthy controls, GABs were seen in 3% (1 of 35) and 2% (1 of 56), respectively. The differences between control groups and both groups of patients or their first-degree relatives were significant.

CONCLUSIONS

The high prevalence in first-degree relatives suggests that GABs may represent a marker characterizing susceptibility to inflammatory bowel disease.

Influence of prophylactic local administration of epinephrine on bleeding complications after polypectomy

BACKGROUND AND STUDY AIMS

Data concerning the potential benefit of local application of vasoconstricting substances prior to snare excision of colonic polyps are scarce. The influence of prophylactic submucosal injection of epinephrine in the prevention of hemorrhage after polypectomy was therefore evaluated in larger polyps.

PATIENTS AND METHODS

Seventy-three patients, in whom 77 polyps more than 15 mm in diameter had been excised during a 30-month period, were included in this retrospective analysis. Twenty-eight polyps were excised with prophylactic injection of epinephrine into the polyp base, and 49 polyps were excised without the injection. All data were retrieved by reviewing the medical records.

RESULTS

No bleeding occurred in the epinephrine group (28 polyps). In contrast, nine of the 49 polypectomies that were carried out without prior administration of epinephrine were associated with a bleeding episode (P = 0.015).

CONCLUSIONS

Local injection therapy appears to reduce the risk of bleeding after the excision of larger polyps. Controlled trials are warranted in order to provide conclusive evidence concerning the prophylactic effect of epinephrine on hemorrhage after polypectomy.

Injection of fibrin tissue adhesive versus laser photocoagulation in the treatment of high-risk bleeding peptic ulcers: a controlled randomized study

BACKGROUND AND STUDY AIMS

A controlled and randomized multicenter study was carried out in order to compare the efficacy of fibrin sealant and Nd:YAG laser photocoagulation in patients with high-risk arterial bleeding from peptic ulcers of the stomach and the small intestine.

PATIENTS AND METHODS

In four teaching hospitals, 53 patients presenting with either active arterial ulcer bleeding (Forrest class 1 a) or a large visible vessel in the ulcer base (diameter over 2 mm, Forrest class 2 a) were treated with infiltration of epinephrine 1: 10,000 followed by the injection of fibrin tissue adhesive (n = 28), or with epinephrine plus laser photocoagulation (n = 25). Permanent hemostasis for at least seven days served as the principal end point; rebleeding, emergency surgery, and hospital mortality served as further end points.

RESULTS

There were no significant differences between the study groups in terms of age, risk factors, initial hemoglobin values, number of patients showing signs of hemodynamic impairment, ulcer size and localization, or bleeding activity. Primary hemostasis was achieved in all patients. Rebleeding rates were seven of 28 and four of 25 among the patients treated with fibrin sealant and laser coagulation, respectively (not significant). There were no significant differences regarding the rates of ultimate hemostasis (24 of 28 vs. 24 of 25), emergency surgery (four of 28 vs. one of 25), or hospital mortality (0 vs. two of 25). No complications occurred with either form of treatment. Patients who had a visible vessel in the ulcer floor at the first control endoscopy had a significantly higher incidence of rebleeding, regardless of the type of endoscopic therapy.

CONCLUSIONS

We conclude that both the injection of fibrin tissue adhesive and laser photocoagulation are effective methods of treating high-risk arterial peptic ulcer bleeding. As the number of high-risk patients necessary to reach significance are difficult to recruit within a reasonable period even in a multicenter study, a new meta-analysis of all studies now available should be considered.