Transluminal removal of a giant fibrovascular polyp of the esophagus

Giant fibrovascular polyps of the esophagus are rare benign tumors that originate at the hypopharynx or the upper third of the esophagus. Because of the indolent and benign nature they are mostly discovered when very large with symptoms like dysphagia or regurgitation of the polyp into the mouth which can cause asphyxia and dead. The removal of these polyps is obligatory. Although more than 100 cases of giant fibrovascular esophageal polyps have been described in literature so far, the approach for removal is not yet standard and needs a customized use of medical technology from different disciplines. We present the case of a 42 year old man in whom a giant polyp was removed transorally by a combination of instruments and materials from different disciplines (gastroenterological, surgical and laryngological).

Cheilitis granulomatosa and Crohn's disease : a case report

In this case report we describe the evolution of Cheilitis granulomatosa (GC) in a young patient with Crohn's disease during treatment with anti-TNF-alfa therapy.

Terminal ileitis after kidney transplantation : Crohn's disease or other? Case reports and literature review

The finding of a terminal ileitis after kidney transplantation can cause a diagnostic challenge. Because the development of Crohn's disease under immunosuppressive therapy is unlikely, this diagnosis should only be considered after exclusion of infectious disease and drug-related intestinal toxicity. Defining the underlying cause of terminal ileitis is often hampered by a shortage of specific diagnostic tests or their lack of sensitivity. We present three patients with terminal ileitis after kidney transplantation resulting from different etiologies. Subsequently, we describe the characteristics that can help to make the differential diagnosis.

Two jenuno-jenunal intussusceptions in a patient with coeliac disease

We present a case of a 41-year-old woman with severe abdominal pain caused by two jejuno-jejunal intussusceptions. Further investigation showed coeliac disease as the underlying cause. The patient recovered rapidly on a gluten-free diet. So coeliac disease could be the underlying cause of idiopathic intussusception more often than previously thought and intussusception should be suspected in patients with known coeliac disease presenting with abdominal pain. (Acta gastro-enterol. belg., 2016, 79, 000-000).

Distal intestinal obstruction in CF patients

Distal intestinal obstruction syndrome (DIOS) - the incomplete of complete intestinal obstruction by intestinal contents in the terminal ileum and proximal colon- is frequently seen in cystic fibrosis (CF) patients. Diagnosis is based on suggestive symptoms of abdominal pain in the right lower quadrant, a palpable mass on examination and signs of obstruction on plain radiography. Treatment consists of intensive laxative treatment with oral laxatives and enemas. Surgery only serves as the last resort for patients not responding to medical therapy, because of the well-known high rate of peri- and postoperative morbidity of surgery in CF patients. In this article we present 3 cases of DIOS, followed by a review of the relevant literature.

Diverticulitis: new insights on the traditional point of view

Diverticulosis of the colon is a common disease with an increasing incidence in Western countries. Recent literature has shown some changes in the traditional approach of this disease. The theory that diverticulosis is caused by a reduced intake of dietary fibre, is doubtful. There might be some chemical and histological overlap between diverticulitis, inflammatory bowel disease and irritable bowel disease. High quality clinical study found no effect for antibiotics in acute, uncomplicated diverticulitis. Cyclic administration of mesalazine and rifaximin result in reduced symptoms of diverticular disease. For the treatment of diverticular abscesses, percutaneous drainage shows promising results. Recurrence of acute diverticulitis is rare and most serious complications are linked to the first episode. Recent evidence does not support the traditional recommendation for elective surgery after two episodes of acute diverticulitis any more. This review summarizes the last evidence in diverticular disease and diverticulitis.

Resolving bile reflux by lanreotide in patients with Roux-en-Y gastrojejunostomy

Reflux into the esophagus after partial or total gastrectomy is a well known problem. Even a Roux-en-Y reconstruction is not always a definitive solution. Bile reflux might occur and cause disabling symptoms, unresponsive to the classic anti-acid or anti-reflux therapy. Endoscopy and a Tc-99m-BrIDA hepatobiliary (HIDA) scan can be used to make the diagnosis. Clinical studies have shown that lanreotide (somatuline), which strongly inhibits many gastro-intestinal hormones, reduces the bile salts outputs. We present a case of a patient with bile reflux after Roux-en-Y. After administration of lanreotide he had a good clinical improvement and mucosal healing on endoscopy. Lanreotide can be a good treatment option for bile reflux when classic treatment fails, but clinical trials with more patients will have to confirm this.

Crohn's disease presenting with acute pancreatitis

Crohn's disease is often accompanied by extraintestinal inflammation. Acute pancreatitis can be a rare manifestation of Crohn's disease. The present report describes a patient who developed two episodes of pancreatitis before the diagnosis of Crohn's disease. Clinical and laboratory evaluation excluded other causes of pancreatitis, confirming a direct association of the pancreatitis with Crohn's disease. This case report supports the hypothesis that acute pancreatitis may precede the clinical manifestations and diagnosis of the underlying inflammatory bowel disease.

[Optimal use of proton pump inhibitors in primary care]

Acid peptic diseases such as peptic ulcer and gastrointestinal reflux disease have a high prevalence; they can have an important impact on the patient's quality of life and generate a considerable health care cost. Proton pump inhibitors are the most potent pharmacological inhibitors of gastric acid secretion currently available and are the mainstay medical therapy for acid peptic diseases. This review provides primary care clinicians with best practice guidelines for optimal use of these drugs.

Optimal use of proton pump inhibitors for treating acid peptic diseases in primary care

Heartburn, reflux and epigastric pain are frequently encountered symptoms in primary care medicine. Acid peptic diseases such as peptic ulcer and gastrointestinal reflux disease have a high prevalence, can have important impact on patient quality of life and represent a considerable health care cost. Proton pump inhibitors (PPIs) are the most potent pharmacological inhibitors of gastric acid secretion currently available and are the mainstay medical therapy for acid peptic diseases. This review summarizes current evidence on treatment of acid-peptic diseases with proton pump inhibitors and provides primary care clinicians with best practice guidelines for optimal use of these drugs.

Prevalence of and risk factors for H. pylori infection in healthy children and young adults in Belgium anno 2010/2011

OBJECTIVE

Estimation of prevalence and risk factors for Helicobacter pylori (H. pylori) infection in children and young adults in Belgium.

STUDY DESIGN

Five hundred and sixteen schoolchildren between 12 and 25 years old were tested for H. pylori infection using 13C-UBT in different regions in Belgium. A questionnaire was used to evaluate risk factors.

RESULTS

Fifty six (11%) tested positive. In children born in Belgium, with parents from Belgium, 13 (3,2%) tested positive. In children born in a foreign country, 20 (60%) tested positive; if born in Belgium but 1 or 2 parents were from a foreign country, 15 (30%) tested positive. Differences were significant (p <0.001). In the multivariate analyses, significant risk factors were staying in a day nursery, a birthplace of child or father outside Belgium, and lower education levels of mother.

CONCLUSION

In this cohort of Belgian asymptomatic children and young adults, the prevalence of H. pylori infection is 11%, ranging from 3,2% in Belgian born children with Belgian parents to 60% in children born in high prevalence countries from foreign parents. The most significant risk factor found in this study was origin.

Primary antimicrobial resistance of Helicobacter pylori in Belgium

The increasing antimicrobial resistance of Helicobacter pylori jeopardizes the efficiency of the classical eradication triple therapy. In this article we assessed the primary resistance rates of Helicobacter pylori to the commonly used antibiotics for eradication in the area of Brussels and determined prospectively, through a questionnaire, the possible risk factors for resistance. Gastric biopsies were taken for histology and culture in all adult patients in whom Helicobacter pylori was searched from February 2009 to April 2010 at the UZBrussel hospital. Clinical and demographic data were collected through a questionnaire. Histology was positive in 222 out of 507 patients tested (43.7%). Culture was successful in 189 patients with a positive histology (85.1%), 4 patients had a positive culture with a negative histology. Resistance to clarithromycin, metronidazole, ciprofloxacin, and amoxicillin was tested. Primary resistance rates were 13.3% for clarithromycin, 26.1% for metronidazole, 23.9% for ciprofloxacin, 0.8% for amoxicillin. Dual resistance to claritromycin and metronidazole was seen in 3.9%, triple resistance (claritromycin, metronidazole and ciprofloxacin) in 1.7% and resistance to the 4 antibiotics in 0.6% of patients. We conclude that there is a decreasing resistance for clarithromycin, metronidazole resistance is stable and rapidly increasing ciprofloxacin resistance. Resistance to any of the tested antibiotics was not associated with origin, age, gender, number of siblings, level of education or status (p > 0.05).

Small bowel metastases from melanoma: does videocapsule provide additional information after FDG positron emission tomography?

Finding small bowel metastases of melanoma can be important because surgical removal of unique small bowel metastasis of melanoma could improve survival. In this study, we evaluated if capsule endoscopy provides additional information after Pet CT has been performed. In this series of 9 patients collected from 3 university centers, capsule endoscopy influenced the therapeutic decision (to perform or not a surgical segmental resection) in 2/9 patients. All metastatic lesions were found in the proximal bowel. Capsule identified jejunum metastases in one case while Pet CT was negative, and identified metastases while Pet CT result was not conclusive. In one case PET CT identified mesenteric metastases while capsule was negative. SBCE influenced therapeutic decision in 2/9 patients concerning the decision of performing small bowel resection or not. In 1 patient SBCE changed the stage of the disease without affecting medical therapeutic strategy. The prognosis of patients with positive PET and/or capsule findings is very limited (2/3 died within the year). In selected patients, capsule endoscopy can provide complementary information once PET CT has been performed.

Atypical indications for small bowel capsule endoscopy

Obscure bleeding remains the most important indication for small bowel capsule endoscopy, but some other small bowel diseases have also been studied. The aim of this paper is to provide an overview of the recent literature concerning atypical or rare indications for the small bowel capsule endoscopy.

Daily cannabis use and the digestive tract: an underrecognized relationship

A 33-year-old man presented with recurrent episodes of hyperemesis with symptom-free intervals since eight years. The diagnosis of cyclic vomiting syndrome due to longstanding and daily cannabis use was retained, after exclusion of any organic cause of vomiting. Although the patient was informed that the clinical response after cessation of smoking is proven to be spectacular, he continued the use of cannabis and kept on presenting with cyclic symptoms of hyperemesis.

Dyspeptic symptoms in the general population: a factor and cluster analysis of symptom groupings

Both dyspeptic and gastro-oesophageal reflux-like symptoms are frequent in the general population, but their degree of overlap is unknown. In severe functional dyspepsia (FD), symptoms are organized in factors associated with pathophysiological mechanisms. The aims of this study were: (i) to assess the prevalence of dyspeptic symptoms with and without overlapping reflux symptoms in the general population and their impact on daily life and on healthcare utilization; and (ii) to compare symptom groupings in the general population to FD patients. A total of 2025 subjects, representative of the Belgian general population, were used in this study. The subjects were submitted to a questionnaire with validated questions on their dyspeptic and reflux symptoms and with evaluators of impact on daily life and use of healthcare resources. Significant dyspeptic symptoms were found in 417 (20.6%). Overlapping reflux symptoms were present in 141 (33.8%). In this group, symptoms were more frequent and more severe. Dyspeptic symptoms induced weight loss (12.7%) and absenteeism (12.4%), affected daily life (61.2%) and generated use of healthcare resources, such as medical consultations (61.4%) and medication (70.9%). Factor analysis revealed a three-component structure with factor 1 including fullness, bloating and early satiety, factor 2 including nausea and vomiting and factor 3 including discomfort, pain, belching and reflux. If forced in a four-factor model, the analysis separates belching as independent factor. Dyspeptic symptoms are frequent in the general population, with overlapping reflux symptoms and increased symptom burden in about a third.

Strongyloides Stercoralis infection associated with repititive bacterial meningitis and SIADH: a case report

Strongyloidiasis is an infection by the intestinal parasite Strongyloides Stercoralis, which usually stays asymptomatic. In some situations a hyperinfection or disseminated disease can occur. We report a case of a 49-year-old Congolese man with a medical history of 5 episodes of bacterial meningitis, who presents himself with a paralytic ileus and a low serum sodium. A Strongyloides hyperinfection with a syndrome of inappropriate secretion of the antidiuretic hormone (SIADH) was diagnosed. After treatment with ivermectine the abdominal symptoms subsided and the serum sodium returned to normal values. In comparison to other case reports our patient had no respiratory or gastrointestinal symptoms during the episodes of bacterial meningitis. Screening for Strongyloides stercoralis is indicated in patients with unexplained SIADH, bacterial meningitis or bacterial septicaemia, who originally come from endemic countries.

Use of sedation for routine diagnostic upper gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy Survey of National Endoscopy Society Members

BACKGROUND/AIMS

Sedation rates may vary among countries, depending on patients' and endoscopists' preferences. The aim of this survey was to investigate the rate of using premedication for routine diagnostic upper gastrointestinal (UGI) endoscopy in endoscopy societies, members of the European Society of Gastrointestinal Endoscopy (ESGE).

METHODS

We evaluated a multiple-choice questionnaire which was e-mailed to representatives of national endoscopy societies, which are members of the ESGE. The questionnaire had 14 items referring to endoscopy practices in each country and the representatives' endoscopy units.

RESULTS

The response rate was 76% (34/45). In 47% of the countries, less than 25% of patients undergo routine diagnostic UGI endoscopy with conscious sedation. In 62% of the responders' endoscopy units, patients are not asked their preference for sedation and do not sign a consent form (59%). Common sedatives in use are midazolam (82%), diazepam (38%) or propofol (47%). Monitoring equipment is not available 'in most of the endoscopy units' in 46% (13/28) of the countries. Though they were available in 91% of the national representatives' endoscopy units, they are rarely (21%) used to monitor unsedated routine diagnostic UGI endoscopy.

CONCLUSIONS

In about 50% of ESGE-related countries, less than 25% of patients are sedated for routine diagnostic UGI endoscopy. Major issues to improve include availability of monitoring equipment and the use of a consent form.

Hypophosphatemia and refeeding: a corrective or a preventive attitude?

Hypophosphatemia is a rare but potentially lethal complication of the refeeding of cachectic patients. Up until now a careful monitoring of the serum phosphor level was recommended and the deficit was corrected as needed. Illustrated by two case reports we propose the use of a preventive schedule in patients with a normal renal function. We show that preventively treated patients do not develop hypophosphatemia and thereby avoid serious complications such as sudden death. In the presence of normal kidney function we propose to administer phosphor at 2 x 10 mmol/day orally or between 10 and 30 mmol IV depending on the initial phosphor levels. Further treatment is then adapted to measured levels. In the presence of kidney malfunction we propose to keep the corrective schedule.

Video capsule endoscopy in small-bowel malignancy: a multicenter Belgian study

BACKGROUND AND STUDY AIMS

Early diagnosis of small-bowel tumors is crucial for therapy. Video capsule endoscopy has improved the diagnosis of small-bowel diseases, but data concerning the role of this technique in detecting small-bowel malignancy are scarce. The aim of this paper was to review all capsule endoscopy findings at Belgian hospitals, in order to evaluate the diagnostic yield of capsule endoscopy in the field of small-bowel malignancy.

PATIENTS AND METHODS

For this retrospective study, the seven Belgian academic hospitals where the device was being used were asked to review the findings obtained by means of video capsule endoscopy, and to collect information about the cases of small-bowel malignancy.

RESULTS

In total, 443 capsule endoscopies were performed up to November 2004, and 11 malignant small-bowel processes were detected (2.5%). The most frequent indications for performing capsule endoscopy in those 11 cases were intestinal bleeding of undefined origin or iron-deficiency anemia. The mean number of diagnostic procedures performed before capsule endoscopy was 3.6. The capsule endoscopy results had a diagnostic yield of 1.6% after classical work-up. In 55% of these cases, capsule endoscopy findings had an influence on therapy.

CONCLUSIONS

Tumors of the small bowel remain a rare condition. Video capsule endoscopy is able to detect tumors undiagnosed by classical procedures in about 1.6% of cases and has an impact on the therapy in 55% of the tumor cases.

Role of the Intrinsic Coagulation Pathway in Atherogenesis Assessed in Hemophilic Apolipoprotein E Knockout Mice

Objective— The contribution of thrombosis and coagulation in atherogenesis is largely unknown. We investigated the contribution of the coagulation intrinsic factor VIII (FVIII)–dependent pathway in atherogenesis.

Methods and Results— Apolipoprotein E and FVIII double–deficient mice (E°/FVIII°) were generated. Aortic root lesions were analyzed in 14-week-old and 22-week-old female mice maintained for 8 or 16 weeks, respectively, on a normal chow diet or a hypercholesterolemic diet.

Conclusion— Despite a higher plasma total cholesterol concentration compared with E° mice, E°/FVIII° mice developed dramatically less early-stage atherosclerotic lesions. Whereas early lesions in E° mice contained abundant fibrin(ogen) deposits on which few platelets adhered, lesions in E°/FVIII° were almost devoid of fibrin(ogen), and no platelets could be detected. The genotype effect on development and composition of lesions tended to decrease with time. This study demonstrates that the activation of the intrinsic pathway of coagulation is potently proatherogenic at the early stage of atherogenesis.

The early effect of proton pump inhibitor therapy on the accuracy of the 13C-urea breath test

BACKGROUND

The intake of proton pump inhibitors may interfere with the reliability of the urea breath test.

AIM

Prospective study to assess the accuracy of the urea breath test during the first days of therapy with proton pump inhibitors.

PATIENTS

Thirty patients who needed to start proton pump inhibitors therapy and 53 volunteers.

METHODS

A 13C-urea breath test was performed respectively before starting proton pump inhibitors therapy and every morning before its intake up until 10 days. The test was considered positive for values of 13CO2 > or = 3.0% delta over baseline. The coefficient of reproducibility for 95% interval of confidence of the urea breath test was calculated in both groups.

RESULTS

Of the 30 patients receiving proton pump inhibitors, 47% were positive for Helicobacter pylori. Among these, 43% developed false negative breath tests in the first 10 days. False positive results occurred in 37.5% of H. pylori-negative subjects in the first 10 days. The coefficient of reproducibility of the urea breath test was significantly higher in the group treated with proton pump inhibitors (11.0 versus 1.8 for the control group, p < 0.0001).

CONCLUSION

The intake of proton pump inhibitors impairs the accuracy of the 13C-urea breath test. False negative and false positive 13C-urea breath tests are common, occur as soon as after 1 day and increase with prolonged duration of treatment. The coefficient of reproducibility of the test in patients receiving proton pump inhibitors is not acceptable for clinical purpose and the test should not be performed once the medication has been started.

Expression of somatostatin receptors in normal and cirrhotic human liver and in hepatocellular carcinoma

BACKGROUND

Somatostatin analogues have been used with conflicting results to treat advanced hepatocellular carcinoma (HCC). The aim of this study was to investigate expression of somatostatin receptor (SSTR) subtypes in human liver, and to examine the effect of selective SSTR agonists on proliferation, apoptosis, and migration of hepatoma cells (HepG2, HuH7) and hepatic stellate cells (HSCs).

METHODS

Expression of SSTRs in cell lines, normal and cirrhotic liver, and HCC was examined by immunohistochemistry and reverse transcription-polymerase chain reaction. Effects of SSTR agonists on proliferation and apoptosis of tumour cells and HSCs were assessed by the 5-bromo-2' deoxyuridine and TUNEL methods, respectively. The influence of SSTR agonists on migration was investigated using Boyden chambers.

RESULTS

In normal liver, both hepatocytes and HSCs were negative for all five SSTRs. Cirrhotic liver and HCC as well as cultured hepatoma cells and HSCs expressed all five SSTRs, both at the protein and mRNA levels, except for HuH7 cells which did not immunoreact with SSTR3. None of the agonists influenced proliferation or apoptosis. However, compared with untreated cells, L-797,591, an SSTR1 agonist, reduced migration of HepG2, HuH7, and HSCs significantly to 88 (7)% (p<0.05), 83 (11)% (p<0.05), and 67 (13)% (p<0.01), respectively.

CONCLUSIONS

Cirrhotic liver and HCC express SSTRs. Although the somatostatin analogues used in this study did not affect proliferation and apoptosis, stimulation of SSTR1 may decrease invasiveness of HCC by reducing migration of hepatoma cells and/or HSCs. Clinical trials evaluating somatostatin analogues for the treatment of HCC should take these findings into account.

Is ambulatory 24-h dual-probe pH monitoring useful in suspected ENT manifestations of GERD?

BACKGROUND AND AIMS

The present study is aimed at assessing the relationship between ear, nose and throat manifestations and proximal reflux in gastro-oesophageal reflux disease by using 24-h dual-probe pH monitoring.

PATIENTS AND METHODS

Fifty-eight patients were included: (;) 28 patients with suspected ear, nose and throat manifestations of gastrooesophageal reflux disease: (ii) 18 patients with typical symptoms of gastro-oesophageal reflux disease without extraoesophageal manifestations of gastro-oesophageal reflux disease; (iii) 12 healthy volunteers. Ambulatory 24-h dual-probe pH monitoring was performed in all patients. Oesophagogastroscopy was performed in all patients of groups I and II. Ear, nose and throat examination was performed in all patients with ear, nose and throat complaints.

RESULTS

At the upper oesophageal sphincter, results of pH monitoring were significantly different between groups I and III (0.009 < P < 0.02) and between groups I and II (0.008 < P < 0.03). When comparing data at the lower oesophageal sphincter, we found a significant difference between groups II and III (0.002 < P < 0.009) and between groups I and III (0.001 < P < 0.002). Endoscopic examination of the oesophagus did not show any significant difference between groups I and II. Laryngoscopy was abnormal in 86% of the patients with ear, nose and throat symptoms.

CONCLUSIONS

Ambulatory 24-h dual-probe pH monitoring is useful in the assessment of patients with suspected ear, nose and throat manifestations of gastro-oesophageal reflux disease, especially in the case of abnormal laryngoscopy.

Treatment of acute diarrhoea: update of guidelines based on a critical interuniversity assessment of medications and current practices

Further to a thorough analysis of the problem of acute diarrhoea and the therapeutic options, recommendations were defined following a multidisciplinary approach. These guidelines take into account the reality of frequent self-medication. They further differ as a function of age (children, primarily treated by ORS and for whom self-medication is not advised versus adults who can self-medicate), symptoms (uncomplicated diarrhoea versus dysentery) and location where the diarrhoea is contracted (at home or when travelling).

Factor V inhibitor after injection of human thrombin (tissucol) into a bleeding peptic ulcer

Endoscopic injection of fibrin glue into a bleeding peptic ulcer is an effective and safe treatment modality. The present report describes a patient who developed rectal bleeding from an arteriovenous malformation after endoscopic injection of fibrin glue containing human thrombin into a gastric ulcer. Additional laboratory investigations revealed the presence of an inhibitor against coagulation factor V, which resulted in severe coagulopathy, triggering the bleeding. Acquired factor V inhibitors have frequently been reported with the use of bovine thrombin, but to our knowledge, they have never been documented in patients exposed to human thrombin. Endoscopists should be aware of this rare, but potentially serious, complication.

Influence of the physiological changes of gastric emptying on the simplified single sample 14 C-urea breath test

The aim of this study was to assess the influence of the physiological changes of gastric emptying on the simplified 14C-urea breath test. Thirty patients performed the test in fasting conditions. Patients were orally administered 0.074 mega Bq of 14C-urea, mixed with 0.0185 mega Bq of 99mTc-S colloids in 25 ml water. A breath sample was taken before and 10 min after intake of the tracers and followed by a 2 min planar anterior scintigraphic image of the abdomen to measure gastric activity. Gastric emptying was estimated by dividing the residual gastric activity at 10 min by the total activity in the abdomen. The procedure was performed twice for each patient after a 24 h interval. The repeatability of both the gastric emptying test and the urea breath test was assessed by the method described by Bland and Altman. The coefficient of repeatability of the urea breath test was 1.18 for a confidence interval of 95%. The coefficient of repeatability of gastric emptying was 27.4. There was no significant correlation (r= 0.08) between the plot of the individual modifications of urea breath test and residual gastric activity in two successive tests. It is concluded that the physiological changes of gastric emptying do not influence the results obtained by the simplified, single-sample 14C-urea breath test.

Somatostatin suppresses endothelin-1-induced rat hepatic stellate cell contraction via somatostatin receptor subtype 1

BACKGROUND & AIMS

Hepatic stellate cells (HSCs) are considered therapeutic targets to decrease portal hypertension. To elucidate some of the hemodynamic effects of somatostatin (SST) on portal pressure, the presence and function of SST receptors (SSTRs) on HSCs were investigated.

METHODS

SSTR messenger RNA expression, and SSTR presence was investigated using reverse-transcription polymerase chain reaction, real-time quantitative polymerase chain reaction, Western blotting, and immunohistochemistry. The function of SSTRs was studied by examining the effects of SST and specific SSTR agonists on endothelin-1(ET-1)-induced HSC contraction.

RESULTS

Specific amplicons for SSTR subtypes 1, 2, and 3 were demonstrated in rat liver and in activated HSCs. The presence of SSTR subtypes 1, 2, and 3 was confirmed by Western blotting. With immunohistochemistry, a strong staining of HSCs was obtained for SSTR subtypes 1, 2, and 3 in CCl4-treated rats, but not in normal rat liver. Incubation of HSCs on collagen gels with buffer, 10(-8) mol/L SST, and 2 x 10(-8) mol/L ET-1 resulted in collagen surface area decreases of 5.5% +/- 3.3%, 6.8% +/- 4.4%, and 49.8% +/- 8.3%, respectively. Relative contraction of gels preincubated with 10(-8) mol/L SST followed by 2 x 10(-8) mol/L ET-1 or vice versa as compared with maximal contraction (100%) with 2 x 10(-8) mol/L ET-1 were 72.6% +/- 17.9% and 76.2% +/- 12.6%, respectively (P < 0.05). SSTR agonist 1, but not SSTR agonist 2 or 3, was able to counteract the contractile effect of ET-1. CONCLUSIONA: Activated rat HSCs bear SSTR subtypes 1, 2, and 3. SST causes significant partial inhibition of ET-1-induced contraction of activated HSCs, mainly by stimulation of SSTR subtype 1.

Endoscopic Volume Adjustment of Intragastric Balloons for Intolerance

BACKGROUND

A new type of saline-filled, spherical-shaped balloon, which moves freely within the stomach, has been increasingly used as a tool to assist weight reduction. Balloon intolerance is an infrequent complication, characterized by continuous nausea and vomiting or abdominal pain, uncontrollable by medical therapy. This has usually been followed by puncture, deflation and extraction of the balloon.

METHODS AND RESULTS

We present 4 patients in whom intolerance was treated by endoscopic volume adjustment of the device. After partial defilling of the balloon, epigastric symptoms disappeared rapidly, while the patients respectively lost 5.2, 14.4, 5.9 and 15.8 kg of body weight at the end of the treatment. Practical recommendations are provided to ensure a successful endoscopic reintubation of the balloon's valve.

CONCLUSION

Early intolerance to an intragastric balloon can be successfully treated by endoscopic volume adjustment of the device.

Jaundice caused by a pancreatic mass: an exceptional presentation of Crohn's disease

It is well known that Crohn's disease can involve the pancreas. However, granulomatous inflammation of the pancreas causing jaundice is extremely rare. In this report, we describe a patient presenting with jaundice in whom a Whipple procedure was performed because of the suspicion of a malignant pancreatic tumor. However, on histologic examination a benign granulomatous pancreatic mass was found. Further investigations revealed no other organ involvement and no underlying disease could be identified. Therefore, the tentative diagnosis of an idiopathic inflammatory pseudotumor was made. Only 6 months later, when the patient developed bloody diarrhea, Crohn's disease was diagnosed. This case stresses that, especially in young patients, Crohn's disease should be included in the differential diagnosis of benign common bile duct strictures even if no other symptoms of Crohn's disease are present.

Importance of precise timing in the simplified 10-min 14C-urea breath test procedure

This study was performed to assess the impact of precise timing and the repeatability of the simplified 10-min 14C-urea breath test. Thirty-three patients underwent a 14C-urea breath test at 10 and 12 min (test I) and after 24 h (test II). The paired t-test was applied to assess differences between two successive measurements at 10 and 12 min, and the method of Bland and Altman was used to evaluate the repeatability of the test. Only test I (P = 0.004) showed a significant difference between two successive measurements at 10 and 12 min. The coefficients of repeatability at 10 and 12 min were 1.54 and 1.48, respectively. No bias was found. From this study, we can conclude that breath collections, delayed by 2 min (20% error), have no impact on the clinical interpretation of the results. The repeatability of the simplified 10-min 14C-urea breath test is sufficient for clinical use.

PH monitoring in the distal and proximal esophagus in symptomatic infants

BACKGROUND

Standard distal esophageal pH monitoring data are sometimes within normal ranges in children with clinically suspected gastroesophageal reflux disease. Therefore, the authors hypothesized that the amount of acid reflux reaching the proximal esophagus may be greater in some subgroups of patients than in healthy controls or in other subgroups of patients.

METHODS

The parameters of 24-hour pH monitoring in the proximal part of the esophagus were analyzed in 120 symptomatic infants in who the reflux parameters in the lower esophagus were clearly within normal ranges (reflux index < 5.0%). The infants were classified into four patient groups: excessive regurgitation (n = 41): inconsolable crying (n = 31), apparent life-threatening event (ALTE) (n = 18), and chronic respiratory disorders (n = 30). The control group consisted also of 120 infants. The following parameters were calculated: reflux index, the number of reflux episodes, the number of reflux episodes lasting longer than 5 minutes, the duration of the longest reflux episode, and the acid clearance time (ACT, duration of reflux episodes divided by number of reflux episodes).

RESULTS

The patients with chronic respiratory disorders were significantly older than the patients in the other groups and the controls. In the distal esophagus, there was no statistically significant difference between the reflux parameters. As could be expected, every parameter was statistically (paired t test, Wilcoxon signed-rank test) significantly smaller in the proximal than in the distal esophagus, except for the ACT in infants who presented with inconsolable crying. In the proximal esophagus, there was no statistically significant difference between the different patient subgroups or controls, except for the number of reflux episodes in the group with chronic respiratory disorders and the group with inconsolable crying, applying one-way analysis of variance. As determined by applying the Mann-Whitney test, the number of reflux episodes in the upper esophagus was significantly higher in the group with chronic respiratory disorders than in the other patient groups and controls. Therefore, the authors' data do not support the hypothesis that reflux reaching the proximal esophagus is a frequent cause of ALTE. However, the data may suggest that the number of reflux episodes reaching the proximal esophagus in children with chronic respiratory disorders and with distal pH monitoring data within normal ranges may be increased. Whether this finding reflects reality or a statistical coincidence, or is influenced by the older age of this patient group, needs further evaluation.

CONCLUSIONS

In theory, dual simultaneous esophageal pH monitoring in the distal and proximal esophagus may increase the diagnostic accuracy of pH monitoring in infants. Our results do not support a substantial advantage of a systematic application of this new technique, especially not in infants presenting with ALTE, excessive regurgitation, or inconsolable crying. In the subgroup of patients with chronic respiratory disorders, more data are needed before conclusions can be determined and recommendations can be made.

Cut-off point, timing and pitfalls of the 13C-urea breath test as measured by infrared spectrometry

BACKGROUND

The best timing and the best cut-off level of the 13C-urea breath test have not yet been well established.

AIMS

To evaluate the cut-off value and the influence of medication on the 13C-urea breath test as measured by infrared spectrometry.

METHODS

A series of 223 patients, sent for endoscopy performed 13C-urea breath test in fasting conditions with 75 mg of 13C-urea and 20 ml of citric acid. Breath samples were collected before and then 10, 20, 25 and 30 minutes after ingestion. As gold standard, histological examination of gastric biopsies was used. A questionnaire was completed concerning the intake of medication, likely to influence the test, in the 2 months preceding the test. Sensitivity, specificity, positive predictive value and negative predictive value at 10, 20, 25 and 30 minutes at different cut-off values (3, 3. 5, 4, 4. 5, 5.0 0/00 DOB] were calculated.

RESULTS

A total of 182 patients did not take medication. There was no significant difference between the different cut-off levels at different times. Compared with the group of 41 patients who did take medication, likely to influence the test, the differences were significant (Fisher exact test).

CONCLUSION

There was no significant difference between the different cut-off values. A 10-minute test with a cut-off level between 4 and 5% delta over baseline (sensitivity: 100%, specificity: 95%) is, therefore, proposed. To avoid false negative results due to unknown intake of medication, every patient submitted to the 13C-urea breath test should fill out a questionnaire.

Evaluation of the 13C-aminopyrine breath test using nondispersive infrared spectrometry

OBJECTIVE

The aim of the study was to assess the value of the 13C Aminopyrine Breath Test (ABT) when performed using the NonDispersive InfraRed Spectrometry (NDIRS), which is a simple and cheap alternative to the mass spectrometry.

METHODS

The results obtained by using the NDIRS method for performing the ABT were compared to the results obtained by a reference method, the 14C Aminopyrine Breath Test. For this purpose, in 32 patients admitted for various liver problems, an ABT was performed by using the 2 methods simultaneously. The repeatability of the results obtained at 120 minutes by the NIDRS method as compared to the 14C test was assessed by the method of Bland and Altman.

RESULTS

The mean of difference between the results obtained by both methods at 120 minutes was 0.06 +/- 0.46. The coefficient of repeatability between the two tests was 0.92 for a confidence interval of 95%. A good correlation (r = 0.93) was found between all individual results obtained in breath samples at different times of collection (30, 60, 90, 120 minutes), and between the results obtained at 120 minutes for both 13C and 14C tests (r = 0.94).

CONCLUSION

The 13C ABT performed using NDIRS is a valid alternative to the 14C technique in routine clinical practice.

[Cyanosis and cirrhosis of liver: hepatopulmonary syndrome]

A 66-year-old man with Child-B alcoholic cirrhosis presented with melaena due to hemorrhagic gastritis. Clinical examination revealed cyanosis and clubbing accompanied by severe hypoxaemia without signs of obstructive or restrictive lung disease. Contrast-enhanced echocardiography showed right to left shunt due to intrapulmonary shunting leading to the diagnosis of hepatopulmonary syndrome. Hypoxaemia in patients suffering from chronic liver disease can have different causes but in the presence of cyanosis and clubbing without signs of lung disease the hepatopulmonary syndrome should be suspected. When presence of intrapulmonary shunts has been proven by contrast-enhanced echocardiography, a 100% oxygen test can determine the need for pulmonary angiography and thus determine the indication for interventional therapy or liver transplantation. The patient described was treated supportively with long-term oxygen therapy 6 l/min. Three months later his clinical condition was stable. An attempt to reduce the need for nasal oxygen failed.

13C urea breath test with nondispersive isotope-selective infrared spectrometry: reproducibility and importance of the fasting status

BACKGROUND

The 13C urea breath test (13C-UBT) is the most convenient method for diagnosing Helicobacter pylori infection noninvasively. Nondispersive isotope-selective infrared spectrometry (NDIRS) is an inexpensive and easy alternative to mass spectrometry. The objective of this study was to evaluate: (1) the reproducibility of the 13C-UBT as performed by using the NDIRS method; (2) the repeatability of bags analysis and the impact of delayed analysis; and (3) the need for fasting status for the 13C-UBT.

METHODS

The 13C-UBT was performed with 75 mg urea labeled with 13C, with breath samples collected at times 0 and 30 minutes. Results are expressed as delta over baseline (0/00). Fifty-three patients underwent two successive 13C-UBTs with an interval of 48 to 72 hours. The 106 collected bags were randomly reanalyzed immediately or 72 hours later. In 26 volunteer subjects, the 13C-UBT was performed both in a fasting condition and after a nonstandardized meal. The reproducibility was assessed by the method of Bland and Altman.

RESULTS

The mean of difference between two successive tests was 0. 14 0/00 (standard deviation, 0.90), and the coefficient of repeatability was 1.80 (confidence interval, 95%). The difference between two successive analyses was always less than 2.2% of the initial value. The coefficient of variation between two successive tests for the influence of a meal was 11.24.

CONCLUSION

The 13C-UBT as performed by using NDIRS is reproducible, analyses can be delayed up to 72 hours, and the test must be performed in fasting conditions.