Non-endoscopic diagnosis of multifocal atrophic gastritis; efficacy of serum gastrin-17, pepsinogens and Helicobacter pylori antibodies

BACKGROUND/AIMS

Infection with H. pylori is an important risk factor for the development of gastric cancer and glandular atrophy is an intermediate stage in gastric carcinogenesis. While screening the patients with atrophic gastritis by endoscopy is unrealistic, a concept of "serological gastric biopsy" based on measurement of gastric secretory proteins and peptides should be further validated. We sought to determine if the laboratory panel composed of serum PGI and protein stimulated gastrin-17 might select patients with MAG, and what is diagnostic significance of H. pylori serology in population of high prevalence of H. pylori infection.

MATERIAL AND METHODS

55 consecutive patients of both sexes (M/F 25/30; range of age 55 -81 years) were referred for gastroscopy with antrum and corpus mucosal biopsies. Patients with histological signs of glandular atrophy at any site of the stomach were considered to have multifocal atrophic gastritis. A first blood sample was collected for measurement of basal gastrin-17, pepsinogens and H. pylori IgG-antibodies, and second was taken 20 minutes after use of protein-rich drink to measure stimulated gastrin-17.

RESULTS

Signs of mucosal atrophy were found in 19 patients, while 29 patients showed non-atrophic gastritis and seven H. pylori-negative patients had no histological pathology. Low serum level of stimulated gastrin-17 (< 5 pmol/l) and/or pepsinogen I (< 50 microg/l), were found in 16 of 19 patients (84.2%) with and in 7 of 36 patients (19.4%) without atrophy in the histological study. Combining of H. pylori serology with serum levels of secretory peptides had no significant effect on diagnostic sensitivity of the test panel.

CONCLUSION

The test panel composed of pepsinogen I and protein stimulated gastrin-17 may be used as the "serological gastric biopsy" detecting multifocal atrophic gastritis. The diagnostic sensitivity of this test panel is not increased by knowledge of H. pylori status.

Even young patients with no alarm symptoms should undergo endoscopy for earlier diagnosis of gastric cancer

BACKGROUND AND STUDY AIMS

There has been a tendency in recent years to omit endoscopy in dyspeptic patients younger than 45 years with no so-called "alarm symptoms." This study was conducted to test whether this policy might lead to an increased rate of delayed diagnosis of gastric cancer, especially in a population with a high prevalence of the disease.

PATIENTS AND METHODS

The study included 860 patients (465 women, 395 men; median age 44) referred for the first time for upper gastrointestinal endoscopy because of suspected upper gastrointestinal pathology, to a secondary referral center between 1983 and 1993. Symptoms were assessed using a special questionnaire prior to endoscopy. The endoscopic diagnosis was always confirmed by histology.

RESULTS

Gastric cancer was found in 83 patients (12 early cancers, 71 advanced). Patients with cancer were predominantly male (68 %, compared with 44 % in the no-cancer group; P < 0.001), and significantly older (median age 56, 44 and 42 years for advanced, early cancer, and no cancer, respectively; P < 0.001). As many as 24 % of patients with cancer were aged under 45 years. Symptoms occurring more frequently in the gastric cancer group compared with the no-cancer group were weight loss (11 % vs. 0.1 %; P < 0.001), gastrointestinal bleeding (18 % vs. 8 %; P < 0.001), anorexia (43 % vs. 25 %; P < 0.001), and fatigue (53 % vs. 30 %; P < 0.001). In 27 % of cancer patients none of the above symptoms was observed. No statistical difference was seen for pain, nausea, vomiting, and other symptoms. The mean symptom score (1 point for one symptom) was higher in patients with cancer compared with those without (3.1 vs. 2.4; P < 0.001). The duration score (1 to 4 points for durations of less than 6, less than 12, less than 24, and more than 24 months) was lower (1.3 vs. 1.8; P < 0.001) in cancer patients. In three-quarters of cancer patients the duration of symptoms was shorter than 6 months.

CONCLUSIONS

Symptoms suggesting gastric cancer are gastrointestinal bleeding, weight loss, and to a lesser degree anorexia and fatigue. Gastric cancer patients show a greater intensity but shorter duration of symptoms than patients with no cancer. Age and alarm symptoms cannot determine the need for upper gastrointestinal endoscopy, at least in areas of high prevalence of gastric cancer.

Neuroendocrine pancreatic carcinoma causing sinistral portal hypertension

BACKGROUND

Non-functioning neuroendocrine pancreatic tumors are usually connected with non-specific syndromes.

CASE REPORT

This case history presents the diagnosis and treatment of a non-functioning neuroendocrine pancreatic tumor causing sinistral portal hypertension and gastrointestinal bleeding in a 36-year-old man.

RESULTS

A peripheral resection of the pancreas with splenectomy was performed. Intraoperative examination of the specimen revealed a malignant neoplasm, probably neuroendocrinal carcinoma.

CONCLUSIONS

Peripheral resection of the pancreas with splenectomy treats not only the symptoms of segmental portal hypertension caused by pathology of this organ, but also allows the etiology of the disease to be determined.

Neurogenic tumors of the digestive tract: report of two cases

We report two female patients with neurogenic tumors of the digestive tract. In the first patient, the tumor of 10 cm diameter originated in the stomach and at preoperative CT imitated a peripancreatic cyst. In the second patient, the tumor of 6 cm diameter originated in the duodenum. Despite large size, the tumors were clinically indolent and escaped detection at routine endoscopic evaluation. In both cases the neoplasm was removed and postoperative histopathology combined with immunohistochemistry was consistent with diagnosis of digestive Schwannoma.

[Endoscopic ultrasonography in the preoperative localization of a pancreatic tumor producing insulin (insulinoma)]

Pancreatic endocrine tumors include insulinomas, gastrinomas and some other less frequent neoplasms produce different GI hormones. Preoperative localization of the tumor in patients with evident clinical and biochemical features is usually difficult to obtain in conventional imaging methods. This is due to typically small size of these tumors. Non-invasive methods (conventional ultrasound, computerized tomography, nuclear magnetic resonance, positron emission tomography) and invasive methods (visceral angiography, portal veins catheterization) are often of no use in such condition, as their sensitivity is low. Preoperative localization is of importance for the surgeon, as he can plan his operation for reducing the length of the procedure with obvious consequences. This paper describes for the first time on Polish literature the usefulness of endoscopic ultrasonography in preoperative assessment of insulinoma in one patient. This finding was confirmed during surgery. The operation led to enucleation of two small insulinomas in the head of the pancreas and resulting in complete healing of the patient as found in one year follow up.

Effect of propranolol on portosystemic collateral circulation estimated by per-rectal portal scintigraphy with technetium-99m pertechnetate

BACKGROUND/AIMS

Propranolol is widely used in the prevention of variceal bleeding. However, in certain patients with cirrhosis, the portal hypotensive effect of propranolol cannot be obtained. An explanation for portal unresponsiveness to propranolol could be an increase in portocollateral vascular resistance mediated by this drug.

METHODS

In 33 patients with cirrhosis the effect of chronic administration of propranolol on portocollateral blood flow from the inferior mesenteric vein was examined by means of per-rectal portal Tc-99m pertechnetate scintigraphy.

RESULTS

Propranolol significantly reduced the shunt index by 15.3 +/- 4.2%. This reduction was observed only in patients with cirrhosis classified as Child-Pugh A and B groups, but not group C. Differences between groups in portosystemic shunt index changes after propranolol were significant (F = 3.4, p < 0.05).

CONCLUSIONS

The data presented suggest that propranolol changes the distribution of blood between the portal and systemic circulation, which is probably due to the increase in vascular resistance of portocollateral vessels. The magnitude of the vascular response to propranolol depends on the severity of liver disease.

[Per-rectal scintigraphy of the portal system with pertechnetate TC-99M: effect of propranolol on portosystemic collateral circulation in patients with cirrhosis. Part II]

Propranolol can reduce portal hypertension, therefore is recommended in prevention of variceal bleeding in patients with liver cirrhosis. However, in certain patients with cirrhosis portal hypotensive effect of propranolol cannot be obtained, and the reason of this finding is unknown. In 28 patients with cirrhosis the effect of seven days administration of propranolol on collateral blood flow from inferior mesenteric vein was examined by means of per-rectal portal scintigraphy. Portosystemic shunt index was significantly reduced by propranolol by 17.4 +/- 4.8%. This reduction was observed in cirrhotics classified to A and B, but not C Child-Pugh. These data suggest that propranolol increases vascular resistance in portosystemic circulation which depends on severity of liver failure. This mechanism opposes reduction of portal pressure.

[Per-rectal scintigraphy of the portal system with pertechnetate TC-99M: clinically useful examination of patients with chronic liver disease.Part I]

Per-rectal portal scintigraphy with Tc-99m pertechnetate is a method to evaluate portosystemic shunting (shunt index) in inferior mesenteric vein. In this study the shunt index was estimated in patients with chronic liver disease in relation to the severity of liver injury, portal hypertension and incidence of oesophageal varices. Shunt index was elevated in patients with non-cirrhotic liver disease as compared with healthy normals (34 +/- 6% vs 8 +/- 2%; p < 0.0005). Moreover, patients with cirrhosis had the shunt index of 65 +/- 4% which was higher than in other groups. There was no correlation of the shunt index to the Child-Pugh classification, hepatic venous pressure gradient and varices size in the cirrhotic patients. Conversely, the shunt index differentiated variceal bleeders from non-bleeders (80 +/- 4% vx 59 +/- 6%; p < 0.005). These data show that peripheral collateral circulation develop in response to mild elevation of portal pressure, but its hemodynamic efficacy to alleviate portal hypertension seems to be unremarkable. High shunt index might reflect elevated risk of bleeding from varices.

[Cystic hepatic malignant tumors]

Non-parasitic hepatic cysts are common finding at abdominal sonography and in vast majority they are benign lesions. We report two cases of cystic liver neoplasms, namely the biliary cystadenocarcinoma and malignant hemangioendothelioma. In both cases, despite slow development of the tumour the presence of cyst considerably delayed diagnosis and hindered surgical treatment. We believe that more aggressive approach in "atypical" hepatic cysts could improve prognosis in such cases.

[Angiomatosis of the liver]

Cavernous haemangioma of the liver is the most frequently observed benign hepatic tumour. Polyangiomatosis is a great rarity, and in view of the similarity to metastatic tumours, it is a serious diagnostic problem. In the paper three cases are described of polyangiomatosis of the liver diagnosed on the basis of abdominal ultrasonography. Final diagnosis was made analysing USG, CT, scintigraphy with labelled erythrocytes, and laparoscopy. In all described cases, despite significant enlargement of the liver containing multiple hemangiomas, no features indicating liver damage were found in the laboratory investigations. This seems to be an important diagnostic indicator in the diagnosis of this disease.

[Evolution of cutaneous changes observed in cirrhosis patients before and after liver transplantation]

In 11 patients with liver cirrhosis a prospective study concerning the evolution of skin changes before and after liver transplantation was performed. Etiology of the disease was: alcoholic in 5 cases, post-inflammatory in 4 cases and primary biliary cirrhosis in 2. Evolution of: nevi spiders, erythema palmar, changes in nails, Hippocrates fingers, discoloration of legs, bilateral Dupuytren's disease and gynecomastia (in man) were estimated. At the same time sex hormones levels were measured. One month after liver transplantation a reduction of total spiders number as well as the frequency of the erythema palmare and nails changes was observed. During the next few months we observed disappearance of the legs discoloration and signs of gynecomastia and Hippocrates fingers. Only the Dupuytren's contractures remained unchanged. There was no correlation between sex hormones levels and skin changes except decrease of the total testosterone level (p < 0.05) and an increase of free testosterone to total testosterone ratio (p < 0.02) in women and a decrease of estradiol level (p < 0.02) in women and a decrease of estradiol level (p < 0.002) in men after operation.

CONCLUSION

skin changes typical for liver cirrhosis can be reversible after liver transplantation.

[Diagnostic difficulties in prajmaline-induced intrahepatic cholestasis]

A case of prajmalium-induced intrahepatic cholestasis is presented. A proper diagnosis was delayed because differential diagnosis did not include toxic liver damage. Pathogenetic considerations included immunological background of the disease which improved completely within one year. No clinical and biochemical complications were seen.

[Fibrosing cholangiolitis after administration of methyltestosterone]

A case of intrahepatic cholestasis of great intensity was observed in a patient taking methyltestosterone. In histological examination of liver biopsy specimen evidence was found of fibrosing intralobular cholangiolitis. The histological findings and the clinical course are discussed considering the disease as an atypical liver reaction to methyltestosterone.

[Usefulness of the evaluation of blood supply and mass of the liver for predicting the rate of pharmacokinetics of lidocaine, propranolol and phenazone]

A group of patients with hepatocirrhosis were studied for the speed of liver elimination of lidocaine iv (n = 11), propranolol per os (n = 8) and phenazone per os (n = 19); they were also studied for blood supply in liver by means of sequential hepatoscintigraphy. Ultrasonography was used to evaluate the portal system and collaterals of the collateral circulation, endoscopy was used to evaluate the size of oesophageal varices, lateral projection of scintigraphic picture made it possible to calculate the liver mass. The half-life of propranolol and lidocaine in the initial phase of elimination correlated with the degree of portal-arterial disorders in liver blood supply. Propranolol bioavailability correlated with the diameter of the portal vein and was dependent on the size of oesophageal varices and the presence of cavernous transformation of the portal vein. No correlation was found between hepatic clearance of phenazone and vascular pathology of cirrhotic liver, but positive correlation was found between clearance and liver mass. Morphological and functional examinations of the vascular system of the cirrhotic liver were of greater predicative value for the evaluation of the pharmacokinetics of drugs than clinical progression of hepatocirrhosis in the Child-Turcott classification.

Circadian rhythms of four marker enzymes activity of the jejunal villi in man

Bioptic specimens taken from the lower duodenum were studied in 12 volunteers at different times of the day for the activity of 4 marker enzymes. The activity of alkaline phosphatase in brush border of villi was the strongest at 06h, while the nadir at 22h; acid phosphatase activity in the supranuclear zone and in macrophages was the strongest at 06h and reduced at other test times; the peak activity of 5' nucleotidase was found at 14h with the nadir at 02h; activity of NADPH was the strongest at 18h. It is suggested that circadian rhythmicity of intestinal function exists in man like in animals.