Applicability and efficacy of qualifying criteria for an appropriate use of diagnostic upper gastrointestinal endoscopy.

UNLABELLED: Appropriate indication for upper gastrointestinal endoscopy (UGE) may be facilitated by referring to qualifying criteria such as those devised by the European Panel (EPAGE) and French Experts (ANAES). This prospective study evaluates the applicability and efficacy of these criteria in clinical practice. PATIENTS AND METHODS: A total of 522 patients was included (55% inpatients, 57% male, mean age 55 years). Appropriateness of referral was evaluated using EPAGE and ANAES criteria sets by a single independent expert. RESULTS: EPAGE criteria were applicable in 71% of cases. Indications for UGE were appropriate, inappropriate and uncertain in 62%, 27% and 11% respectively; 74%, 16% and 10% of clinically significant lesions detected by UGE were disclosed in patients having appropriate, inappropriate and uncertain indications respectively. ANAES criteria were applicable in 81% of cases. Indications for UGE were appropriate in 74%, inappropriate in 26%; 76% and 24% of clinically significant lesions detected by UGE were disclosed in patients having appropriate and inappropriate indications respectively. Whatever the criteria set used, all cancers and most of the severe lesions were observed in patients with appropriate indications: those patients were more often in-patients and were significantly older than patients belonging to the inappropriate group. CONCLUSION: Reference to EPAGE and ANAES qualifying criteria facilitates patient selection for UGE. Final decision must however rely upon practitioner advice. ANAES criteria are significantly more often applicable than EPAGE ones. However EPAGE referential when applicable is more predictive of the UGE findings.

[The gastric antrum: a rare primitive location of a gastrinoma within a type I multiple endocrine neoplasia]. / L'antre gastrique, localisation primitive exceptionnelle d'un gastrinome dans le cadre d'une néoplasie endocrine multiple de type I.

We report the case of an 18-year-old man, with no previous medical history, presenting with recurrent hemorrhagic duodenal ulcers revealing a Zollinger-Ellison syndrome. The initial diagnosis of sporadic gastrinoma of the antrum associated with satellite lymph nodes led to surgical treatment. The evolution of clinical and secretory tests associated with the outbreak of a primary hyperparathyroïdism demonstrated that the patient had a type I multiple endocrine neoplasia. To our knowledge, this is the first described case of primitive gastrinoma of the antrum occurring in a type I multiple endocrine neoplasia.

Long-term efficacy of radionuclide therapy in patients with disseminated neuroendocrine tumors uncontrolled by conventional therapy.

UNLABELLED: Therapeutic options in patients with advanced-stage gastroenteropancreatic (GEP) neuroendocrine tumors are limited. We compared the efficacy of radionuclide therapy with 111In-pentetreotide and 131I-metaiodobenzylguanidine (MIBG) in 20 patients (group A) with the outcome of similar patients who could not be treated for nonmedical reasons (group B, n = 12). The intent was to treat all patients because of uncontrolled tumor disease (n = 21), contraindication to chemotherapy or surgery (n = 7), or uncontrolled and badly tolerated clinical symptoms (n = 4). METHODS: Group A patients received 3 monthly administrations of 3.7-7.4 GBq of 131I-MIBG (n = 5) or 7 GBq of 111In-pentetreotide (n = 15), according to the best tracer uptake. Clinical evaluation, biologic tests, and conventional imaging were performed at 3, 6, 12, 18, and 24 mo. Therapy was considered beneficial if clinical status improved, laboratory tests for secreting tumors improved by >20%, tumor progression was halted, the size of the most significant localization had decreased by >25%, and the dosage of analgesic and cold somatostatin therapy could be lowered. Pejorative events were defined as side effects due to therapy, relapse in clinical symptoms, tumor progression, tumor laboratory marker increase, and death. RESULTS: The overall survival rate at 3 mo was significantly higher in group A (P = 0.05). Radionuclide therapy was beneficial in 14 patients (73% of group A), with only 1 significant side effect. The average time before relapse was 16.1 +/- 7.8 mo. The overall Kaplan-Meier survival rate and cumulative progression-free and cumulative event-free survival rates during the first 15 mo were significantly higher in patients receiving radionuclide therapy (P = 0.019, P = 0.024, and P = 0.019, respectively). CONCLUSION: Radionuclide therapy is feasible and safe and significantly defers the occurrence of fatal and nonfatal events in patients clinically uncontrolled by conventional therapy.

[Diagnostic and therapeutic strategies in Zollinger-Ellison syndrome associated with multiple endocrine neoplasia type I (MEN-I): experience of the Zollinger-Ellison Syndrome Research Group: Bichat 1958-1999]. / Stratégie diagnostique et thérapeutique du Syndrome de Zollinger-Ellison associé à une néoplasle endocrine multiple de type I (NEM I): l'expérience du Groupe d'Etudes et de Recherches sur le Syndrome de Zollinger-Ellison (GRESZE): Bichat 1958-1999.

About 25% of patients with ZES have MEN 1. Except diarrhoea, less frequent in patients with ZES-MEN 1 than in sporadic ZES, and specific MEN 1-related signs, clinical characteristics are similar in both ZES types. Acid output and gastrin levels are also similar whether in the basal state or after secretin stimulation. Primary hyperparathyroidism (PHPT) exists in the majority of ZES-MEN 1 patients, 30% have pituitary adenoma (prolactinomas for half), 30% adrenal involvement, 25 to 30% have EC-Lomas; bronchial and thymic carcinoids have probably been underevaluated. Gastrinomas are multiple predominantly located in the duodenal wall, but also in the pancreas in association with clinically silent endocrine tumors. The spread of the disease: metastases to the liver (LM), mediastinum, bones, is evaluated at best by Octreoscan. Endoscopic ultrasonography evaluates the number, size and anatomical characteristics of gastrinomas. Patients without LM have an excellent prognosis. Surgery never cures ZES, but is necessary in case of associated life-threatening condition such as insulinoma and has been advocated to prevent LM development in patients with large pancreatic tumor(s). However although, indeed, the size of the tumor, when located in the pancreas > 3 cm, favours metachronous LM occurrence, surgery, in our experience, has not been able to prevent LM development. Hepatic malignancies remain however the most pejorative prognostic determinant for survival and raise the most difficult therapeutic challenge. Surgery is the best option whenever feasible; specific chemotherapy and chemo-embolisation have not conclusively achieved definite successes. Long-term octreotide treatment, however, has been shown recently to obtain tumour stabilisation. Internal irradiation with 90 Ytrium-labelled octreotide is a new promising option, presently under evaluation (Novartis European trial). Preliminary results are promising.

Detection of neuroendocrine tumors: 99mTc-P829 scintigraphy compared with 111In-pentetreotide scintigraphy.

UNLABELLED: The aim of this study was to evaluate the diagnostic value of a new somatostatin analog, 99mTc-P829, compared with that of 111In-pentetreotide. METHODS: Forty-three patients (32 men, 11 women; age range, 24-78 y; mean age, 56 y) with biologically or histologically proven neuroendocrine tumors were prospectively included: 11 patients with Zollinger-Ellison syndrome, 16 patients with carcinoid tumors, and 16 patients with other types of functioning (n = 6) or nonfunctioning (n = 10) endocrine tumors. 111In-Pentetreotide planar images (head, chest, abdomen, and pelvis) were obtained 4 and 24 h after injection of 10 microg somatostatin analog labeled with 148 +/- 17 MBq 111In, and SPECT was performed 24 h after injection. Similar (99m)Tc-P829 planar images were obtained at 1, 4-6, and 24 h after injection of 50 microg peptide labeled with 991.6 +/- 187.59 MBq 99mTc. Abdominal SPECT was performed 4-6 h after injection. RESULTS: 111In-Pentetreotide detected 203 tumoral sites in 39 (91%) of 43 patients, whereas 99mTc-P829 detected 77 sites in 28 (65%) of 43 patients (P < 0.005). In the liver, 129 sites (in 24 patients) were detected by 111In-pentetreotide scintigraphy and 34 sites (in 10 patients) were detected by 99mTc-P829 scintigraphy. CONCLUSION: In patients with endocrine tumors, the detection rate of 99mTc-P829 scintigraphy was lower than that of 111In-pentetreotide scintigraphy, which appeared to be more sensitive, especially for liver metastases.

Effect of pantoprazole versus other proton pump inhibitors on 24-hour intragastric pH and basal acid output in Zollinger-Ellison syndrome.

AIM: In this open prospective study, the efficacy of pantoprazole in reducing gastric acid secretion in Zollinger-Ellison syndrome patients was compared to that obtained previously with other proton pump inhibitors. METHODS: Eleven male patients previously treated with omeprazole (n=7, mean dosage: 63 mg/day; range: 20-100 mg/day) or lansoprazole (n=4, mean dosage: 75 mg/day; range: 30-120 mg/day) were included. These patients underwent a 24-hour intragastric pH-metry, measurement of basal acid output and of serum gastrin first while receiving their usual therapy and second after 7 to 10 days of pantoprazole treatment at a mean dosage of 116 mg/day (range: 40-200 mg/day). Basal acid output was evaluated after each intragastric pH-metry, one hour before the next intake of proton pump inhibitor and a serum gastrin curve was determined according to 9 fixed time points. RESULTS: One patient dropped out before the second intragastric pH-metry due to an adverse event (varicella) unrelated to pantoprazole and was reinvestigated thereafter. The median 24-h intragastric pH with pantoprazole was not significantly different than that with the other proton pump inhibitors (5.3 versus 4.6, respectively; P=0.90). Neither the median basal acid output values nor the median serum gastrin levels were significantly different between pantoprazole and the other proton pump inhibitors. CONCLUSION: In these patients with the Zollinger-Ellison syndrome, pantoprazole was well tolerated and equally effective to the other proton pump inhibitors in terms of antisecretory potency.

Anal fissure and thrombosed external hemorrhoids before and after delivery.

PURPOSE: Thrombosed external hemorrhoids and anal fissures are common and are responsible for severe discomfort during childbirth. However, the real incidence of these lesions is unknown. The aim of our study was to evaluate their incidence and the risk factors for these lesions during childbirth. METHODS: A prospective study with proctologic examination during the last 3 months of pregnancy and after delivery (within 2 months) was performed in 165 consecutive pregnant females. RESULTS: Fifteen females (9.1 percent) with anal lesions (13 thrombosed external hemorrhoids and 2 anal fissures) were observed during pregnancy. Fifty-eight females (35.2 percent) with anal lesions (33 thrombosed external hemorrhoids and 25 anal fissures) were observed during the postpartum period. Ninety-one percent of thrombosed external hemorrhoids were observed during the first day after delivery, whereas anal fissures were distributed, with no peak, over the two months after delivery. The 2 independent risk factors for anal lesions (among obstetric, baby's, and mother's information) were dyschezia, with a 5.7 odds ratio (95 percent confidence interval, 2.7-12), and late delivery, with a 1.4 odds ratio (95 percent confidence interval, 1.05-1.9). Furthermore, many thrombosed external hemorrhoids were observed after superficial perineal tears and heavier babies (P < 0.05). Only 1 of the 33 patients with thrombosed external hemorrhoids who were observed underwent a cesarean section. CONCLUSION: One third of females have thrombosed external hemorrhoids or anal fissures in the postpartum period. The most important risk factor is dyschezia. Traumatic delivery appears to be associated with thrombosed external hemorrhoids.

Putative effect of Helicobacter pylori and gastritis on gastric acid secretion in cat.

Helicobacter pylori may increase or inhibit gastric acid. We studied acid variations and plasma gastrin in cats harboring Helicobacter felis, harboring H. pylori, or free of gastric pathogens with reference to thioperamide (H(3) receptor antagonist) and SR-27417A (PAF receptor antagonist). In cats harboring H. felis, gastric mucosa were histologically normal. After H. felis eradication, pentagastrin-stimulated acid secretion was increased (40%) compared with the situation before eradication. Thioperamide abolished this inhibitory effect of H. felis, whereas SR-27417A did not. Basal and meal-stimulated plasma gastrin levels were not affected by eradication therapy. Acid secretion was inhibited (-80%) in week 3, increased from weeks 5 to 9, and remained constant for up to 42 weeks after H. pylori infection. SR-27417A had no effect on acid secretion before week 8 but inhibited it thereafter, and thioperamide increased it (20%) only before week 7 in those cats. Helicobacter inhibits gastric acid via an H(3) receptor pathway. Inflammatory mediators are thus involved in adaptation to the inhibitory effects of H. pylori on acid secretion.

El humanismo médico: un reto para el tercer milenio ¿Hay que enseñarlo? ¿Como? / Medical humanism, a challenge for the third millenium. Should it be taught? How?

El humanismo médico está en peligro, su preservación es un reto para los siglos venideros. Intentaré en nombre del "Círculo André Lambling" (Círculo de Humanismo y de Etica que fundamos hace más de 15 años en recuerdo de nuestro maestro, el profesor André Lambling, Jefe de Servicio de Hepatogastroenterología del Hospital Bichat durante muchos años) mostrar por qué el humanismo médico debe ser uno de los ejes de reflexión de un buen Médico Clínico y por qué, a mi manera de ver, se encuentra amenazado