Severe gastritis in the Peruvian Andes.

OBJECTIVE: To compare the Helicobacter pylori-associated pathology in gastric biopsies taken from patients living at sea level with those taken from patients living at high altitude. METHODS AND RESULTS: We included 38 patients from a hospital in the Andean city of La Oroya, Peru, located at 3700 m in altitude, and 40 control patients taken from Comas Clinic located in the city of Lima at sea level. Fibrepanendoscopy and multiple biopsies were performed in all the patients followed by histopathological examination. In the antrum, patients from the Andean town had a higher prevalence of glandular lymphoid adherence lesions, active germinal centres, moderate to severe chronic atrophic gastritis, intestinal metaplasia and moderate to severe total deep gland loss, than did patients from the coastal town. Furthermore, the severity of the histological lesions seen in the gastric body and cardia was significantly greater in the high-altitude patients than in those from sea level. CONCLUSION: This study suggests that the severity of H. pylori-associated gastric lesions seen on histopathological examination is greater in patients living at high altitude, the cause of which is most probably multifactorial but nonetheless principally altitude related.

[Microscopic colitis in patients with chronic diarrhea]. / Colitis microscópica en pacientes con diarrea crónica

It has recently been suggested that there is an association between infectious gastroenteritis and irritable bowel syndrome with chronic diarrhea; and a striking similarity between the microscopic lesion observed in this condition and the lesion described in microscopic colitis (MC). As in developed countries MC is found in only 12.6 to 15% of patients with chronic diarrhea, we thought it worthwhile to investigate in Perú, a developing country with high prevalence of infectious gastroenteritis, the prevalence of MC also in patients with chronic diarrhea. One hundred and ten patients with chronic diarrhea underwent biopsies from the right and left colon, and the biopsies were examined histologically to detect MC of lymphocytic or collagenous type.MC was present in 44 (40%) of the 110 patients with chronic diarrhea, being of lymphocytic type in 42, and of collagenous type in. The prevalence of MC observed in Peruvian patients with chronic diarrhea is high when compared to reports from developed countries. This finding supports the idea that infectious gastroenteritis may, under certain conditions, precipitate the appearance of MC, probably by an autoimmune reaction.

Amoeba angeitic lesions of the central nervous system in Balamuthia mandrilaris amoebiasis.

Balamuthia mandrilaris amoebiasis is a fatal disease. It primarily affects the nasal pyramid or the skin, producing granulomatous amoebic lesions. The amoeba spread from the primary nasal lesion to the meninges where they infiltrate vessels. Thrombotic amoebic angitis produce infarcts of the central nervous system substance which then become infiltrated by amoeba. The primary cutaneous lesion can be present for weeks or even months. However, the appearance of neurological disease predicts a poor prognosis, in which death usually occurs within a few days or weeks.

Chronic atrophic gastritis: early diagnosis in a population where Helicobacter pylori infection is frequent.

Chronic atrophic gastritis (CAG) is a premalignant condition characterized by loss of gastric antral deep glands. The histologic changes in antral gastric biopsy specimens from 54 Peruvian patients with dyspepsia were studied to detail the development and characteristics of CAG. Ninety-six percent of the biopsies revealed severe superficial mucosal inflammation and 89% showed deep inflammation. Moderate or severe CAG was present in 36 (67%) of the 54 patients. In the early stages of CAG, a glandular lymphoid adherence lesion was noted in 17 (31%) of the 54 biopsy specimens. This lesion consisted of lymphocytes adherent to the antral deep gland cells and was associated with glandular epithelium alterations. The late stage was characterized by small glands, remnants of glands, and gland replacement with a fibrocellular infiltrate or intestinal metaplasia. We propose that the development of CAG probably proceeds via a stereotyped sequence, with an early deep inflammatory component that may trigger local gland destruction and eventual permanent loss.

Geographic factors probably modulating alternative pathways in Helicobacter pylori-associated gastroduodenal pathology: a hypothesis.

It is hypothesized that probable geographic factors of nutritional type, nonrelated to development or socioeconomic level, may modulate the conversion of Helicobacter pylori-associated active chronic gastritis from its early stages to chronic atrophic gastritis (CAG). The factors could be diets low in antioxidant vitamins and other micronutrients such as selenium. In regions of the world where these modulating factors are not present, active chronic gastritis tends to stay in its early stages and to predispose individuals to duodenal ulcer. On the contrary, in regions where the modulating factors are present, the frequency of CAG increases markedly. When CAG becomes severe and extensive, hypochlorhydria ensues. Hypochlorhydria decreases the predisposition to duodenal ulcer, while CAG, a precancerous lesion, predisposes individuals to gastric cancer of the intestinal type. The hypothesis could be tested in a multicenter, multiregional study to (1) determine endoscopically and histologically the prevalence rates of duodenal ulcer, gastric ulcer, gastric cancer, and H. pylori-associated CAG in large series of dyspeptic patients and (2) correlate these prevalence rates with blood levels of micronutrients in these patients.

Rapid recurrence of Helicobacter pylori infection in Peruvian patients after successful eradication. Gastrointestinal Physiology Working Group of the Universidad Peruana Cayetano Heredia and The Johns Hopkins University.

Helicobacter pylori is associated with gastritis, peptic ulcer disease, and gastric cancer. Since gastric cancer is common in Peru, eradication of H. pylori may help to reduce the occurrence of gastric cancer. This study involved three randomized trials to determine the efficacy of four different triple-drug therapy regimens. The most successful regimen was furazolidone combined with bismuth subsalicylate and amoxicillin, which eradicated infection in 82% of patients. Patients successfully treated were followed every 2-3 months to determine the recurrence rate of H. pylori infection. Of 105 patients with H. pylori eradication documented by pathology and culture, 52% (55) returned for follow-up endoscopy, and in 73% (40) of these 55 the infection recurred during the 8-month follow-up period. Thirty-five patients from whom H. pylori was eradicated and who were tested for antibodies to H. pylori remained consistently seropositive. Rapid recurrence of H. pylori infection after successful eradication suggests that measures other than antimicrobial therapy are needed to fight H. pylori in developing countries.

[Helicobacter pylori and gastric cancer]. / Helicobacter pylori y cáncer gástrico.

A review is done on the evidence in favor of a link between Helicobacter pylori infection and gastric cancer of the intestinal type. In countries at high risk of gastric cancer, like Perú, Hp infection begins early in life and is highly frequent and persistent. When Hp colonizes the gastric mucosa, it causes active chronic gastritis. Initially, the gastritis is of the superficial type. With time, and probably as a result of the concurrent action of nutritional, epidemiologic and immunologic modulating factors, chronic superficial gastritis may give rise to a progressive gastric pathology that leads to gastric premalignant lesions (chronic atrophic gastritis, intestinal metaplasia and dysplasia of the gastric mucosa) and increases the predisposition to gastric cancer. The principal modulating factors are described. The epidemiology of gastric premalignant lesions in Perú is also described. Finally, a discussion is done on the effect that eradication of Hp infection might have on the prevalence of gastric cancer.

Low prevalence of gastric metaplasia in the duodenal mucosa in Peru.

We compared the prevalence of gastric metaplasia of the duodenal mucosa (GM) and its characteristics in 204 Peruvian patients from a low socioeconomic level with the corresponding prevalence reported in dyspeptic patients from a developed country, the United Kingdom. Gastric metaplasia was significantly less prevalent in the Peruvian than in the United Kingdom series. However, when present, GM was not significantly different in extent or frequency of colonization by Helicobacter pylori or association with active duodenitis, despite a higher prevalence of H. pylori-associated gastritis. Hypochlorhydria was markedly more frequent in the Peruvian than in the United Kingdom series. The finding of a low prevalence of H. pylori-colonized GM in patients with previously reported low prevalence of duodenal ulcer gives further support to a pathogenic link between both conditions.

Helicobacter pylori and progressive gastric pathology that predisposes to gastric cancer.

Evidence is presented suggesting that infection by Helicobacter pylori triggers and continuously contributes to the pathophysiology of progressive gastric changes that can ultimately lead to gastric cancer. In Peru, especially in population groups of low socioeconomic status, infection by H. pylori begins earlier in life and is more prevalent and persistent than in developed countries. The infection produces a destructive lesion of the mucinous surface epithelium which probably enables other aggressive luminal factors to cause further mucosal damage. As a consequence, active chronic gastritis appears. The gastritis is of the superficial type at the beginning but may progressively change to atrophic. Chronic atrophic gastritis is found more frequently and at a younger age in dyspeptic patients with low socioeconomic status--that is, in patients having higher prevalence of persistent infection by H. pylori since earlier in life. When chronic atrophic gastritis becomes severe and extensive, hypochlorhydria ensues. Hypochlorhydria favors the appearance of bacterial overgrowth, nitrites, and N-nitroso compounds in the gastric lumen. N-nitroso compounds, because of their mutagenic-carcinogenic properties, probably induce gastric premalignant lesions like intestinal metaplasia and dysplasia of the gastric mucosa. Oral bismuth therapy apparently reverses H. pylori-associated gastric dysplasia. It is proposed that future programs designed for the control of gastric cancer would be incomplete if they do not include further evaluation of the many effects of infection by H. pylori on the gastric mucosa and of cost-effective methods to eradicate the infection.

Campylobacter pilórico y nivel socio-económico / Campylobacter pyloricus and socio-economic level

El presente trabajo tiene por objeto determinar si existe alguna relación entre el nivel socio-económico (NSE) de pacientes y la colonización del estómago por el Campylobacter pilórico (CP). Estudiamos diversos aspectos de esta bacteria en dos grupos de pacientes de NSE diferente, nos pareció de inicio apreciar una aparente diferencia en relación a la colonización del estómago por esta bacteria. Hemos evaluado 256 pacientes examinados mediante esofagogastroduodenoscopía (Panendocopio Olympus GIF-K2) por presentar síntomas del tracto gastrointestinal superior. De ellos, 143 pertenecen al Hospital Arzobispo Loayza (38 varones y 105 mujeres) y 122 a la práctica privada de 3 de los autores (77 varones y 45 mujeres), con edades comprendidos entre 16 y 75 años (media de 45.5 años). En cada caso se tomó biopsias del antro gástrico (curvatura mayor y menor) las que fueron coloreadas con hematoxilina-eosina y con plata. Tomando en cuenta recomendaciones para clasificar el NSE de acuerdo a la procedencia los pacientes fueron considerados habitantes de: distritos nucleares, distitos intermedios y distritos periféricos. Los cálculos estadísticas han revelado que aunque de acuerdo a la procedencia, los grupos de pacientes del Hospital Arzobispo Loayza y de la práctica privada tuvieron un NSE significativamente diferente, la frecuencia de infección por CP en ellos no mostró diferencia estadísticamente significativa. Lo cual parecería indicar pues, que el distrito del cual procede un paciente con trastornos del tracto gastrointestinal no es factor determinante de infección por CP

Campylobacter pilórico, gastritis crónica, úlcera gástrica y úlcera duodenal / Pyloric campylobacter, chronic gastritis, gastric ulcer and duodenal ulcer

Diversos trabajos demuestram un elevado porcentaje de hallazgo del campylobacter pilórico en casos de gastritis crónica y úlcera péptica. Presentamos nuestra experiencia en 672 pacientes evaluados mediante esofagogastroduodenoscopía, por presentar síntomas del tracto gastrointestinal superior. Se utilizó el Panendoscopio Olympus GIF-k2 tomándose dos biopsias del antro gástrico. Los especimenes fueron sometidos a coloración con hematoxilinaeosina y con plata, métodos que nos han dado los mejores resultados diagnósticos. El diagnóstico de úlcera gástrica o duodenal se hizo sobre la base del hallazgo endoscópico y para el diagnóstico de gastritis crônica se consideró el criterio histológico. La gastritis se ha dividido en activa e inactica. Se ha cuantificado el daño mucinoso y el grado colonización bacteriana. Hemos encontrado a la bacteria en el 91.8% de pacientes con gastritis crónica activa, 72.7% con úlcera gástrica y 84.2% con úlcera duodenal. Nuestros resultados sosn concordantes con los de otros autores. Concluimos que el campylobacter pilórico no es un germen oportunista en el estómago, pues produce cuadro inflamatorio y daño celular mucinoso. Su presencia puede jugar algún rol en la etiopatogenia de la úlcera péptica y gastritis

[Campylobacter pyloridis and socioeconomic levels]. / Campylobacter pilórico y nivel socio-económico.

The purpose of this study was to determine if there was any relationship between the socio-economic level of patients and the colonization of the stomach by Campylobacter pyloridis. We have studied 256 patients who underwent esophagogastroduodenoscopy because they had upper gastrointestinal symptoms of this group, 143 from Arzobispo Loayza Hospital (38 males and 105 females) and 122 from the private practice of three of the authors (77 males and 45 females). The ages ranged from 16 to 75 years (media 45.5 years). In each case biopsies of the antrum were taken and stained with hematoxylin-eosin and Warthin-Starry Silver Stein. We classified patients into 3 different groups based on where they lived: nuclear districts, intermediate districts, and peripheral districts. In Lima, the type of district from the patient strongly correlates with their socio-economic status. The hospital and private patients differed significantly in the distribution of which type of district their patients came from. In contrast there was a no marked similarity between these two patient groups in their rate of colonization by Campylobacter pyloridis. It appears that the socio-economic level of peruvian patients, presenting to clinic with symptomatic gastro-intestinal disease is not an important factor with pyloric campylobacter infection.

[Campylobacter pyloric, chronic gastritis, gastric ulcer and duodenal ulcer]. / Campylobacter pilórico, gastritis crónica, úlcera gástrica y úlcera duodenal.

After the initial report of Marshall and Warren, several publications have also demonstrated the presence of pyloric campylobacter in an elevated percentage of cases of chronic gastritis and peptic ulcer. We present our experience studying 672 patients examined by esophagogastroduodenoscopy after referral to clinical because of upper gastrointestinal symptoms. We used an Olympus GIF-K2 panendoscope taking two biopsies from the gastric antrum. Specimens were stained with hematoxilin-eosin and silver. In our experience these methods have given us the best results in detecting this bacteria. Diagnosis of gastric and duodenal ulcer was made by endoscopic criteria and chronic gastritis diagnosed by histology. Chronic gastritis was categorized into active and inactive based in the invasion of polymorphonuclear into mucosa. We have also quantitated damage of the mucin producing cells as well as the degree of bacterial colonization. We have found pyloric campylobacter in 91.8% of patients suffering from chronic active gastritis, 72.7% of patients with diagnosis of gastric ulcer and 84.2% of cases of duodenal ulcer. Our results agree with the ones reported by other authors. We conclude that pyloric campylobacter is not an opportunist microorganism within the stomach because it produces inflammatory changes as well as damage of the mucin producing cells. Its presence may play some role in the etiology of gastritis and peptic ulcer disease.

Detección del Campylobacter pilórico en pacientes con enfermedades gastroduodenales / Detection of pyloric Campylobacter in patients with gastroduodenal diseases

Presentamos un estudio de 127 pacientes a quienes con fines diagnósticos se efectuó esofagogastroduodenoscopía. Se tomaron muestras de cepillado y biopsias del esófago, estómago y duodeno, que han sido examinadas por coloración con Gram, cultivo de cepillado y biopsia y estudio histológico de las biopsias con coloración con hematoxilina-eosina y plata con el fin de detectar la presencia de Campylobacter pilórico. En la gastritis crónica activa hemos hallado la bacteria en 91% de casos, en 73% en la úlcera péptica gástrica y en 84% en la úlcera péptica duodenal. Cuando se encuentra campylobacter en el antro, la distribución es igual en el cuerpo y cardias. Comparando los diferentes métodos que hemos empleado, los mejores resultados obtendos en forma decreciente, han sido con la coloración con plata, Gram, hematoxilina-eosina, cultivo de biopsia y cultivo de cepillado. En nuestra serie de estudio en algunos casos se ha hallado campylobacter en esófago y duodeno con la coloración con Gram y por cultivo no habiéndose detectado con las coloraciones de plata y hematoxilina-eosina, lo que sugiere que la contaminación procedente del estómago puede ser un problema para tomar muestras del esófago y duodeno al investigar la presencia de campylobacter pilórico

[Mediterranean lymphoma in Peru. Its treatment with oral oxytetracycline]. / Linfoma mediterráneo en Peru. Su tratamiento con oxitetraciclina oral.

A new Peruvian case of malabsorption associated with primary diffuse lymphoma of the small bowel and mesenteric lymph glands is reported, having found no alpha chains either in blood or in urine. Like in most of the 8 previous cases, medium oral doses of oxytetracycline supressed diarrhea, markedly atenuated steatorrhea, restored the sense of well-being to the patient, and significantly increased his body weight. Critic is made on the denominations "mediterranean lymphoma" and "primary upper small intestinal lymphoma" ("PUSIL") that have been inappropriately assigned to the condition.