Systematic review: the epidemiology of eosinophilic oesophagitis in adults.

BACKGROUND: The epidemiology of eosinophilic oesophagitis (EoE) in adults remains unclear. AIM: To estimate the prevalence and incidence of EoE through a systematic review of published literature. METHODS: We conducted systematic literature searches in PubMed in September 2009. Studies were excluded if they contained any participants below 18 years of age, published in languages other than English, or had no exact reporting of prevalence or incidence rates. RESULTS: Nine studies fulfilled the criteria; one evaluated a population-based sample, one examined patients referred from a defined geographical region and seven studies examined the prevalence in a total of 6018 patients in clinic or hospital settings. The lowest prevalence was reported in population-based studies (4 and 0.23 per 1000), followed by studies of unselected patients (1.0%, 6.5%) and highest in the other five clinic/hospital based studies (2.2-48.2%). Men were more affected in seven of eight studies (64.5-100%). The sample size weighted average prevalence from the population-based studies was 0.03%. For studies evaluating symptomatic patients, it was 2.8%. CONCLUSIONS: The prevalence of EoE in adults varies considerably based on the study sampling frame: high in dysphagia patients, quite low in population-based studies and intermediate among unselected endoscopy patients.

Laparoscopic cholecystectomy in cirrhotic patients.

BACKGROUND: Due to unacceptable increases in intra- and postoperative complications and associated morbidity, cirrhosis of the liver is often considered to be a contraindication for laparoscopic cholecystectomy (LC). However, recent advances have now made it increasingly possible for experienced surgeons to perform LC on this high-risk population. The aim of this study was to evaluate the impact of the coagulopathy associated with cirrhosis on the performance and results of LC. We hypothesized that the factors leading to hemorrhage, rather than Child's classification, would drive operating time and resource utilization. METHODS: Between 1 July 1996 and 30 June 2003, 1,285 cholecystectomies were performed. Thirty one of these patients had evidence of cirrhosis at the time of operation. The 31 patients were divided into high, (low platelets, prolonged International Normalized Ratio) (n = 18), intermediate, (abnormal liver function tests, normal clotting) (n = 5), and low, (normal platelets, normal clotting, and normal liver function tests) (n = 8) surgical risk categories for further analysis. Based on the Child-Turcotte-Pugh (CTP) classification of cirrhosis, there were three grade C and 28 grade A or grade B patients. RESULTS: There were 24 LC, three of which were started laparoscopically and then converted to open, and four open cholecystectomies. Operating room time ranged from 79 to 450 min, with the extent of coagulopathy correlating with the length of time needed to achieve satisfactory hemostasis. Median length of stay postoperatively in the high-risk group was 2 days (range, 0-20). Nine of the cholecystectomies were performed on an outpatient basis. One patient received a liver transplantation 5 months post-LC. There were no operative deaths, bile duct injuries, or returns to the operating room for bleeding. Blood product usage correlated with preexisting coagulopathy. CONCLUSIONS: Currently, the classification of cirrhotic patients is normally done using the CTP score. However, preoperative platelet levels and INR more accurately predict the difficulty of cholecystectomy than CTP score, because intraoperative hemorrhage is the primary concern in these patients. This study demonstrates that preoperative degree of coagulopathy, and not Child's class, should guide the surgeon's approach and expectations when LC is performed in a cirrhotic patient.

Laparoscopic cholecystectomy after the learning curve: what should we expect?

BACKGROUND: The introduction of laparoscopic cholecystectomy (LC) in the late 1980s was accompanied an increase in common bile duct (CBD) injuries. This retrospective analysis of 2,005 cholecystectomies performed at a single institution investigates the factors that have contributed to a record of zero CBD injuries in 1,674 consecutive LC. METHODS: The medical records of 1,285 consecutive patients operated on from 7 July 1996 to 6 June 2003 were obtained. We also examined the peer review records of an additional 720 LC performed between 1 January 1990 and 7 July 1996. RESULTS: There were no CBD injuries among 1,674 consecutive LC patients spanning the period since 1990. Of the 954 patients who underwent LC since 1996, six had a cystic duct leak and five had a duct of Luschka leak. Intraoperative cholangiography (IOC) was performed in 20.2% of cases (n = 193/954). Seventy of 157 patients who underwent cholangiography alone demonstrated one or more stones in the CBD (44.6%). In 40 patients (58.0%), endoscopic retrograde cholangio pancreatography (ERCP) was uniformly successful in clearing intraoperatively identified stones. In36.2% of cases, the stones were removed via laparoscopic CBD exploration (CBDE) (n = 25). In 5.8% of positive cases, the stones were removed via open CBDE (n = 4). Among 761 patients who did not undergo IOC, seven patients (0.92%) returned to the hospital for retained stones. Three of these patients had elevated liver function tests (LFT) preoperatively (1.3%) and four had normal LFT (1.1%). CONCLUSIONS: Injuries of the CBD can be avoided by performing an extensive dissection of the triangle of Calot and by developing a critical view of the operative field to ensure the patient's safety during LC. If all LFT are normal and IOC is not performed, the occurrence of clinically significant stones postoperatively is minimal; in this group, only four patients had retained stones. Thus, in the face of normal LFT, routine IOC is unnecessary for a low CBD injury rate, and a return to the hospital for retained bile duct stones is rarely required, regardless of the number of times ductal stones are found on routine cholangiography. This implies that the significance of the stones discovered at IOC is questionable in most cases, thereby providing an argument against routine cholangiography. Most discovered CBD stones can be treated by ERCP, thus obviating the need for the T-tube drainage associated with CBDE. The 21st century finds LC to be a mature and safe surgical procedure.

Genotypes of alcohol-metabolizing enzymes in Mexicans with alcoholic liver cirrhosis.

With the use of the polymerase chain reaction (PCR), we investigated the frequency of the typical and atypical genes of the alcohol dehydrogenase 2 (ADH2) and aldehyde dehydrogenase 2 (ALDH2) loci, in a group of patients with alcoholic liver cirrhosis and two comparison groups. Contrary to what has been found in the Japanese population, there was no difference in the frequencies of these genes in the groups investigated, and we conclude that in Mexicans, the particular mutation of the ALDH2 locus which "protects" Orientals from alcoholic hepatic diseases, by making them very susceptible to alcohol and therefore discouraging its ingestion, is not present.

The regulation of ammonia assimilating enzymes in Lemma minor.

Lemna minor has the potential to assimilate ammonia via either the glutamine or glutamate pathways. A 3-4 fold variation in the level of ferredoxindependent glutamate synthase may occur, when plants are grown on different nitrogen sources, but these changes show no simple relationship to changes in the endogenous pool of glutamate. High activities of glutamate synthase and glutamine synthetase at low ammonia availability suggests that these two enzymes function in the assimilation of low ammonia concentrations. Increasing ammonia availability leads to a reduction in level of glutamate synthase and glutamine synthetase and an increase in the level of glutamate dehydrogenase. Glutamine synthetase and glutamate dehydrogenase are subject to concurrent regulation, with glutamine rather than ammonia, exerting negative control on glutamine synthetase and positive control on glutamate dehydrogenase. The changes in the ratio of these two enzymes in response to the internal pool of glutamine could regulate the direction of the flow of ammonia into amino acids via the two alternative routes of assimilation.

The control of glutamine synthetase level in Lemna minor L.

The specific activity of glutamine synthetase (E.C. 6.3.1.2) of Lemna minor L. is markedly reduced when either ammonium ions or glutamine are present in the growth medium. Combinations of 5 mM ammonia and 5 mM glutamic acid or 5 mM ammonia and 5 mM glutamine as nitrogen source, lead to a 4-5 fold reduction of the maximum activity measurable on 5 mM γ-aminobutyric acid. Analyses of the soluble pool of nitrogen indicate that the reduction in enzyme level is associated with an increase in the pool of glutamine. There is an inverse correlation between the apparent rate of synthesis of glutamine synthetase and the intracellular concentration of glutamine, and this relationship suggests that the glutamine synthetase of Lemna minor is subject to end product repression by the endogenous pool of glutamine.