A new colonic lavage system to prepare the colon for colonoscopy: a retrospective study.

BACKGROUND: One of the most unpleasant and sometimes difficult elements of colonoscopic examination is the bowel preparation which is usually performed 6 or more hours prior to the examination ("early" preparation), causing many patients to refrain from undergoing this procedure. We present a novel technique for bowel preparation that begins approximately 30 min prior to the introduction of the colonoscope and eliminates the need for significant pre-procedure preparation. METHODS: The medical records of all consecutive patients who underwent colonoscopy without "early" preparation (CWEP) from May 2009 through June 2010 were retrospectively reviewed. The procedure was performed using a novel cleansing device, the "ColonoScoPrep™", with which the colon is prepared about half an hour prior to insertion of the colonoscope. The only medication required is two to three bisacodyl tablets the night before. The quality of bowel preparation was graded as excellent, good, satisfactory, or poor, and patient satisfaction was assessed according to a prospective protocol. RESULTS: During this period, 125 patients underwent CWEP. Of these, 110 (89.4 %) patients had an excellent or good preparation, permitting complete colonoscopic examination unimpeded by fecal matter. In 11 patients, preparation was satisfactory, in 2 it was poor and in 2, colonoscopy was not completed due to unsatisfactory preparation. None of the patients suffered from abdominal pain or cramps during or after the CWEP and none had post-colonoscopy diarrhea. All patients were satisfied with the procedure. CONCLUSIONS: Despite the fact that the study is retrospective, CWEP appears safe and easy to perform. A prospective study comparing conventional bowel preparation and CWEP is now underway.

Validation of the Capsule Endoscopy Crohn's Disease Activity Index (CECDAI or Niv score): a multicenter prospective study.

BACKGROUND AND STUDY AIMS: The Capsule Endoscopy Crohn's Disease Activity Index (CECDAI or Niv score) was devised to measure mucosal disease activity using video capsule endoscopy (VCE). The aim of the current study was to prospectively validate the use of the scoring system in daily practice. METHODS: This was a multicenter, double-blind, prospective, controlled study of VCE videos from 62 consecutive patients with isolated small-bowel Crohn's disease. The CECDAI was designed to evaluate three main parameters of Crohn's disease: inflammation (A), extent of disease (B), and stricture (C), in both the proximal and distal segments of the small bowel. The final score was calculated by adding the two segmental scores: CECDAI = ([A1 × B1] + C1) + ([A2 × B2] + C2). Each examiner in every site interpreted 6 - 10 videos and calculated the CECDAI. The de-identified CD-ROMs were then coded and sent to the principal investigator for CECDAI calculation. RESULTS: The cecum was reached in 72 % and 86 % of examinations, and proximal small-bowel involvement was found in 56 % and 62 % of the patients, according to the site investigators and principal investigator, respectively. Significant correlation was demonstrated between the calculation of the CECDAI by the individual site investigators and that performed by the principal investigator. Overall correlation between endoscopists from the different study centers was good, with r = 0.767 (range 0.717 - 0.985; Kappa 0.66; P < 0.001). There was no correlation between the CECDAI and the Crohn's Disease Activity Index or the Inflammatory Bowel Disease Quality of Life Questionnaire or any of their components. CONCLUSION: A new scoring system of mucosal injury in Crohn's disease of the small intestine, the CECDAI, was validated. Its use in controlled trials and/or regular follow-up of these patients is advocated.

Comparison of central and intraesophageal factors between gastroesophageal reflux disease (GERD) patients and those with GERD-related noncardiac chest pain.

Gastroesophageal reflux disease (GERD) causes a wide range of symptoms. Some patients present with typical symptoms such as heartburn and regurgitation and others with atypical symptoms such as chest pain. The mechanism responsible for the varying clinical presentation of GERD is still not fully elucidated. The aim of this study was to prospectively evaluate differences in central and local intraesophageal factors between patients with typical GERD symptoms and those with noncardiac chest pain (NCCP). Patients presenting with typical and atypical symptoms suspicious of GERD underwent upper endoscopy and 24-hour pH monitoring with four sensors, each positioned at a different esophageal level. All patients completed GERD symptom, Hospital Anxiety and Depression Scale, and Symptom Stress Rating questionnaires. From January 2006 to December 2009, 50 patients were recruited, 29 with typical symptoms, and 21 with NCCP. Patients with proven GERD and NCCP had higher proximal extension of acid during reflux episodes than patients with typical symptoms. They were found to be older, had a shorter history of symptom onset, worse anxiety scores, and more endoscopic findings compatible with gastritis. Proximal extension of acid during the reflux episodes in patients with GERD presenting with NCCP may play a role in symptom generation.

Evidence for aberrant regulation of MAP kinase signal transduction pathway in peripheral blood mononuclear cells in patients with active celiac disease.

BACKGROUND: Aberrant signaling via the p21/mitogen-activated proteins (MAP) kinase pathway has been described in lymphocytes of patients with various autoimmune diseases. There is little published data about the intracellular mediators and signals that regulate expression and activity of transcription factors and their effect on celiac disease induction and progression. AIM: To investigate the possible involvement of MAP kinase pathway in peripheral blood mononuclear cells (PBMC) in celiac disease and its correlation with disease activity. METHODS: Expression of the total and activated forms of two MAP kinases [extracellular response kinase (ERK) and c-Jun amino terminal kinase (JNK)] were studied by Western blots in PBMC of 17 untreated and 19 treated celiac patients, and 17 controls. Seven of these untreated celiac patients were studies before and after 6 months of gluten-free diet. RESULTS: Phosphorylated ERK of active celiac disease patients was significantly lower compared with controls (P < 0.01) and was increased towards normal after 6 month of gluten-free diet (P < 0.01). Phosphorylated JNK was increased significantly in the untreated celiac group (P < 0.01) and normalized towards the control level after 6 months of gluten-free diet (P < 0.04). CONCLUSIONS: Aberrant MAP-kinase pathway activity is associated with active celiac disease (CD). Further studies should examine the potential role of this aberration in pathogenesis of CD.

Antiplatelet therapy and the risk of bleeding induced by gastrointestinal endoscopic procedures. A systematic review of the literature and recommendations.

Antiplatelet drugs may increase the risk of bleeding induced by gastrointestinal endoscopic procedures. The antiplatelet effect of cyclooxygenase-1 inhibitors lasts less than 4 h. Skin and colonic bleeding times are prolonged for 3 and 5 days after aspirin and ticlopidine withdrawal respectively. Major bleeding from endoscopic biopsies is extremely rare. In the four recent largest series, the general incidence of polypectomy-induced major bleeding was 0.11-0.42%. In more than half of the cases the bleeding was delayed, usually up to 2 weeks after the endoscopy. Although three retrospective studies suggested that aspirin does not increase the risk of polypectomy-induced bleeding, the power of these studies is limited. Similarly, it is difficult to draw conclusions from the two studies that assessed the risk of aspirin use during sphincterotomy. Aspirin withdrawal may be harmful in susceptible patients, mainly if it is for more than 7 days. There is no indication to stop aspirin before esophagogastroduodenoscopy, which may reveal aspirin-induced lesions. We recommend discontinuation of aspirin 4-7 days (according to the cardiovascular risk) before other endoscopic procedures. When aspirin is indicated for primary prevention, it can be resumed 14 and 10 days after polypectomy and sphincterotomy respectively. In cases of secondary prevention, it should be resumed after 1 week.

Chronic hepatitis C infection in children.

Hepatitis C virus infection may differ in the pediatric age group with respect to transmission, natural history and response to treatment. Most infected children develop chronic hepatitis but with a relatively mild course of the disease. The most efficient transmission of hepatitis C virus is through direct percutaneous exposure to infected blood or blood products. However, the major risk factor for acquisition of hepatitis C virus in children at present is maternal-infant transmission. The rate of progression to advanced liver disease seems to be more rapid in post transfusional and vertically acquired hepatitis C virus infection than in sporadic hepatitis C virus infection acquired postnatally, or in those without known risk factors. There is a wide variety of histopathological expression, depending on the geographical distribution of the different countries. Treatment for hepatitis C virus in children has not yet been approved. However, combination treatment with peginterferon-alpha-2b with ribavirin shows encouraging results and is generally well tolerated. More randomized controlled trials are needed in the future to optimize the approach to hepatitis C virus infection in children.

Differences in CEA values determined by EIA and RIA in patients with benign and malignant biliary obstructions.

Serial carcinoembryonic antigen (CEA) levels were determined by both the Roche RIA and Abbott EIA methods in 11 patients with pancreatic cancer (9 with extrahepatic biliary obstruction); 7 with benign extrahepatic obstruction; 26 with colonic cancer without biliary obstruction; and 12 normal, non-smoking controls. The Roche/Abbott CEA ratios in the patients with malignant and benign obstruction (mean ratios = 3.05 and 3.08, respectively), were significantly higher than those in patients with colon cancer without biliary obstruction and in normal controls (mean ratios = 1.35 and 1.06, respectively). Four patients with malignant obstructions were decompressed successfully (bilirubin less than or equal to 1.5 mg/dL); the ratios for two of these patients declined to "normal" (1.0), while the ratios for the other two remained elevated despite decompression. These findings show that some patients with benign or malignant biliary obstruction have elevated CEA levels when measured by the Roche RIA but not with the Abbott EIA.

Effect of N-methylpyridinium-2-aldoxime methane sulphonate (P2S) on rat intestinal, (Na-K)ATPase and adenyl cyclase activities.

The effect of N-methylpyridinium-2-aldoxime methane sulphonate (P2S), a drug recommended for prophylactic and therapeutic purposes in organophosphate poisoning, on intestinal (Na-K) ATPase and adenyl cyclase activities, was tested in rats. Intestinal (Na-K) ATPase activity was determined 5 h after intragastric administration of either 0.15 M NaCl or P2S 200 mg/kg body weight. P2S decreased significantly jejunal and colonic (Na-K)ATPase activity, 17.1 +/- 4.8 (S.E.) and 13.5 +/- 3.0, as compared to that in saline-treated rats, 41.5 +/- 3.0 (S.E.) and 25.4 +/- 1.2 mumol Pi/mg protein per h, respectively. Pretreatment with methyl prednisolone did not prevent the decrease in enzyme activity induced by P2S. Mucosal PGE2 and cAMP contents, adenyl cyclase and phosphodiesterase activities, were similar in P2S and saline-treated rats. It is thus suggested that P2S-induced inhibition of intestinal (Na-K)ATPase activity might be among the mechanisms contributing to looseness of the stool frequently observed following P2S administration.

Superoxide dismutase activity in duodenal ulcer patients.

OBJECTIVE: To investigate whether duodenal ulcer (DU) is associated with increased free radical generation at the site of ulceration and to attempt, indirectly, to confirm the hypothesis by determining activity of free radical scavengers such as superoxide dismutase (SOD). STUDY DESIGN: Prospective study comparing SOD activity in biopsies taken from the ulcer edge, and antrum in DU patients before and after one month of treatment to SOD activity in biopsies from the duodenal bulb and antrum in a control population. SETTING: Institute of Gastroenterology of a university hospital. STUDY POPULATION: Twenty-five patients with DU. The diagnosis was confirmed by endoscopy. MEASUREMENTS: SOD activity in biopsy specimen, red blood cells (RBC) and serum was measured using the cytochrome c method by spectrophotometry and expressed as U SOD/mg protein. Helicobacter pylori was diagnosed by the rapid urease test (CLO test) from antral biopsies. RESULTS: SOD activity was markedly depleted in the ulcer edge (2.78 +/- 0.9 U SOD/mg protein) as compared to the same patients after one month of treatment (4.59 +/- 2.2 U SOD/mg protein) (P = 0.05) and to biopsies from the duodenal bulb in control population (6.7 +/- 2.4 U.SOD/mg protein) (P = 0.05). SOD activity in the antrum of both groups was similar. There was no difference in SOD activity in RBC and serum of both groups. CONCLUSION: Products of free radical reactions are implicated in the pathogenesis of DU disease. SOD, which is a key enzyme in gastric mucosal protection, is depleted significantly in the ulcer edge compared with controls and increases after healing. However, it is not clear whether this abnormality in oxygen free radical metabolism reflects, rather than causes, the condition which characterizes DU.

Prevalence of celiac antibodies in children with neurologic disorders.

Neurologic complications are a recognized but unusual manifestation of celiac disease (CD) in adults and children. The use of antigliadin and antiendomysial antibodies in screening has revealed the frequency of CD among symptom-free individuals to be high. Recently, a high frequency (57%) of antigliadin antibodies was demonstrated in adult patients with neurologic dysfunctions of unknown cause. We investigated the yield of screening for CD in children with common neurologic disorders. One hundred sixty-seven children, 1-16 years of age, were included in the study: 41 with migraine headaches, 39 with attention-deficit disorder with or without hyperactivity, 36 with epileptic disorders, and 51 with hypotonia and motor abnormalities. Positive IgG antigliadin antibodies were evident in 22 children (13%) in the study group compared with three children (9%) in the control group. However, in all children, negative IgA and endomysial antibodies were observed; thus duodenal biopsies were not performed. Contrary to studies performed in adults, these results did not demonstrate any relationship between common neurologic disorders without a specific diagnosis during childhood and CD. Thus screening for CD does not need to be routinely included in the diagnostic evaluation of children with these disorders.

Elevated carcinoembryonic antigen (CEA) levels in a patient with no malignancy.

Carcinoembryonic antigen rarely exceeds serum levels of 10-12 ng/mL in benign diseases and has never been found above 24 ng/ml. We report a case in which carcinoembryonic antigen serum levels reached the value of 44.9 ng/ml without any overt reason (after 22 months of follow-up). A decline of the carcinoembryonic antigen to normal ranges was noticed after a radiolabeled anti-carcinoembryonic antigen monoclonal antibody scan was performed. The reason for this phenomenon is unclear.

Does general anesthesia affect sinusoidal liver cells as measured by beta-N-acetyl hexosaminidase serum activity level?

BACKGROUND/AIMS: General anesthesia causes temporary hypoxia of liver tissue, resulting in several metabolic changes. The purpose of this study was to explore whether the function of hepatic sinusoidal cells, especially the Kupffer and endothelial cells, are damaged following general anesthesia. METHODOLOGY: Liver sinusoidal cell (LSC) function was evaluated by means of measuring the serum level of activity of the lysosomal hydrolase beta-N-acetyl hexosaminidase before and 24 hours after general anesthesia in 20 patients who underwent orthopedic surgery. RESULTS: The only change in liver function which might be of clinical significance was a mild decline in the serum albumin level. CONCLUSIONS: Liver sinusoidal cells, especially Kupffer and endothelial cells, most probably remain undamaged after 1 to 5 hours of general anesthesia.

Serum-beta-N-acetyl hexosaminidase (beta-NAH) in the elderly.

Serum levels of beta-N-Acetyl Hexosaminidase (beta-NAH) provide information on the normal non-phagocytic function of Kupffer cells in the liver. Beta-NAH can thus be used as an indicator for non-parenchymal non-phagocytic liver cell function, whereas most of the more routine liver function tests measure hepatocytic status or function. Serum beta-NAH activity levels found in 49 patients and 10 healthy individuals above the age of 65 did not differ significantly from those found in younger controls. The results clearly indicate that beta-NAH serum activity in the aged is within normal limits and, if accepted as a routine measure of the non-phagocytic function of non-parenchymal liver cells, could be used in all adults.

Does laparoscopic cholecystectomy influence peri-sinusoidal cell activity?

BACKGROUND/AIMS: To investigate the influence of laparoscopic procedures on perisinusoidal cell function. METHODOLOGY: In 31 patients who underwent laparoscopic cholecystectomy for symptomatic cholelithiasis, the serum levels of beta-N-acetyl hexosaminidase (beta-NAH) and hyaluronic acid (HA) were measured. Six female patients, who underwent other laparoscopic procedures, not involving the hepatobiliary system, served as controls. RESULTS: HA serum levels increased significantly in both study and control groups, while beta-NAH serum levels remained within normal values. Post-operative AST and ALT serum levels increased significantly only in the study group. No elevation of serum ALP was noted in any of our patients, and post-operative bilirubin levels did not increase in patients with normal pre-operative levels. CONCLUSIONS: Laparoscopic procedures caused detectable damage to Kupffer and endothelial cells as reflected by elevation of post-operative HA serum levels. The damage to the liver hepatocytes and perisinusoidal cells has no clinical significance and the laparoscopic procedure itself is the probable cause of the Kupffer and endothelial cells damage, while other mechanisms caused damage to the hepatocytes.

Anuria in childhood due to bilateral urolithiasis. A report of four cases.

Four children with anuria due to occlusion of both ureters by calculi are presented. A plain film of the abdomen revealed faintly radiopaque urinary calculi bilaterally in three patients. In the fourth case, one calculus was visualized in the right ureter, but further contralateral exploration showed an obstructing ureteral calculus in the left ureter as well. It is concluded that in children with acute anuria, the possibility of bilateral ureteral obstruction due to calculi should be the physician's first consideration.

Chlamydia trachomatis and inflammatory bowel disease--a coincidence?

Serological tests of 35 patients suffering from inflammatory bowel disease were compared to those of 35 healthy controls. The tests were performed using the indirect immunoperoxidase assay. Ninety-three per cent of 15 patients with Crohn's disease had IgG antibodies against Chlamydia, compared to 26% in the control group. In the 20 patients with ulcerative colitis, 45% had IgG antibodies against Chlamydia, compared to 10% in the control group. High serum titres of IgG antibodies were found in most of the patients with inflammatory bowel disease, mainly with Crohn's disease, while weak reactions appeared in most of the controls in which antibodies were detected. These results suggest a high incidence of Chlamydia infection in the studied patients with inflammatory bowel disease, especially in those with Crohn's disease. The possible association between Chlamydia trachomatis and inflammatory bowel disease is discussed.

[Stromal uterine sarcoma arising from intestinal endometriosis after abdominal hysterectomy and salpingo-oophorectomy].

The incidence of ectopic endometriosis is 4% to 18%. The intestinal type is quite common with the rectosigmoid the most likely part of the bowel to be involved due to its pelvic location. A 43-year-old woman, whose symptoms, X-ray and endoscopic findings suggested malignancy of the rectosigmoid, is presented. Primary malignancy of the bowel was excluded by endoscopic biopsies. Histological examination at operation showed stromal sarcoma of the uterus with foci of endometriosis. There is no report in the English literature of transformation of intestinal endometriosis into malignancy, such as stromal sarcoma of the uterus, which imitates a primary malignancy with obstruction of the rectosigmoid.

[Groove pancreatitis and adenocarcinoma of the pancreatic head].

A mass within the head of the pancreas causing obstructive jaundice is frequently adenocarcinoma, or infrequently focal pancreatitis. Groove pancreatitis is an inflammation of the head of the pancreas which fills the anatomic space between the head of the pancreas on 1 side and the second part of the duodenum on the other. Obstruction from either cause may cause vomiting, abdominal pain, and loss of weight. It is sometimes impossible to differentiate between the 2 conditions clinically. We present 2 women, aged 41 and 42 years, respectively, with recent onset of diabetes mellitus, obstructive jaundice, abdominal pain and severe loss of weight in whom diagnosis was difficult. In 1 repeated fine needle biopsy directly from the mass did not show adenocarcinoma, but she died of the disease a few months later. The other, in whom malignancy was also suspected, recovered from what was retrospectively diagnosed as groove pancreatitis.

[Acute liver damage after using ecstasy].

Ecstasy is a stimulant used mainly by youngsters to get 'high.' There are few reports of acute injury of the liver due to ecstasy. We describe a 37-year-old woman who presented with the clinical picture of recurrent hepatitis following ingestion of the drug. After several months she developed liver cirrhosis shown by biopsy and CT scanning. This case emphasizes the potential danger of ecstasy. Every patient with hepatitis of unknown origin must be questioned about ingestion of the drug.

[Percutaneous endoscopic gastrostomy].

Although percutaneous endoscopic gastrostomy (PEG) for feeding purposes has been in use for the past 10-12 years, many practitioners are unaware of this option. We describe 10 patients who underwent PEG with only 1 major, but nonfatal, complication. We stress that PEG is indicated for those who cannot swallow, and is safe, easy to perform, and a relatively cheap procedure. It is therefore a useful substitute for surgical gastrostomy.