Dutch Chronic Pancreatitis Registry (CARE): design and rationale of a nationwide prospective evaluation and follow-up.

BACKGROUND: Chronic pancreatitis is a complex disease with many unanswered questions regarding the natural history and therapy. Prospective longitudinal studies with long-term follow-up are warranted. METHODS: The Dutch Chronic Pancreatitis Registry (CARE) is a nationwide registry aimed at prospective evaluation and follow-up of patients with chronic pancreatitis. All patients with (suspected) chronic or recurrent pancreatitis are eligible for CARE. Patients are followed-up by yearly questionnaires and review of medical records. Study outcomes are pain, disease complications, quality of life, and pancreatic function. The target sample size was set at 500 for the first year and 1000 patients within 3 years. RESULTS: A total of 1218 patients were included from February 2010 until June 2013 by 76 participating surgeons and gastroenterologist from 33 hospitals. Participation rate was 90% of eligible patients. Eight academic centers included 761 (62%) patients, while 25 community hospitals included 457 (38%). Patient centered outcomes were assessed by yearly questionnaires, which had a response rate of 85 and 82% for year 1 and 2, respectively. The median age of patients was 58 years, 814 (67%) were male, and 38% had symptoms for less than 5 years. DISCUSSION: The CARE registry has successfully recruited over 1200 patients with chronic and recurrent pancreatitis in about 3 years. The defined inclusion criteria ensure patients are included at an early disease stage. Participation and compliance rates are high. CARE offers a unique opportunity with sufficient power to investigate many clinical questions regarding natural course, complications, and efficacy and timing of treatment strategies.

Microscopic colitis: prevalence and distribution throughout the colon in patients with chronic diarrhoea.

BACKGROUND: Microscopic colitis presents with chronic diarrhoea with or without abdominal pain. Microscopic colitis is an important cause of chronic diarrhoea. It can be distributed throughout the colon, as well as limited to the right colon. Microscopic colitis is associated with coeliac disease. We studied the prevalence and distribution of microscopic colitis in patients with diarrhoea and normal colonoscopy and we studied the association with coeliac disease. METHODS: Colonoscopy was performed. Biopsies were taken from every segment of the colon. Lymphocytic colitis was defined as the presence of more than 20 lymphocytes per 100 epithelial cells and collagenous colitis was defined as thickening of the basal membrane of more than 10 microm. Upper endoscopy was performed if upper intestinal symptoms were present. If this was the case, small bowel biopsies were taken. RESULTS: Microscopic colitis was found in 13 out of 103 patients. The distribution was diffuse throughout the colon in ten and restricted to the right colon in three patients. In seven patients, upper endoscopy was performed. Marsh I/II lesions were found in six out of seven patients. CONCLUSION: Microscopic colitis was limited to the right colon in 23% of patients. Biopsies of macroscopically normal colonic mucosa in patients with diarrhoea is mandatory.

[Screening for coeliac disease currently not indicated]. / Screening op coeliakie voorlopig niet aangewezen.

Coeliac disease is a common disorder, but most persons with coeliac disease remain undetected because they have only mild aspecific symptoms or are free of symptoms. For a definitive diagnosis small bowel biopsies showing partial or (sub)total villous atrophy are required. The presence of anti-endomysium and/or anti-tissue-transglutaminase antibodies in serum is strongly predictive for coeliac disease. In case of clear clinical suspicion the most straightforward way to diagnose or exclude coeliac disease is by taking endoscopic biopsies from the distal duodenum. When the suspicion is low, determination of the above mentioned antibodies as a first step suffices. At present there are insufficient reasons to initiate population-wide screening for coeliac disease by means of serological testing or individual screening by taking duodenal biopsies during each gastroscopy.

[Eosinophilic oesophagitis in young men with food swallowing complaints]. / Eosinofiele oesofagitis bij jonge mannen met voedselpassageklachten.

Three men, aged 20, 24 and 42 years, reported difficulties in passing food through the oesophagus. The diagnosis of eosinophilic oesophagitis was made after endoscopic investigation, laboratory tests and histological tests. In all three patients the symptoms disappeared: respectively spontaneously, during systemic treatment with corticosteroids due to a kidney complaint, and after topical corticosteroid treatment lasting 6 weeks. Eosinophilic oesophagitis occurs in particular in young men. There are complaints about the passage of food through the oesophagus, with frequent food impaction, also without any obvious stenosis. Endoscopic features are subtle and comprise a vulnerable oesophageal mucosa with a ringed appearance or small white spots on the oesophageal mucosa. Histopathology reveals an eosinophilic infection infiltrate in the oesophageal epithelium. Food allergies may play a causal role. With respect to the treatment, favourable results have been described for oral fluticasone, while endoscopic treatment may consist of dilation.

One-week triple therapy with omeprazole, amoxycillin and tinidazole for Helicobacter pylori infection: the significance of imidazole resistance.

BACKGROUND: Triple therapy involving a proton pump inhibitor and two antibiotics has been suggested as an effective treatment for Helicobacter pylori infection. The impact of imidazole resistance on the efficacy of such regimens is largely unknown. METHODS: One hundred patients with culture proven H. pylori infection were treated with omeprazole 40 mg b.d., amoxycillin 1000 mg b.d., and tinidazole 500 mg b.d. for one week. Pre-treatment imidazole susceptibility was measured by disk diffusion. Resistance was confirmed by E-test. Eradication was assessed by endoscopy 6-8 weeks after the end of treatment. In cases of doubt a 13C-urea breath test was performed. Side-effects were scored using a semiquantitative scale. RESULTS: H. pylori was eradicated in 95% of the patients with an imidazole-susceptible strain and in 69% of the patients with a resistant strain (P < 0.005). Significant side-effects were seen in 12%. CONCLUSION: This proton pump inhibitor triple therapy is a simple, reasonably effective regimen with few significant side-effects. The efficacy is dependent on the susceptibility of the infecting H. pylori strain.

Evaluation of clinical and home performance of the 13C-urea breath test for the detection of Helicobacter pylori.

OBJECTIVE: This study analyses the 13C-urea breath test with the aim of determining the optimal time interval between dosing and breath sampling and examines the feasibility of having patients perform the test without supervision at home. DESIGN: Prospective study comparing the 13C-urea breath test with four antral biopsy-based tests in a random population undergoing upper gastrointestinal endoscopy. SETTING: One university hospital and one general hospital. PATIENTS: One hundred and four patients were included; 61 were Helicobacter pylori-positive and 43 H. pylori-negative according to biopsy-based tests. INTERVENTIONS: The 13C-urea breath test was performed at home by collecting a baseline and two post-dosing samples; the next day it was performed clinically by collecting a baseline and six post-dosing samples. A 100 mg dose of 13C-urea and a test meal were used. OUTCOME MEASURES: The breath samples collected were analysed. Excess delta 13CO2/12CO2 values above five per million were considered positive. RESULTS: The specificity of the clinical test was 100% whereas that of the home-based test was 95.1%. The sensitivity of the clinical test depended on the time interval between dosing and collection of the evaluated sample. Sensitivity was 100% if the sample was taken 50 min or more after dosing. The home-based test had a sensitivity of 94.8%. CONCLUSION: To obtain maximum sensitivity (100%) using the single-sample technique the sample has to be collected at least 50 min after dosing. It is feasible to have the test performed at home. Patient selection and thorough instruction are necessary.

Correlation between predicted and actual consequences of capsule endoscopy on patient management.

BACKGROUND: Capsule endoscopy (CE) is a relatively new diagnostic modality in the evaluation of patients with suspected small bowel pathology. It is unclear to what extent physicians are able to predict the clinical consequences of CE on patient management. METHODS: In this prospective study, 180 consecutive CE examinations were analysed. Prior to CE, referring physicians were asked to indicate the consequences of CE according to potential different CE outcomes. The influence of CE on patient management was determined with at least 1 year follow-up. Management consequences were defined as major (surgical or endoscopic intervention, or medical therapy) or minor (nonspecific therapy, including iron supplementation, or no further diagnostic tests). RESULTS: CE led to major management consequences in 32% of cases. Of patients with obscure gastrointestinal bleeding and normal CE findings, 91% were independent of blood transfusions and experienced no further bleeding episodes during a mean follow-up of 33 months. In 78% of 118 cases that were evaluated, the actual consequences of CE matched the consequences predicted by the referring physicians. CONCLUSION: CE had a major impact on patient management in about one third of investigations. In the majority of cases, physicians adequately predicted the clinical consequences of CE.

Duodenal versus jejunal biopsies in suspected celiac disease.

BACKGROUND AND STUDY AIMS: In the past, small-bowel biopsies for diagnosis of celiac disease were taken from the jejunum with a suction capsule, but nowadays most physicians take endoscopic biopsies from the distal duodenum. To validate that practice we compared the diagnostic yield of endoscopic duodenal biopsies with that of endoscopic jejunal biopsies. In addition, we describe a method of orienting biopsy specimens optimally. PATIENTS AND METHODS: Upper endoscopy was performed with a colonoscope. Four jejunal and four duodenal biopsies were taken and oriented immediately thereafter. The pathologist rated the orientation as poor, adequate, or good, and histopathological results were expressed according to the Marsh classification. Jejunal and duodenal biopsy results were compared. RESULTS: 146 patients were included. Jejunal biopsies were taken in 142 patients, and Marsh I-II lesions were found in 56 and Marsh III lesions in 15 patients. In three patients duodenal biopsies were normal while jejunal biopsies showed Marsh I-II lesions. No discrepancies were found in patients with Marsh III lesions. Orientation was good in all biopsies. CONCLUSION: Duodenal biopsies are sufficient to diagnose full-blown celiac disease (Marsh III), but Marsh I-II lesions may be missed in some cases.

Diagnostic tests for Helicobacter pylori: a prospective evaluation of their accuracy, without selecting a single test as the gold standard.

OBJECTIVE: To assess the accuracy of six commonly used diagnostic tests for Helicobacter pylori in a prospective study without using any specific test as the gold standard (the patient was regarded as H. pylori-infected if two or more tests, whatever their nature, were positive). METHODS: In 105 outpatients undergoing upper GI endoscopy, 62 without significant abnormalities, 28 with gastroesophageal reflux disease, 19 with peptic ulcer, one with erosive gastritis, and one with atrophic gastritis (some patients had more than one diagnosis), antral biopsy specimens were taken for culture, polymerase chain reaction, histological examination (hematoxylineosin and Giemsa stains), and rapid urease test. Corpus biopsy specimens were taken for histological examination. Serology (ELISA) and a 13C-urea breath test were also performed. Consistency of diagnosis between two pathologists was assessed by kappa statistics. RESULTS: Sensitivity and specificity, respectively, were as follows: culture, 98.4 and 100%; polymerase chain reaction, 96.7 and 100%; histological examination (antrum), 96 and 98.8%; histological examination (antrum + corpus), 98.4 and 98.8%; rapid urease test, 90.2 and 100%; 13C-urea breath test, 100 and 100%; and serological examination, 98.4 and 88.4% (95% in those who had not been previously treated for H. pylori). All H. pylori-positive cases were detected by culture and rapid urease test. In 86.4% of these cases all antral biopsy-based tests were positive. Agreement between pathologists was good, with a kappa coefficient around 0.90 for antral biopsy specimens. CONCLUSIONS: All antral biopsy-based tests, as well as the 13C-urea breath test, are accurate for the diagnosis of H. pylori infection. Sampling error is a problem of minor importance. The lower specificity of serological tests may be largely explained by previous treatment of H. pylori.