Omeprazole induces a long-term clinical remission of protein-losing gastropathy of Ménétrier's disease.

We report a patient with Ménétrier's disease presenting with extensive subcutaneous oedema, ascites and pleural effusion due to hypoalbuminaemia. Gastric secretory studies showed no free basal and stimulated acid secretion. The gastric juice contained significant amounts of albumin (0.2 g/dl) and immunoglobulin G (IgG) (1.11 mg/dl), corresponding to an estimated daily loss of 9.7 g and 45 mg, respectively. Protein-losing gastropathy was initially unsuccessfully treated with famotidine (80 mg/day) for 17 months, but a long-term (25 months) clinical remission was subsequently achieved with omeprazole (20 mg/day). We suggest that excellent clinical remission of Ménétrier's disease and the associated protein-losing gastropathy may be obtained with long-term omeprazole maintenance treatment, possibly due to Helicobacter pylori suppression.

A three-day octreotide-containing helicobacter pylori eradication therapy for cure of peptic ulcers.

BACKGROUND/AIMS: Octreotide is used to arrest peptic ulcer hemorrhage. Since it has anti-secretory properties, it could also be used in Helicobacter pylori eradication therapy, to cure peptic ulcer before discharging patients from hospital. The aim of this pilot study was to determine safety and efficacy of an ultra short quadruple octreotide containing H. pylori eradication therapy in patients with peptic ulcer. METHODOLOGY: Twenty-six consecutive symptomatic H. pylori-positive patients with duodenal (n = 20) or gastric ulcer (n = 6), were treated with a three-day course of octreotide 0.3 mg/day subcutaneously, amoxicillin plus metronidazole 2 g/day orally and colloid bismuth subcitrate 480 mg/day. CLO-test, culture and crush tissue smears were performed on admission to the study, at 4 and 8 weeks post treatment. The effect of octreotide on intragastric pH (n = 10) was also investigated. RESULTS: Octreotide significantly increased the mean 24-hour intragastric pH > 3 over 68.9% of the time (37.1%-99.5%). There were no treatment side effects. Ulcer pain was abolished at between 2-12 days. By intention-to-treat 24/26(92.3%, 95% CI 82%-100%) ulcers had healed at 4 weeks. H. pylori eradication rate at 8 weeks was 88.5% (23/26) (95% CI 76%-100%). CONCLUSIONS: Our ultra-short octreotide containing quadruple therapy is a safe and effective regime in eradicating H. pylori and healing peptic ulcers. It may be a suitable therapy for hospitalized patients with peptic ulcer hemorrhage.

Pancreatic duct width: its significance as a diagnostic criterion for pancreatic disease.

The significance of main pancreatic duct width in the diagnosis of pancreatic disease, was studied in 338 endoscopic retrograde pancreatographies. Two hundred and forty patients referred for suspected biliary disease had normal pancreatograms (Group 1), 60 had pancreatic carcinoma (Group 2) and 38 had a history and pancreatogram compatible with chronic pancreatitis (Group 3). After categorizing patients by decade, in group 1 the effect of aging on the pancreatic duct width in the head, body and tail (F5,234 > 3.71, p < 0.003) was pronounced, especially after the fifth decade. There was a significant difference between groups 1, 2 and 3 in terms of the width of the main pancreatic duct in all three parts of the pancreas (F2,325 > 42.24, p < 0.001). The upper range of normal pancreatic duct width was 8.0 mm, 4.0 mm and 2.4 mm in the head, body and tail, respectively. Abnormal ductograms were wider than the normal ranges in the head, body and tail of the pancreas in 14%, 49% and 59% (p < 0.001) of the patients, respectively. Establishing normal ranges of the pancreatic duct width may help in the diagnosis of pancreatic disease. Measurements in the body and tail, as compared with the head, are a more sensitive indicator of pancreatic duct dilation.

Selection of patients for successful maintenance treatment of esophagitis with low-dose omeprazole: use of 24-hour gastric pH monitoring.

OBJECTIVE: Treating patients with erosive esophagitis and maintaining remission in a cost-effective fashion is a desirable goal in clinical practice. There are no established criteria to identify patients with healed esophagitis who will subsequently remain in remission with low-dose omeprazole therapy. We investigated whether 24-h esophageal-gastric pH monitoring could provide criteria to select patients for low-dose omeprazole maintenance therapy. METHODS: Seventy consecutive symptomatic outpatients with grade 2-3 reflux esophagitis were prospectively investigated. They were treated with 20 mg/day omeprazole for 2 months. Those with healed esophagitis were given alternate-evening 20-mg omeprazole maintenance therapy for 6 months. Clinical evaluation, endoscopy, and 24-h esophageal-gastric pH were done at the end of each treatment period. Results of pH studies of patients in remission were compared with those with endoscopically documented relapse of esophagitis. RESULTS: In 63/70 patient (intention-to-treat, 90%; 95% confidence interval [CI], 83-97%) esophagitis was healed at 2 months. During the 6-month maintenance period esophagitis remain healed in 28 (G1) (40%; 95% CI, 29-52%), but recurred in 32 patients (G2). During healing with omeprazole 20 mg/day the 24-h gastric pH was below 4 for <10% of the time in 96% of the patients, who subsequently remained in long-term remission with low-dose maintenance therapy (G1), but not in any patient with recurrence of esophagitis (G2). The 10% threshold value has a specificity of 1.00 and sensitivity of 0.96. CONCLUSIONS: The 24-h intragastric pH monitoring during 20 mg/day omeprazole therapy provides criteria by which to preselect patients with reflux esophagitis who will remain in remission with low-dose omeprazole therapy.

Coincidental malabsorption of lactose, fructose, and sorbitol ingested at low doses is not common in normal adults.

Normal subjects may incompletely absorb either lactose, fructose, or sorbitol and may therefore have abdominal symptoms. The frequency of coincidental malabsorption of these sugars is not known. This is clinically important, since we often ingest them during the same day and malabsorption may cause abdominal symptoms. To shed light on this issue we studied 32 normal subjects. Volunteers drank in random order the following solutions: 20 g lactulose, 50 g sucrose, 50 and 25 g lactose, 50 and 25 g fructose, 20 and 10 g sorbitol. Semiquantitative carbohydrate malabsorption was estimated with lactulose standards. Frequency of 50-g lactose (69%), 50-g fructose (81%), and 20-g sorbitol (84%) malabsorption was not significantly different (P = 0.3). The estimated median fraction of the ingested high dose malabsorbed was 42, 19, and 68% for lactose, fructose, and sorbitol, respectively. At low challenging doses, 63% of the volunteers absorbed two of three or all three sugars, and 88% were asymptomatic to two or all three sugars. In conclusion, the frequency of coincidental malabsorption of lactose, fructose, and sorbitol and intolerance to these sugars is not common, when normal adults ingest them at low doses.

Acquisition of competence in colonoscopy: the learning curve of trainees.

BACKGROUND AND STUDY AIMS: Most official training programs in colonoscopy recommend that trainees should carry out a minimum of 100 procedures, but limited data exist on the technical progress of trainees. The aim of our study was to estimate the number of supervised procedures required for obtaining competence in colonoscopy. MATERIALS AND METHODS: Between 1990 and 1997 we have prospectively evaluated the performance of eight consecutive trainees in colonoscopy. The extent of intubated colon was recorded after each endoscopic procedure. Regression analysis was used to study the effect on the trainees' success rates on the number of colonoscopies which they had done. RESULTS: Out of 2,255 colonoscopies carried out over an 8-year period 1,408 were suitable for evaluation, fulfilling the training criteria for diagnostic colonoscopy. Senior staff (n=2) did 430 colonoscopies with a success rate of 91%, which was significantly reduced to 79% (344/434 colonoscopies; X2=20.67, df=l, P<0.001), when taking over colonoscopies which trainees had failed to complete. Regression analysis of trainees' data (y=88.97-(2185/x), r=0.74, F1,21=23.43, P<0.001) showed success rates of 67 % (95 % CI, 59 to 75 %) and 77 % (95 % CI, 66 to 88 %), when 100 and 180 procedures, respectively, had been done. These figures had been attained by the end of the second and third year of training in colonoscopy. CONCLUSIONS: Our regression analysis model shows the technical progress of trainees over a 3-year period as they learned how to carry out colonoscopy. Depending on individual skill, between 100-180 procedures, done over a 2-3-year period, are required before trainees can be considered competent in colonoscopy.

The clinical need for sphincter of Oddi manometry in gastrointestinal endoscopy units.

The clinical need for sphincter of Oddi manometry (SOM) was investigated by retrospective analysis of 736 consecutive endoscopic retrograde cholangiopancreatography (ERCP) referrals (1985-89). During this period SOM was not performed in any unit in Greece including our own. Assuming a conservative or a more liberal policy in the utilization of SOM, a biliary and a pancreatic group of patients were established respectively, depending on the clinical presentation. ERCP was diagnostic in 168/194 (86.6%) of patients referred for post-cholecystectomy symptoms, but SOM was considered to be necessary to establish a diagnosis in the remaining 26 (13.4%) patients (biliary group). ERCP revealed pancreatic and/or biliary pathology in 46/69 (66.7%) patients, referred for symptoms attributed to pancreatitis, but 11/69 (15.9%) patients with pancreas divisum and 12/69 (17.4%) with acute recurrent idiopathic pancreatitis may have benefitted from SOM for planning endoscopic therapy (pancreatic group). Thus, only 5 patients from each group per 147 ERCP annual referrals were candidates for SOM. When taking into account that to run a SOM service the minimum annual number of investigations should be 50 and that the provision of ERCP in the UK is 50 per 100,000 of population per year, it is extrapolated that such a Gastrointestinal Endoscopy Unit should serve a population of 1.5 to 3 million.